Get your sleep and treat depression to guard against Alzheimer’s disease

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The September International Psychogeriatrics Article of the Month is entitled “Associations between depression, sleep disturbance, and apolipoprotein E in the development of Alzheimer’s disease: dementia” by Shanna L. Burke, Peter Maramaldi, Tamara Cadet and Walter Kukull. This blog piece was released by Florida International University and can be viewed here.

New research suggests that lack of sleep and untreated depression may increase the risk of Alzheimer’s disease, even for those who do not have a genetic predisposition for the disease.

Depression and sleeplessness have long been considered symptoms of Alzheimer’s disease. This study indicates that whether in combination with genetic risk factors or on their own, untreated depression and lack of sleep may lead to the onset of Alzheimer’s disease dementia later in life.

“Previous research has attempted to explore the relationship between depression, sleep disturbance and Alzheimer’s disease. Our research is significant in that it is the first to find an increased risk of Alzheimer’s disease due to insomnia and depression independently, as well as in combination with genetic risk factors,” said Shanna L. Burke, assistant professor of social work at the FIU Robert Stempel College of Public Health & Social Work.

Alzheimer’s disease currently affects more than 39.9 million people worldwide. In the United States, it is the most common form of dementia in the elderly, affecting 1 in 10 people over the age of 65.

Although treating the genetic risk factors for Alzheimer’s disease isn’t possible yet, these findings suggest that alleviating depression and sleep disturbance may decrease the chances of a person developing the disease.

Burke served as the primary investigator for the study. She and the other members of the research team—Peter Maramaldi, Tamara Cadet and Walter Kukull—present their findings in Associations between depression, sleep disturbance, and apolipoprotein E in the development of Alzheimer’s disease: dementia, which was recently highlighted as “Paper of the Month” in the journal International Psychogeriatrics. Commentary and associated findings on the study were provided by Dr. David Steffens, chair of the department of psychiatry at the University of Connecticut.

“Future studies are needed to better understand the role of sleep in development of Alzheimer’s Disease, either as an independent risk factor or as a key depressive symptom that might further unlock the link between depression and Alzheimer’s,” said Steffens.

The full paper “Associations between depression, sleep disturbance, and apolipoprotein E in the development of Alzheimer’s disease: dementia” is available free of charge for a limited time here.

The commentary paper “J’accuse! depression as a likely culprit in cases of AD” by David C. Steffens is also available free of charge for a limited time here.

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Poisoning among older people with dementia

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The November International Psychogeriatrics Article of the Month is entitled “Dementia and intentional and unintentional poisoning in older people: a 10 year review of hospitalization records in New South Wales, Australia” by Rebecca J. Mitchell, Lara A. Harvey, Henry Brodaty, Brian Draper and Jacqueline C. T. Close.

This blog post was written for us by one of the paper’s authors, Rebecca Mitchell.

Older people who have dementia are hospitalized far more commonly than people without dementia. One of the most common reasons that older people with dementia are hospitalized is due to injuries, with poisoning one of the most common types of injury experienced. Some poisonings may be unintentional mistakes, but others are due to a person intentionally trying to harm themselves.

It is not surprising that older people with dementia might experience difficulty with taking different doses of medication on specific days or at specific times. In this study, we wished to identify if older people with dementia had a higher rate of being hospitalised following poisoning than people without dementia and to try to identify commonalities surrounding the circumstances of the poisoning event that would allow us to raise awareness of approaches needed to prevent future poisonings.

Most research that has looked at older people with dementia and poisoning has involved small studies that examined admission at only one or two hospitals. In this study, we were able to examine all hospital admissions following poisoning of older people in the largest state in Australia, New South Wales, and to identify the circumstances of the poisoning event for both people with and without dementia.

Our research found that older people with dementia had double the rate of hospitalisations for unintentional poisoning and one and a half times the rate of hospitalisation for intentional poisoning compared to older people who did not have dementia. We identified that anticholinesterase medications (taken for Alzheimer’s disease), antihypertensive drugs and laxatives were the common medications taken by an older person with dementia when they unintentionally poisoned themselves. The home was the most common location of the poisoning, but unintentional poisoning was 5 times more likely to occur in aged care facilities and at least 4 times more likely to occur in health service facilities compared to intentional poisoning.

As all people age, the number of medications they take generally increase, with around 4 or more medications taken by people aged 60 years and older. It is more common for mistakes with medications to be made, the higher the number of medications that need to be taken. The presence of dementia is only likely to increase the potential for errors to be made and make problems of adherence to a medication regimen more difficult.

The findings of our study suggest that there are opportunities to prevent unintentional poisoning by older people with dementia by improving medication storage options, such as the use of blister packs or Dosette boxes, by getting family members or carers to assist in medication administration and, in the aged care and hospital settings, by ensuring quality use of medicines, and accurate documentation and review regarding polypharmacy.

The full paper “Dementia and intentional and unintentional poisoning in older people: a 10 year review of hospitalization records in New South Wales, Australia” is available free of charge for a limited time here.

The commentary paper “Poisoning among older people with dementia: a wake up call” by Christopher D. Etherton-Beer is also available free of charge here.

Struggling to make Indian Curry…. Early indication of dementia?

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The September International Psychogeriatrics Article of the Month is entitled “Discriminative power of the advanced activities of daily living (a-ADL) tool in the diagnosis of mild cognitive impairment in an older population” by P. De Vriendt, T. Mets, M. Petrovic and E. Gorus.

 

This blog post was written for us by one of the paper’s authors, Prof. Dr. Patricia De Vriendt

Struggling to make Indian Curry…. Early indication of dementia?

With a diagnosis of Alzheimer’s dementia (AD) comes an understanding that the affected individual will suffer an inevitable and progressive decline in their functional abilities. In order to identify and treat dementia as early as possible the concept of Mild Cognitive Impairment (MCI) was established. MCI is seen as the intermediate stage between normal aging and AD and is characterized by subjective and objective memory impairments in the absence of functional decline [the loss of ability to perform everyday tasks without assistance]. However, this criterion is controversial since our previous studies and also many other studies showed that mild changes in Activities of Daily Living (ADL) can be present and probably predict conversion to dementia.

The overall issue was whether an evaluation of ADL might underpin the diagnosis of MCI in a valid and reliable way, with an accuracy comparable with cognitive assessment.

For this reason, we hypothesized that an evaluation of ADL should be done on the level of “the advanced (a)-ADL”, encompassing all the most complex activities one can perform, such as using (household) technology, preparing complex dishes, driving, going on holidays, doing sports, practice hobbies, or arts, etc. The a-ADL are considered as the most difficult activities, requiring high level cognitive organization, and accordingly are most vulnerable to early cognitive decline.

We set out to study this issue by developing and validating a new advanced (a)-ADL tool, based on the International Classification of Functioning, Disability and Health framework (ICF), evaluating high-level activities. Taking each participant as their own reference, we calculated a global Disability Index (a-ADL-DI), a Cognitive Disability Index (a-ADL-CDI), and a Physical Disability Index (a-ADL-PDI), based on the number of activities performed and the severity and causes of the functional problem.

The study published as ‘paper of the month’ evaluated the discriminative power of the a-ADL tool in order to establish diagnostic accuracy.

Based upon clinical evaluation and a set of global, cognitive, mood, and functional assessments, 150 community-dwelling participants (average age 80.3 years) were included and diagnosed as (1) cognitively healthy participants (n = 50); (2) patients with a-MCI (n = 48), or (3) mild to moderate AD (n = 52). The a-ADL tool was not a part of the clinical evaluation.

The a-ADL tool was able to detect the diagnostic distinction between cognitively healthy older persons, patients with a-MCI, and patients with AD. Both the a-ADL-DI and the a-ADL-CDI – of interest in this population – showed promising results and differed significantly between the groups; in contrast, the a-ADL-PDI did not.

What is the take home message of this research?

The a-ADL tool showed a good ability to distinguish normal and pathological cognitive aging. Its discriminative power for underlying causes of limitations is an advantage. Concluding, the evaluation of a-ADL, when administered in a systematic and scientific way, enables the diagnosis of MCI and – moreover – is experienced as less invasive by the patients. In the same time, this evaluation offers directions for clinical treatment, rehabilitation, advice and coaching.

 

The full paper “Discriminative power of the advanced activities of daily living (a-ADL) tool in the diagnosis of mild cognitive impairment in an older population” is available free of charge for a limited time here.

The commentary paper “A useful development in measuring activities of daily living” by David Ames is also available free of charge here.

International Psychogeriatrics – Special issue on Young Onset Dementia

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International Psychogeriatrics
has published a special issue on Young Onset Dementia, guest edited by Raymond Koopmans and Tor Rosness.

The rising prevalence of dementia includes an increase of people with Young Onset Dementia (YOD). Studies have scrutinized the literature and documented distinct differences in traits between younger and older persons with dementia in several areas such as medical treatment, physical activity, functional level, activities of daily living, comorbidity, risk profiles, and caregiver distress. However, the cut-off of 65 years is arbitrary and there is still no consensus on if a diagnosis of dementia has to be made before the age of 65 years or if it is sufficient that the first symptoms are detected before the age of 65 years?

YOD is being steadily recognized as an important psychosocial and medical health problem with specific-age-related adverse consequences for both these younger persons and their families, however, many countries lack specific plans in their dementia strategies and do not offer any specific form of services or support for this group of individuals. Therefore the International Psychogeriatric Association (IPA) established a taskforce on YOD. The idea of composing a special issue on YOD was raised during The Hague meeting in 2011, and the issue consists partially of papers that have been presented during the symposia and workshop-meetings of the taskforce.

The YOD special issue provides an overview of important topics including unmet needs of carers, different clinical approaches to YOD diagnoses, needs of children with YOD parents, and medical treatment of behavioral symptoms of YOD patients.

We are offering limited time free access to the articles from this issue – simply register using our short form, using the code IPGYOD2

Traumatic Brain Injury and the speed of decline of Alzheimer’s Disease

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The October International Psychogeriatrics Article of the Month is entitled ‘The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County Dementia Progression Study’ by Mac Gilbert, Christine Snyder, Chris Corcoran, Maria C. Norton, Constantine G. Lyketsos and JoAnn T. Tschanz

With a diagnosis of Alzheimer’s dementia comes an understanding that the affected individual will suffer an inevitable and progressive decline in their cognitive and functional abilities. However, what is not known is how fast the decline will occur. Will the person need 24 hour supervision and care shortly after diagnosis or five to ten years in the future?

We have studied this question in our population-based sample of persons with Alzheimer’s dementia and found tremendous variability in the course of decline. It seems that about half of those in our sample declined slowly and a small but significant percentage declined quite rapidly. Is there anything in person’s background that will predict whether they will become a slow or a fast decliner?

We set out to study this issue by examining a person’s medical history, specifically, whether they had a history of concussion or traumatic brain injury (TBI). Several studies have found that those who have had a history of TBI in their lifetimes show an increased risk for Alzheimer’s dementia later in life. However, it was not known whether TBI also predicts the rate of decline after the onset of dementia.

As published in this month’s issue of the journal, we obtained the medical history of persons with Alzheimer’s dementia before onset, and characterized them as either positive or negative for a history of TBI and its severity. We also examined number of TBI (0, 1, 2 or more) and timing of TBI relative to the onset of dementia (none, within 10 years of onset, or greater than 10 years of onset). We repeatedly tested those with Alzheimer’s dementia about every 6 to 18 months, checking their memory, attention, concentration, language and visuospatial abilities. We also rated their functional decline from their caregiver’s report.

We found that a history of TBI predicted more rapid functional decline, but only among those who had experienced a TBI within 10 years of dementia onset. This finding adds to our previous work where a history of TBI was associated with disinhibited behavior after the onset of Alzheimer’s dementia, and persons in better overall health tended to function at higher levels after the onset of dementia.

What is the take home message of this research? While we can’t change the past, we can be proactive by taking steps to prevent TBI and other health problems from occurring. Preventing falls (a major cause of TBI in late life) by ensuring proper foot ware, installing safety bars, and ensuring safe walkways may help prevent new instances of TBI in older adults. Following up with one’s health care provider for any health problems is also suggested. Although there is currently no cure for Alzheimer’s dementia, adopting preventive measures may be one way to slow the progression of decline and optimize one’s level of functioning over the course of the illness.

 

The full paper “The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County Dementia Progression Study” is available free of charge for a limited time here.

The commentary on the paper, “The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County dementia progression study by Gilbert et al. Late effects of traumatic brain injury on dementia progression” is also available free of charge for a limited time here.

 

Good days and bad days in dementia

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The August International Psychogeriatrics Article of the Month is entitled ‘Good days and bad days in dementia: a qualitative chart review of variable symptom expression’ by Kenneth Rockwood, Sherri Fay, Laura Hamilton, Elyse Ross and Paige Moorhouse.

Anyone who works with people with dementia is bound to experience poignant moments. Especially striking is hearing that a person seemingly lost to permanent unknowing – even near muteness – suddenly spoke a full sentence, or sometimes more. Much more common, but still compelling, are reports of people with dementia having remarkably good or bad days.

In what does daily variability consist? For some years, that question has motivated our group. In a paper in this month’s issue, we report the findings of a clinical chart review spanning 30 months, to understand how patients and families experienced variability living with dementia from day to day. This line of inquiry was born from the realization that, for many patients and families, variability was a source of expectations – and often disappointments. Families asked questions that I couldn’t answer: “why can he be so helpful some days, and other days can’t even do for himself?” Often, they had answers as good as anything I could muster: “it’s best if he has a good night’s sleep”, or “I can tell if he’s missed his medications”.

The challenge is to understand the mechanisms of variability. To get there, we need to know just what is happening, and for that we need careful qualitative studies. The area is tricky, because variability threatens reliability, and that undermines measurement, which undermines understanding. Or so the argument goes. Progress however, obliges investigating the variability itself – as is being done in Lewy body dementia – and not just seeking ways to reduce it for testing purposes.

Our study offers some clues. For an important proportion of patients, variability occurs within the same symptom set: a good day is when the symptom is seen less, and a bad day when it occurs more. This makes fluctuation in specific neurochemical transmission seem likely. That some are implicated more than others is suggested by the patterns: most of these symptoms involve social conduct and engagement; other descriptions sound like attentional problems. For a second group of dementia symptoms, a bad day is marked by even a single occurrence of a bad problem: not being struck does not constitute a good day, even if being struck means a bad one.

Our group also gives thought to the mathematics of variable disease expression in dementia. On scales of months and years, a comprehensible, stochastic process can be modeled with high precision. Is what we see clinically another face of that, or does it signal instability that so often heralds more rapid decline, or is it a variation of the fluctuating attention seen in delirium and in Lewy Body dementia?

However it works, we should aim for treatment. Many families believe that some part is modifiable. Are they correct? Aiming for therapies might seem obvious, but against the thankfully fading fashion of rubbishing symptomatic treatments, it’s good to be reminded of how big is the gap between what we offer and what people need. And that is poignant.

Kenneth Rockwood, Dalhousie University, Halifax, Canada

 

The full paper “Good days and bad days in dementia: a qualitative chart review of variable symptom expression” is available free of charge for a limited time here.

The commentary on the paper, “Symptom variability in dementia” is also available free of charge for one month here.

 

Rates of diagnostic transition and cognitive change – an 18-month follow-up of the cohort from the AIBL study

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The April International Psychogeriatrics Article of the Month is entitled ‘Rates of diagnostic transition and cognitive change at 18-month follow-up among 1,112 participants in the Australian Imaging, Biomarkers and Lifestyle Flagship Study of Ageing (AIBL)’ by Kathryn A. Ellis, Cassandra Szoeke, Ashley I. Bush et al.

The Australian Imaging, Biomarkers and Lifestyle (AIBL) Flagship Study of Ageing is a prospective study of 1,112 individuals (211 with Alzheimer’s disease (AD), 133 with mild cognitive impairment (MCI), and 768 healthy controls (HCs)).

In this paper, the authors report diagnostic and cognitive findings at the first (18-month) follow-up of the cohort. The first aim was to look at rates of transition from HC to MCI, and MCI to AD. The second aim was to characterize the cognitive profiles of individuals who transitioned to a more severe disease stage compared with those who did not.

Eighteen months after baseline, participants underwent comprehensive cognitive testing and diagnostic review, provided an 80 ml blood sample, and completed health and lifestyle questionnaires. A subgroup also underwent amyloid PET and MRI neuroimaging.

The diagnostic status of 90% of the cohorts was determined (972 were reassessed, 28 had died, and 112 did not return for reassessment). The 18-month cohort comprised 692 HCs, 82 MCI cases, 197 AD patients, and one Parkinson’s disease dementia case. The transition rate from HC to MCI was 2.5%, and cognitive decline in HCs who transitioned to MCI was greatest in memory and naming domains compared to HCs who remained stable. The transition rate from MCI to AD was 30.5%.

Cognitive decline with age is not a rapid process for most people, and 18 months is a fairly short period over which to detect emergent decline or transition to clinically diagnosable MCI or AD among previously healthy individuals. Nevertheless, the detailed cognitive data collected in the AIBL study give us the best possible opportunity of detecting such changes that, after future waves of follow-up are complete, may allow us to make a major contribution to determining factors that may be predictive of future cognitive decline in older individuals who are cognitively healthy at present.

The author of the commentary paper, John O’Brien, commented “Of particular note, the AIBL cohort predominantly focuses on the early transition from normality to cognitive impairment, as around three quarters of the participants in the cohort are healthy controls. It also provides a combination of a comprehensive and longitudinal clinical and biomarker assessment with a focus on prior lifestyle factors such as diet and exercise.

There are several extremely interesting and important observations from this study, which have relevance for all cohort studies.Clearly, the combination of clinical, cognitive, risk factor, and biomarker data from the AIBL cohort will help provide some answers to several current questions about the key factors associated with cognitive decline and the rate and temporal ordering of clinical and biomarker changes. However, challenges still remain; even cohorts as sizeable as the AIBL study are relatively limited in size (partly because of the great expense of undertaking such longitudinal deep phenotyping studies) to fully address the investigation of all interactions between environmental, genetic, and lifestyle risk factors. Increased collaborative efforts both nationally and internationally are emerging and will be essential to make future progress.

 

The full paper “Rates of diagnostic transition and cognitive change at 18-month follow-up among 1,112 participants in the Australian Imaging, Biomarkers and Lifestyle Flagship Study of Ageing (AIBL)” is available free of charge for a  limited time here.

The commentary on the paper, “The importance of longitudinal cohort studies in understanding risk and protective factors for dementia” is also available free of charge for one month here.

 

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