Background: Inability to walk compromises the well-being of the growing number of nursing home residents with dementia. The purpose of this study was to estimate the incidence and identify predictors of walking disability that may be remediable.

Methods: A cohort was followed fortnightly for a year in15 nursing homes in western Canada. The study participants comprised 120 ambulatory residents with middle-stage Alzheimer's, vascular or mixed dementia. Standardized measures of potential predictors of disability included the Charlson Comorbidity Index, Global Deterioration Scale, and Professional Environment Assessment Protocol. Walking disability was defined as using a wheelchair to go to meals in the dining room.

Results: Incidence of walking disability was 40.8% (95% confidence interval (CI): 32.7–50.2). Approximately half of this (27.0%; 95% CI: 19.7–36.5) was excess disability. Residents with more advanced dementia and living in a less supportive nursing home environment experienced an increased hazard of walking disability (Hazard Ratio (HR): 2.1; 95% CI: 1.2–3.8 and HR: 2.4; 95% CI: 1.3–4.4 respectively). After adjusting for age, comorbidity and stage of dementia, predictors of excess disability in walking included using antidepressants (HR: 2.2; 95% CI: 1.02–4.6), and not using cognitive enhancers (HR: 2.6; 95% CI: 1.03–6.4).

Conclusions: Over half of walking disability in nursing home residents with middle-stage dementia may be modifiable. Creating supportive environments, ensuring access to cognitive enhancer drugs, and preventing and treating depression and the adverse effects of antidepressants, may help to reduce walking disability and excess disability.

Background: Cognitive status has been reported to be an important predictor of rehabilitation outcome. The Montreal Cognitive Assessment (MoCA) was designed to overcome some of the limitations of established cognitive screening tools such as the Mini-Mental State Examination (MMSE). The purpose of this study is to evaluate the psychometric characteristics of the MoCA as a screening tool in a geriatric rehabilitation program and its ability to predict rehabilitation outcome.

Methods: Forty-seven geriatric rehabilitation program patients participated in the study. Assessments of each patient's functional (Functional Independence Measure) and cognitive status (MMSE and MoCA) were performed. Information on discharge destinations were obtained and rehabilitation efficacy and efficiency scores were calculated.

Results: Significant correlations were found between the MoCA and other cognitive status measures. Cognitive status at admission and successful rehabilitation were also associated. Defining rehabilitation success on the basis of relative functional efficacy (an indicator that includes the patient's potential for improvement), the sensitivity and specificity of the MoCA were 80% and 30% respectively. The attention subscale of the MoCA was also uniquely predictive of rehabilitation success. The attention subscale (cutoff 5/6) of the MoCA had a sensitivity of 40% and specificity of 90%, as did the MMSE.

Conclusions: As a cognitive screening tool, the MoCA appears to have acceptable psychometric properties. Results suggest that the MoCA can have a considerable advantage over the MMSE in sensitivity and equivalence in specificity using both total and attention scale scores. The MoCA may be a more useful measure for detecting cognitive impairment and predicting rehabilitation outcome in this population.

Background: Sleep disturbance is a common complaint in the general population. There is, however, little cross-national comparative evidence on the prevalence of sleep disturbance and its association with age.

Methods: Cross-sectional data from the third wave of the European Social Survey were used to compare both the prevalence of sleep disturbances and its relationship to age among 27,103 respondents over the age of 40 years from 23 European countries. The outcome measures for the study were based on the proportion of respondents reporting restless sleep over the past week and percentage change in the reporting of restless sleep between the 41–65 age group and the 66 and over age group.

Result: The prevalence rate of sleep disturbance varied between and within age groups, as well as between the 23 European countries. Depressive symptoms (OR = 4.14), anxiety (OR = 2.80), and general health (OR = 1.52) were the strongest correlates of sleep disturbance among both the 41–65 age group and the over 66 age group. The highest positive correlation with change in restless sleep reports occurred with respect to health deterioration. Satisfaction with living standards showed the strongest negative association with change in restless sleep reports.

Conclusion: There is considerable variation in reports of sleep disturbance across different European countries. Being in an older age group appears to be associated with worsening sleep, though not always. Different patterns of sleep disturbance seem to indicate the considerable variability of the aging experience across Europe.

Objectives: The aim of this study was to investigate the prevalence of depression among very old individuals with dementia compared to those without dementia and to examine if there were any differences regarding associated factors between people with or without depression in these conditions.

Methods: In a population-based study in Sweden, 363 participants aged 85 years and above, were evaluated for depression and dementia.

Results: The prevalence of depression was significantly higher among the people with dementia than without dementia, 43% vs. 24% (p < 0.001). Approximately 2/3 of the depressed in both groups used antidepressants and of those, approximately 50% had responded. Depression in the group without dementia was, among other factors, associated with higher total number of medication, the use of significant more analgesics and benzodiazepines, loneliness, inability of going outside and recent loss of child. The loss of a child was the only factor that was independently associated with depression in those with dementia.

Conclusions: The present study confirms that in the very old, depression is more common among people with dementia than without dementia. A large proportion, both with and without dementia, are under-diagnosed and untreated, and in addition many subjects in both groups studied were non-responders to treatment. Many of the factors associated with depression among people without dementia in this study were not associated with depression among those with dementia, thus supporting the theory that the spectrum of associated factors for depression in dementia seems to be different from that for depression in people without dementia.

Background: There is a strong demand for screening instruments for mild cognitive impairment (MCI), as a pre-stage of dementia. The clock drawing test (CDT) is widely used to screen for dementia, but the utility in screening for MCI remains uncertain. In particular, it is still questionable which scoring system is the best in order to screen for MCI. We therefore aimed to compare the utility of different CDT scoring systems for screening for MCI.

Methods: In a sample of 428 subjects of the Leipzig Longitudinal Study of the Aged (LEILA 75+) study, CDT scores of different scoring systems were compared between subjects with and without MCI. Comparison of receiver operating characteristic (ROC; area under the curve, sensitivity, specificity) was performed and inter-rater reliability was calculated.

Results: The CDT scores differed significantly between MCI and non-MCI subjects according to all scoring systems applied. However, ROC of the CDT scores was not adequate.

Conclusions: None of the present CDT scoring systems has sufficient utility to screen reliably for MCI. The clinical value of the CDT could be improved by using semi-quantitative scoring, having a wider score range and focusing on specific details of the clock (e.g. the hands and numbers).

Background: Chronic pain is quite common in the elderly and is often associated with comorbid depression, limitation of functioning and reduced quality of life. The aim of this study was to ascertain whether there is a differential risk of depression among persons with pain in different anatomical sites and to determine which pain conditions are independent risk factors for depression.

Methods: Data are from the Ibadan Study of Ageing (ISA), a community-based longitudinal survey of persons aged 65 years and older from eight contiguous Yoruba-speaking states in Nigeria (n = 2152). Data were collected in face-to-face interviews; depression was assessed using the World Mental Health initiative version of the Composite International Diagnostic Interview (CIDI) while chronic pain was assessed by self-report (response rate = 74%).

Results: Estimates of persistent pain (lasting more than six months), in different anatomical sites range from 1.3% to 12.8%, with the commonest being joint pains (12.8%), neck or back (spinal) pain (7.6%) and chest pain (3.0%). Significantly more pain conditions were reported by females and by respondents who were aged over 80 years. The risk for depression was higher in respondents with spinal, joint and chest pain. However, only chest pain was independently associated with depression after adjustments were made for pains at other sites and for functional disability.

Conclusion: Our data suggests that, among elderly persons, there is a differential association of depression with chronic pain that is related to the anatomical site of the pain.

Background: Alzheimer's disease (AD) is characterized by memory loss and cognitive impairment. Phonological, syntactic, semantic and discursive aspects of language may also be affected. Analysis of micro- and macrolinguistic abilities of discourse may assist in diagnosing AD. The aim of this study was to identify changes in the discourse (lexical errors and syntactic index) of AD patients.

Methods: 121 elderly subjects narrated a story based on a seven-figure picture description.

Results: Patients with AD presented more word-finding difficulties, revisions and repetitions, and the syntactic index was lower than controls.

Conclusion: Performance in microlinguistics at the lexical and syntactic levels was lower than expected in participants with AD.

Background: This study sought to examine the trends in the prescribing of subsidized and unsubsidized cognition enhancing drugs (CEDs) in Australia over five years from 2002 to 2007. Subsidized cholinesterase inhibitor medication could be prescribed to people with mild to moderate Alzheimer's disease (AD) once a specialist physician had confirmed this diagnosis. Memantine was available for use in moderately severe AD but not subsidized.

Methods: We analyzed the Medicare Australia and Drug Utilisation Sub-Committee databases for CED prescription data, 2002–2007, by gender, age and prescriber class. Aggregated prescription data for each medication were converted to defined daily doses (DDD) per 1000 persons per day using national census data.

Results: There were 1,583,667 CED prescriptions dispensed during the study period. CED use increased 58% from 0.91 to 1.56 DDD/1000 persons/day between 2002 and 2007. Peak use was in those aged 85–89 years. Age-adjusted utilization was slightly higher in females than males. Donepezil was the most widely used CED (66%), followed by galantamine (27%) then memantine (4%). General practitioners prescribed the majority of CEDs. Geriatricians exhibited a greater preference for galantamine than other prescribers. CED dispensing peaked towards the end of each calendar year, reflecting stockpiling by patients under the influence of a federal safety net subsidy.

Conclusions: Despite subsidized access to CEDs in Australia, only a minority of people with AD was prescribed these drugs during the period of the study. It is likely that the combination of complex prescribing rules and negative perceptions about efficacy or cost-effectiveness might have contributed to these findings.

Background: Adverse consequences following elopement among older people with dementia have been widely reported but the phenomenon of elopement has been under-researched. This study aimed to examine patterns of elopement incidents, search processes and subsequent prevention strategies and to explore factors that predict elopement among community-dwellers with dementia.

Methods: Twenty subjects with a recent history of elopement and 25 subjects without any history of elopement completed the study. Their cognitive status, dementia severity and behavioral manifestations were evaluated. Family informants were interviewed to gather data on demographic characteristics, clinical conditions, caring patterns, lifestyle, history of elopement, and information about any elopement incidents.

Results: Two-thirds of subjects had moderate severity of dementia (Clinical Dementia Rating ≥2). The elopers did not differ from the non-elopers in demographics, caring arrangements, clinical conditions or lifestyle patterns. Eighty percent of eloped subjects had a prior history of elopement. Logistic regression analyses suggested that manifestation of behavioral symptoms predicted elopement (OR = 1.410). Analysis of the 68 elopement incidents revealed that the vast majority of family caregivers failed to recognize any emotional/behavioral clues prior to elopement. Immediate and multiple search strategies were adopted, with eloped subjects mostly found near the point last seen. Yet, subsequent preventive strategies adopted were largely conventional.

Conclusion: Although elopement is difficult to predict, there is a need to enhance and sensitize caregivers’ understanding of elopement as related to dementia and more effective preventive strategies. Public education on dementia could also serve to engage lay people more effectively in the search process of eloped persons with dementia.

Background: The goal of this study is to determine patterns of psychotropic drug use (PDU), the association with neuropsychiatric symptoms (NPS), and the variability across dementia types in nursing home residents with dementia. In addition, PDU was analyzed across multiple indications.

Methods: This was a prospective cohort study over a two-year period from 2006 to 2008, which involved 14 dementia special care units in nine nursing homes. A total of 117 residents with dementia participated in the study, of whom 35% had Alzheimer's dementia (AD) and 11% vascular dementia (VaD). PDU was classified according to anatomical therapeutic chemical-classification as either “present” or “absent”.

Results: The majority of residents had moderately severe to severe dementia. At all successive assessments, almost two-thirds of residents received any psychotropic drug (PD) and almost one-third continued to receive any PD. Of all PDs, antipsychotics (APs) were prescribed most frequently. Fewer residents started with antidepressants, but continued to receive antidepressants at higher percentages. Anxiolytics showed an intermittent course, but a subgroup of 9% showed two-year continuation. Once started on PDs at baseline, residents continued to use PDs at high percentages: three-quarters continued to receive APs for at least six months. Half of residents received at least one PD; one-fifth received at least two PDs simultaneously. Residents with AD received more hypnotics and antidementia drugs; residents with VaD received more antipsychotics, antidepressants, anxiolytics and anticonvulsants.

Conclusions: PDs have different utilization patterns, but overall, consistently high continuation rates were found. These results warrant scrutiny of continuous PDU.

Over the past five to ten years, neuroimaging capability for neurodegenerative diseases has made remarkable progress. However, debate remains as to the true clinical utility of these advanced and costly investigations. Not only is the place of these tests in diagnostic algorithms unclear, but the access to them varies both within and between countries. We sought to gather informed opinion from recognized leaders in the field who can combine both an academic and a clinical perspective on the use of neuroimaging in their own countries. Opinion is presented from Scotland, Argentina, the Czech Republic, France, the USA and Australia. The emerging consensus was one of ongoing caution. While in most countries there was a sense that the use of more advanced imaging techniques was growing, their hour has not yet cometh. However, these techniques, rather than falling from the Ivory Tower, should descend slowly step by step onto fertile and receptive clinics from where better clinical guidelines will emerge.

Background: The Prospective Research In MEmory clinics (PRIME) is a three-year non-prescriptive, observational study identifying and measuring relationships among predictor and outcome variables.

Methods: Patients from nine memory clinics, diagnosed with dementia or mild cognitive impairment (MCI), living in the community with <40 hours/week nursing care were divided into diagnostic groups defined at baseline as Alzheimer's disease (AD) early or late onset, frontotemporal dementia (FTD), vascular dementia (VaD), mixed (AD and VaD) and other dementia. To achieve outcome measures, baseline and change over six months in all measures by diagnostic group, and predictors of change at six months were examined.

Results: Of the 970 patients enrolled, 967 were eligible for analysis. The most common disorder was AD (late onset) accounting for 46.5% of this population. Patients had an overall slight worsening on all assessment scales over the six-month period. Patients with FTD had a more marked change (decline) in cognition, function and behavior over six months compared to other diagnostic groups. However, in the regression analysis the difference was not significant between groups. Predictors of decline in Mini-Mental State Examination (MMSE) scores were not robust at six months, and longer follow-up is required. Patients with FTD were more likely to be prescribed psychotropics.

Conclusion: The PRIME study is continuing and will provide important data on predictors of decline along with differences between diagnosis groups on the rate of change.

Background: An expanding elderly population poses challenges for the provision of care and treatment for age-related physical and mental disorders. Cognitive impairment (CI)/dementia is one such mental disorder that is on the rise in Singapore and has concomitant implications for social and health systems. The objective of this study is to understand the perspectives of prominent stakeholders about current and future issues and challenges associated with CI/dementia among the elderly in Singapore.

Methods: Using indepth interviews, this qualitative study obtained the views of multiple stakeholders on issues and challenges associated with CI/dementia in Singapore. The 30 individuals interviewed as part of the study included clinicians, policy-makers, researchers, community workers, administrators, and caregivers. Using a framework approach, interview texts were indexed into domains and issues by utilizing NVivo 9.0 software.

Results: The stakeholders expressed concerns related to multiple domains of the CI/dementia care system: attitude and awareness, economics, education, family caregiving, inputs to care system, living arrangements, prevention, screening and diagnosis, and treatment and management of care. Within each domain, multiple issues and challenges were identified by respondents.

Conclusions: The study identifies a complex set of inter-related issues and challenges that are associated with the care and treatment of people with CI/dementia. The results suggest that CI and dementia profoundly affect patients, families, and communities and that the issues related to the two disorders are truly system-wide. These findings lay the foundation for utilization of a systems approach to studying CI/dementia and provide an analytic framework for future research on complex health care issues.

Background: Although research has highlighted the importance of including cultural factors in the analysis of caregiver stress, little is known about the effects of motives for caregiving on the stress and coping process. This study is aimed at analyzing the dimensional structure of the Cultural Justifications for Caregiving Scale – Revised (CJCS-R), and the effects of motives for caregiving on stressors, caregiver resources and outcome variables.

Methods: Dementia caregivers (N = 166) were interviewed and the following variables were assessed: motives for caregiving (CJCS-R), stressors (frequency of behavioral problems), resources (rumination, cognitive reappraisal), and outcomes (depression, anxiety and anger).

Results: A bidimensional structure was obtained for the CJCS-R, and the two factors were labeled Intrinsic and Extrinsic motives for caregiving. Participants were divided into four groups corresponding to four motivation profiles: HIHE = High Intrinsic Motives + High Extrinsic motives; LILE = Low Intrinsic Motives + Low Extrinsic Motives; HILE = High Intrinsic Motives + Low Extrinsic Motives; and LIHE = Low Intrinsic Motives + High Extrinsic Motives. No differences between groups were found in frequency of behavioral problems. Caregivers in the LIHE group had significantly worse consequences on caregiver resources and outcome variables compared to the other groups.

Conclusions: The results support the usefulness of considering motives for caregiving as a multidimensional construct. Analyzing caregivers' motivation profiles may constitute a useful strategy for identifying caregivers at risk. Caregivers scoring simultaneously low on intrinsic motives and high on extrinsic motives may be at particular risk for negative caregiving outcomes.

Background: Olfactory dysfunction is present in early Alzheimer's disease (AD), and has now been reported in people with amnestic mild cognitive impairment (aMCI). Recent evidence suggests that unawareness of an olfactory deficit may predict which MCI patients will subsequently meet AD criteria. However, important methodological limitations challenge this suggestion. While addressing some of the limitations of previous research, this preliminary study explores unawareness of olfactory deficits as a predictive factor of future AD among people with aMCI.

Methods: Twenty-five participants with aMCI, 25 AD patients, and 22 healthy elderly participants underwent testing of olfactory identification. Subjective reports regarding perceived decline in olfactory detection and olfactory identification were also obtained. A subset of participants was reassessed 12 months later.

Results: Control participants performed better than both aMCI and AD patients on olfactory identification. Almost uniformly, participants did not report decline in either olfactory detection or identification. Prediction of olfactory identification scores from subjective reports of olfactory function was poor, and awareness of olfactory decline bore no relationship to the likelihood of aMCI patients progressing to AD by the 12-month review.

Conclusions: Treating awareness of olfactory function as a unitary construct can be misleading, and there is a poor relationship between subjective and objective measures of olfactory ability. Our preliminary data suggest that unawareness of olfactory decline does not improve the identification of patients with MCI who are more likely to be in the prodromal phase of AD. Replication in a larger cohort is needed to support these findings.

Background: The purpose of this study is to determine if the three-step Luria test is useful for differentiating between cognitive disorders.

Methods: A retrospective record review of performance on the three-step Luria test was conducted on 383 participants from a university-based dementia clinic. The participants ranged in their diagnosis from frontotemporal dementia (FTD; n = 43), Alzheimer disease (AD; n = 153), mild cognitive impairment (MCI; n = 56), and normal controls (NC; n = 131). Performance of the Luria test was graded as normal or abnormal.

Results: An abnormal test occurred in 2.3% of NC, 21.4% of MCI, 69.8% of FTD, and 54.9% of AD subjects. The frequency of abnormal tests in all diagnostic groups increased with functional impairment as assessed by the Clinical Dementia Rating scale (CDR). When CDR = 3 (severe), 100% of the FTD and 72.2% of the AD subjects had abnormal Luria tests.

Conclusions: The three-step Luria test distinguished NC and persons with MCI from FTD and AD, but did not distinguish FTD from AD subjects.

Background: To assess the long-term impact of the “Reducing Use of Sedatives” (RedUSe) trial on antipsychotic and benzodiazepine prevalence and dosage.

Methods: RedUSe was a six-month controlled trial conducted in 25 Tasmanian nursing homes in 2008–9 which led to significant reductions in benzodiazepine and antipsychotic use and a doubling of dose reductions of these agents. In a follow-up study, data on psychotropic use was collected from all nursing homes a year after the final RedUSe measure. Mean daily doses for each home were calculated by converting antipsychotic and benzodiazepine doses to chlorpromazine and diazepam equivalents, respectively. To determine the long-term impact of the project, 6-month and initial baseline data were compared to the 18-month follow-up data.

Results: 1578 residents were audited for the follow-up measure. In the 18 months since the RedUSe project was instigated, benzodiazepine prevalence fell by 25% in intervention nursing homes. Similarly, the mean daily diazepam equivalence in these homes had fallen by 24%. In contrast, after a significant reduction during the RedUSe trial, antipsychotic prevalence returned to baseline levels in intervention nursing homes, with mean chlorpromazine equivalence remaining relatively constant with time. There was a delayed reduction in benzodiazepine and antipsychotic use in the control homes.

Conclusions: Both benzodiazepine usage and mean daily diazepam equivalence continued to decline in intervention nursing homes in the year following the RedUSe trial. However, the effect of the RedUSe intervention on antipsychotic prevalence and dosage was not sustained.

Background: Although social network relationships are linked to mental health in late life, it is still unclear whether it is the structure of social networks or their perceived quality that matters.

Methods: The current study regressed a dichotomous 8-item version of the Center for Epidemiological Studies Depression Scale (CESD-8) score on measures of social network relationships among Americans, aged 65–85 years, from the first wave of the National Social Life, Health and Aging Project. The network indicators included a structural variable – social network type – and a series of relationship quality indicators: perceived positive and negative ties with family, friends and spouse/ partner. Multivariate logistic regression analyses controlled for age, gender, education, income, race/ethnicity, religious affiliation, functional health and physical health.

Results: The perceived social network quality variables were unrelated to the presence of a high level of depressive symptoms, but social network type maintained an association with this mental health outcome even after controlling for confounders. Respondents embedded in resourceful social network types in terms of social capital – “diverse,” “friend” and “congregant” networks – reported less presence of depressive symptoms, to varying degrees.

Conclusions: The results show that the structure of the network seems to matter more than the perceived quality of the ties as an indicator of depressive symptoms. Moreover, the composite network type variable stands out in capturing the differences in mental state. The construct of network type should be incorporated in mental health screening among older people who reside in the community. One's social network type can be an important initial indicator that one is at risk.