Delirium is a common neuropsychiatric syndrome associated with poor outcomes. Evidence supports a neuroinflammatory etiology, but the role of the inflammatory marker C-reactive protein (C-RP) remains unclear. We investigated the relationship between C-RP and delirium and its severity as well as interaction with medical diagnosis.

From an existing database (710 patients over 70 years old admitted to a Medical Acute Admissions Unit) we analyzed data which included C-RP levels, delirium (using the Confusion Assessment Method), and other clinical and demographic factors. Primary diagnoses were grouped (cardiovascular, musculoskeletal, infection, metabolic, and other).

There was a strong association between elevated C-RP and delirium (t = 5.09; p < 0.001), independent of other potential risk factors for delirium (odds ratio (OR) = 1.32 (95% CI: 1.10–1.58) p = 0.003). There was no significant association between C-RP and delirium severity, and between C-RP and delirium in the populations with cardiovascular disease, infection upon admission, or from the metabolic group despite an OR of 2.24 (95% CI: 0.92–5.45). There was an association in the musculoskeletal group (OR 2.19 (95% CI: 1.19–4.02)).

Conclusions: There is an association between elevated C-RP and delirium. This is strongest in patients admitted with musculoskeletal disease but not in others, implying that C-RP is involved in the genesis of delirium in musculoskeletal disease, but that other factors or processes may be more important in those with cardiovascular disease or infection.

Chronic stress negatively affects health and well-being. A growing population of informal dementia caregivers experience chronic stress associated with extraordinary demands of caring for a relative with dementia. This review summarizes physiological and functional changes due to chronic dementia caregiver stress.

A literature search for papers assessing effects of dementia caregiving was conducted focusing on publications evaluating differences between caregivers and non-caregivers in objective measures of health and cognition.

The review identified 37 studies describing data from 4,145 participants including 749 dementia caregivers and 3,396 non-caregiver peers. Objective outcome measures affected in dementia caregivers included markers of dyscoagulation, inflammation, and cell aging as well as measures of immune function, sleep, and cognition. Though diverse in designs, samples, and study quality, the majority of the studies indicated increased vulnerability of dementia caregivers to detrimental changes in health and cognition. Demographic and personality characteristics moderating or mediating effects of chronic stress in caregivers were also reviewed.

There is accumulating evidence that chronic dementia caregiver stress increases their vulnerability to disease and diminishes their ability to provide optimal care. Clinicians and society need to appreciate the extent of deleterious effects of chronic stress on dementia caregiver health.

This study examines the association between marital and parental status and their individual and combined effect on risk of dementia diseases in a population-based longitudinal study while controlling for a range of potential confounders, including social networks and exposure to stressful negative life events.

A total of 1,609 participants without dementia, aged 65 years and over, were followed for an average period of 8.6 years (SD = 4.8). During follow-up, 354 participants were diagnosed with dementia. Cox regression was used to investigate the effect of marital and parental status on risk of dementia.

In univariate Cox regression models (adjusted for age as time scale), widowed (hazard ratio (HR) 1.42, 95% confidence interval (CI) = 1.13–1.78), and not having children (HR 1.54, 95% CI = 1.15–2.06) were significantly associated with incident dementia. In multivariate analyses that included simultaneously marital and parental status and covariates that were found to be significant in univariate models (p < 0.10), the HR was 1.30 (95% CI = 1.01–1.66) for widowed, and 1.51 (95% CI = 1.08–2.10) for those not having children. Finally, a group of four combined factors was constructed: married parents (reference), married without children, widowed parents, and widowed without children. The combined effect revealed a 1.3 times higher risk (95% CI = 1.03–1.76) of dementia in widow parents, and a 2.2 times higher risk (95% CI = 1.36–3.60) in widowed persons without children, in relation to married parents. No significant difference was observed for those being married and without children.

Our findings suggest that marital- and parental status are important risk factors for developing dementia, with especially increased risk in those being both widowed and without children.

Prospective memory, or remembering to do things in the future, is crucial for independent living in old age. Although there is evidence of substantial age-related deficits in memory for intentions, older adults have demonstrated the ability to compensate for their deficits in everyday life. The present study investigated feedback as a strategy for facilitating prospective memory in the elderly.

Young and older adults played a computer-based task, Virtual Week, in which they had to remember to carry out life-like intentions. After each virtual day, specific feedback on prospective memory performance was automatically provided on the computer screen that participants either proceeded through by themselves (non-social feedback) or were taken through by an experimenter (social feedback). The control group received no feedback.

We found that, compared with no-feedback group, only social feedback substantially reduced the age-related deficit in prospective memory. Older adults significantly benefited from feedback provided by the experimenter on the tasks of intermediate difficulty. Unexpectedly, prospective memory with non-social feedback was not only worse than with social feedback, but it was not any better than without any feedback at all.

The results extended previous findings on the effectiveness of feedback in improving the memory performance of older adults to include memory for intentions. Despite the feedback meeting the critical recommendations of being specific, objective, and well-targeted, it was ineffective when the feedback displayed on the computer was not introduced by the experimenter. This has implications for computerized training tasks where automated feedback is considered crucial.

In the European Rosetta project three separate, previously developed, ICT systems were improved and integrated to create one modular system that helps community-dwelling people with mild cognitive impairment and dementia in different stages of the disease. The system aims to support them in daily functioning, monitor (deviations from) patterns in daily behaviour and to automatically detect emergency situations. The study aimed to inventory the end users’ needs and wishes regarding the development and design of the new integrated Rosetta system, and to describe the to be developed Rosetta system.

Qualitative user-participatory design with in total 50 persons: 14 people with dementia, 13 informal carers, 6 professional carers, 9 dementia experts, 7 care partners within the project, and 1 volunteer. In the Netherlands user focus group sessions were performed and in Germany individual interviews. Dementia experts were consulted by means of a questionnaire, an expert meeting session, and interviews.

Persons with dementia and informal carers appreciated the following functionalities most: help in cases of emergencies, navigation support and the calendar function. Dementia experts rated various behaviours relevant to monitor in order to detect timely changes in functioning, e.g. eating, drinking, going to the toilet, taking medicine adequately, performance of activities and sleep patterns. No ethical issues regarding the use of sensors and cameras were mentioned.

The user participatory design resulted in valuable input from persons with dementia, informal carers and professional carers/dementia experts, based on which a first prototype Rosetta system was built.

Many stroke research trials do not include assessment of cognitive function. A Very Early Rehabilitation Trial (AVERT) is an international multicenter study that includes the Montreal Cognitive Assessment (MoCA) as an outcome. At the Malaysian AVERT site, completion of the MoCA has been limited by low English proficiency in some participants. We aimed to develop a Bahasa Malaysia (BM) version of the MoCA and to validate it in a stroke population.

The original English version of the MoCA was translated into BM and then back-translated to ensure accuracy. Feasibility testing in a group of stroke patients prompted minor changes to the BM MoCA. In the validation phase, a larger group of bilingual stroke patients completed both the original English MoCA and the finalized BM MoCA, with presentation order counter-balanced.

Forty stroke patients participated, with a mean age of 57.2 (SD = 10.3). Agreement between BM MoCA and English MoCA was strong (intra-class correlation coefficient = 0.81, 95% CI 0.68–0.90). Scores on BM MoCA were slightly higher than scores on English MoCA (median absolute difference = 2.0, IQR 0–3.5), and this difference was present regardless of which version was completed first.

The existence of a validated BM version of the MoCA will be of major benefit to clinicians and researchers in Malaysia and the wider South-east Asian region, where the Malay language is used by over 200 million people.

The Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) were compared with and without the addition of a brief processing speed test, the symbol digit modalities test (SDMT), for vascular cognitive impairment (VCI) screening at three to six months after stroke.

Patients with ischemic stroke and transient ischemic attack were assessed with MoCA and MMSE, as well as a formal neuropsychological battery three to six months after stroke. VCI was defined by impairment in any cognitive domain on neuropsychological testing. The area under the receiver operating characteristic curve (AUC) was used to compare test discriminatory ability.

One hundred and eighty-nine patients out of 327 (58%) had VCI, of whom 180 (95%) had vascular mild cognitive impairment (VaMCI), and nine (5%) had dementia. The overall AUCs of the MoCA and MMSE scores and performance at their respective cut-off points were equivalent in detecting VCI (AUCs: 0.87 (95% CI 0.83–0.91) vs. 0.84 (95% CI 0.80–0.88), p = 0.13; cut-offs: MoCA (≤23) vs. MMSE (≤26), sensitivity: 0.78 vs. 0.71; specificity: 0.80 vs. 0.82; positive predictive value: 0.84 vs. 0.84; negative predictive value: 0.72 vs. 0.67; and correctly classified 78.6% vs. 75.5%; p = 0.42). The AUCs of MMSE and MoCA were improved significantly by the SDMT (AUCs: MMSE+SDMT 0.90 (95% CI 0.87–0.93), p <0.001; MoCA+SDMT 0.91 (95% CI 0.88–0.94), p < 0.02).

The MoCA and MMSE are equivalent and moderately sensitive, and can be supplemented with the SDMT to improve their accuracy in VCI screening.

Pharmaceutical therapy for patients with dementia including cholinesterase inhibitors (ChEI) and memantine is covered by Taiwan's National Health Insurance (NHI) but with strict reimbursement criteria. This study compared utilization of selected cognitive enhancers among elderly patients with dementia and estimated associated differences in medical care costs.

This study used medical claims and pharmacy claims from the NHI Research Database of Taiwan from 2009 to 2011, which included all patients 65 years or older diagnosed with dementia in their outpatient or inpatient claims. Both individual-level and market-level analysis were performed to calculate the average medical costs per person and the share of drug expenditures. Generalized linear models with propensity score adjustment estimated differences in medical care costs by use of selected cognitive enhancers.

Users of ChEI had the highest medication and outpatient costs but the lowest inpatient costs among all users of cognitive enhancers. However, annual adjusted total medical care costs per ChEI user were not significantly different from those who used cerebral vasodilators (CBV). In 2011, 52.4% of the elderly with dementia in Taiwan used cognitive enhancers, but among them 88.3% used CBV while 9.2% used ChEI. Among patients with dementia who used at least one cognitive enhancer, the aggregated expenditure as a share of their total drug expenditures was 9.7% in 2011.

Given that CBV had a much higher utilization rate than ChEI or memantine among elderly people with dementia, the strict reimbursement policy for ChEI and memantine may need to be revisited to increase access to those drugs by patients with dementia in Taiwan.

Over the past few decades, new care models that are more resident-oriented and directed toward small-scale and homelike environments have been developed worldwide. The impact of these care models on the quality of life of residents has been studied. However, little research has been conducted to gain insight into how these new care models influence healthcare staff's work environment. This study focuses on the consequences of small-scale care on staff's perceived job characteristics.

Data were derived from a sample of 136 Dutch living arrangements providing nursing home care for people with dementia (2008/2009), in which 1,327 residents and 1,147 staff participated. The relationship between two indicators of small-scale care (small-scale care characteristics and total number of residents with dementia in facility) and staff's job characteristics (job demands, decision authority, coworker and supervisor support) were studied with multilevel regression analyses. All analyses were adjusted for staff, resident, and living arrangement characteristics when needed.

Both indicators of small-scale care were associated with job demands; staff perceived less time and work pressure as more characteristics of small-scale care were integrated and the facility had less residents with dementia in total. Only one indicator was associated with decision authority. As more characteristics of small-scale care were integrated, staff's perceived decision authority was higher. No relationship was found with coworker and supervisor social support.

Knowing that job demands and decision authority are important predictors of job appraisal and well-being, our findings show that small-scale care could have a beneficial impact on healthcare staff's work environment.

Depressive symptoms are common in patients with Alzheimer's disease (AD) and increase the caregiver burden, although the etiology and pathologic mechanism of depressive symptoms in AD patients remain unclear. In this study, we tried to clarify the cerebral blood flow (CBF) correlates of subjective depressive symptoms in AD.

Seventy-six consecutive patients with AD were recruited from outpatient units of the Memory Clinic of Okayama University Hospital. Subjective depressive symptoms were evaluated using the short version of the Geriatric Depression Scale (GDS). All patients underwent brain SPECT with 99mTc-ethylcysteinate dimer, and the SPECT images were analyzed by the Statistical Parametric Mapping 8 program.

No significant differences between groups with high and low GDS scores were found with respect to age, sex, years of education, and revised Addenbrooke's Cognitive Examination scores. Compared to patients with low scores on GDS, patients with high scores showed significant hypoperfusion in the left inferior frontal region.

The left inferior frontal region may be significantly involved in the pathogenesis of subjective depressive symptoms in AD. Subjective and objective depressive symptoms may have somewhat different neural substrates in AD.

Quality of life (Qol) is an increasingly used outcome measure in dementia research. The QUALIDEM is a dementia-specific and proxy-rated Qol instrument. We aimed to determine the inter-rater and intra-rater reliability in residents with dementia in German nursing homes.

The QUALIDEM consists of nine subscales that were applied to a sample of 108 people with mild to severe dementia and six consecutive subscales that were applied to a sample of 53 people with very severe dementia. The proxy raters were 49 registered nurses and nursing assistants. Inter-rater and intra-rater reliability scores were calculated on the subscale and item level.

None of the QUALIDEM subscales showed strong inter-rater reliability based on the single-measure Intra-Class Correlation Coefficient (ICC) for absolute agreement ≥ 0.70. Based on the average-measure ICC for four raters, eight subscales for people with mild to severe dementia (care relationship, positive affect, negative affect, restless tense behavior, social relations, social isolation, feeling at home and having something to do) and five subscales for very severe dementia (care relationship, negative affect, restless tense behavior, social relations and social isolation) yielded a strong inter-rater agreement (ICC: 0.72–0.86). All of the QUALIDEM subscales, regardless of dementia severity, showed strong intra-rater agreement. The ICC values ranged between 0.70 and 0.79 for people with mild to severe dementia and between 0.75 and 0.87 for people with very severe dementia.

This study demonstrated insufficient inter-rater reliability and sufficient intra-rater reliability for all subscales of both versions of the German QUALIDEM. The degree of inter-rater reliability can be improved by collaborative Qol rating by more than one nurse. The development of a measurement manual with accurate item definitions and a standardized education program for proxy raters is recommended.

Squalor is an epiphenomenon associated with a range of medical and psychiatric conditions. People living in squalor are not well described in the literature, and prior work has indicated that up to 50% do not have a psychiatric diagnosis. Squalor appears to be linked with neuropsychological deficits suggestive of the presence of impaired executive function. We present a case series of people living in squalor that examines their neuropsychological assessment and diagnosis.

Clinicians from local health networks were invited to submit neuropsychological reports of patients living in squalor. These selected reports were screened to ensure the presence of squalor and a comprehensive examination of a set of core neuropsychological domains. Assessments were included if basic attention, visuospatial reasoning, information processing speed, memory function, and executive function were assessed.

Sixty-nine neuropsychological reports were included. Sixty-eight per cent of the group underwent neuropsychological assessments during an inpatient admission. For participants where it was available (52/69), the mean Mini-Mental State Examination score was 25.29 (SD = 3.96). Neuropsychological assessment showed a range of cognitive impairment with nearly all the participants (92.75%) found to have frontal executive dysfunction. One person had an unimpaired neuropsychological assessment. Results indicated that dorsolateral prefrontal rather than orbitofrontal functions were more likely to be impaired. Vascular etiology was the most common cause implicated by neuropsychologists.

Frontal executive dysfunction was a prominent finding in the neuropsychological profiles of our sample of squalor patients, regardless of their underlying medical or psychiatric diagnoses. Our study highlights the importance of considering executive dysfunction when assessing patients who live in squalor.

The knowledge base regarding the pathogenesis of postoperative delirium is limited. The primary aim of this study is to investigate whether increased levels of IL-2 and TNF-α are associated with delirium in patients who underwent coronary-artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). The secondary aim is to establish whether any association between raised cytokine levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing conditions associated with raised cytokine levels, such as major depressive disorder (MDD), cognitive impairment, or aging.

Patients were examined and screened for MDD and cognitive impairment one day preoperatively, using the Mini International Neuropsychiatric Interview and The Montreal Cognitive Assessment and Trail Making Test Part B. Blood samples were collected postoperatively for cytokine levels.

Postoperative delirium screening was found positive in 36% (41 of 113) of patients. A multivariate logistic regression revealed that an increased concentration of pro-inflammatory cytokines is associated with delirium, and related to advancing age, preoperative cognitive decline of participants, and duration of CPB. According to receiver operating characteristic analysis, the most optimal cut-off for IL-2 and TNF-α concentrations in predicting the development of delirium were 907.5 U/ml and 10.95 pg/ml, respectively.

The present study suggests that raised postoperative cytokine concentrations are associated with delirium after CABG surgery. Postoperative monitoring of pro-inflammatory markers combined with regular surveillance may be helpful in the early detection of postoperative delirium in this patient group.

Behavioral and psychological symptoms of dementia (BPSD) are often considered to be the greatest challenge in dementia care, leading to increased healthcare costs, caregiver burden, and placement into care facilities. With potential for pharmacological intervention to exacerbate behaviors or even lead to mortality, the development and rigorous testing of non-pharmacological interventions is vital. A pilot of the Tailored Activities Program (TAP) for reducing problem behaviors in people with dementia was conducted in the United States with promising results. This randomized trial will investigate the effectiveness of TAP for reducing the burden of BPSD on persons with dementia and family caregivers within an Australian population. This trial will also examine the cost-effectiveness and willingness to pay for TAP compared with a control group.

This randomized trial aims to recruit 180 participant dyads of a person with dementia and their caregivers. Participants will have a diagnosis of dementia, exhibit behaviors as scored by the Neuropsychiatric Inventory, and the caregiver must have at least 7 h per week contact. Participants will be randomly allocated to intervention (TAP) or control (phone-based education sessions) groups, both provided by a trained occupational therapist. Primary outcome measure will be the revised Neuropsychiatric Inventory – Clinician rating scale (NPI-C) to measure BPSD exhibited by the person with dementia.

This trial investigates the effectiveness and cost-effectiveness of TAP within an Australian population. Results will address a significant gap in the current Australian community-support base for people living with dementia and their caregivers.