Background: Patients living in squalor have a wide range of psychiatric diagnoses, but these may have a common neural basis involving frontal systems. This study investigated frontal executive function, theory of mind, emotional processing including disgust, and appreciation of squalor in elderly patients found living in squalor.

Methods: Six patients referred to an old age psychiatry service underwent a battery of neuropsychological tests, assessment of living conditions and awareness of self and others’ squalor.

Results: All six patients showed impairment in frontal executive function, typically accompanied by amnesic deficits. Theory of mind and emotional processing were surprisingly preserved. While five of the patients could recognize severely unclean or cluttered living conditions in newspaper photographs, more than half did not appreciate that their own living conditions were squalid.

Conclusion: Deficits in frontal executive function appear important in the genesis of squalor although functions linked to orbito-frontal ability appear preserved.

Background: Although caring for individuals with dementia is known to result in increased burden and depression among caregivers, little research has investigated caregiver's anxiety or concern about eventually developing dementia themselves (i.e. dementia anxiety). Existing research reports mixed findings regarding variables (e.g. relationship to care recipient, sex, education) that predict dementia anxiety among caregivers and non-caregivers. Potential relationships among burden, depression and dementia anxiety have not been extensively examined. The present study explored caregiver and care recipient factors as predictors of dementia anxiety in older adult caregivers.

Methods: A sample of 116 older adult caregivers answered demographic/background questions and completed a series of self-report measures assessing dementia anxiety, caregiver burden, depression, and the physical disability of the care recipient.

Results: The majority of caregivers were female, Caucasian, and reported caring for a spouse. Analyses revealed that background variables were generally not related to dementia anxiety, while depression and caregiver burden were significantly associated. Using linear regression analysis, it was found that a diagnosis of dementia in the care recipient and caregiver depression were both significant predictors of caregiver dementia anxiety.

Conclusion: Health care providers should be aware that dementia anxiety is associated with caring for individuals with dementia as well as with depression. Dementia anxiety may place additional strain on caregivers of individuals who have dementia and are suffering from depression and thus should be the focus of future research.

Background: Cholinesterase inhibitors (ChEIs) represent the mainstay of symptomatic treatment in Alzheimer's disease. Three medications belonging to this class are presently widely available. These agents differ in their individual mechanisms of action and pharmacokinetic properties. Switching ChEIs can be a reasonable option in cases of intolerance or lack of clinical benefit.

Methods: A systematic literature search of switching ChEIs was conducted, and all studies specifically evaluating this issue were identified. Published consensus guidelines were also searched for recommendations on ChEI switching.

Results: Eight clinical studies are summarized and discussed. All of these studies are open-label or retrospective and they cannot be readily compared because of heterogeneity in design, number of patients, agents used, and endpoints. Switching in most of these studies was done for both “lack of benefit” or “loss of response” after up to 29 months of treatment. Nevertheless, the majority of studies did not include individuals switched for lack of response after several years of treatment. Lack of satisfactory response or intolerance with the initial agent was not predictive of similar results with the second agent.

Conclusions: In light of these findings, we propose the following practical approach to switching ChEIs: (1) in the case of intolerance, switching to a second agent should be done only after the complete resolution of side-effects following discontinuation of the initial agent; (2) in the case of lack of efficacy, switching can be done overnight, with a quicker titration scheme thereafter; (3) switching ChEIs is not recommended in individuals who show loss of benefit several years after initiation of treatment.

Both perfusion SPECT and FDG-PET provide images that closely reflect neuronal activity. There is a characteristic regional impairment in Alzheimer's disease (AD) that involves mainly the temporo-parietal association cortices, mesial temporal structures and to a more variable degree also the frontal association cortex. This pattern of functional impairment can provide a biomarker for diagnosis of AD and other neurodegenerative dementias at the clinical stage of mild cognitive impairment, and for monitoring of progression. FDG-PET is quantitatively more accurate and thus better suited to multicenter studies than perfusion SPECT. Regional metabolic and blood flow changes are closely related to clinical symptoms, and most areas involved in these changes will also develop significant cortical atrophy. FDG-PET is complementary to amyloid PET, which targets a molecular marker that does not have a close relation to current symptoms. Current restrictions in the availability and cost of FDG-PET are being reduced, as oncological FDG-PET is being adopted as a standard clinical service in most countries. Limitations in the availability of trained staff should be overcome by training programs set up by professional organizations. Against the background of the development of new criteria for diagnosing AD before the onset of dementia, FDG-PET is expected to play an increasing role in diagnosing patients at an early stage of AD and in clinical trials of drugs aimed at preventing or delaying the onset of dementia.

Background: Adult leg length is influenced by nutrition in the first few years of life. Adult head circumference is an indicator of brain growth. There is a limited literature linking short legs and small skulls to an increased risk for cognitive impairment and dementia in late life.

Methods: One phase cross-sectional surveys were carried out of all residents aged over 65 years in 11 catchment areas in China, India, Cuba, Dominican Republic, Venezuela, Mexico and Peru (n = 14,960). The cross-culturally validated 10/66 dementia diagnosis, and a sociodemographic and risk factor questionnaire were administered to all participants, and anthropometric measures taken. Poisson regression was used to calculate prevalence ratios for the effect of leg length and skull circumference upon 10/66 dementia, controlling for age, gender, education and family history of dementia.

Results: The pooled meta-analyzed fixed effect for leg length (highest vs. lowest quarter) was 0.82 (95% CI, 0.68–0.98) and for skull circumference 0.75 (95% CI, 0.63–0.89). While point estimates varied between sites, the proportion of the variability attributable to heterogeneity between studies as opposed to sampling error (I2) was 0% for leg length and 22% for skull circumference. The effects were independent and not mediated by family history of dementia. The effect of skull circumference was not modified by educational level or gender, and the effect of leg length was not modified by gender.

Conclusions: Since leg length and skull circumference are said to remain stable throughout adulthood into old age, reverse causality is an unlikely explanation for the findings. Early life nutritional programming, as well as neurodevelopment may protect against neurodegeneration.

Background: Cholinesterase inhibitors (ChEIs) are being used for increasingly long periods of time, even in patients with severe Alzheimer's disease. Because there is little data to help clinicians to decide on when it is safe and appropriate to discontinue ChEIs after long-term use, practices may vary widely.

Methods: An internet-based survey was undertaken of Canadian dementia experts (geriatric psychiatrists, neurologists, geriatricians) involved in clinical trial research. Recommendations for ChEI discontinuation were determined based on responses to questions dealing with patient/caregiver preference, administrative considerations, effectiveness, and adverse events.

Results: There was reasonable consensus that ChEIs should be discontinued based on patient and caregiver preference, and in the presence of severe bothersome adverse events. There was much less consensus on issues related to effectiveness – in particular, what constitutes greater than expected decline. There was a general reluctance to rely on any single measure of cognition, function and/or behavior, and in particular, the MMSE was seen as unhelpful for making decisions about discontinuation.

Conclusion: Recommendations for discontinuing ChEIs after long-term use from a survey of dementia experts are presented. Ideally, clinical practice guidelines based on controlled discontinuation trials are needed.

Background: In Asia, where illiteracy rates are high, determining the degree to which neuropsychological measures can be used to identify cognitive impairment in illiterate elders is important. The aim of this study was to evaluate the effectiveness of using formal neuropsychological assessments to distinguish healthy illiterate elders from dementia patients.

Methods: We compared the cognitive performance of healthy elders who were illiterate (illiterate NC, n = 25) with those who were literate (literate NC, n = 25), literate patients with mild Alzheimer's disease (literate AD, n = 25), and illiterate patients with mild AD (illiterate AD, n = 25). Neuropsychological measures included the Mini-Mental State Examination (MMSE), the verbal fluency test, the Boston naming test, the Rosen drawing test, and the verbal learning test.

Results: In the between-group analyses, the scores on all tests, except verbal fluency and recognition memory, were lower for illiterate NC compared to the literate NC. The scores on the MMSE, Boston naming test, Rosen drawing test, and immediate free recall could not distinguish the illiterate NC from literate AD. However, the scores on all tests, except the Rosen drawing test, could distinguish illiterate NC from illiterate AD. ROC analyses showed the same pattern of results. In addition, age-, sex-, and education-matched cut-off scores of all tests, except immediate recall and delayed recall trials of the verbal learning test, showed good specificities in participants who were illiterate compared to those in participants who were literate.

Conclusion: These findings suggest that the impact of literacy on neuropsychological test performance is an important aspect of cognitive evaluations for elders who are illiterate.

Background: This study explores how the views of a panel of experts on dementia would affect projected long-term care expenditure for older people with dementia in England in the year 2031.

Methods: A Delphi-style approach was used to gather the views of experts. The projections were carried out using a macro-simulation model of future demand and associated expenditure for long-term care by older people with dementia.

Results: The panel chose statements that suggested a small reduction in the prevalence of dementia over the next fifty years, a freeze in the numbers of people in care homes, and an increase in the qualifications and pay of care assistants who look after older people with dementia. Projections of expenditure on long-term care that seek to capture the views of the panel suggest that future expenditure on long-term care for this group will rise from 0.6% of GDP in 2002 to between 0.82% and 0.96% of GDP in 2031. This range is lower than the projected expenditure of 0.99% of GDP in 2031 obtained under a range of base case assumptions.

Conclusions: This paper attempts to bridge the gap between qualitative forecasting methods and quantitative future expenditure modelling and has raised a number of important methodological issues. Incorporating the panel's views into projections of future expenditure in long-term care for people with dementia would result in projected expenditure growing more slowly than it would otherwise.

Over the past ten years, dopaminergic imaging has become increasingly part of the assessment and diagnosis of dementia. There are numerous PET and SPECT ligands available that target different steps in the process of neurotransmission. Abnormalities in dopaminergic imaging measures are consistent features of dementia with Lewy bodies (DLB) and other parkinsonian syndromes, and can be used to facilitate diagnosis, particularly in distinguishing between DLB and Alzheimer's disease. This review summarizes present knowledge in this area and the implications for current and future clinical practice.

Background: The clinical impact of risk score use in end-of-life settings is unknown, with reports limited to technical properties.

Methods: We conducted a mixed-methods study to evaluate clinical impact of a validated mortality risk score aimed at informing prognosis and supporting clinicians in decision-making in dementia patients with pneumonia. We performed a trial (n = 69) with physician-reported outcomes referring to the score's aims. Subsequently, physician focus group discussions were planned to better understand barriers to clinical impact, and we surveyed families (n = 50) and nurses practicing in nursing homes (n = 29). We finally consulted with experts and key persons for implementation.

Results: Most (71%) physicians who used the score considered it useful, but mainly for its learning effects. Families were never informed of numerical risk estimates. Two focus group discussions revealed a reluctance to use a numerical approach, and physicians found that outcomes conditional on antibiotic treatment were inadequate to support decision-making. Nurses varied in their perceived role in informing families. Most families (88%) wished to be informed, preferring a numerical (43%), verbalized (35%), or other approach (18%) or had no preference (5%). Revising the score, we added an ethical framework for decision-making to acknowledge its complexity, an explanatory note addressing barriers related to physicians’ attitudes, and a nurses’ form.

Conclusion: The combined quantitative and qualitative studies elicited: substantial barriers to a numerical approach to physicians’ end-of-life decision-making; crucial information for revisions and further score development; and a need for implementation strategies that focus on education.

Background: This study aimed to test the effects of yoga exercises on the physical and mental health of elderly people with dementia living in long-term care facilities.

Methods: A quasi-experimental, pretest–post-test design was used. A convenience sample of 68 residents in long-term care facilities in southern Taiwan, aged 60 years and above with mild to moderate dementia, was selected. An experimental group of 33 elders participated in a 12-week yoga training program of three 55-minute sessions a week; a control group of 35 elders maintained their usual daily activities. Data were collected before and after completing the 12-week study. Measurements included body composition, cardiopulmonary functions, body flexibility, muscle strength and endurance, balance, joints motion, depression, and problem behaviors.

Results: The yoga-trained participants had better physical and mental health than those who did not participate, including lowered blood pressure, reduced respiration rate, strengthened cardiopulmonary fitness, enhanced body flexibility, improved muscle strength and endurance, improved balance, and increased joints motion (all p values < 0.05). In addition, the depression state (p < 0.001) and problem behaviors (p < 0.001) of these demented elders were significantly reduced.

Conclusion: Yoga exercise has positive benefits for both the physical and mental health of elders with dementia living in long-term care facilities. It is recommended that yoga be included as one of the routine activities in these long-term care facilities.

Background: Elderly adults with human immunodeficiency virus (HIV) are at greater risk of developing cognitive impairment. The purpose of this study was to describe clinical and tomographic characteristics of HIV-1 associated dementia (HIVD) in older adults.

Methods: A descriptive study was carried out involving eight HIVD patients. Seven tests were employed for cognitive assessment and transformed to whole number z-scores using appropriate normative sets.

Results: The average age of the patients was 71 years; seven cases described the route of HIV infection as being heterosexual; and mean schooling was 6.5 years. Six subjects were using highly active anti-retroviral therapy (HAART), with an average CD4 count of 407.8 cells/mm3. Mild dementia was detected in most cases (87.5%). Deficits on neuropsychological tests showed results similar to multi-center transversal studies on HIVD. The classic HIVD triad observed in younger adults was also seen in this population: i.e. cognitive changes, psychiatric changes and motor impairment. Cortical injury shown by dyscalculia, visual-spatial change and language deficits were frequent. Brain images showed cortical atrophy in all patients but was restricted to frontal lobes in five cases.

Conclusion: The findings on brain imaging were non-specific, revealing images similar to those of the elderly brain and to HIVD in younger adults. HIVD in the elderly is a challenge and become an increasingly significant differential diagnosis for cognitive loss in old age. This dementia must be clinically suspected and image exams are useful in excluding other central disorders. Prospective studies of HIV-positive elderly people are warranted to better understand HIVD.

Background: The Kana Pick-out Test (KPT), which was developed in Japan, is suitable for evaluating frontal lobe function and screening for mild dementia. However, the neural substrates involved remain to be elucidated. The aim of the present study was to identify the regional perfusion patterns in the brain associated with performance scores on the KPT in patients with mild Alzheimer's disease (AD), using brain perfusion assessed by single photon emission computed tomography (SPECT).

Methods: Twenty AD patients with high scores on the KPT and 20 age- and sex-matched AD patients with low scores were selected from 227 consecutive Japanese patients of the Memory Clinic of Okayama University Hospital. All 40 subjects underwent brain SPECT with 99mTc-ethylcysteinate dimer, and the SPECT images were analyzed by Statistical Parametric Mapping.

Results: With the exception of KPT scores, no significant differences were found between high and low scoring groups with respect to Addenbrooke's Cognitive Examination scores, Mini-mental State Examination scores, or the depression score of the Neuropsychiatric Inventory subscale. Compared to patients with high scores on the KPT, AD patients with low scores on the KPT showed significant hypoperfusion in the left subgenual cingulate gyrus (SGC) extending to the right SGC.

Conclusions: Our results suggest that functional activity of the SGC is closely related to scores on the KPT. KPT might be a promising strategy to use in detecting early stages of AD with low SGC function.

Background: Recognizing and diagnosing early onset dementia (EOD) can be complex and often takes longer than for late onset dementia. The objectives of this study are to investigate the barriers to diagnosis and to develop a typology of the diagnosis pathway for EOD caregivers.

Methods: Semi-structured interviews with 92 EOD caregivers were analyzed using constant comparative analysis and grounded theory. A conceptual model was formed based on 21 interviews and tested in 29 additional transcripts. The identified categories were quantified in the whole sample.

Results: Seven themes emerged: (1) changes in the family member, (2) disrupted family life, (3) misattribution, (4) denial and refusal to seek advice, (5) lack of confirmation from social context, (6) non-responsiveness of a general practitioner (GP), and (7) misdiagnosis. Cognitive and behavioral changes in the person with EOD were common and difficult to understand for caregivers. Marital difficulties, problems with children and work/financial issues were important topics. Confirmation of family members and being aware of problems at work were important for caregivers to notice deficits and/or seek help. Other main issues were a patient's refusal to seek help resulting from denial and inadequate help resulting from misdiagnosis.

Conclusion: EOD caregivers experience a long and difficult period before diagnosis. We hypothesize that denial, refusal to seek help, misattribution of symptoms, lack of confirmation from the social context, professionals’ inadequate help and faulty diagnoses prolong the time before diagnosis. These findings underline the need for faster and more adequate help from health-care professionals and provide issues to focus on when supporting caregivers of people with EOD.

Background: Several studies of patients with mild cognitive impairment (MCI) have revealed that this population, like people with dementia, have neuropsychiatric symptoms (NPS) as well as memory impairment. No study has reported on the natural history and course of NPS in MCI although this is important in terms of management. We aimed to determine the persistence of NPS over six months in participants with MCI.

Method: The Neuropsychiatric Inventory (NPI) was used to rate the severity of NPS in 241 consecutive referrals with MCI from a Korean clinic at baseline and in 220 patients at 6-month follow-up. We also collected information about the cognition and quality of life of patients and their caregivers.

Results: Ninety-seven (44.1%) MCI participants who completed the 6-month follow-up exhibited at least one NPS at baseline; 60 (27.3%) were clinically significant NPS. Seventy (72.1%) of those with any symptom had at least one persistent NPS at 6-month follow-up, and 44 (73.3%) of those with clinically significant symptoms had at least one significant and persistent NPS at 6-month follow-up. Those with persistent symptoms had more severe baseline symptoms. Both patients and caregivers had a poorer quality of life when the patient had at least one clinically significant symptom.

Conclusions: NPS were highly persistent overall in older people with MCI. Persistence was predicted by having more severe symptoms at baseline. Clinically significant levels of NPS were associated with decreased quality of life. We conclude that clinicians should be aware that NPS symptoms in MCI usually persist.

Background: There is no valid instrument currently in use at acute-care hospitals in Hong Kong to aid the detection of cognitive impairment. The objectives of this study were to (1) validate the Digit Span Test (DST) in the identification and differentiation of dementia and delirium; and (2) determine the prevalence of major cognitive impairment in elderly people in an acute medical unit.

Methods:During the study period from January to February 2010, 144 patients aged 75 years or more who had had unplanned medical admissions were assessed by nurses, using the Digit Span Forwards (DSF) and the Digit Span Backwards (DSB) tests. The DST scores were compared with the psychiatrists’ DSM-IV-based diagnoses. Receiver Operating Characteristics curve (ROC) was used in conjunction with sensitivity and specificity measures to assess the performance of DST.

Results: The prevalence rates of dementia alone, delirium alone and delirium superimposed on dementia were 21.5%, 9% and 9% respectively. The prior case-note documentation rate was 13.2% for dementia and 2.8% for delirium. Regarding the detection of major cognitive impairment, the ROC curve of DSB showed a sensitivity of 0.77 and specificity of 0.78 at the optimal cutoff of <3. A significant association between scores on the DST and the Cantonese version of the Mini-Mental State Examination (CMMSE) was found in this study (p < 0.05 for DSF, p = 0.00 for DSB).

Conclusions: Dementia and delirium were prevalent, yet under-recognized, in acute medical geriatric inpatients. The DSB is an effective tool in identifying patients with major cognitive impairment.

Background: Epidemiological studies show that the number of older adults using marijuana is increasing. This study aimed to determine the correlates and patterns of marijuana use among older adults that might help health and social service providers better assist this group.

Methods: Data are from the 2008 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration in the U.S.A. The sample consisted of 5,325 adults aged 50 years and older.

Results: Of the sample, 2.8% were past-year marijuana users. Of them, 23% had used marijuana on at least half the days of the year. Past-year users were more likely to be younger (50–64 years old), black, and not married, and they had significantly higher psychological distress scores, but they did not rate their health as poorer than others in the sample, nor did they attribute many problems, including psychological problems, as being related to their marijuana use. Nevertheless, past-year users present a high-risk profile because, in addition to frequent marijuana use, they also are more likely to smoke cigarettes, engage in binge drinking, and use other illicit drugs.

Conclusions: Health and social service providers should be alert to the small number of routine marijuana users among the younger members of the older adult population, especially those suffering significant psychological distress, so that these individuals can be encouraged to utilize services that will help alleviate this distress and promote a healthier lifestyle and increase general well being.

Background: This study determined the reliability, validity, and factor structure of self-report emotions in persons with mild Alzheimer's disease (AD) and mild cognitive impairment (MCI) relative to controls.

Methods: Participants (mild AD, n = 73; MCI, n = 159; controls, n = 96) rated current emotions with the Visual Analogue Mood Scales (Stern, 1997).

Results: Internal consistency reliabilities were comparable across groups, as were the factor structures of emotion. Persons with AD reported more negative affect (NA) than persons with MCI and controls. The emotion that most differentiated groups was confusion. NA and PA may be more bipolar in persons with AD than for persons with MCI and controls.

Conclusions: The underlying structure of affect was similar in persons with mild AD, MCI, and controls. Further, persons with MCI appeared to be “transitional” between cognitive health and dementia with regard to mood and affect. That is, participants with MCI tended to have affect scores that were intermediate between those with AD and controls. Implications for interventions to improve emotional well-being in AD and MCI are discussed.

Background: Dementia has important public health implications. The magnitude of the problem remains largely unknown in the developing countries.

Methods: Three hundred and twenty-two community dwelling elderly persons and their caregivers in Zaria, Northern-Nigeria were enrolled in this study. They were interviewed using Community Screening Interview for Dementia (CSI-D), Consortium to Establish Registry for Alzheimer's disease (CERAD), Stick Design Test (SDT), Blessed Dementia Scale and a sociodemographic questionnaire. The data obtained were analyzed using the Statistical Package for Social Sciences version 15 for Windows. Diagnosis was based on fulfilling criteria for dementia in both the International Classification of Disease, 10th edition and the Diagnostic and Statistical Manual, 4th edition.

Results: The mean age of the subjects was 75.5 ± 9.4 years. The prevalence of dementia was 2.79% (CI 1–4.58%). Alzheimer's disease constituted 66.67% of all the cases of dementia in this community. Age was the only demographic factor associated with dementia.

Conclusion: The prevalence rates of dementia and dementia subtypes in the developing countries are similar using standard diagnostic criteria and methods.