Desire to institutionalize in Alzheimer's caregivers: An empirical analysis on Italian data.

OBJECTIVE: Families choice to institutionalize an Alzheimer's disease (AD)-affected relative is hard and possibly painful. Recent literature contributions have investigated the causes of the emergence of desire to institutionalize (DI) who is affected by AD. This paper contributes to the topic by providing an Italy-based empirical analysis of factors correlated with DI in primary informal caregivers of patients affected by AD. METHODS: Data were drawn from an original survey carried out over 2009. 171 primary informal caregivers of patients followed in two Italian outpatients AD Care Units, located in two of the major Italian cities, Naples (46.78%) and Rome (53.22%), were interviewed. The caregiver desire to institutionalize AD affected patients was observed and its heterogeneity was studied through logistic regression. RESULTS: DI was positively correlated with patient poor autonomy, to the housewife/househusband status of primary caregiver and to the presence of a formal caregiving. DI was also barely correlated with patient gender and with the hours of informal supervision (p < 0.10). The housewife status of the primary caregiver was also positively associated with DI, while the female gender of the patient was negatively associated to it. DISCUSSION: The institutionalization of an AD-affected relative is a painful decision which is discouraged by the scarcity of adapted facilities and the need of an economical contribution in case of institutionalization in private facilities not receiving public support.

Alzheimer's disease costs: what we know and what we should take into account.

BACKGROUND/OBJECTIVE: Alzheimer's disease (AD) is a very costly pathology. Total costs of AD result from the sum of direct and indirect costs. Intangible costs represent an additional burden that is difficult to quantify. This paper has reviewed the evaluation of the costs of AD and the methodologies to estimate them, and proposes the use of some tools which may be useful in establishing the financial weight of the disease. METHOD: A systematic literature search was conducted using the Pubmed and Medline databases as a source of published papers. RESULTS: In AD, direct and indirect costs and their sum (total costs) are very high and tend to increase parallel with the evolution of the pathology. The evolution of AD is characterized by the loss of functional autonomy, the onset of behavioral and sleep disorders, and the development of delusions and hallucinations. This requires more frequent medical examinations and hospitalizations resulting in higher direct costs, which become the relevant weight. None of the papers reviewed investigated intangible cost. CONCLUSION: The calculation of costs of AD is frequently based on cognitive decline and the degree of dependence of patients. The evaluation of intangible costs (psychological pain of the patient and of the unpaid caregivers' and their impaired quality of life) is a missing aspect in all reviewed studies. Due to the complexity of AD, it will be necessary to adopt cost evaluation systems including the different dimensions of the problem and its various aspects.

Is anterior communicating artery syndrome related to fornix lesions?

Anterior communicating artery (ACoA) syndrome, which may occur after rupture of ACoA aneurysms, consists of anterograde memory problems, executive dysfunctions, confabulations, and personality changes. Recently, the employment of diffusion tensor tractography (DTT) has related ACoA to microstructural lesions in the cingulum and the fornix, but an accurate characterization of these subjects should be provided. We report the clinical and neuropsychological findings of a patient who developed a severe and persistent amnesia together with significant behavioral changes, as well as her imaging results, where the sole evidence of brain damage was that of the fornix demonstrated by DTT. The four-year neuropsychological follow-up of the subject allows exclusion of other causes. This case demonstrates that microstructural lesions of fornix may lead to persistent amnesia, executive impairments, and behavioral changes and contributes to the knowledge of its role in cognition.

Efficacy of memantine, donepezil, or their association in moderate-severe Alzheimer's disease: a review of clinical trials.

BACKGROUND: Acetylcholinesterase (AChE)/cholinesterase (ChE) inhibitors (Is) and memantine are licensed for symptomatic treatment of mild-moderate and moderate-severe forms of Alzheimer's disease (AD), respectively. High doses of the AChE-I donepezil were licensed in the USA for moderate-severe AD, and the association AChE/ChE-Is plus memantine was proposed for AD at this stage. OBJECTIVES: This paper has reviewed evidence from clinical trials of the effectiveness of memantine, donepezil, or the two drugs in association in managing moderate-severe AD. METHOD: Double-blind, placebo-controlled randomized trials (RCTs) using memantine or donepezil alone or in association versus placebo in moderate-severe AD were reviewed. Analysis done in January 2013 considered the years 2007-2012. RESULTS AND CONCLUSION: Only 83 of the 941 papers selected were considered relevant, and only 13 met the criterion of "adequacy and representativeness." Memantine and donepezil lead to improvements in moderate-to-severe AD and the choice between the compounds should be based on their contraindications more than on disease severity. No evidence was found of advantages of the association of memantine-donepezil. The heterogeneity of conditions explored by RCTs, the relatively short time of observation (24-52 weeks), and the different cognitive assessment tools used did not allow comparing properly different trials.

Late and early onset dementia: what is the role of vascular factors? A retrospective study.

BACKGROUND: Neuropathology of Alzheimer's disease (AD) demonstrates that the common occurrence of vascular lesions and vascular factors is suggested to contribute significantly to the clinical progression of the disease. This study has assessed the presence of vascular brain lesions and risk factors in subjects with diagnosis of AD and their influence on the disease course both in Late Onset Dementia (LOD) and in Early Onset Dementia (EOD). METHODS: MRI scans of 374 LOD and of 67 EOD patients were evaluated for the presence of vascular associated lesions and rated according to the age-related white matter changes (ARWMC) scale as "pure degenerative", "mixed" and "vascular" cases of dementia. Vascular risk factors burden (hypertension, diabetes, dyslipidemia, myocardial infarction) and disease progression were also assessed. RESULTS: 44% of LOD cases and 46% of EOD were classified as "mixed dementia cases". The vascular risk factors burden showed an increase from the pure degenerative to the pure vascular forms. Disease progression, calculated in two years using the Mini Mental State Evaluation (MMSE), Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scores, did not reveal differences among the three different classes of dementias. CONCLUSIONS: Vascular lesions are found in the majority of LOD cases and in about one half of EOD. This observation is consistent with the hypothesis of a synergistic effect of the degenerative and vascular factors on the development of cognitive dysfunction. The linear increase of the vascular burden supports the idea of a continuum spectrum between the pure degenerative and the pure vascular forms of adult-onset dementia disorders.

Effectiveness of nootropic drugs with cholinergic activity in treatment of cognitive deficit: a review.

Nootropics represent probably the first "smart drugs" used for the treatment of cognitive deficits. The aim of this paper is to verify, by a systematic analysis of the literature, the effectiveness of nootropics in this indication. The analysis was limited to nootropics with cholinergic activity, in view of the role played by acetylcholine in learning and memory. Acetylcholine was the first neurotransmitter identified in the history of neuroscience and is the main neurotransmitter of the peripheral, autonomic, and enteric nervous systems. We conducted a systematic review of the literature for the 5-year period 2006-2011. From the data reported in the literature, it emerges that nootropics may be an effective alternative for strengthening and enhancing cognitive performance in patients with a range of pathologies. Although nootropics, and specifically the cholinergic precursors, already have a long history behind them, according to recent renewal of interest, they still seem to have a significant therapeutic role. Drugs with regulatory indications for symptomatic treatment of Alzheimer's disease, such as cholinesterase inhibitors and memantine, often have transient effects in dementia disorders. Nootropics with a cholinergic profile and documented clinical effectiveness in combination with cognate drugs such as cholinesterase inhibitors or alone in patients who are not suitable for these inhibitors should be taken into account and evaluated further.