Predictors of high level of burden and distress in caregivers of demented patients: results of an Italian multicenter study.

BACKGROUND: Considerable suffering is experienced by carers of patients with dementia. Most existing studies do not consider the coexistence of subjective and objective aspects that cause, interacting to each other, this suffering. OBJECTIVES: In this study we: (1) define the high-risk group of caregivers on the bases of the scores obtained on the four scales evaluating burden, distress, depression and anxiety (BDDA) taken into account simultaneously and (2) evaluate risk factors related to the high level of BDDA. SUBJECTS AND METHODS: 419 elderly outpatients with dementia and their caregivers were enrolled. Patients were evaluated for their cognitive, neuropsychological and functional impairment and for comorbidity. Caregivers were evaluated with four scales for the assessment of burden, distress related to neuropsychological disturbances, depression and anxiety. Cluster analysis was used to identify the group with the High level of BDDA (HBDDA). RESULTS: By multiple logistic analysis, disability, specific behavioural disturbances of the patients as well as caregiver's age, type of relationship and living in the south of Italy were observed to be a major risk factor for HBDDA. CONCLUSION: The targeted use of scales specifically assessing BDDA of the caregiver and the identification of particular patient and caregiver characteristics are able to allow a precise and early definition of caregivers at high risk of burden and distress. This might be helpful in planning the correct social/clinical/rehabilitative approach.

Neuropsychological assessment of the severely impaired elderly patient: validation of the Italian short version of the Severe Impairment Battery (SIB). Gruppo di Studio sull'Invecchiamento Cerebrale della Società Italiana di Gerontologia e Geriatria.

One hundred and sixty-nine severely demented patients were tested in a multicenter study with the short version of the Severe Impairment Battery which was translated into Italian with the purpose of adapting and validating it for an Italian population. Patients were enrolled in Italian geriatric centers participating in the Study Group on Aging Brain of the Italian Society of Gerontology and Geriatrics. Following thorough clinical and instrumental examinations, they were evaluated with the Mini Mental State Examination, the Clinical Dementia Rating, the Severe Impairment Battery (SIB), the Gottfries-Bråne-Steen Rating Scale for Dementia, the Activity of Daily Living index, and the Bedford Alzheimer Nursing Severity scale (BANS.s). The inter-rater reliability of the SIB was highly significant for the total score and its subtests; test-retest reliability showed the same significance in all items. Also concurrent validity, performed comparing the total SIB score with the total BANS.s score, was significant. The short Italian version of the SIB proved to be a very reliable tool for the evaluation of severely demented patients; it has the advantage of being easy to administer, it evaluates more cognitive domains that, are typically assessed in dementia, and has a wide enough range of scores to detect even small differences in the examined abilities.

Posatirelin for the treatment of degenerative and vascular dementia: results of explanatory and pragmatic efficacy analyses.

In order to confirm the efficacy and safety of posatirelin (L-pyro-2-aminoadipyl-L-leucyl-L-prolinamide), a synthetic peptide having cholinergic, catecholaminergic and neurotrophic activities, a multicentre, double-blind, controlled study versus placebo was planned in elderly patients suffering from Alzheimer's disease and vascular dementia, according to National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and National Institute of Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria, respectively. The trial consisted of a 2-week run-in phase with placebo administered once a day orally, followed by a double-blind period of 3 months, with posatirelin or placebo administered once a day intramuscularly. Efficacy was assessed using the Gottfries-Bråne-Steen (GBS) Rating Scale (primary variable) and the Rey Memory Test (secondary variable). Laboratory tests, vital signs and adverse events were monitored. A total of 360 patients were randomized, the intent-to-treat sample (ITT) being made up of 357 patients and the per protocol sample (PP) of 260 patients. Both pragmatic and explanatory analyses showed significant differences between treatment groups in the GBS Rating Scale and the Rey Memory Test, with no difference in the two types of dementia. No difference between treatments was observed in safety variables, the incidence of adverse events in the posatirelin group being 7.3%. The study confirms previous results showing that treatment with posatirelin can improve cognitive and functional abilities of patients suffering from degenerative or vascular dementia.

Acid-stable serine proteinase inhibitors in the urine of Alzheimer disease subjects.

A comparative study of the levels of acid-stable proteinase inhibitors (kallikrein and trypsin inhibitors) in the urine of healthy and Alzheimer subjects, of both sexes, has been performed. A preliminary characterization of the purified inhibitors indicates that the urinary antitryptic activity is accounted for by the presence of the well known Urinary Trypsin Inhibitor (UTI) while an apparently new molecule appears to be responsible for the antikallikrein activity. The urinary levels of kallikrein inhibitors are very similar in healthy and sick subjects while the levels of trypsin inhibitors appear significatively increased in Alzheimer subjects of both sexes. The data presented here support the hypothesis that unpaired proteolytic processes could be involved in the pathogenesis of Alzheimer's disease and suggest that the levels of urinary acid-stable inhibitors may prove to be useful markers of the disease.

Survival and dementia: a 7-year follow-up of an Italian elderly population.

The objective of this study was to investigate the association between dementia and mortality in an elderly Italian population. Demented subjects were identified by a previous prevalence study of Alzheimer's disease (AD) and specific dementing disorders. The study sample included all inhabitants of Appignano aged 60 and over (778 subjects), and was followed-up over a period of about 7 years. Periodic records of dates of death were obtained from the Registry Office of Appignano. We found considerably higher mortality ratios for subjects previously diagnosed as having dementia syndrome (12.5% at 1 year and 81.3% at about 7 years) than for those who were non-demented (3.0% at 1 year and 21.5% at about 7 years). In the group of demented subjects (N = 48), we also investigated the influence of sex, age, and specific dementing disorders on mortality ratios. The percentage of demented subjects who died during the whole period of follow-up was higher among men than women (100% vs. 66.7%) and increased considerably with increasing age (50.0% for age class 60-69, 76.5% for age class 70-79, and 86.2% for age class 80+). Mortality of subjects with multi-infarct dementia (MID) and mixed dementia (MD) tended to be slightly higher than in subjects affected by AD. Our results are consistent with those reported in previous population-based studies on survival of dementia patients.

Education and occupation as risk factors for dementia: a population-based case-control study.

To further investigate the putative associations between education and dementia and between occupation and dementia, we conducted a population-based case-control study. Cases were all subjects affected by dementia ascertained through a prevalence survey conducted in the municipality of Appignano, Macerata Province, Italy. For each case (n = 48), we randomly selected 2 population controls residing in the same municipality and matched for age and sex (n = 96). Information regarding exposures was collected by nonmedical personnel during the first contact for the prevalence survey. Although we found a striking trend toward decreasing prevalence with increasing education, this association was suggestive but not significant after age and sex adjustment at case-control analyses (odds ratio for illiterates = 1.4; 95% CI 0.6-3.1). In contrast, we found a significant association between manual principal lifetime occupation and dementia using both unadjusted and adjusted analyses (odds ratio = 2.9; 95% CI 1.2-7.4). Our findings suggest that, although education and occupation are related, occupation is a stronger indicator of risk than education.

Study on the validity of the Hodkinson Abbreviated Mental Test Score (AMTS) in detecting dementia of elderly subjects in appignano (Macerata province), Italy.

The accuracy of the Hodkinson Abbreviated Mental Test Score (AMTS) as a screening instrument for dementia has been investigated in an Italian population. The AMTS was administered by nonmedical personnel to a random sample of 109 subjects over the age of 59; each subject was evaluated by a standardized dementia protocol (DSM-III criteria); and scores on the AMTS were compared to corresponding clinical diagnoses (standard for comparison). Five of the 109 subjects were found to be affected by dementia upon clinical investigation. Although a score of 6 showed the best combination of sensitivity (80%) and specificity (89%), only a score of 7 yielded 100% sensitivity (71% specificity). At all screening levels, specificity was higher for males vs. females, for younger vs. older, and for more educated vs. less educated subjects. The results suggest that brief cognitive tests may be successfully used in population screening for dementia, and that tests not requiring reading, writing or drawing, and not strictly dependent on the education level, are preferable; however, the instruments should be adapted and validated in the target population.

Validation of the Hodkinson abbreviated mental test as a screening instrument for dementia in an Italian population.

We investigated the accuracy of the Hodkinson abbreviated mental test (AMT) as a screening instrument for dementia in an Italian population. The AMT was administered by nonmedical personnel to 124 subjects > 59 years old. Each subject independently underwent a clinical evaluation for dementia (DSM-III criteria), and scores on the AMT were compared to corresponding clinical diagnoses (standard for comparison). Twenty of the 124 subjects were found to be affected by dementia upon clinical investigation. Although a score of 6 on the AMT showed the best combination of sensitivity (90%) and specificity (89%), only a score of 7 yielded 100% sensitivity (71% specificity). Specificity was higher in men, younger, and more educated subjects.

[Clinical investigation on depression on a randomized and stratified sample in an elderly population]. / Indagine clinica sulla depressione in un campione randomizzato e stratificato di popolazione anziana.

The prevalence of depression in the elderly was investigated in a random stratified sample of 100 subjects from the general population of Appignano (Macerata, Regione Marche, Italy). After sampling with the simple random method, each subject underwent a diagnostic work-up including: a) three psychodiagnostic tests (Short Scale for the Assessment of Mental Health--SSAMH, Geriatric Depression Scale--GDS, and Scale for the Self-evaluation of Depression from the Psychogeriatric Interview--PGI) and b) psychiatric evaluation (according to DSM-III-R diagnostic criteria). Results were as follows: a) all the 3 tests (SSAMH, GDS, PGI) were suitable for the goals of this research, with a sensibility of 95.4%, 90.9%, and 95.4%, and a specificity of 90.4%, 88.9%, and 90.5%, respectively; b) the prevalence of depression in the sample was 25.9% (26.1% in females and 25.6% in males); c) the most common disorder was dysthymia, with higher percentage in females than in males (75% and 50% of all the depressive syndromes, respectively); d) the prevalence of depression was higher in females 60-69 years old and in males 70-79 years old.

Prevalence of clinically diagnosed Alzheimer's disease and other dementing disorders: a door-to-door survey in Appignano, Macerata Province, Italy.

The purpose of this study was to investigate the prevalence of dementia in an Italian population using a door-to-door 2-phase design. As part of a social and health survey, we administered the Hodkinson abbreviated mental test to all persons over age 59 residing in the Commune of Appignano on January 1, 1987 (N = 778). We then investigated all subjects scoring 7 or less on the cognitive test following a standardized diagnostic protocol. We found 48 patients affected by dementia, yielding a crude prevalence ratio (cases per 100 population over age 59) of 6.2; prevalence ratios were 2.6 for Alzheimer's disease, 2.2 for multi-infarct dementia, 0.8 for mixed dementia, 0.4 for secondary dementia, and 0.3 for unspecified dementia. Age- and sex-specific prevalence ratios increased steeply with age and were consistently higher in women for Alzheimer's disease and in men for dementia of all types and multi-infarct dementia. Alzheimer's disease was slightly more frequent than multi-infarct dementia; however, the most common type of dementia varied across age groups. Most cases of Alzheimer's disease were sporadic and had a late age of onset. Comparison with other populations suggests that dementia of all types is as frequent in Appignano as elsewhere, and that Alzheimer's disease might be more frequent in rural than in urban populations.