Diagnostic tools for general practitioners and specialists

Background: Comorbidities and polypharmacy are highly prevalent in older adults. Many medications have anticholinergic properties, whose cumulative effect, known as anticholinergic burden (AB), may impair cognitive health, especially among older adults. Most evidence comes from single-center studies in high-income countries, with no prior multicenter research in Latin America. Objective: To investigate whether AB is independently associated with questionable cognitive impairment and with cognitive and functional measures in older adults from the LatAm-FINGERS study. Methods: This study included 1,243 participants aged 60–77 from 12 Latin American countries, without dementia (CDR=0–0.5), and complete baseline clinical/neuropsychological data. Measures included the Anticholinergic Cognitive Burden (ACB) scale, Clinical Dementia Rating (CDR), Mini-Mental State Examination (MMSE), Instrumental Activities of Daily Living (IADL), and Cognitive Function Index (CFI). Results: The mean education level of the population studied was 13.28 years. ACB was negatively associated with MMSE and positively with CDR-SB and CFI (p=0.030, 0.007, and 0.001, respectively). No association was found with IADL (p=0.403). Each ACB point increased the odds of scoring 0.5 on CDR Global by 28% (OR=1.28; 95%CI 1.05–1.56; p=0.015). Discussion: Our findings support that AB plays a significant role in cognitive performance, and subjective cognitive decline, and increases the likelihood of scoring in CDR, even when controlled for major confounders. Conclusion: AB might be a relevant predictor of cognitive impairment and probably mediates the negative effects of polypharmacy in the LatAm-FINGERS cohort.

The Mini-Mental State Exam (MMSE) is a brief cognitive test that assesses several cognitive domains, such as orientation, attention, concentration, memory, language, and constructional abilities. While the MMSE was found to be valid and reliable in the diagnosis of moderate dementia, its sensitivity and specificity for the diagnosis of mild dementia has been rarely examined. We assessed the specificity and sensitivity of the MMSE in a consecutive series of 44 patients with mild dementia, and a group of age-comparable normal controls. While the specificity of the MMSE for the diagnosis of mild dementia was very high (100%), the sensitivity was only 55% [20 of the 44 patients with mild dementia had an MMSE score in the normal range (≥26 points)]. On the other hand, the assessment with both the Buschke Selective Reminding and the Boston Naming tests discriminated mild Alzheimer's disease patients with normal MMSE scores from controls with a sensitivity and specificity of 64%. In conclusion, the assessment with verbal memory and naming tasks provided a significantly more sensitive measure of early dementia than the MMSE.

This trial aimed to test whether education and audit can change documentation of dementia by general practitioners (GPs). We measured the number of new dementia diagnoses documented and Mini Mental State Examinations (MMSEs) performed following the interventions of education and audit, using electronic data for audit and outcomes. GPs in Mackay were randomly assigned to the interventions of either an educational workshop or education combined with audit of their documented dementia diagnoses and MMSE performed in electronic medical records. The results were compared with a control group of GPs in Townsville. Together with education, audit significantly improved documentation of dementia compared with education alone and a control group. We developed a data extraction tool for Medical Director (MD) software producing a report of dementia diagnoses, MMSE tests and practice population at risk of dementia. General practitioners participating in this project were likely to be motivated to learn about dementia. Education using Royal Australian College of General Practitioners’ (RACGP) guidelines and audit using an IT extraction tool can improve computer documentation of dementia. Differences in practice software and past adverse experiences with new software were barriers to using our data extraction software for audit purposes.

A national survey on health-related quality of life for people with dementia in residential long-term care institutions

BackgroundThis study investigated whether a 24-week, community-based multicomponent exercise intervention (MCEI) can improve body composition and cognitive function in older adults with mild cognitive impairment (MCI).MethodsIn this single-center, parallel-group randomized controlled trial (RCT), 64 community-dwelling adults aged 65–75 years with MCI characterized by Mini-Mental State Examination (MMSE) ≥ 24, Montreal Cognitive Assessment (MoCA) ≤ 26, Clinical Dementia Rating (CDR) = 0.5, low skeletal muscle mass were randomly allocated (1:1) to a MCEI (aerobic, resistance and balance training, 3 × 60 min/week) or to a usual-activity control (UAC) group receiving weekly health education. Primary outcomes were skeletal muscle mass (SMM), fat-mass index (FMI), MMSE and MoCA; secondary outcomes included skeletal muscle index (SMI), basal metabolic rate (BMR), Instrumental Activities of Daily Living (IADL) and Animal Fluency Test (AFT). Assessments were conducted at baseline and within 1 week post-intervention by trained, blinded assessors. Intervention effects were examined with a 2 (group) × 2 (time) repeated-measures analysis of variance (ANOVA), reporting partial eta-squared (η2) as the effect-size estimate.ResultsA significant Group × Time interaction was observed for SMM (p < 0.001, η2 = 0.195) and FMI (p = 0.003, η2 = 0.153), indicating differential changes between groups; with significant improvements observed only in the MCEI group. SMI showed no significant interaction effect (p = 0.270, η2 = 0.021), whereas no significant interactions were found for MMSE, MoCA, or AFT (p ≥ 0.18, η2 ≤ 0.03).ConclusionA 24-week community-based multicomponent exercise program safely increased skeletal muscle mass and reduced fat mass in older adults with MCI, but did not produce measurable improvements on screening-level cognitive measures. Future studies with longer duration, larger samples, and inclusion of cognitive challenges are warranted to clarify exercise–cognition interactions and establish dose–response relationships for both body composition and domain-specific cognition.Clinical trial registrationIdentifier ChiCTR2000035012.

Objective To investigate the characteristics of cognitive impairment and psychotic symptoms in general paresis of insane (GPI) before and after penicillin therapy, and explore factors that may predict the clinical outcomes. Methods Thirty patients with GPI were recruited. All GPI patients underwent a comprehensive neuropsychological assessment before receiving penicillin therapy, and returned for follow-up visits after 7 months. The severity of dementia was determined by Clinical Dementia Rating Scale (CDR), cognitive functions were assessed by Mini Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-Cog), ability of daily living was assessed by Instrumental Activities of Daily Living Scale (IALD) and Physical Self maintenance Scale(PSMS), behavioral and psychological symptoms were assessed by Neuropsychiatric Inventory (NPI). Aqueous crystalline penicillin G 24 million units per day was administered as continuous infusion for 14 days, followed by benzathine penicillin 2.4 million units IM once per week for 3 weeks. Patients returned for follow-up visits after 7 months. Clinical outcomes were determined by the improvement of neuropsychological test scores at the end of the treatment. Grouped by CDR scores, changes in neuropsychological tests scores among different GPI groups were used to explore the correlation between severity of dementia and clinical outcomes. Univariate analysis and multivariate linear regression analysis were used to identify factors that may predict the clinical outcomes. Results (1)After penicillin therapy, GPI patients' MMSE scores (14.4±6.9 vs.17.1±9.1) and IADL scores (4.0 (2.0, 5.0) vs.6.0 (2.0, 7.3) ) both improved significantly (t=5.820, Z=3.710, P 1,significant change was found only in total scores of NPI (t=-3.772,P<0.05) . (3) Univariate analysis and multivariate linear regression analysis showed that improvement of MMSE scores after the treatment was significantly correlated with IADL scores and MMSE scores at baseline (β=0.541, P=0.004; β=0.364, P=0.044) . Conclusions After penicillin treatment, GPI patients may improve in both cognitive function and psychotic symptoms but not in all the domains. Symptoms of anxiety, sleep/nigh-time behavior change, and apathy, as well as moderate to severe GPI patients may not benefit much from the treatment. Key words: Neurosyphilis; Cognition disorders; Neurobehavioral manifestations; Therapy; Prognosis

The aim of the present study was to explore the magnetic resonance imaging correlates of the performance of instrumental activities of daily living (IADL) in patients with Alzheimer's disease combined with cerebrovascular disease. A total of 66 patients with Alzheimer's disease combined with cerebrovascular disease formed the study sample. Two regression models were constructed to find correlates of IADL. Model 1 only included clinical variables and model 2 included both clinical and magnetic resonance imaging variables. In model 1, with IADL as the dependent variable, the Mini-Mental State Examination (MMSE) score, Physical Self-Maintenance Scale score at baseline and age were significant correlates accounting for 40.1% of the variance of IADL at baseline. MMSE score and age were also significant correlates of IADL at 6 months, accounting for 38.1% of the variance of it. In model 2, severity of white matter lesions, MMSE and Physical Self-Maintenance Scale scores at baseline significantly correlated with IADL at baseline, accounting for 52.1% of the variance of the dependent variables; severity of white matter lesions and MMSE significantly correlated with IADL at 6 months, accounting for 41.5% of the variance of the dependent variables. In patients with Alzheimer's disease combined with cerebrovascular disease, subcortical ischemic lesions might be significant contributor to the functional status.

ABSTRACTObjective: Despite response variability, cholinesterase inhibitors are recommended in mild to moderate Alzheimer's disease. Dose titration is common; however randomized controlled trials (RCTs) have mainly investigated fixed-dose regimens. We examined practice patterns and outcomes of 6 ± 1.5-month rivastigmine therapy.Methods: Prospective, pharmacoepidemiologic, naturalistic study of 175 evaluable patients with mild to moderate Alzheimer's disease (+ 151 caregivers) from 52 centers in Belgium on 6 ± 1.5 month (titrated) rivastigmine treatment.Main outcome measures: Measured at baseline (enrollment) and follow-up (6 ± 1.5 months). For patients: Mini-Mental State Exam (MMSE), Activities of Daily Living (ADL), Neuropsychiatric Inventory (NPI), Global Deterioration Scale (GDS) scores; treatment response (improvement, maintenance, or decline less than normative slope). For caregivers: hours/week spent caring; Zarit Caregiver Burden Scale (ZCBS), 12‐item version of General Health Questionnaire (GHQ‐12), Instrumental Activities of Daily Living (IADL) scores.Results: Patients’ MMSE and NPI scores ( p < 0.001) improved from baseline to follow-up, but not ADL and GDS scores. Treatment response was 89.1% of patients for MMSE (including 60.6% with improvement) and 77.7% for NPI (including 57.1% with improvement). Quadratic curves were fitted for the average daily dose and the MMSE and NPI scores; with a trend towards average daily dose of 6.0 ± 3.0 mg/day. Caregivers’ ZCBS ( p = 0.036) and GHQ‐12 ( p = 0.029) scores improved, but not IADL scores and time spent caring.Conclusions: Patients’ MMSE and ADL scores confirmed the meta-analyses of rivastigmine efficacy trials, while NPI scores exceeded efficacy results. Proportionately more patients responded to (titrated) treatment than in fixed-dose RCTs. Caregivers reported less burden (similar to meta-analysis) and better general health over the study period. Where efficacy and effectiveness results diverge, the benefit is in ‘real-world’ effectiveness. Large sample, multi-country replications, less sensitive to censoring secondary to missing data and powered to permit advanced modeling, as well as RCTs with adaptive designs to accommodate titration, are needed. The profile of patients most likely to benefit from treatment or most vulnerable to treatment outcome must be studied, as must the impact of physician- and center-related variables on outcomes.

BackgroundSeveral factors may play a role in the ability of patients with Alzheimer’s disease to perform activities of daily living (ADL). The aim of this study was to examine the impact of different aspects of physical performance and cognitive functions on ADL in patients suffering from mild-to-moderate Alzheimer’s disease.MethodsWe conducted secondary analyses on cross-sectional baseline data from the randomized controlled multicentre study “Preserving quality of life, physical health and functional ability in Alzheimer’s Disease: The effect of physical exercise” (ADEX). In total, 185 AD patients (76 women and 109 men), with a mean age on 70,4 years, were included. Data from physical performance tests (Astrand cycle test, Timed up & Go (TUG), Sit to Stand test (STS)) and cognitive tests (Mini Mental Status Examination (MMSE), Symbol Digit Modalities Test (SDMT), Stroop Color and Word test (Stroop)) were used. Their associations with ADL, measured on the ADCS-ADL scale was assessed in multivariable regression analyses.ResultsSDMT and MMSE had significant, moderate correlations with total ADL (SDMT: r = 0.33, MMSE: r = 0.42) and instrumental ADL (SDMT: r = 0.31, MMSE: r = 0.42), but not with basic ADL. Adjusting for age and sex, the associations between SDMT and MMSE to total ADL and instrumental ADL persisted. No significant associations were found between Astrand, TUG, STS or Stroop and total ADL, basic ADL or instrumental ADL.ConclusionTotal ADL and instrumental ADL are associated with cognitive functions, including executive function. No significant association between examined physical performance parameters and ADL functions was observed, and consequently does not support an impact of physical function on ADL functions in patients with mild-to-moderate Alzheimer’s disease and relatively well-preserved physical function. Strategies aimed to improve cognition may be better suited to improve ADL function in patients with mild-to-moderate Alzheimer’s disease.Trial registrationNCT01681602. Registered 10 September 2012, retrospectively registered.

Objective To observe the effect and safety of Memantine Hydrochloride in the treatment of moderate to severe Alzheimer's disease.Methods 79 cases of moderate to severe Alzheimer's disease in our hospital from January 2011 to March 2013 were treated with Memantine Hydrochloride for 12 weeks.The score of Mini-Mental State Examination (MMSE),Activities of Daily Living (ADL) and Clinical Dementia Rating (CDR) was recorded and compared before and 4,8,12 weeks after treatment.Used t test,P ＜ 0.05meant significant difference.Results 4 weeks after treatment,MMSE increased (t =7.151,P ＜ 0.01),ADL decreased slightly (t =1.926,P ＞ 0.05),CDR didn't change significantly (t =1.56,P ＞ 0.05); 8 and 12weeks after treatment,MMSE increased significantly (t =11.24,17.16,P ＜ 0.01),ADL and CDR decreased significantly (P ＜ 0.01).No serious adverse reactions occurred in the treatment.Conclusion Memantine Hydrochloride in the treatment of moderate to severe Alzheimer's disease is safe and effective,and the longer patients accept the treatment,the more obvious the effect is. Key words: Memantine Hydrochloride; Alzheimer's disease; MMSE; ADL; CDR

A combination of tests for the diagnosis of dementia had a significant diagnostic value

The assessment of daily living activities could provide information about daily functions and participation restrictions to develop intervention strategies. The purposes of this study were to assess the scores of the Barthel Index (BI) and Lawton Instrumental Activities of Daily Living (IADL) scale in older adults with cognitive impairment and to explore the different effects that levels of cognitive functions have on changes in IADL functions. We recruited 31 participants with dementia, 36 with mild cognitive impairment (MCI), and 35 normal controls (NCs) from the neurology outpatient department of a regional hospital. The results of the demographic and clinical characteristics through the Lawton IADL scale, BI, Quick Mild Cognitive Impairment (Qmci) screen, Montreal Cognitive Assessment (MoCA), and Mini-Mental State Examination (MMSE), were collected on the same day and compared with the Kruskal–Wallis test, Wilcoxon rank-sum test, Fisher’s exact test, and a multiple linear regression analysis, as appropriate. In the BI, bathing was the most discriminating activity to differentiate patients with MCI and dementia; in the Lawton IADL scale, medication responsibility and shopping were the most discriminating activities to differentiate NCs and patients with MCI, and patients with MCI and dementia, respectively. In addition, the predictors of changes in Lawton IADL scale scores were the problem-solving score of the Clinical Dementia Rating scale, a Qmci score of > 20.4 and an age of ≤ 81.2 years, a MoCA score of < 9.4 and an age of > 81.2 years, and the MMSE score and an age of > 81.2 years. This study adds to the evidence that the description of basic and instrumental daily activities is integrated in older adults with cognitive impairment. Notably, the Qmci is the most significant predictor of changes in IADL function for “young” older adults, as are the MoCA and MMSE for “old” older adults.

To examine the prevalence of coronal and root caries in a memory clinic-based population of elderly patients with and without a diagnosis of dementia and to examine the influence of age, sex, social relations, social position, and functional ability. Cross-sectional. Patients referred with possible cognitive dysfunction were recruited from two university hospital dementia clinics. In total, 106 dentate persons participated in the study. Mean age was 82, 69 were women, and 87 had a diagnosis of dementia. Data from interviews and a clinical examination were collected. The diagnosis of dementia was made at the dementia clinics according to the criteria of International Classification of Diseases, Tenth Revision. Active coronal and root caries was assessed using previously defined diagnostic criteria from the National Institute of Dental and Craniofacial Research. The mean number of coronal and root surfaces with caries was statistically significantly higher in subjects with a diagnosis of dementia (7.0 vs 2.7, P<.05). Subjects with a diagnosis of Alzheimer's disease had a significantly higher mean number of root surfaces with caries (4.9, P<.05) than subjects with other dementia diagnoses (2.3) and those without dementia (1.7). People with Alzheimer's disease also had significantly more mean total caries than subjects without dementia (7.8 vs 2.7, P<.05). Participants with a Mini-Mental State Examination (MMSE) score less than 24 had significantly more caries than participants with a MMSE-score of 24 or higher (7.6 vs 4.3, P<.05). Patients with newly diagnosed dementia already had a high level of active dental caries when they were referred to the memory clinic. The high caries prevalence was related to dementia type and severity.

Aim. This study sought to establish the discriminant validity of a rapid cognitive screen, that is, the National Institute of Neurological Disease and Stroke-Canadian Stroke Network (NINDS-CSN) 5-minute protocol, and compare its discriminant validity to the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE) in detecting cognitive impairment (CI) in PD patients. Methods. One hundred and one PD patients were recruited from a movement disorders clinic in Singapore and they received the NINDS-CSN 5-minute protocol, MoCA, and MMSE. No cognitive impairment (NCI) was defined as Clinical Dementia Rating (CDR) = 0 and CI was defined as CDR ≥ 0.5. Results. Area under the receiver operating characteristic curve of NINDS-CSN 5-minute protocol was statistically equivalent to MoCA and larger than MMSE (0.86 versus 0.90, P = 0.07; 0.86 versus 0.76, P = 0.03). The sensitivity of NINDS-CSN 5-minute protocol (<9) was statistically equivalent to MoCA (<22) (0.77 versus 0.85, P = 0.13) and superior to MMSE (<24) (0.77 versus 0.52, P < 0.01) in detecting CI, while the specificity of NINDS-CSN 5-minute protocol (<9) was statistically equivalent to MoCA (<22) and MMSE (<24) (0.78 versus 0.88, P = 0.34). Conclusion. The NINDS-CSN 5-minute protocol is time expeditious while remaining statistically equivalent to MoCA and superior to MMSE and therefore is suitable for rapid cognitive screening of CI in PD patients.

BackgroundAlzheimer disease (AD) is a degenerative progressive brain disorder where symptoms of dementia and cognitive impairment intensify over time. Numerous factors exist that may or may not be related to the lifestyle of a patient that result in a higher risk for AD. Diagnosing the disorder in its beginning period is important, and several techniques are used to diagnose AD. A number of studies have been conducted on the detection and diagnosis of AD. This paper reports the empirical study performed on the longitudinal-based magnetic resonance imaging (MRI) Open Access Series of Brain Imaging dataset. Furthermore, the study highlights several factors that influence the prediction of AD.ObjectiveThis study aimed to correlate the effect of various factors such as age, gender, education, and socioeconomic background of patients with the development of AD. The effect of patient-related factors on the severity of AD was assessed on the basis of MRI features, Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), estimated total intracranial volume (eTIV), normalized whole brain volume (nWBV), and Atlas Scaling Factor (ASF).MethodsIn this study, we attempted to establish the role of longitudinal MRI in an exploratory data analysis (EDA) of AD patients. EDA was performed on the dataset of 150 patients for 343 MRI sessions (mean age 77.01 [SD 7.64] years). The T1-weighted MRI of each subject on a 1.5-Tesla Vision (Siemens) scanner was used for image acquisition. Scores of three features, MMSE, CDR, and ASF, were used to characterize the AD patients included in this study. We assessed the role of various features (ie, age, gender, education, socioeconomic status, MMSE, CDR, eTIV, nWBV, and ASF) on the prognosis of AD.ResultsThe analysis further establishes the role of gender in the prevalence and development of AD in older people. Moreover, a considerable relationship has been observed between education and socioeconomic position on the progression of AD. Also, outliers and linearity of each feature were determined to rule out the extreme values in measuring the skewness. The differences in nWBV between CDR=0 (nondemented), CDR=0.5 (very mild dementia), and CDR=1 (mild dementia) are significant (ie, P&lt;.01).ConclusionsA substantial correlation has been observed between the pattern and other related features of longitudinal MRI data that can significantly assist in the diagnosis and determination of AD in older patients.