Background: Dementia screening in elderly people with low education can be difficult to implement. For these subjects, informant reports using the long (L) (26 items) and short (C) (16 items) versions of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) can be useful. The objective of the present study was to investigate the performance of Brazilian versions of the IQCODE L, S and a new short version (SBr) (15 items) in comparison with the Mini-mental State Examination (MMSE) for dementia screening in elderly people with low education.

Methods: Thirty-four patients with mild to moderate dementia, diagnosed according to ICD-10 criteria, and 57 controls were evaluated and divided into three groups based on their socioeconomic status and level of education. Patients were evaluated using the MMSE and the informants were interviewed using the IQCODE by interviewers blind to the clinical diagnosis.

Results: Education was correlated with MMSE results (r = 0.280, p = 0.031), but not with the versions of the IQCODE. The performance of the instruments, evaluated by the ROC curves, was very similar, with good internal consistency (Cronbach's α = 0.97). MMSE correctly classified 85.7% of the subjects while the three IQCODE versions (L, S and SBr) correctly classified 91.2% of the subjects.

Conclusions: The long, short and the new short Brazilian IQCODE versions can be useful as a screening tool for mild and moderate patients with dementia in Brazil. The IQCODE is not biased by schooling, and it seems to be an adequate instrument for samples with low levels of education.

Background: The Cognitive Abilities Screening Instrument (CASI) was designed for use in cross-cultural studies of Japanese and Japanese-American elderly in Japan and the U.S.A. The measurement equivalence in Japanese and English had not been confirmed in prior studies.

Methods: We analyzed the 40 CASI items for differential item functioning (DIF) related to test language, as well as self-reported proficiency with written Japanese, age, and educational attainment in two large epidemiologic studies of Japanese-American elderly: the Kame Project (n=1708) and the Honolulu-Asia Aging Study (HAAS; n = 3148). DIF was present if the demographic groups differed in the probability of success on an item, after controlling for their underlying cognitive functioning ability.

Results: While seven CASI items had DIF related to language of testing in Kame (registration of one item; recall of one item; similes; judgment; repeating a phrase; reading and performing a command; and following a three-step instruction), the impact of DIF on participants' scores was minimal. Mean scores for Japanese and English speakers in Kame changed by <0.1 SD after accounting for DIF related to test language. In HAAS, insufficient numbers of participants were tested in Japanese to assess DIF related to test language. In both studies, DIF related to written Japanese proficiency, age, and educational attainment had minimal impact.

Conclusions: To the extent that DIF could be assessed, the CASI appeared to meet the goal of measuring cognitive function equivalently in Japanese and English. Stratified data collection would be needed to confirm this conclusion. DIF assessment should be used in other studies with multiple language groups to confirm that measures function equivalently or, if not, form scores that account for DIF.

Background: The aging society will bring an increase in the number of people with dementia living in the community. This will mean a greater demand on care and welfare services to deliver efficient and customized care, which requires a thorough understanding of subjective and objective care needs. This study aims to assess the needs of community-dwelling people with dementia as reported by themselves and by their informal carers. The study also aims to give insight into the service use and gaps between needs and the availability of services.

Methods: 236 community-dwelling people with dementia and 322 informal carers were interviewed separately. (Un)met needs were assessed using the Camberwell Assessment of Needs for the Elderly (CANE).

Results: Most unmet needs were experienced in the domains of memory, information, company, psychological distress and daytime activities. People with dementia reported fewer (unmet) needs than their carers. Type and severity of dementia, living situation and informal carer characteristics were related to the number of reported needs.

Conclusions: This study showed a large number of unmet needs in dementia. Reasons for unmet needs are lack of knowledge about the existing service offer, a threshold to using services and insufficient services offer. These results provide a good starting point for improving community care for people with dementia.

Background: Insulin resistance (IR) may play a role in most pathogenic processes that promote the development of late onset Alzheimer's disease (LOAD). This study was designed to evaluate whether galantamine influenced peripheral IR in LOAD.

Methods: Ninety-five consecutive elderly patients, 40 LOAD and 55 non-demented patients were evaluated. IR was calculated with HOMA and modified-HOMA. All the patients were evaluated through comprehensive geriatric assessments at baseline and at 6, 12 and 18 months.

Results: Over three 6-month periods of galantamine treatment, compared to the baseline values, there was a significant increase at 6 and 12 months in the MMSE and at 6 months in the IADL scores (t = 3.25, p = 0.002 and t = 2.69, p = 0.011 for MMSE; t = 2.03, p = 0.049; for IADL, respectively). Although, there was an improvement in MMSE and IADL scores of galantamine-treated patients, there was no significant change in IR indexes and correlation between IR indexes and cognitive status in both groups during the treatment period.

Conclusions: This study showed no relation between cognitive improvement and IR by galantamine therapy in AD. In conclusion, peripheral IR and central nervous system IR may be different, and galantamine itself may show its effects without affecting the insulin-signaling pathway.

Background: The aim of this study is to determine whether B12 replacement would ameliorate cognitive and psychiatric symptoms in elderly subjects with dementia and low serum B12 levels.

Methods: A test group (n = 28) of nursing home residents with low serum B12 levels (<250 pg/mL) and a matched comparison group (n = 28) with normal serum B12 levels (>300 pg/mL) were evaluated by blinded raters while the test group received intramuscular (IM) B12 replacement therapy. All subjects were assessed at baseline, 8 weeks, and 16 weeks with the Dementia Rating Scale, Brief Psychiatric Rating Scale, and Geriatric Depression Scale.

Results: Although B12 replacement produced significant improvement in hematologic and metabolic parameters, it yielded no significant effect on cognitive or psychiatric variables. A few subjects evidenced notable individual treatment responses; however, these were not statistically more frequent than in the normal B12 group.

Conclusions: These results suggest that B12 replacement is unlikely to benefit cognitive or psychiatric symptoms in the vast majority of elderly dementia patients with low serum B12 levels.

Background: This study examined knowledge levels of Alzheimer's disease (AD) in a sample of Latin American seniors attending AD educational sessions in a Canadian city; and investigated the relationship between knowledge of AD, demographic variables, education level, acculturation level (years living in Canada), subjective memory complaint and objective memory impairment.

Methods: One hundred and twenty-five Spanish-speaking adults living independently in the Greater Toronto Area completed subjective and objective memory measures and completed a questionnaire on their knowledge of AD.

Results: Knowledge of AD was very weakly correlated with level of education and years living in Canada. In addition, there were no correlations between knowledge level and gender or subjective memory complaints.

Conclusions: The results suggest that Latin American seniors, in the Toronto community, are not knowledgeable about AD. In spite of showing subjective cognitive impairment the sample were not aware of the principal cause of their symptoms. Additional research is needed to develop better focused and specifically directed health promotion initiatives for the Latin American seniors living in the Toronto community.

Background: Many screening instruments for the diagnosis of dementia are not education and culture fair. In addition, despite good sensitivity and specificity, they result in unacceptable levels of false positives when used in the community. This study aimed to develop appropriate instruments for populations with low literacy and to consider strategies to reduce the false positive rates in low prevalence settings.

Methods: Activities of daily living, which are not influenced by education and culture, were used to develop a patient screen and an informant version to identify people with dementia. The instruments were validated in the hospital and in the community setting against the standards of DSM-IV and the education-adjusted 10/66 Dementia Research Group diagnosis of dementia.

Results: The instruments were administered to 90 patients attending a hospital and 101 subjects living in the community in Vellore, South India. The psychometric properties and inter-rater reliability of these screening instruments were good. While the sensitivity and specificity of the patient screen and the informant version were good their false positive rates were high in the community setting. However, the false positive rates reduced when these instruments were used in combination.

Conclusion: The patient screen and the informant version are short culture- and education-fair instruments. They reduce false positive rates, when used in combination in the community.

Background: Previous studies have found the Mini-mental State Examination (MMSE) predictive of capacity to consent to power of attorney and to enter into residential care. We aimed to assess the utility of the MMSE in predicting capacity to consent to research in elderly U.K. care home residents, to determine the optimal cut-point score, and to ascertain which items of the MMSE most predicted capacity.

Methods: Care home residents (n = 227) who had been recruited into a randomized controlled trial and assessed for capacity to consent were subsequently administered the MMSE and a measure of depression. A receiver operator characteristic (ROC) curve was generated and the maximal MMSE cut-point that best predicted capacity status determined. Multiple regression analyses were conducted to assess the effect of other variables on capacity status.

Results: The area under the ROC curve was 0.86 (p < 0.001, 95% CI 0.80–0.91). The optimal cut-point was 13/14, which provided a positive predictive value of 0.84 (0.79–0.89) and negative predictive value of 0.69 (0.62–0.75). The odds ratio of a MMSE score ≥14 predicting having capacity was 11.95 (6.03–23.94). Depression reduced the odds of having capacity (OR 0.32, 0.17–0.62, p = 0.001). All individual items of the MMSE apart from following a written command (“close your eyes”) had odds ratios significantly associated with capacity status. The item most associated with capacity status was being able to verbally repeat a sentence (“no ifs, ands, or buts”) correctly (OR 5.6, 95% CI 3.0–10.5).

Conclusions: The MMSE is predictive of capacity to consent to research and may have a role in guiding researchers in this domain. It should not, however, be used in lieu of a formal capacity assessment as even the optimal cut-point of 13/14 mislabeled 24% of capable subjects as lacking capacity, and 21% of incapable subjects as having capacity.

Background: This retrospective chart review evaluated a comparison of the clinical profiles of older outpatients having mania and those with unipolar depression.

Methods: The charts of elderly outpatients with mania and unipolar depression in tertiary care settings were reviewed and relevant information incorporated regarding clinical presentation, past and family history of affective disorder, treatment history and previous psychiatric and neurological history.

Results: Charts for 30 patients with mania (23 men and 7 women with mean (±SD) age of 68.5(± 5.75 years) and 92 with depression (47 men and 45 women with mean (±SD) age of 68.18 (±6.0 years) were evaluated. Fifteen patients (50%) with manic episodes had psychotic symptoms in the form of delusions and hallucinations while only 33 (35.8%) depressed patients had psychotic symptoms. One-third of manic patients received mood stabilizers at index visit. More than half (n = 16; 53.3%) of the patients in the mania group were prescribed antipsychotic medications. On cognitive functions, patients with manic episodes scored poorly compared with those with depression.

Conclusions: These findings suggest that mania in the elderly is a severe form of affective disorder with respect to psychotic and cognitive symptoms. Conclusions from this study are limited due to its retrospective design. Further studies in this area are warranted.

Background: To date, no single instrument has proved to be adequate for screening for Alzheimer's dementia (AD). The aim of this study was to identify a combination of instruments which were highly sensitive for screening late onset AD.

Methods: Subjects were drawn from the Vienna TransDanube Aging (VITA) study. This is an interdisciplinary, longitudinal community-based cohort study of the 21st and 22nd district of Vienna (Austria). Data refer to the cohort of 478 individuals at age 78 who took part in the first follow-up investigation of the VITA study. The psychometric instruments which were investigated were: the Ten-Point Clock Test, the Human-Figure Drawing Test, a Delayed Selective Reminding Test, Naming, the Trail Making Test-B, and Verbal Fluency. Further instruments were the Pocket Smell Test, and Subjective Memory Complaints. Data were analyzed using logistic regression analyses and cross validation.

Results: A combination of the Delayed Selective Reminding Test and Verbal Fluency was best for screening AD (R2 = 0.38, main model). An area under the ROC curve of 0.829 was reached. This model discriminated between subjects with incident AD and subjects who did not have incident AD with a sensitivity of 91% and a specificity of 56%.

Conclusion: The combination of an episodic memory test and a test of verbal fluency was an effective way of screening for AD.

Background: The objectives of this study were to examine the reliability and validity of a 26-point telephone version of the Cantonese Mini-mental State Examination (T-CMMSE) for a sample of 65 elderly patients, comprising 31 patients without dementia and 34 patients with dementia, in an acute regional hospital in Hong Kong, and to identify an optimal cut-off score to discriminate between those patients with dementia and those without.

Methods: Participants were rated by using the face-to-face Mini-mental State Examination (MMSE) before inpatient discharge and the T-CMMSE after inpatient discharge, and were rated separately by two raters in two telephone follow-up sessions using the T-CMMSE.

Results: The results of the study indicated that the scale had excellent inter-and intra-rater reliabilities. There was substantial agreement between the two versions of the examination (κ > 0.6–0.8 ≤) for orientation, registration, and recall items. An optimal cut-off score of ≤ 16 was suggested for the T-CMMSE to discriminate between those with and without dementia.

Conclusion: The T-CMMSE can be used in telephone follow-ups as an alternative to the conventional face-to-face version.

Background: Little is known about how cognitive domains other than episodic memory are affected during the mild cognitive impairment (MCI) stage of Alzheimer's disease (AD). We attempted to clarify this issue in this study.

Methods: Fifty-seven Japanese subjects were divided into two groups: one comprising people in the MCI stage of AD (MCI group, n = 28) and the other of normal controls (NC group, n = 29). Cognitive functions were assessed using the Japanese version of the neurobehavioral cognitive status examination (J-COGNISTAT).

Results: The MCI group performed significantly worse than the NC group on subtests that assessed orientation, confrontational naming, constructive ability, episodic memory, and abstract thinking. Three-quarters of the MCI group had deficits in memory and other non-mnemonic domains, particularly constructive ability and abstract thinking. However, within-subject comparisons showed that the MCI group performed significantly worse on the memory subtest compared to any other subtest.

Conclusions: Besides episodic memory, multiple non-mnemonic cognitive domains, such as constructive ability and abstract thinking, are also impaired during the MCI stage of AD; however, these non-mnemonic deficits are smaller than episodic memory impairment.

Background: Several follow-up [18F]fluorodeoxy glucose (FDG)-positron emission tomography (PET) studies have been performed in patients with mild cognitive impairment, but none have examined subjects with a Clinical Dementia Rating (CDR) of 0.5. Therefore, we used FDG-PET to investigate whether baseline glucose metabolism (CMRglc) in CDR 0.5 converters to dementia showed changes consistent with early Alzheimer's disease (AD).

Methods: Based on our earlier study, which we refer to as Prevalence Study 1998, we were able to examine 14 CDR 0, 42 CDR 0.5, and 12 AD subjects with PET and follow these subjects for five years. Baseline neuropsychological and CMRglc values were compared among groups of CDR 0, CDR 0.5/converters, CDR 0.5/non-converters, and AD subjects.

Results: All CDR 0 subjects were reassessed as CDR 0 after the five-year period. For CDR 0.5 subjects, 20 had converted to AD and 22 remained as CDR 0.5. In cognitive tests, CDR 0.5/converters showed significantly deteriorated recent memory function compared with CDR 0.5/non-converters at the baseline evaluation. Most brain areas showed decreased CMRglc in AD patients. CDR 0.5/converters had a significantly lower baseline CMRglc in the right cingulate, left inferior parietal and left temporal gyrus compared with CDR 0.5/non-converters.

Conclusions: Our findings suggest that CDR 0.5/converters have a baseline metabolic decline in areas that might be specific to AD.

Background: Behavioral and psychological symptoms of dementia (BPSD) cause caregiver distress and earlier institutionalization. We compared the prevalence and characteristics of BPSD between institution residents and memory clinic outpatients with Alzheimer's disease (AD) to test the hypothesis that there is more BPSD among institution residents than among their outpatient counterparts.

Methods: We assessed BPSD by interviewing the patients’ principal caregivers, either family or professionals, using the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). Data from 138 patients with probable AD from the memory clinic and 173 residents with possible AD living in the long-term care facilities were collected. The diagnoses followed the NINCDS-ADRDA criteria.

Results: BPSD profiles of the two groups were similar but not identical. The prevalence of at least one BPSD was high in both groups (community 81.9%, institution 74.9%). Activity disturbance was the most frequently reported BPSD in both groups (community 52.2%, institution 38.7%). Delusions, hallucinations, anxiety and aggressiveness were seen more frequently in memory clinic outpatients. The outpatients also had higher scores of BEHAVE-AD subscales in delusion/paranoid ideation, affective disturbance, and global rating of severity. With the increase of disease severity there were significantly more activity disturbance, psychosis, and aggressiveness in patients with AD.

Conclusions: Caregiver factor and institution effect were two possible reasons for the higher prevalence and the greater severity of BPSD in community patients. BPSD caused more distress to family caregivers than the professional caregivers. High levels of psychotropic prescriptions for patients living in the long-term care facilities may also play a role.

Background: The reported decline in elderly suicide rates in England may have been, in part, due to prompt and successful resuscitation of those who attempt suicide. This study examines the impact of prompt and successful resuscitation of those who attempt suicide on elderly suicide rates in England.

Methods: Possible changes in rates of attempted suicides in elderly age-bands over a nine-year period and the correlation between rates of attempted suicide and suicide in elderly age-bands in England were examined using nationally collected data.

Results: There was a significant increase in the rates of attempted suicide over the study period in the age-band 60–74 years, but not in the age-band 75+ years. There was a positive correlation between rates of attempted suicide and suicide in the age-band 75+ years, but not in the age-band 60–74 years.

Conclusions: The findings of this study were unable to confirm conclusively that prompt and successful medical resuscitation of those who attempt suicide makes a contribution to the decline in elderly suicide rates and requires further study. Public health initiatives should be designed to reduce not only suicide rates but also rates of attempted suicide; otherwise they are failing in the prevention of mental illness and suicidal behavior, early identification and treatment of those with mental illness and those at risk of suicide, and systematic follow-up of those recovering and recovered from mental illness.

Background: Increasing evidence suggests that neprilysin (NEP) may be the major degrading enzyme of amyloid beta (Aβ) in the brain and the NEP gene has been proposed as a candidate gene for Alzheimer's disease (AD). Association results between the NEP gene and AD are still preliminary. This study investigates the effect of the polymorphisms of −204G/C and 159C/T in the NEP gene on the development of sporadic Alzheimer's disease (SAD) in a southern Chinese community.

Method: 236 sporadic late-onset AD patients were recruited from Guangzhou Psychiatric Hospital in southern China, and 332 healthy elderly controls were enrolled from three old age homes in suburban Guangzhou. NEP and ApoE genotype were determined by PCR–RFLP.

Results: No differences in genotypic and allelic frequencies of −204G/C and 159C/T polymorphisms in NEP were found between AD and control group (for −204G/C genotype: χ2 = 2.34, P > 0.05; for allele: χ2 = 2.31, P > 0.05; for 159C/T genotype: χ2 = 1.34, P > 0.05; for allele: χ2 = 0.88, P > 0.05). Neither was any difference found in genotypic and allelic frequency when stratified by sex or by ApoE ε4 allele (P > 0.05).

Conclusions: Our results suggest that −204G/C and 159C/T polymorphisms of the NEP gene may not be associated with SAD. Moreover, both sex and ApoE ε4 allele do not affect the distribution of NEP gene polymorphisms.

Background: Alzheimer's disease (AD) is a neurodegenerative disease with a higher prevalence in women. Expression of estrogen receptor 1 (ESR1) gene has been identified throughout the brain. Owing to the putative neuroprotective effects of estrogen, estrogen receptor gene is a potential candidate modulating the development of AD. Preliminary associations between two polymorphisms of ESR1 (PvuII and XbaI) gene and AD have been reported.

Methods: In this study, 16 single nucleotide polymorphisms (SNPs) of the ESR1 gene (including four commonly studied ESR1 SNPs and 12 other tagging SNPs selected from the HapMap database) were investigated to further evaluate the association between ESR1 polymorphisms and the risk of AD in the Chinese population.

Results: A total of 233 Chinese AD patients and 245 age-matched elderly control subjects were recruited. Genetic associations were analyzed by chi-square test and interaction effect was analysed by logistic regression analysis. Five SNPs (clustered between intron 3 and intron 7) were associated with the risk of AD (p-value ranges from 0.001 to 0.035); another two SNPs (located on exon 2 and intron 2) were shown to modulate the age-at-onset (AAO) in AD (p-value = 0.036 and 0.011).

Conclusions: ESR1 gene polymorphisms may be associated with the AAO in AD. The present results provided information for possible associations between certain polymorphisms of ESR1 gene and the risk of AD.

Background: Patients with Alzheimer's disease (AD) and concomitant atrophy of the hippocampus may be extra vulnerable to the consequences of psychological distress, leading to greater decline in memory function. The present study investigated whether symptoms of anxiety and depression predict decline of memory function in elderly people diagnosed with early stage AD.

Methods: A sample of 44 elderly people diagnosed with early stage AD was tested on their memory function, anxiety and depression and confounding variables with one year follow-up. Episodic memory was measured with a modified Dutch version of the Auditory Verbal Learning Test (AVLT) which measures learning and recall abilities. Linear regression analyses were used to investigate the association between anxiety and depressive symptoms and decline of memory function.

Results: Anxiety symptoms predicted a smaller decline in learning on the AVLT. Anxiety symptoms did not predict decline on the recall of the AVLT. No association was found between depressive symptoms and decline in either learning or recall of the AVLT.

Conclusions: In early AD, symptoms of anxiety and depression generally seem to be mild, and do not accelerate decline of memory function over time. On the contrary, anxiety symptoms were found to predict a smaller decline in memory function.

Objective: The purpose of the present study was to investigate the influence that education and depression have on the performance of elderly people in neuropsychological tests.

Methods: The study was conducted at the Institute of Psychiatry, University of São Paulo School of Medicine, Hospital das Clínicas. All of the individuals evaluated were aged 60 or older. The study sample consisted of 59 outpatients with depressive disorders and 51 healthy controls. We stratified the sample by level of education: low = 1–4 years of schooling; high = 5 or more years of schooling. Evaluations consisted of psychiatric assessment, cognitive assessment, laboratory tests and cerebral magnetic resonance imaging.

Results: We found that level of education influenced all the measures of cognitive domains investigated (intellectual efficiency, processing speed, attention, executive function and memory) except the Digit Span Forward and Fuld Object Memory Evaluation (immediate and delayed recall), whereas depressive symptoms influenced some measures of memory, attention, executive function and processing speed. Although the combination of a low level of education and depression had a significant negative influence on Stroop Test part B, Trail Making Test part B and Logical Memory (immediate recall), we found no other significant effects of the interaction between level of education and depression.

Conclusion: The results of this study underscore the importance of considering the level of education in the analysis of cognitive performance in depressed elderly patients, as well as the relevance of developing new cognitive function tests in which level of education has a reduced impact on the results.

Background: A third of family carers of people with dementia describe acting abusively in research studies, but far fewer cases of abuse are currently detected in clinical situations. This discrepancy may be explained by inadequate detection by health professionals, or disagreement regarding what constitutes elder abuse. This study was undertaken to determine the sensitivity and specificity of the revised Modified Conflict Tactics Scale (MCTS) for detecting clinically significant abuse.

Methods: We interviewed 220 family carers of people consecutively referred to psychiatric services with dementia in Essex and London (U.K.), using the MCTS to measure abuse. We defined abuse cases using (1) the MCTS conventional scoring system; (2) the Pillemer criteria; and (3) clinical judgment of an expert panel.

Results: Our panel judged that 15 (6.8%) of carers reported potentially clinical concerning abusive behavior; but 47 (21%) were cases according to the Pillemer criteria and 74 (34%) using the MCTS conventional scoring system. We developed a weighted MCTS scoring system, with high sensitivity and specificity for detecting clinically concerning abuse.

Conclusions: The MCTS could be used routinely in clinical practice with carers of people with dementia to detect clinically concerning cases of abuse, many of which are currently being missed.