Age, memory loss and perceptions of dementia in South Asian ethnic minorities.

BACKGROUND: South Asian older adults are represented less frequently in mainstream mental health services or those for people with dementia. This study aimed to explore in detail the perceptions of dementia (symptoms, causes, consequences, treatments) held by South Asians and to discern how these understandings vary by age and by the self-recognition of memory problems, as these influence help-seeking behaviour. METHODS: Participants were allocated to three groups: younger adults; older adults; and older adults with subjective memory problems. They completed the semi-structured Barts Explanatory Model Inventory for Dementia schedule, whilst older adults also completed measures of cognition (MMSE), and depression (GDS). Interviews were conducted in English, Gujarati or Urdu. RESULTS: Groups were similar in identifying unusual forgetting and confusion as the most frequent symptoms; stress and age as the most frequent causes; and talking to your GP/nurse, taking medication, and talking to family and friends as the most frequent treatments. Younger adults more often knew about risk factors and reported practical consequences more than older adults. Older adults with subjective memory problems were more likely to describe sleep related problems or symptoms commonly associated with depression. They more often cited as causes of dementia lack of sleep, side effects of medication and medical reasons, and mentioned religion as a means to cope. CONCLUSIONS: Findings highlight variability in perceptions of dementia across the South Asian Community and identify specific areas where dementia awareness could be raised in South Asian sub-groups to improve timely diagnosis, treatment outcomes and service access.

Perceptions of self-defined memory problems vary in south Asian minority older people who consult a GP and those who do not: a mixed-method pilot study.

OBJECTIVE: South Asian older adults access services for mental health problems and dementia less than other older people in the UK, unlike for physical health problems. This pilot study investigated how South Asians with self-defined memory problems, with and without GP consultation, construe the symptoms, causes, consequences and treatment of the condition. METHODS: Participants were recruited through community centres, their networks and memory clinics in Greater Manchester. The newly developed Barts Explanatory Model Inventory for Dementia (BEMI-D) was administered to 33 (18 M, 15 F) older South Asians aged 65 or above with memory problems in English, Gujarati or Urdu. Furthermore, cognition, executive function and depression were assessed. RESULTS: Perceptions of dementia varied by GP consultation for memory problems. A greater proportion of older adults without a consultation considered memory problems to be given by God, saw acceptance of fate as an alternative treatment and did not identify medical support as appropriate. Forgetfulness and loss of social meaning were identified as symptoms of dementia more by those with a consultation. Higher levels of diabetes, heart disease and depression were found in those without a consultation. CONCLUSIONS: Differences in perceptions may influence the decision about consulting a GP. Similarly, consultation for memory problems appears linked to extent physical health problems and mental health consultation (depression). These variations reported on a small scale in this pilot study suggest the need to explore the impact of perceptions on rates of GP consultation, so as to improve timely diagnosis and access to appropriate services.

Adaptation of the Barts Explanatory Model Inventory to dementia understanding in South Asian ethnic minorities.

OBJECTIVE: Studies indicate a limited understanding of dementia and its associated symptoms, causes and consequences among South Asian older adults. As a consequence, fewer people from this ethnic group receive a diagnosis of dementia. The aim of this study was to adapt the previously designed Barts Explanatory Model Inventory Checklist (BEMI-C), a tool designed to elicit perceptions of mental illness from people with different cultural backgrounds, for use with people with dementia in the South Asian population. METHOD: Both a literature review and 25 qualitative interviews were conducted to find themes and perceptions that are relevant to the South Asian culture in recognising and dealing with symptoms of dementia. The emergent themes and perceptions were then added to the BEMI-C through synthesis of findings. RESULTS: The initial four checklists of symptoms, causes, consequences and treatments from the BEMI-C were retained in the new BEMI-Dementia (BEMI-D) and expanded with six additional themes, including 123 new perceptions relevant to the understanding of dementia. All new themes emerged from the qualitative interviews, some of which were also found in the literature. CONCLUSION: Given the national priority of improving dementia awareness and timely diagnosis, the BEMI-D can serve as a useful tool, in research and perhaps practice, to assess the barriers to dementia service uptake in this population and their understandings of dementia. Based on the detailed methodological description of the adaptation of the BEMI-C, this paper further suggests how this tool can be adapted to suit other ethnic minority groups.

South Asian older adults with memory impairment: improving assessment and access to dementia care.

OBJECTIVE: With increasing international migration, mental health care of migrants and ethnic minorities is a public health priority. South Asian older adults experience difficulties in accessing services for memory impairment, dementia and mental illness. This review examines barriers and facilitators in the pathway to culturally appropriate mental health care. METHODS: Web of Knowledge, Pubmed and Ovid databases were searched for literature on South Asian older adults or their family carers, their understandings of mental illness and dementia and their pattern of service use. Dates were from 1984 to 2012. Abstracts were assessed for relevance, followed by detailed reading of salient papers. Three researchers rated the quality of each included study. A narrative synthesis was undertaken of extracted and charted data. RESULTS: Eighteen studies met the eligibility criteria for the review. South Asians and health professionals highlighted several difficulties which deterred help seeking and access to care: a lack of knowledge of dementia and mental illness, and of local services; stigma; culturally preferred coping strategies; and linguistic and cultural barriers in communication and decision making. CONCLUSIONS: To improve access for these groups, service users and providers need to be better informed; services need to be more culturally tailored, sometimes employing staff with similar cultural backgrounds; and health professionals can benefit from dementia education and knowledge of local services. These factors are key to the delivery of the National Dementia Strategy in England.

Peripheral inflammatory markers in amnestic mild cognitive impairment.

OBJECTIVE: To prospectively monitor plasma inflammatory marker concentrations in peripheral blood, over 12 months, in subjects with amnestic mild cognitive impairment (MCI), and to determine the relationship between peripheral inflammatory markers and cognitive decline. METHODS: Seventy patients with amnestic MCI were recruited from two sites providing specialist memory assessment services in Manchester. The baseline assessment included physical examination, neuro-psychological testing and venous blood samples for C-reactive protein (CRP) and interleukin 6 (IL-6) concentrations. Sixty two participants were followed up after 12 months and the assessments were repeated. RESULTS: Data analysis revealed a significant rise in CRP, but not IL-6 concentrations over 12 months, which was not confounded by demographic variables. The neuro-psychological test scores had no association with CRP or IL-6 concentrations at baseline or 12 months follow-up. CONCLUSION: This study adopted the unique approach of prospectively investigating peripheral inflammatory markers in a cohort with amnestic MCI. A significant rise in CRP concentrations over 12 months, but lack of significant association with cognition, provide no evidence for a relationship between systemic inflammation and cognitive decline in amnestic MCI.

A mixed-methods evaluation of a pilot psychosocial intervention group for older people with schizophrenia.

BACKGROUND: There is a strong evidence base for psychological treatments in younger adults with schizophrenia, but limited work has been done on adapting these interventions for older people. AIMS: We describe a study of a pilot psychosocial intervention group specifically designed to meet the needs of older people with schizophrenia in NHS settings. METHOD: We used a mixed-methods approach to evaluate the group. We assessed feasibility and acceptability by monitoring uptake and retention in the study. We used a within groups design comparing participants on a range of potentially relevant outcomes at baseline and posttreatment. Treatment acceptability was also assessed by semi-structured interviews conducted at the end of treatment. RESULTS: We recruited 11 participants to the study and 7 of these completed the majority of the group sessions. At a group level participants made improvements in self-esteem and negative symptoms that were statistically significant even in this small sample. Feedback interviews suggested that participants valued the social contact provided by the group and made actual changes in their day-to-day lives as a result of attending. CONCLUSION: The intervention could offer help with some of the secondary disability associated with the diagnosis of schizophrenia and is acceptable to older adults. Further evaluation is, however, warranted.

Mediterranean diet, cognitive function, and dementia: a systematic review.

BACKGROUND: Adherence to a Mediterranean diet has been associated with lower risk of various age-related diseases including dementia. Although narrative reviews have been published, no systematic review has synthesized studies on the association between Mediterranean diet adherence and cognitive function or dementia. METHODS: We conducted a systematic review of 11 electronic databases (including Medline) of published articles up to January 2012. Reference lists, selected journal contents, and relevant websites were also searched. Study selection, data extraction, and quality assessment were performed independently by two reviewers using predefined criteria. Studies were included if they examined the association between a Mediterranean diet adherence score and cognitive function or dementia. RESULTS: Twelve eligible papers (11 observational studies and one randomized controlled trial) were identified, describing seven unique cohorts. Despite methodological heterogeneity and limited statistical power in some studies, there was a reasonably consistent pattern of associations. Higher adherence to Mediterranean diet was associated with better cognitive function, lower rates of cognitive decline, and reduced risk of Alzheimer disease in nine out of 12 studies, whereas results for mild cognitive impairment were inconsistent. CONCLUSIONS: Published studies suggest that greater adherence to Mediterranean diet is associated with slower cognitive decline and lower risk of developing Alzheimer disease. Further studies would be useful to clarify the association with mild cognitive impairment and vascular dementia. Long-term randomized controlled trials promoting a Mediterranean diet may help establish whether improved adherence helps to prevent or delay the onset of Alzheimer disease and dementia.

Risk factors for repetition and suicide following self-harm in older adults: multicentre cohort study.

BACKGROUND: Older adults have elevated suicide rates. Self-harm is the most important risk factor for suicide. There are few population-based studies of self-harm in older adults. AIMS: To calculate self-harm rates, risk factors for repetition and rates of suicide following self-harm in adults aged 60 years and over. METHOD: We studied a prospective, population-based self-harm cohort presenting to six general hospitals in three cities in England during 2000 to 2007. RESULTS: In total 1177 older adults presented with self-harm and 12.8% repeated self-harm within 12 months. Independent risk factors for repetition were previous self-harm, previous psychiatric treatment and age 60-74 years. Following self-harm, 1.5% died by suicide within 12 months. The risk of suicide was 67 times that of older adults in the general population. Men aged 75 years and above had the highest suicide rates. CONCLUSIONS: Older adults presenting to hospital with self-harm are a high-risk group for subsequent suicide, particularly older men.

Investigating the stability of neuropsychiatric sub-syndromes with progression of dementia: a 2-year prospective study.

OBJECTIVES: Previous studies have identified sub-syndromes of behavioral and psychological symptoms of dementia. But because of their cross-sectional design, the stability of these sub-syndromes over time remains unknown. METHOD: Behavioral and psychological symptoms of dementia of 84 participants (out of an original sample of 144 patients) with Alzheimer's disease and vascular dementia were assessed by using the Neuropsychiatric Inventory every six months for two years. Principal component factor analysis with Varimax rotation was used to detect neuropsychiatric sub-syndromes at each time point. RESULTS: The 12 symptoms were reduced to four factors at baseline, 12, 18, and 24 months and three factors at six months. None of the factor structures matched the four sub-syndromes previously identified by studies. The most stable group of symptoms were a combination of "psychosis" and "hyperactivity" symptoms (delusions, hallucinations, irritability, agitation), which became stable at 18 months. CONCLUSIONS: The pattern of behavioral and psychological symptoms of dementia sub-syndromes over time has not been studied before, and this research suggests that some stability is evident particularly during the later stages of the disease process. These findings have implications for patients and their caregiver.

Underdiagnosis of dementia in primary care: variations in the observed prevalence and comparisons to the expected prevalence.

OBJECTIVES: Dementia is a major and growing health problem. Diagnosis is an important step in the access to care, but many dementia patients remain undiagnosed. This study investigated the magnitude and variation in the difference between 'observed' and 'estimated' prevalence of dementia in general practices. We also explored practice characteristics associated with observed prevalence rates. METHOD: Six Primary Care Trusts (PCTs) provided data on all general practices (N = 351) in their area in terms of number of doctors, patient list size, number of patients over 65 years of age, socio-economic deprivation status of practices and number of patients on dementia registers. RESULTS: The average observed prevalence overall of dementia amongst patients 65 years and over was 3.0% [95CI 2.8, 3.2]. The observed prevalence was 54.5% [95CI 49.2, 58.9] lower than the prevalence observed in the epidemiological studies in the UK. For an average size general practice (list size of 5269 patients) approximately 27 [95CI 22, 32] patients with dementia may remain undiagnosed. Statistically significant differences in prevalence rates were found between the different PCTs (Wald chi-square = 103.8 p < 0.001). The observed prevalence of dementia was significantly lower among practices run by one GP compared to multiple GPs (p = 0.003), and in more affluent areas (p < 0.001). CONCLUSION: Just under a half of the expected numbers of patients with dementia are recognised in GP dementia registers. The underdiagnosis of dementia varies with practice characteristics, socio-economic deprivation and between PCTs, which has implications for the local implementation of the National Dementia Strategy.

Long-term care for people with dementia: environmental design guidelines.

BACKGROUND: A large and growing number of people with dementia are being cared for in long-term care. The empirical literature on the design of environments for people with dementia contains findings that can be helpful in the design of these environments. A schema developed by Marshall in 2001 provides a means of reviewing the literature against a set of recommendations. The aims of this paper are to assess the strength of the evidence for these recommendations and to identify those recommendations that could be used as the basis for guidelines to assist in the design of long term care facilities for people with dementia. METHODS: The literature was searched for articles published after 1980, evaluating an intervention utilizing the physical environment, focused on the care of people with dementia and incorporating a control group, pre-test-post-test, cross sectional or survey design. A total of 156 articles were identified as relevant and subjected to an evaluation of their methodological strength. Of these, 57 articles were identified as being sufficiently strong to be reviewed. RESULTS: Designers may confidently use unobtrusive safety measures; vary ambience, size and shape of spaces; provide single rooms; maximize visual access; and control levels of stimulation. There is less agreement on the usefulness of signage, homelikeness, provision for engagement in ordinary activities, small size and the provision of outside space. CONCLUSIONS: There is sufficient evidence available to come to a consensus on guiding principles for the design of long term environments for people with dementia.

Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review.

BACKGROUND: The population of older adults in long-term care (LTC) is expected to increase considerably in the near future. An understanding of the prevalence of psychiatric disorders in LTC will help in planning mental health services for this population. This study reviews the prevalence of common psychiatric disorders in LTC populations. METHODS: We searched electronic databases for studies on the prevalence of major psychiatric disorders in LTC using medical subject headings and key words. We only included studies using validated measures for diagnosing psychiatric disorders or psychiatric symptoms. Our review focused on the following psychiatric disorders: dementia, behavioral and psychological symptoms of dementia (BPSD), major depression, depressive symptoms, bipolar disorder, anxiety disorders, schizophrenia, and alcohol use disorders. We also determined the prevalence of psychiatric disorders in the U.S. LTC population using data from the 2004 National Nursing Home Survey (NNHS). RESULTS: A total of 74 studies examining the prevalence of psychiatric disorders and psychological symptoms in LTC populations were identified including 30 studies on the prevalence of dementia, 9 studies on behavioral symptoms in dementia, and 26 studies on depression. Most studies involved few LTC facilities and were conducted in developed countries. Dementia had a median prevalence (58%) in studies while the prevalence of BPSD was 78% among individuals with dementia. The median prevalence of major depressive disorder was 10% while the median prevalence of depressive symptoms was 29% among LTC residents. There were few studies on other psychiatric disorders. Results from the 2004 NNHS were consistent with those in the published literature. CONCLUSIONS: Dementia, depression and anxiety disorders are the most common psychiatric disorders among older adults in LTC. Many psychiatric disorders appear to be more prevalent in LTC settings when compared to those observed in community-dwelling older adults. Policy-makers and clinicians should be aware of the common psychiatric disorders in LTC and further research into effective prevention and treatments are required for this growing population.

Dental health of community-living older people attending secondary healthcare: a cross-sectional comparison between those with and without diagnosed mental illness.

BACKGROUND: Mental illness and cognitive impairment are risk factors for poor dental health. METHODS: We conducted a cross-sectional study to compare the dental health of older patients attending out-patient clinics and day hospitals of old age psychiatry services (the psychiatry group, n = 103) with those attending general/geriatric medical services (the medical group; n = 99). Those living in care homes, and those with diagnosed mental illness (in the medical group) were excluded. A registered mental health nurse assessed mental and general health using validated and previously published instruments. A registered dentist made an independent assessment of dental health (examination to assess oral pathology, status of remaining teeth, and dentures) and made an overall judgment about whether the patient needed any dental treatment (a "normative" need). RESULTS: The normative need for dental treatment was significantly higher among the psychiatry group compared to the medical group (85% vs 52%; p<0.001); even after taking account of the effect of age, gender, teeth status, physical comorbidity, cognition, depressive symptoms, and overall mental and social health [adjusted odds ratio, OR (95% confidence interval): 4.32 (2.09, 8.91)]. The presence of any natural remaining teeth [OR: 4.44 (2.10, 9.42)] and Barthel Index [OR: 0.96 (0.93, 0.99)] were the two other independent predictors of the need for treatment. CONCLUSION: Dental problems are common in community-living older people, especially those with some natural remaining teeth and those with mental illness. There is a need to develop integrated mental health and dental care services for older people with emphasis on prevention of dental problems.

Preventing dementia: role of vascular risk factors and cerebral emboli.

INTRODUCTION OR BACKGROUND: Dementia, Alzheimer's disease and vascular dementia being two main causes, is major and growing health problem. Vascular risk factors are thought to be involved in the causation of both dementias. SOURCES OF DATA: A review of the literature was conducted using MedLine to identify current evidence for role of vascular risk factors as potential targets in preventing dementia. Cross-references were hand searched. AREAS OF AGREEMENT: The evidence from prospective epidemiological studies suggests that optimizing the control of vascular risk factors such as hypertension, high cholesterol, diabetes, smoking and heart disease may prevent dementia. However, this has been proven in randomized placebo-controlled trials (RCT) for only hypertension. AREAS OF CONTROVERSY: Dementia is a secondary outcome in most RCTs and it is not known if there is a therapeutic time window between mid- and late-life when interventions are most effective. Also, we do not know precise mechanisms by which interventions for vascular risk factors offer brain protection. GROWING POINTS: Our research suggests that asymptomatic cerebral emboli, which are preventable, may be involved in the causation of dementia. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need for RCT targeting multiple vascular risk factors in patients at high risk of dementia such as those with mild cognitive impairment.

Suicide in dementia: 9-year national clinical survey in England and Wales.

BACKGROUND: Knowledge of suicide in people with dementia is limited to small case series. AIMS: To describe behavioural, clinical and care characteristics of people with dementia who died by suicide. METHOD: All dementia cases (n=118) from a 9-year national clinical survey of suicides in England and Wales (n=11 512) were compared with age- and gender-matched non-dementia cases (control group) (n=492) by conditional logistic regression. RESULTS: The most common method of suicide in patients with dementia was self-poisoning, followed by drowning and hanging, the latter being less frequent than in controls. In contrast to controls, significantly fewer suicides occurred within 1 year of diagnosis in patients with dementia. Patients with dementia were also less likely to have a history of self-harm, psychiatric symptoms and previous psychiatric admissions. CONCLUSIONS: Known indicators of suicide risk are found less frequently in dementia suicide cases than non-dementia suicide cases. Further research should clarify whether suicide in dementia is a response to worsening dementia or an underappreciation of psychiatric symptoms by clinicians.

Domiciliary and day care services: Why do people with dementia refuse?

OBJECTIVE: To explore the reasons given for refusal of day services, and to examine the relationship between willingness to accept day services and clinical variables. METHOD: Fifty people with dementia who lived alone and had refused day services were interviewed. RESULTS: The most common reasons for reluctance to attend day services were the belief that they did not need day services, that they liked being on their own, and the belief that they would not enjoy it. People who persistently refused day services tended to have additional worries about meeting new people, losing their independence and being institutionalised. Fifty-four per cent of people with dementia who lived alone and had refused day services scored six or more on the Cornell Scale for Depression in Dementia, suggesting possible presence of major depression. CONCLUSION: In patients with dementia who live alone and refuse day services, their misconceptions about day services and possibility of undiagnosed depression need further exploration.

Asymptomatic spontaneous cerebral emboli predict cognitive and functional decline in dementia.

BACKGROUND: Spontaneous cerebral emboli (SCE) are frequent in Alzheimer's disease (AD) and vascular dementia (VaD). We investigated the effect of SCE on the rates of cognitive and functional decline in AD and VaD. METHODS: One hundred thirty-two patients with dementia (74 AD, National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association [NINCDS/ADRDA] criteria; 58 VaD, National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences [NINDS/AIREN] criteria) underwent 1-hour transcranial Doppler for detection of SCE (mean [SD] age 75.5 (7.4) years; 46% female). Neuropsychological tests (Mini-Mental State Examination [MMSE], Alzheimer's Disease Assessment Scale-Cognitive subscale [ADAS-Cog], and Neuropsychiatric Inventory [NPI]) and assessment of activities of daily living (Interview for Deterioration in Daily Living Activities in Dementia [IDDD]) were performed initially and 6 months later. SCE positive (SCE+ve, n = 47) and SCE negative (SCE-ve, n = 85) patients were compared using repeated measures analyses of variance (ANOVAs) adjusted for age, gender, and cardiovascular risk factors. RESULTS: SCE+ve patients with dementia, both AD and VaD, suffered a more rapid decline in cognitive functioning over 6 months (ADAS-cog, mean increase 7.1 for SCE+ve compared with 3.3 for SCE-ve, p = .006) and activities of daily living (IDDD, mean increase 24.4 for SCE+ve compared with 10.8 for SCE-ve, p = .014). CONCLUSIONS: Asymptomatic SCE are associated with an accelerated cognitive and functional decline in dementia. SCE may be a potentially treatable cause of disease progression in dementia.

What are the benefits of cognitive enhancers for Alzheimer's Disease: use of Population Impact Measures.

BACKGROUND: The study aims to quantify the population impact of prescribing cholinesterase inhibitors to slow the cognitive decline in Alzheimer's disease (AD), and to compare with the benefit of treating hypertension to prevent the onset of AD. METHODS: Literature review to ascertain the prevalence of AD, benefits of interventions, analysis of local and national surveys to measure the current use of interventions in the relevant population and application of the relevant findings to calculate Population Impact Measures. The Number of Events Prevented in a Population (NEPP) by the intervention over a defined time period is calculated for a UK urban population in one Local Authority (population size 217,000). RESULTS: Treatment of all eligible patients with mild to moderate AD with Cholinesterase Inhibitors would prevent cognitive deterioration (measured by ADAS - cog scale) in 123.6 (95% Confidence Intervals (CI) 82.3, 169.1), 16.4 (95% CI 2.1, 31.2) would show a mild improvement (4 points or more on the ADAS - cog scale) and 2.6 (95% CI 0.2, 5.8) would show an improvement of 7 points or more over a period of 6 months. This would require the treatment of 406 patients with Cholinesterase Inhibitors. Increasing from the current treatment rate of 46% of eligible patients to 'best practice' level would prevent cognitive deterioration in 66.8 (95% CI 44.0, 92.6), 8.99 (95% CI 1.2, 16.8) and 1.4 (95% CI 0.11, 3.2) would improve by 4 and 7 points respectively on the ADAS - cog scale over 6 months. This would require the treatment of an extra 187 patients with Cholinesterase Inhibitors beyond current practice, at an additional annual direct drug cost of pound187,000. Improving the treatment of hypertension from current practice by 20% could prevent 8.2 (95% CI 2.3, 16.8) incident cases of AD in the next year. This would require the treatment of an extra 2711 patients with antihypertensive drugs. CONCLUSION: Population Impact Measures are a new method to allow a demonstration of the magnitude of the benefit for the whole population following interventions. The use of drugs to slow cognitive decline, or to prevent AD by treating hypertension, can thus be assessed in a prioritisation exercise in competition with alternative use of resources.

Deletion/insertion polymorphism of the angiotensin-converting enzyme gene and white matter hyperintensities in dementia: A pilot study.

OBJECTIVES: To examine the association between the angiotensin-converting enzyme (ACE) deletion/insertion (D/I) polymorphism and white matter hyperintensities (WMHs) in patients with dementia. DESIGN: Observational pilot study with adjustment for potential confounders using analysis of covariance. SETTING: Secondary care old-age psychiatry services in greater Manchester, United Kingdom. PARTICIPANTS: Ninety-seven patients with dementia: 49 with Alzheimer's disease (AD, National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association criteria) and 48 with vascular dementia (VaD, National Institute of Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences criteria). MEASUREMENTS: The ACE D/I polymorphism, WMHs (deep WMHs (DWMHs) and periventricular hyperintensities (PVHs)) on T2-weighted magnetic resonance imaging, and potential cardiovascular confounders. RESULTS: The D/D polymorphism of the ACE genotype was associated with severity of DWMH (P = .005) but not PVH (P = .34), corrected for age, cardiovascular risk factors, and type of dementia. Post hoc analyses were limited by statistical power but suggested an interaction with the apolipoprotein E epsilon4 allele. CONCLUSION: The results support previous observations that genetic factors influence the development of WMHs in dementia. The involvement of the ACE D/I polymorphism in the pathogenesis of DWMHs in dementia (AD and VaD), by a mechanism that is independent of its association with cardiovascular risk factors, should be confirmed in a large population-based sample.

Clinical practice with anti-dementia drugs: a consensus statement from British Association for Psychopharmacology.

The British Association for Psychopharmacology (BAP) coordinated a meeting of experts to review the evidence on the drug treatment for dementia. The level of evidence (types) was rated using a standard system: Types 1a and 1b (evidence from meta-analysis of randomised controlled trials or at least one controlled trial respectively); types 2a and 2b (one well-designed study or one other type of quasi experimental study respectively); type 3 (non-experimental descriptive studies); and type 4 (expert opinion). There is type 1a evidence for cholinesterase inhibitors (donepezil, rivastigmine and galantamine) for mild to moderate Alzheimer's disease; memantine for moderate to severe Alzheimer's disease; and for the use of bright light therapy and aromatherapy. There is type 1a evidence of no effect of anti inflammatory drugs or statins. There is conflicting evidence regarding oestrogens, with type 2a evidence of a protective effect of oestrogens but 1b evidence of a harmful effect. Type 1a evidence for any effect of B12 and folate will be forthcoming when current trials report. There is type 1b evidence for gingko biloba in producing a modest benefit of cognitive function; cholinesterase inhibitors for the treatment of people with Lewy body disease (particularly neuropsychiatric symptoms); cholinesterase inhibitors and memantine in treatment cognitive impairment associated with vascular dementia; and the effect of metal collating agents (although these should not be prescribed until more data on safety and efficacy are available). There is type 1b evidence to show that neither cholinesterase inhibitors nor vitamin E reduce the risk of developing Alzheimer's disease in people with mild cognitive impairment; and there is no evidence that there is any intervention that can prevent the onset of dementia. There is type 1b evidence for the beneficial effects of adding memantine to cholinesterase inhibitors, and type 2b evidence of positive switching outcomes from one cholinesterase inhibitor to another. There is type 2a evidence for a positive effect of reminiscence therapy, and type 2a evidence that cognitive training does not work. There is type 3 evidence to support the use of psychological interventions in dementia. There is type 2 evidence that a clinical diagnosis of dementia can be made accurately and that brain imaging increases that accuracy. Although the consensus statement dealt largely with medication, the role of dementia care in secondary services (geriatric medicine and old age psychiatry) and primary care, along with health economics, was discussed. There is ample evidence that there are effective treatments for people with dementia, and Alzheimer's disease in particular. Patients, their carers, and clinicians deserve to be optimistic in a field which often attracts therapeutic nihilism.