Delirium is an acute, severe deterioration in mental functioning. Inattention is the core feature, yet there are few objective methods for assessing attentional deficits in delirium. We previously developed a novel, graded test for objectively detecting inattention in delirium, implemented on a computerized device (Edinburgh Delirium Test Box (EDTB)). Although the EDTB is effective, tests on universally available devices have potential for greater impact. Here we assessed feasibility and validity of the DelApp, a smartphone application based on the EDTB.

This was a preliminary case-control study in hospital inpatients (aged 60–96 years) with delirium (N = 50), dementia (N = 52), or no cognitive impairment (N = 54) who performed the DelApp assessment, which comprises an arousal assessment followed by counting of lights presented serially. Delirium was assessed using the Confusion Assessment Method and Delirium Rating Scale-Revised-98 (DRS-R98), and cognition with conventional tests of attention (e.g. digit span) and the short Orientation-Memory-Concentration Test (OMCT).

DelApp scores (maximum score = 10) were lower in delirium (scores (median(IQR)): 6 (4–7)) compared to dementia (10 (9–10)) and control groups (10 (10–10), p-values < 0.001). Receiver operating characteristic (ROC) analyses revealed excellent accuracy of the DelApp for discriminating delirium from dementia (AUC = 0.93), and delirium from controls (AUC = 0.99, p-values < 0.001). DelApp and DRS-R98 severity scores were moderately well correlated (Kendall's tau = −0.60, p < 0.001). OMCT scores did not differ between delirium and dementia.

The DelApp test showed good performance, supporting the utility of objectively measuring attention in delirium assessment. This study provides evidence of the feasibility of using a smartphone test for attentional assessment in hospital inpatients with possible delirium, with potential applications in research and clinical practice.

Preventing and/or delaying cognitive impairment is a public health priority. To increase awareness of and participation in behaviors that may help maintain cognitive function or reduce risk of impairment, we need to understand public perceptions about risk and protective factors.

We conducted a scoping review of studies examining the public's perceptions about risk and protective factors related to cognitive health and impairment published since the 2007 National Public Health Road Map to Maintaining Cognitive Health.

A search of five databases yielded 1,115 documents published between June 2007 and December 2013. Initial review of abstracts identified 90 potentially eligible studies. After full-article review, 30 met inclusion criteria; four additional articles identified in reference lists also met inclusion criteria. Of the 34, 16 studies addressed Alzheimer's disease (AD) specifically, 15 dementia broadly, 5 mild to moderate cognitive impairment, and 8 normal functioning, with some content overlap. Across studies, respondents reported genetics (n = 14 studies), older age (n = 8), stress (n = 7), brain/head injury (n = 6), and mental illness/brain disease (n = 6) as perceived risk factors for AD and dementia. Protective factors most commonly identified for maintaining cognitive health were intellectual/mental stimulation (n = 13), physical activity (n = 12), healthy diet (n = 10), and social/leisure activities (n = 10).

Studies identified genetics and older age as key perceived risk factors more so than behaviors such as smoking. Individuals perceived that numerous lifestyle factors (e.g. intellectual stimulation, physical activity) could protect against cognitive impairment, AD, and/or dementia. Results can inform national and international education efforts about AD and other dementias.

Communication is affected by dementia, even in the early stages. Studies directly observing how patients, companions and healthcare professionals communicate have not yet been reviewed.

Eight databases were searched, and hand searches of relevant journals and grey literature were performed up to August 2014. Two authors reviewed abstracts independently and collectively reviewed for agreement of inclusion. Findings were narratively synthesized.

23 studies were identified observing: diagnostic, follow up, day center, primary care and research consent interactions. Companions were present in 14 studies. Three themes emerged: emotional impact of diagnosis, level of patient involvement and participant strategies to save face and cope with cognitive impairment. Eight studies observed diagnostic disclosure describing emotional reactions, with professionals using mitigating language and rarely checking patient understanding. Studies reported varying patient involvement, showing marginalization in primary care but not in assessments or diagnostic feedback. Patients used humor and metaphor to compensate for difficulties retrieving information and responding appropriately, suggesting preserved awareness of the pragmatics of interaction. Companion roles fluctuated between patient advocate and professional informant. Professionals encountered challenges adapting to heterogeneous patient groups with varying capabilities and needs.

Patient-companion-professional communication in dementia care raises various ethical questions: how to strike a balance between different communicative needs of patients and companions; clarity versus sensitivity in delivery of the diagnosis; and whether to minimize or expose interactional difficulties and misunderstanding to enrich patient understanding and involvement. Healthcare professionals need guidance in delivering a diagnosis and strategies to optimize patient and companion participation.

Relatives of people with dementia report that proxy decision-making is difficult and distressing. We systematically reviewed the literature about barriers and facilitators to family carers of people with dementia making proxy decisions, and interventions used to facilitate their decision-making.

We searched electronic databases and references of included papers up to February 2014. Two authors independently evaluated study quality using a checklist.

We included the 30/104 papers from our search which fitted predetermined criteria and prioritized higher quality papers. Family carers report that proxy decision-making is challenging and can be distressing, especially when decisions are made against the wishes of the care recipient and support from healthcare professionals is lacking. Decision-specific manualized aids have been developed, and while results for those supporting decisions about respite and percutaneous endoscopic gastrostomy (PEG) feeding have shown promising results in pilot trials, no intervention has yet been shown to significantly reduce decisional conflict or carer burden, or increase knowledge in randomized controlled trials; a decision aid for advance care planning increased decisional conflict.

We recommend development and testing of decision aids targeting the decisions carers report finding most distressing, including those around where people should live, accessing services, and end of life treatments. Being provided with information to make decisions which have not previously been considered may increase feelings of conflict, suggesting these aids should be carefully targeted.

Behavioral and psychological symptoms of dementia (BPSD) are virtually ubiquitous in dementia. Excessive recourse to use of psychotropics which have high risk to benefit ratio remains a global problem. We aimed to identify components of quality prescribing in BPSD to develop a tool for quality prescribing and to test this tool.

We used Delphi methodology to identify elements of quality prescribing in BPSD. The tool was tested by a range of medical and nursing professionals on 48 patients, in inpatient and ambulatory settings in Northern Sydney Local Health District, Australia.

Consensual opinion using Delphi method was that quality prescribing in dementia comprised ten factors including failure to use first line non-pharmacological strategies, indication, choice of drug, consent, dosage, mode of administration, titration, polypharmacy, toxicity, and review. These elements formed the quality use of medications in dementia (QUM-D) tool, lower scores of which reflected quality prescribing, with a possible range of scores from 0 to 30. When inter-rater reliability was tested on a subgroup of raters, QUM-D showed high inter-rater reliability. A significant reduction in QUM-D scores was demonstrated from baseline to follow-up, mean difference being 5.3 (SD = 3.8; 95% confidence interval 4.1–6.4; t = 9.5; df = 47; p < 0.001). There was also a significant reduction in score from baseline to follow-up when rated by clinical nurse consultants from a specialized behavior assessment management service (BAMS) (N = 12).

The QUM-D is a tool which may help to improve quality prescribing practices in the context of BPSD. In this setting, we consider quality prescribing, and accordingly the obligations of prescribers, to be an inclusive concept rather than just adding to the mantra of “not prescribing.”

Some guidelines recommend to discontinue treatment with cholinesterase inhibitors (ChEIs) in patients with Alzheimer's disease (AD) without an initial response to ChEI treatment. Evidence supporting this recommendation, however, is limited. This study aimed to investigate the relation between the initial cognitive response to ChEI treatment and the subsequent long-term course of cognition of AD patients.

The Frisian Alzheimer's Disease Cohort study is a retrospective longitudinal study of 576 community-dwelling AD patients treated with ChEIs in a “real-life” setting at a large memory clinic. A repeated measures analysis using a marginal model (population based averaged model) was applied to investigate whether there is a difference in the subsequent long-term course of cognition (Mini-Mental State Examination (MMSE)) between initial non-responders and responders. Absence of an initial response was defined as a lower MMSE score after the first six months of treatment compared to baseline, a positive response as the same or a higher MMSE score.

At baseline, median age was 80 years and the median MMSE score 23. Non-responders showed a slower rate of cognitive decline in the three subsequent years than responders, with a mean annual MMSE decline of 0.9 points versus 1.2 points, respectively (p < 0.0001).

Our results suggest that it is not appropriate to discontinue ChEI treatment solely based on the absence of an initial cognitive response.

Continuous treatment is an important indicator of medication adherence in dementia. However, long-term studies in larger clinical settings are lacking, and little is known about moderating effects of patient and service characteristics.

Data from 12,910 outpatients with dementia (mean age 79.2 years; SD = 7.6 years) treated between January 2003 and December 2013 in Germany were included. Continuous treatment was analysed using Kaplan–Meier curves and log-rank tests. In addition, multivariate Cox regression models were fitted with continuous treatment as dependent variable and the predictors antidementia agent, age, gender, medical comorbidities, physician specialty, and health insurance status.

After one year of follow-up, nearly 60% of patients continued drug treatment. Donezepil (HR: 0.88; 95% CI: 0.82–0.95) and memantine (HR: 0.85; 0.79–0.91) patients were less likely to be discontinued treatment as compared to rivastigmine users. Patients were less likely to be discontinued if they were treated by specialist physicians as compared to general practitioners (HR: 0.44; 0.41–0.48). Younger male patients and patients who had private health insurance had a lower discontinuation risk. Regarding comorbidity, patients were more likely to be continuously treated with the index substance if a diagnosis of heart failure or hypertension had been diagnosed at baseline.

Our results imply that besides type of antidementia agent, involvement of a specialist in the complex process of prescribing antidementia drugs can provide meaningful benefits to patients, in terms of more disease-specific and continuous treatment.

The number of people with dementia is increasing rapidly. Providing care to a relative or friend with dementia may lead to serious mental health problems. Internet interventions may offer opportunities to improve the availability and accessibility of (cost)effective interventions to reduce family caregivers’ psychological distress. This study describes the acceptability of a guided self-help Internet intervention “mastery over dementia” (MoD), aimed at reducing caregivers’ psychological distress, in terms of reach, adherence and user evaluation.

The sample for this study is the experimental group that participated in the (cost)effectiveness trial of MoD (N = 149). Data on characteristics of family caregivers and people with dementia, completion and user evaluation were used and analyzed with descriptive statistics, χ2and T-tests.

MoD reaches a wide variety of caregivers, also those aged 75+, having a relative with a recent diagnosis of dementia or living in a care home. However, the percentage of caregivers who did not complete all eight lessons was rather high (55.7%). Among the completers (N = 66; 44.3%) were significantly more spouses, caregivers living in the same household, older caregivers, and those caring for somebody with another formal diagnosis than Alzheimer's disease. Caregivers’ evaluation showed that females rated higher on the comprehensibility of the lessons and feedback and spent less time on the lessons.

The guided self-help Internet intervention MoD is acceptable for a broad range of family caregivers of people with dementia. The next step is to substantiate its (cost)effectiveness.

Caregiver burden is a complex and multidimensional construct. Although previous studies have explored numerous factors associated with caregiver burden, these factors have not been identified with a large population-based sample in a theory-based multidimensional way. This study explores multidimensional determinants associated with family caregiver burden to determine the main contributors of caregiver burden in Alzheimer's disease (AD) using a large community dataset.

A retrospective secondary data analysis was conducted on 1,133 patients with AD and 1,133 primary caregivers who were registered in a metropolitan city dementia center in South Korea. The patient data included socio-demographic and disease profiles. The caregiver data consisted of socio-demographic and caregiving profiles.

The study results identified that dementia-related factors were the most significant factors, representing 25.6% of caregiver burden and were followed by caregiving-related factors explaining caregiver burden significantly. Behavioral problems and instrumental activities of daily living (IADL) dependency of the patient, spousal relationship, hours of caregiving, and the number of diseases associated with the caregiver were found to be significant individual variables.

It is vital to develop a service and support program with a greater emphasis on the behavioral problems and IADL deficiency of patients with AD as well as on improving the competence ability of caregivers to deal with such difficulties.

Few personalized e-interventions are available for informal and professional caregivers of people with dementia. The DEMentia Digital Interactive Social Chart (DEM-DISC) is an ICT tool to support customized disease management in dementia. The aim of this study was to improve and evaluate DEM-DISC, its user-friendliness and usefulness and to investigate the future implementation.

A cluster randomized controlled trial (RCT) design was used with measurements at baseline, 6 and 12 months. A total of 73 informal caregivers of people with dementia, supported by 19 randomized case managers participated in the study. In the intervention group, both carers (n = 41) and case managers (n = 13) could access DEM-DISC during twelve months. The control group, 32 carers and 14 case managers, had no access to DEM-DISC. Semi-structured interviews were conducted with ten stakeholders.

Informal caregivers who used DEM-DISC for twelve months reported an increased sense of competence than controls. A subgroup of users who frequently accessed DEM-DISC reported more met needs after six months than controls. Overall informal caregivers and case managers judged DEM-DISC as easy to learn and user-friendly.

This study demonstrates that using DEM-DISC had a positive effect on the sense of competence and experienced (met) needs of informal carers. This shows the importance of user-friendly ICT solutions to assist carers in finding appropriate care services tailored to their specific situation and needs. For further implementation of DEM-DISC methods to keep the information updated is of great importance.

Mild cognitive impairment (MCI) has been defined as a transitional state between normal aging and dementia. In many cases, MCI represents an early stage of developing cognitive impairment. Patients diagnosed with MCI do not meet the criteria for dementia as their general intellect and everyday activities are preserved, although minor changes in instrumental activities of daily living (ADL) may occur. However, they may exhibit significant behavioral and psychological signs and symptoms (BPS), also frequently observed in patients with Alzheimer's disease (AD). Hence, we wondered to what extent specific BPS are associated with cognitive decline in participants with MCI or AD.

Our sample consisted of 164 participants, including 46 patients with amnestic (single or multi-domain) MCI and 54 patients with AD, as well as 64 control participants without cognitive disorders. Global cognitive performance, BPS, and ADL were assessed using validated clinical methods at baseline and at two-year follow-up.

The BPS variability over the follow-up period was more pronounced in the MCI group than in patients with AD: some BPS improve, others occur newly or worsen, while others still remain unchanged. Moreover, specific changes in BPS were associated with a rapid deterioration of the global cognitive level in MCI patients. In particular, an increase of euphoria, eating disorders, and aberrant motor behavior, as well as worsened sleep quality, predicted a decline in cognitive functioning.

Our findings confirm a higher variability of BPS over time in the MCI group than in AD patients. Moreover, our results provide evidence of associations between specific BPS and cognitive decline in the MCI group that might suggest a risk of conversion of individuals with amnestic MCI to AD.

The objective was to examine whether aspects of social relationships in old age are associated with all-cause dementia and Alzheimer's disease (AD).

We studied 1,715 older adults (≥ 65 years) who were dementia-free at baseline over a period of up to 16 years. Data on living status, contact/visit frequency, satisfaction with contact frequency, and having/not having a close friend were analyzed using Cox proportional hazards regressions with all-cause dementia or AD as the dependent variable. To control for reverse causality and to identify potential long-term effects, we additionally performed analyses with delayed entry.

We identified 373 incident cases of dementia (207 with AD) during follow-up. The variable visiting/visits from friends was associated with reduced risk of all-cause dementia. Further, a higher value on the relationships index (sum of all variables) was associated with reduced risk of all-cause dementia and AD. However, in analyses with delayed entry, restricted to participants with a survival time of three years or more, none of the social relationship variables was associated with all-cause dementia or AD.

The results indicate that certain aspects of social relationships are associated with incident dementia or AD, but also that these associations may reflect reverse causality. Future studies aimed at identifying other factors of a person's social life that may have the potential to postpone dementia should consider the effects of reverse causality.

Impaired spatial navigation is an early sign of Alzheimer's disease (AD), but this can be difficult to assess in clinical practice. We examined how the performance on the Floor Maze Test (FMT), which combines navigation with walking, differed between patients with subjective cognitive impairment (SCI), mild cognitive impairment (MCI), and mild AD. We also explored if there was a significant relationship between the FMT and the cognitive tests or sociodemographic factors.

The study included 128 patients from a memory clinic classified as having SCI (n = 19), MCI (n = 20), and mild AD (n = 89). Spatial navigation was assessed by having the patients walk through the FMT, a two-dimensional maze. Both timed measures and number of errors were recorded. Cognitive function was assessed by the Word List Memory test, the Clock Drawing test, the Trail Making tests (TMT) A and B, and the Mini Mental Status Examination (MMSE).

The patients with MCI were slower than those with SCI, while the patients with mild AD more frequently completed the FMT with errors or gave up than the patients with MCI. Performance on the FMT was significantly associated with executive function (measured by TMT-B).

The performances on the FMT worsened with increasing severity of cognitive impairment, and the FMT was primarily associated with executive function. The explained variance was relatively low, which may indicate that the standard cognitive test battery does not capture impairments of spatial navigation.