Good health care, readers of this journal know, requires more than the physician practicing “evidence-based” medicine, using the wizardry of modern technology in combination with honed diagnostic skills to identify medical troubles and their treatment. It depends on the physician's understanding of the patient's emotional and social needs, and requires skill and sensitivity in relating to patients and their family members.

Background: Cognitive stimulation, training or rehabilitation can achieve modest, skill-specific gains in cognitively healthy older adults. With regard to the limited efficacy of currently available anti-dementia drugs it is crucial to investigate whether such treatments also provide clinically meaningful benefits to cognitively impaired older individuals.

Methods: We conducted a systematic review of randomized controlled trials evaluating cognition-focused interventions in participants with mild cognitive impairment or dementia. Meta-analytic strategies were used to calculate effect sizes.

Results: Cognition-focused interventions confer small and inconsistent effects on trained cognitive skills which, according to some studies, translate into gains on general cognitive ability. Instruments measuring such effects such as the Mini-Mental State Examination (MMSE) or the Alzheimer's Disease Assessment Scale, cognitive part (ADAS-Cog) show standardized mean differences of 0.20 and 0.30, respectively, which are comparable with those of current antidementia drug treatments. However, convincing evidence of clinical significance was only obtained from single trials in terms of delay of cognitive decline, improvement in activities of daily living, or enhanced attainment of personally relevant goals.

Conclusions: The potential of cognition-focused interventions has probably been obscured by the methodological inconsistencies and limitations of the clinical studies conducted thus far. Further randomized controlled trials on the efficacy of these treatment modalities are required using optimized and consistent methods. Emphasis should be placed on tailoring interventions to individual needs and resources while maintaining a high level of standardization, on implementing newly acquired skills and strategies in the everyday context, on appropriate treatment duration, and on including person-centered outcomes.

Background: Ideally putative disease-modifying therapies for Alzheimer's disease (AD) should be tested in patients who have minimal morbidity. Current barriers to such trials in early disease include the lack of disease-specific early biomarkers, insensitivity of quantitative cognitive outcome measures, and expensive trial designs requiring large sample sizes and long duration. This paper describes principles and progress towards a novel trial design that overcomes these problems, utilizing wide-scale cognitive performance screening to define pre-trial cognitive decline trajectories which can serve as trial outcome measures to assess AD disease-modifying efficacy.

Methods: Theoretical principles important for the detection of intra-individual cognitive decline and a practical example are described.

Results: Serial evaluations of community-based volunteers demonstrate how a screening tool method to detect subtle cognitive decline can predict in vivo amyloid pathology as a trigger for etiological evaluation. Trajectories of decline appear consistent over at least two years, suggesting they could be used as a trial inclusion criterion and ameliorable outcome measure together with other AD biomarkers. Informative trial durations could be 6–12 months, or extend to incorporate staggered random withdrawal or start designs, with as few as 20 individuals per treatment arm.

Conclusions: This trial methodology offers significant advantages over current AD trial designs, including treatment at earlier stages of disease, shorter trial duration, obviation of informed consent difficulties, smaller sample sizes, reduced cost and – given adequate screening programs – sufficient subjects for multiple simultaneous trials. Importantly, it allows the rapid evaluation of putative treatments that may only be efficacious in pre-dementia states.

Background: It has been suggested that hypercortisolism contributes to the pathophysiology of Alzheimer's disease (AD), based on the fact that excess glucocorticoid exposure has potent adverse effects on the central nervous system. In contrast, dehydroepiandrosterone (DHEA) has been linked to a broad range of beneficial physiological effects including neuronal excitability and neuroprotection and even memory enhancing properties. Of note, proinflammatory cytokines are present in neuritic plaques (a hallmark of AD) and may regulate cortisol/DHEA release. In this exploratory study, we hypothesized that there is a flattened diurnal curve of cortisol and DHEA in mild to moderate AD, linked to increased cytokine levels.

Methods: Diurnal profiles of cortisol, adrenocorticotropic hormone (ACTH), and DHEA were studied in 15 patients with mild to moderate AD (7 men and 8 women, 75.6 ± 5.5 years) and 15 healthy elderly controls (7 men and 8 women, 73.3 ± 5.8 years, respectively). Interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and soluble TNF receptors were analyzed.

Results: Women with AD had significantly increased morning levels of ACTH, DHEA, and IL-6 compared to healthy elderly women. Cortisol levels were significantly increased in men with AD at 0300 h versus healthy elderly men, in spite of slightly decreased ACTH levels.

Conclusions: Our data suggest important sex differences in hypothalamic–pituitary–adrenal (HPA) axis regulation and steroid hormone clearance in patients with AD. Increased secretion of IL-6 may have a contributory role in this difference.

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

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

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

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

Background: The objective of this study was to investigate the relationship between social network and cognitive decline, taking into account the potential bias of reverse causality.

Methods: The study sample comprised 2055 elderly participants without dementia. We assessed baseline social functioning across four variables: size of social network, satisfaction with relationships, perception of being understood, and participation in social activities. A neuropsychological battery was proposed at baseline and repeated throughout follow-up. Linear mixed models were used to investigate the relationship between social network and baseline cognitive performances and cognitive decline during the 20-year follow-up.

Results: When controlling for the reverse causality bias by excluding participants who developed dementia during the study follow-up and after adjusting for covariates, the results showed that better social functioning at baseline was associated with better initial performances in the Isaacs Set Test and the Wechsler Paired Associate Test. However, there was no significant association with further cognitive decline. By contrast, when the bias of reverse causality was not controlled for (i.e. no exclusion of participants who developed dementia), the association between social network and global cognitive decline measured by MMSE was found to be statistically significant.

Conclusion: With the opportunity to exclude participants who developed dementia, and the particularly long follow-up of participants, we were able to investigate the relationship between social networks and age-related cognitive decline with a minimization of reverse causality bias. The results suggest that even though higher social functioning is concomitantly associated with better cognitive performances, it may not prevent subsequent decline.

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.

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: This study investigated whether brief exposure to information has any effect on stigmatizing attitudes towards older people with dementia, and how people responded to this medical diagnosis.

Methods: 494 adults were randomly assigned to three groups differentiated by experimental conditions. Group A (control) responded to questions on stigma directly. Group B (symptom) read two vignettes that described the symptoms of two fictitious individuals with dementia, before answering questions on stigma. Group C (label) read the same vignettes which ended with a statement that the person was recently diagnosed with dementia by a physician. Data were analyzed with ANOVA, together with other pre-existing between-subjects factors.

Results: Brief exposure to information about dementia led to a statistically significant reduction in stigma (Groups B, C < A), regardless of whether the diagnostic label of “dementia” was included or not. Moreover, lower stigma was reported by persons who knew a relative or friend with dementia, who were younger and more educated, and who thought dementia was treatable.

Conclusions: As stigmatizing attitudes toward dementia are still a hindrance to early help-seeking in Asian communities, the findings suggest that community education may play a useful role in alleviating this barrier to early detection and intervention.

Background: Using a representative secondary care survey for the first time, we explored family carers’ reasons for providing care. We hypothesized that carers with a positive rather than negative motivation for caring would be less abusive towards the care recipient and more likely to be caring for someone still living at home a year later.

Methods: We interviewed 220 consecutively referred dementia family/friend carers from UK Community Mental Health Teams. We asked non-spousal carers why they were the main carer. Our main outcomes were the revised Modified Conflict Tactics Scale scores, measuring abusive behavior by the carer, and admission of the person with dementia to a care home.

Results: Nineteen (17.1%) said they were the main carer due to the high quality of their relationship with the care recipient, their willingness to take on or their suitability for the carer role. A further 22 (19.8%) said they were the main carer due to other potential carers’ negative relationship with the care recipient, unwillingness or lack of suitability for the role. Carers who gave the latter explanation tended to be more anxious at baseline (F = 3.0, p = 0.055), reported higher abusive behavior towards the care recipient a year later after controlling for sociodemographic variables (t = 2.0, p = 0.05), and their care recipient was more likely to be admitted to a care home in the following year (hazards ratio 9.9, p = 0.040).

Conclusions: We found preliminary evidence that carers’ reasons for providing care predict the well-being of the care recipient. Future studies involving dementia family carers should consider asking why the main carer assumed this role.

Background: There is abundant literature on the determinants of caregiver burden in Alzheimer's disease (AD), but little is known about the possible implication of specific patterns of a caregiver's attitudes towards the disease that could increase their risk of – or protect them from – emotional distress and burden. The aim of this study was to test the hypothesis that negative attitudes towards AD are associated with an increased level of burden experienced by caregivers of AD patients.

Methods: Family caregivers of 51 patients with AD were asked to complete a questionnaire regarding their attitudes towards AD. In addition, we assessed the level of their quality of life, anxiety and depression as well as their perceived level of burden. In parallel, we documented the patients’ characteristics: global cognitive efficiency (Mini-Mental State Examination), behavioral and affective symptoms (Neuropsychiatric Inventory) and functional level (Instrumental Activities of Daily Living).

Results: The score of caregiver burden was positively correlated with negative attitudes such as authoritarianism (r = 0.41, p < 0.01) and social restrictiveness (r = 0.49, p < 0.001) as well as emotional reactions of anxiety (r = 0.44, p < 0.01) and aggressiveness (r = 0.47, p < 0.001). In addition, scores of social restrictiveness, rejection and anxiety were significantly higher in women than in men.

Conclusion: These results may have implications in terms of the prevention of caregiver burden. In particular, educational and support programs for caregivers should not be limited to developing their knowledge and skills but should also target attitudes towards the disease.

Background: Sleep disturbance is a common consequence of providing care to a loved one with Alzheimer's disease (AD). We explored the usefulness of the Pleasant Events and Activity Restriction (PEAR) model for predicting multiple domains of sleep disturbance.

Methods: Our sample consisted of 125 spousal AD caregivers. Participants completed the Pittsburg Sleep Quality Index (PSQI) and were questioned regarding the frequency with which they engaged in pleasant events and the extent to which they felt restricted in engaging in social and recreational activities in the past month. Participants were classified into one of three groups: HPLR = High Pleasant Events + Low Activity Restriction (= reference group; N = 38); HPHR/LPLR = either High Pleasant Events + High Activity Restriction or Low Pleasant Events + Low Activity Restriction (N = 52); and LPHR: Low Pleasant Events + High Activity Restriction (N = 35). These three groups were compared on the seven subscales of the PSQI.

Results: Significant differences were found between the HPLR and LPHR groups on measures of subjective sleep quality, sleep latency, habitual sleep efficiency, sleep disturbance, and daytime dysfunction. Additionally, significant differences were found between the HPLR and HPHR/LPLR groups on subjective sleep quality, sleep latency, and habitual sleep efficiency, and between the HPHR/LPLR and LPHR groups on sleep disturbance and daytime dysfunction.

Conclusions: This study provides broad support for the PEAR model and suggests that interventions focusing on behavioral activation may potentially provide benefits to non-affective domains including sleep.

Background: The purpose of this study was to investigate the impact of caregivers’ appraisals of the effectiveness of their own communication strategies on caregiver burden when caring for family members with Alzheimer's disease (AD).

Methods: Family caregivers (N = 84) of participants with AD completed questionnaires appraising communication strategies, problem behaviors, and levels of three types of burden.

Results: Hierarchical linear regression models revealed that effective strategies and kinship status were significantly linked with stress burden, whereas effective strategies and problem behaviors were significantly related to relationship burden. Cognitive status of participants with AD significantly predicted objective burden. Caregivers who rated effective strategies as helpful were more likely to experience lower levels of stress and relationship burden.

Conclusions: Findings provide preliminary support for understanding mechanisms by which the appraisals of communication strategies influence caregiver burden and justify testing empirically derived communication interventions.

Background: Dementia research often requires the participation of people with dementia. Obtaining informed consent is problematic when potential participants lack the capacity to provide it. We investigated comfort with proxy consent to research involving older adults deemed incapable of this decision, and examined if comfort varies with the type of proxy and the study's risk-benefit profile.

Methods: We surveyed random samples of five relevant groups (older adults, informal caregivers, physicians, researchers in aging, and Research Ethics Board members) from four Canadian provinces. Respondents were presented with scenarios involving four types of proxies (non-assigned, designated in a healthcare advance directive with or without instructions specific to research participation, and court-appointed). Given a series of risk-benefit profiles, respondents indicated whether they were comfortable with proxy consent to research for each scenario.

Results: Two percent of the respondents felt proxy consent should never be allowed. In all groups, comfort depended far more on the risk-benefit profile associated with the research scenario than with type of proxy. For research involving little or no risk and potential personal benefits, over 90% of the respondents felt comfortable with substitute consent by a designated or court-appointed proxy while 80% were at ease with a non-assigned proxy. For studies involving serious risks with potentially greater personal benefits, older adults and informal caregivers were less comfortable with proxy consent.

Conclusions: A large majority of Canadians are comfortable with proxy consent for low-risk research. Further work is needed to establish what kinds of research are considered to be low risk.

Background: This is the first study to investigate the associations between chronic health conditions of older people and their impact on co-resident psychological morbidity using population-based samples in low and middle income countries (LAMICs).

Methods: Single-phase cross-sectional catchment area surveys were undertaken in urban sites in Cuba, Dominican Republic and Venezuela, and in rural and urban catchment areas in Mexico, Peru, India and China. All residents aged 65 years and over were interviewed with a co-resident key informant. Exposures were structured clinical diagnoses (10/66 and DSM-IV dementia and ICD-10 depression), self-reported diagnosis (stroke) and physical impairments. Mediating variables were dependence and disability (WHODAS 2.0), and the outcome was co-resident psychological morbidity assessed using SRQ-20.

Results: Poisson regression analysis was used to estimate the prevalence ratios (PRs) for the associations between health conditions and psychological morbidity in each site, and meta-analysis was used to pool the estimates. 11,988 pairs comprising a participant and a co-resident informant were included in the analysis. After meta-analysis, independent effects were noted for depression (PR2.11; 95% CI 1.82–2.45), dementia (PR 1.98; 95% CI 1.72–2.28), stroke (PR 1.42; 95% CI 1.17–1.71) and physical impairments (PR 1.17; 95% CI 1.13–1.21). The effects were partly mediated through disability and dependence. The mean population attributable fraction of total chronic conditions was 30.1%.

Conclusion: The prevalence of co-resident psychological morbidity is higher among co-residents of older people with chronic conditions. This effect was prominent for, but not confined to, depression and dementia. Attention needs to be directed to chronic conditions.

Background: The objectives of this study were to characterize the psychiatric comorbidity of a group of older subacute inpatients and then determine whether their psychiatric comorbidity affected measures of rehabilitation outcomes.

Methods: Eighty-eight older subacute inpatients were recruited for this prospective study. Psychiatric comorbidity was defined according to a participants' performance on four inventory scales: the Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), Brief Psychiatric Rating Scale and Health of the Nation Outcome Scale 65+. Rehabilitation outcome referred to the participants' length of stay and their performance at discharge on the EuroQol-5D health-related quality of life questionnaire and Barthel index.

Results: 68% of the participants scored in the clinical range on at least one of the four scales assessing psychiatric comorbidity at admission, with 51% in the clinical range for GDS and 32% for the GAI. The decrease in scores by the time of discharge was significant for all four scales. Linear regression analyses pointed to a trend for depressive symptoms at admission to be an influential but nonsignificant predictor of rehabilitation outcome. An interesting association was found between the length of the previous acute admission and the GDS score on admission to the subacute unit.

Conclusion: A high prevalence of psychological symptoms was identified upon admission, with a significant decrease by the time of discharge. These factors did not significantly predict the selected measures of rehabilitation outcome. Opportunities for future longitudinal research on the prevalence and impact of psychiatric comorbidities on patient outcomes are considered.

Background: Antipsychotics are frequently used to treat psychosis, aggression and agitation in patients with Alzheimer's disease (AD), but safety warnings abound. Escitalopram was investigated since citalopram has demonstrated some effectiveness in AD. We compared escitalopram and risperidone for psychotic symptoms and agitation associated with AD.

Methods: Inpatients with AD, who had been hospitalized because of behavioral symptoms, were recruited to a six-week randomized, double-blind, controlled trial. Participants (n = 40) were randomized to once daily risperidone 1 mg or escitalopram 10 mg.

Results: The NPI total score improved in both groups. Onset was earlier in the risperidone-treated group, but improvement did not significantly differ between groups by study end. Completion rates differed for escitalopram (75%) and risperidone (55%), mainly due to adverse events. There were no adverse events in the escitalopram group, while in the risperidone group two patients suffered severe extrapyramidal symptoms and four patients suffered acute physical illness necessitating transfer to general hospital.

Conclusion: Escitalopram and risperidone did not differ in efficacy in reducing psychotic symptoms and agitation in patients with AD. Completion rates were higher for escitalopram-treated patients. Replication in larger trials with ambulatory patients is needed.

Background: This study aimed to explore changes in patterns of use of psychotropic medication in Sydney nursing homes over recent years, and to compare current usage rates with those reported from other countries.

Methods: Data were obtained from 44 of the 48 nursing homes in a central Sydney health area. Researchers noted details from medication cards concerning residents’ age, gender and all currently prescribed drugs, checking whether medication had been given as prescribed. Frequency of administration of “as required” drugs in the previous four weeks was noted.

Results: The pattern of use of psychotropic medication changed considerably between 1993 and 2009. The number of residents taking regularly administered antipsychotics increased by 24% during 1998–2009, though mean dosages decreased. In 2009, fewer residents took hypnotic and/or anxiolytic medications than in the 1990s, and fewer than in countries from which equivalent data have been reported. Antidepressant use increased over the 16 years but only to 25.6%. Only 3% of residents in Sydney nursing homes in 2009 took cognition-enhancing drugs.

Conclusions: Compared to other countries, rates of use of hypnotic, anxiolytic and antidepressant medication in Sydney nursing homes are low. Benefits and disadvantages of these differences merit analysis. Antipsychotic medications were administered to similar percentages of survey residents in 1993 and 2009, but at lower mean dosages in 2009 compared to previous surveys, and with a change to using mainly atypical antipsychotic drugs. Compared to various other countries, cognition-enhancing and antidepressant medications are administered to proportionally fewer residents in Sydney nursing homes. Outcome analysis regarding the use and benefits of such drugs in nursing homes is desirable.

In the Netherlands, as well as in other countries, nursing home care has been traditionally modeled on hospital care. However, in the last decades of the twentieth century, realization grew that, unlike hospitals, nursing homes needed to serve as literal homes to people. As a consequence, the concept of group living homes for older people with dementia has taken root.