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Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia
Edeltraut Kr?ger, André Tourigny, Diane Morin, Lise C?té, Marie-Jeanne Kergoat, Paule Lebel, Line Robichaud, Shirley Imbeault, Solange Proulx, Zohra Benounissa
BMC Health Services Research , 2007, DOI: 10.1186/1472-6963-7-195
Abstract: A total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND?/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7–9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic.Initially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57).A multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or pati
Hearing impairment in dementia – how to reconcile two intertwined challenges in diagnostic screening  [cached]
U. Lemke
Audiology Research , 2011, DOI: 10.4081/audiores.2011.e15
Abstract: Prevalence of dementia as well as hearing impairment is increasing with age. As a consequence older people are often affected by both conditions. Especially among the people with dementia a majority also has significant hearing problems. With population aging and more people getting even older the number of these patients will increase immensely over the next years. Dementia refers to a spectrum of brain disorders, all of which involve cognitive impairment but vary widely in terms of the cause, course, and prognosis. Dementia is more than just memory impairment; it involves impairment in multiple areas of cognition. Prevalence of dementia exponentially increases from 2% of people under the age of 65 years with doubling of numbers every five years up to 30-50% at the age of 90 years. Dementia is the leading cause of institutionalization among the elderly. Prevalence among elderly nursing home residents is estimated to be 60- 80%...
Study Protocol: The Behaviour and Pain in Dementia Study (BePAID)
Sharon Scott, Louise Jones, Martin R Blanchard, Elizabeth L Sampson
BMC Geriatrics , 2011, DOI: 10.1186/1471-2318-11-61
Abstract: We shall recruit older people with dementia who have unplanned acute medical admissions and measure the prevalence of BPSD using the Behave-AD (Behaviour in Alzheimer's Disease) and the CMAI (Cohen Mansfield Agitation Inventory). Pain prevalence and severity will be assessed by the PAINAD (Pain Assessment in Advanced Dementia) and the FACES pain scale. We will then analyse how these impact on a variety of outcomes and test the hypothesis that poor management of pain is associated with worsening of BPSD.By demonstrating the costs of BPSD to individuals with dementia and the health service this study will provide important evidence to drive improvements in care. We can then develop effective training for acute hospital staff and alternative treatment strategies for BPSD in this setting.Dementia is common in older people admitted to acute hospitals in the United Kingdom (UK), affecting 42% of adults over 65 years with an unplanned medical admission. These patients have high mortality with a quarter of those with severe impairment dying during the index hospital admission [1]. Dementia significantly increases the length of hospital admission [2-5], complications [4] and the risk of iatrogenic harm through polypharmacy [6]. A number of recent documents including the English National Dementia Strategy, the National Dementia Research Summit and Alzheimer's Society "Counting the Cost" report have raised concerns regarding the quality of care received by people with dementia in acute hospitals and have highlighted lack of original research in this field [7-9].The term "behavioural and psychological symptoms of dementia" (BPSD) encompasses a range of symptoms including agitation, aggression, delusions, hallucinations, depression and apathy. These are common in dementia, multifactorial in origin and often secondary to complex interactions between the severity of dementia, the environment and other illness [10]. BPSD are extremely distressing for the patient and difficult to ma
Neuropsychiatric Symptoms in Parkinson's Disease with Mild Cognitive Impairment and Dementia  [PDF]
Iracema Leroi,Hiranmayi Pantula,Kathryn McDonald,Vijay Harbishettar
Parkinson's Disease , 2012, DOI: 10.1155/2012/308097
Abstract: Neuropsychiatric symptoms commonly complicate Parkinson’s disease (PD), however the presence of such symptoms in mild cognitive impairment (PD-MCI) specifically has not yet been well described. The objective of this study was to examine and compare the prevalence and profile of neuropsychiatric symptoms in patients with PD-MCI (n = 48) to those with PD and no cognitive impairment (PD-NC, n = 54) and to those with dementia in PD (PDD, n = 25). PD-MCI and PDD were defined using specific consensus criteria, and neuropsychiatric symptoms were assessed with the 12-item Neuropsychiatric Inventory (NPI). Self-rated apathy, depression, and anxiety rating scales were also administered. Over 79% of all participants reported at least one neuropsychiatric symptom in the past month. The proportion in each group who had total NPI scores of ≥4 (“clinically significant”) was as follows: PD-NC, 64.8%; PD-MCI, 62%; PDD 76%. Apathy was reported in almost 50% of those with PD-MCI and PDD, and it was an important neuropsychiatric symptom differentiating PD-MCI from PD-NC. Psychosis (hallucinations and delusions) increased from 12.9% in PD-NC group; 16.7% in PD-MCI group; and 48% in PDD group. Identifying neuropsychiatric symptoms in PD-MCI may have implications for ascertaining conversion to dementia in PD. 1. Introduction In Parkinson’s disease (PD), cognitive impairment and the development of dementia (PDD) are increasingly being considered part of the disease course. Mild cognitive impairment in PD (PD-MCI) occurs in about 25% of patients and may predict conversion to PDD [1, 2]. Formal diagnostic criteria for PD-MCI have recently been proposed by the Movement Disorder Society (MDS) Task Force [3]. Risk factors for the development of PD-MCI include older age at disease onset, male gender, depression, severity of motor symptoms, and advanced disease stage [4]. According to the MDS Task Force proposal, PD-MCI is a syndrome defined by three sets of criteria: clinical, cognitive and functional. The proposed cognitive criteria comprise two levels of assessment. Level I involves an abbreviated assessment using a global scale of cognition or limited neuropsychological test batteries for a diagnosis of “possible PD-MCI.” Level II involves more extensive neuropsychological testing using tests in five domains, with impairment on at least two tests in one or more domains for a diagnosis of PD-MCI subtypes. The domains are attention and working memory, executive dysfunction, language, memory, and visuospatial function. PD-MCI predominantly affects the memory, visual-spatial, and
Relationships between Personality Traits, Medial Temporal Lobe Atrophy, and White Matter Lesion in Subjects Suffering from Mild Cognitive Impairment  [PDF]
Emmanuelle Duron,Jean-Sébastien Vidal,Samira Bounatiro,Anne-Sophie Rigaud,Cécile Viollet,Jacques Epelbaum,Guillaume Martel
Frontiers in Aging Neuroscience , 2014, DOI: 10.3389/fnagi.2014.00195
Abstract: Mild cognitive impairment (MCI) is a heterogeneous cognitive status that can be a prodromal stage of Alzheimer’s disease (AD). It is particularly relevant to focus on prodromal stages of AD such as MCI, because patho-physiological abnormalities of AD start years before the dementia stage. Medial temporal lobe (MTL) atrophy resulting from AD lesions and cerebrovascular lesions [i.e., white matter lesions (WML), lacunar strokes, and strokes] are often revealed concurrently on magnetic resonance imaging (MRI) in MCI subjects. Personality changes have been reported to be associated with MCI status and early AD. More specifically, an increase in neuroticism and a decrease in conscientiousness have been reported, suggesting that higher and lower scores, respectively, in neuroticism and conscientiousness are associated with an increased risk of developing the disease. However, personality changes have not been studied concomitantly with pathological structural brain alterations detected on MRI in patients suffering from MCI. Therefore, the objective of the present study was to assess the relationship between MTL atrophy, WML, lacunar strokes, and personality traits in such patients. The severity of WML was strongly associated with lower levels of conscientiousness and higher levels of neuroticism. Conversely, no association was detected between personality traits and the presence of lacunar strokes or MTL atrophy. Altogether, these results strongly suggest that personality changes occurring in a MCI population, at high risk of AD, are associated with WML, which can induce executive dysfunctions, rather than with MTL atrophy.
Beyond mild cognitive impairment: vascular cognitive impairment, no dementia (VCIND)
Blossom CM Stephan, Fiona E Matthews, Kay-Tee Khaw, Carole Dufouil, Carol Brayne
Alzheimer's Research & Therapy , 2009, DOI: 10.1186/alzrt4
Abstract: A better understanding of dementia, including its causes, underlying pathophysiological processes and earliest possible identification, has become a major public health priority. Changes in cognition associated with age are complex, especially with regard to distinguishing usual from pathological brain ageing. Multiple and often intertwined pathological factors, including atrophy, neurodegeneration, inflammation, stroke and genetic-related factors, cause dementia [1]. Here, we explore the link between vascular disease, cognitive decline and dementia risk. Given the relatively high proportion of dementia attributable to possibly reversible midlife vascular causes [2], it has been suggested that vascular risk manipulation may result in up to a 50% reduction in the forecasted dementia prevalence rate in individuals who are 65 years old or older [3,4]. Vascular risk factors for dementia may also contribute to impairments observed in the pre-clinical stage of cognitive decline. This has raised questions regarding (a) whether vascular disease can predict cognitive change and dementia risk in otherwise non-impaired individuals and (b) the duration and possible reversal of cognitive symptoms and dementia depending on vascular disease manipulation and treatment. The aim of this review is to describe the current understanding of the division between pre-clinical cognitive impairment in the context of vascular disease versus the absence of vascular disease. The focus will be on the term 'vascular cognitive impairment, no dementia' (VCIND), an umbrella term that broadly encompasses cognitive deficits associated with vascular disease which fall short of a dementia diagnosis, in order to determine whether within the context of this condition there is a pre-clinical state linked to a high risk of dementia progression.Ageing in the developed world is associated with changes in the vascular system which result in atherogenesis, increased pulse pressure and increased risk of developi
The factorial structure of the mini mental state examination (MMSE) in Japanese dementia patients
Kenta Shigemori, Shohei Ohgi, Eriko Okuyama, Takaki Shimura, Eric Schneider
BMC Geriatrics , 2010, DOI: 10.1186/1471-2318-10-36
Abstract: 30,895 consecutive outpatients with dementia were evaluated. The 11 subtests composing the MMSE and the global MMSE score were analyzed. Factor analysis based on principal component analysis with Promax rotation was applied to the data representing the frequency of failures in each subtest as identified by the MMSE.Factor analysis identified three factors that explained approximately 44.57% of the total variance. The first factor, immediate memory, essentially constituted a simple index of the reading and writing subtests. The second factor, orientation and delayed recall, expressed the ability to handle new information. The third factor, working memory, was most closely related to the severity of dementia at the time of test administration.Japanese dementia patients appear to develop difficulty handling new information in the early stages of their disease. This finding, and our finding that there is a factor associated with disease severity, suggest that understanding the specific factors related to subtest items, which underlie the total MMSE score may be useful to clinicians in planning interventions for Japanese patients in the early stages of dementia.The mini mental state examination (MMSE) is one of the most common tools to screen for cognitive impairment in older adults. The MMSE was developed to distinguish between older individuals with or without neuropsychiatric disorder early in the disease processes. It is also used during follow-up of patients suffering from cognitive impairment to assess disease progression. Folstein et al [1] reported that the MMSE is highly reliable on 24 hr (r = 0.89) and 28 day (r = 0.99) retest by single examiners. They also reported good inter-rater reliability for the MMSE (r = 0.83) when the MMSE was administered by two different examiners 24 hours apart. O'Connor et al [2] reported that 86% of respondents judged to have organic mental disorders scored 23 or less on the MMSE and that 92% of those judged to be cognitively inta
Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities
Philippe Voyer, René Verreault, Ginette M Azizah, Johanne Desrosiers, Nathalie Champoux, Annick Bédard
BMC Geriatrics , 2005, DOI: 10.1186/1471-2318-5-13
Abstract: The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332).The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.Among the entire spectrum of behavioural and psychological symptoms of dementia, aggressive behaviour (AB) is the most disturbing and distressing behaviour displayed by older patients in long-term care facilities. According to Patel and Hope [1], AB refers to an overt act, which is not accidental, involving the delivery of noxious stimuli to (but not necessarily aimed at) an object or towards the self o
Dementia and Impairment, Directions for no specialist physicians
Archibaldo Donoso
Cuadernos de Neuropsicologia , 2007,
Abstract: Alzheimer's disease (AD), that develops with progressive loss of cognitive functions, beginning by memory, is the most important Central Nervous System (CNS) degenerative affection and one of the main causes of invalidity in adults. The mild cognitive impairment (MCI) is defined as a discreet loss of memory and sometimes others abilities. In this case, the affected is not limited in their quotidian activities, meaning that dementia does not exist. However, it is very possible that in the following years the AD becomes evident.In the present review, some basics concepts about dementia are revised; etiologic classification, clinical manifestation and treatment, emphasizing the support that the patients and their families need.
Predictors of the Progression of Dementia Severity in Brazilian Patients with Alzheimer's Disease and Vascular Dementia  [PDF]
Márcia L. Chaves,Ana L. Camozzato,Cristiano K?hler,Jeffrey Kaye
International Journal of Alzheimer's Disease , 2010, DOI: 10.4061/2010/673581
Abstract: Introduction. This study evaluates the progression of dementia and identifies prognostic risk factors for dementia. Methods. A group of 80 Brazilian community residents with dementia (34 with Alzheimer's disease and 46 with vascular dementia) was assessed over the course of 2 years. Data were analyzed with Cox regression survival analysis. Results. The data showed that education predicted cognitive decline ( ; ) when analyzed without controlling for vascular risk factors. After the inclusion of vascular risk factors, education ( ; ) and hypertension were predictive for cognitive decline ( ; ), and Alzheimer's disease diagnosis was borderline predictive ( ). Conclusion. Vascular risk factors interacted with the diagnosis of vascular dementia. Education was a strong predictor of decline. 1. Introduction It is estimated that 24.3 million people suffer from dementia today, with 4.6 million new cases every year. Of those with dementia, 60% live in developing countries, and the rate of increase in prevalence is predicted to be three to four times higher in developing countries than in developed countries [1]. In most prevalence studies, Alzheimer’s disease (AD) has been associated with 70% or more of all cases of dementia and the main contributor to the steep increase with age in the prevalence of dementia [2]. In turn, dementia with a vascular component comprises nearly half of all cases of dementia in persons aged 85 years and older [3]. Patients with vascular dementia (VaD) have poorer survival than those with AD: the median survival from dementia onset to death is 3.9 years for patients with vascular dementia (VaD) and 7.1 years for patients with AD [4]. It is important to evaluate the progression of dementia and to estimate predictors of cognitive and functional decline in patients with an established diagnosis of dementia. Gender, education, and time from AD onset did not significantly predict cognitive and functional decline in one study [5]. In another study, there were also no predictors of disease progression except for gender: men exhibited a greater rate of cognitive decline than women [6]. Another report demonstrated that, during the early and very late stages of AD, cognitive deterioration was slower than during the middle stages and no clinical variables other than the degree of cognitive impairment and previous rate of cognitive decline predicted deterioration [7]. Higher education and participation in prediagnostic activities have been associated with faster cognitive decline in many AD longitudinal studies [8–10]. In addition, psychotic
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