Eligibility for antiamyloid treatment: preparing for disease-modifying therapies for Alzheimer's disease.

BACKGROUND: Disease-modifying therapies (DMTs) for Alzheimer's disease (AD) have early evidence of efficacy. Widespread delivery of DMTs will require major service reconfiguration. Treatment pathways will need to include triaging for eligibility, regular infusions and baseline and follow-up MRI scanning. A critical step in planning is provision of real-world estimates of patients likely to be eligible for triaging, but these are challenging to obtain. METHODS: We performed a retrospective service evaluation of patients attending five memory services across North and East London and a national specialist cognitive disorders service. We examined the likely proportion of patients who would (1) be referred for triaging for DMTs and (2) potentially be suitable for treatments. RESULTS: Data from a total of 1017 patients were included, 517 of whom were seen in community memory services and 500 in a specialist clinic. In the memory services, 367/517 (71%) were diagnosed with possible AD. After exclusions of those in whom cognitive and frailty scores, MRI contraindications or anticoagulant use indicated they would be unlikely to be suitable, an estimated 32% would be eligible for triaging. In the specialist cognitive clinic, where additional investigations are available, 14% of those seen (70/500) would be potentially eligible for treatment. CONCLUSIONS: While a sizeable proportion of patients attending memory clinics may be referred for triaging for DMTs for AD, only a minority are likely to be suitable for these, as demonstrated in patients seen in specialist cognitive services. This will need to be considered when designing pathways for DMT delivery.

The sensitivity and specificity of the Modified Conflict Tactics Scale for detecting clinically significant elder abuse.

BACKGROUND: A third of family carers of people with dementia describe acting abusively in research studies, but far fewer cases of abuse are currently detected in clinical situations. This discrepancy may be explained by inadequate detection by health professionals, or disagreement regarding what constitutes elder abuse. This study was undertaken to determine the sensitivity and specificity of the revised Modified Conflict Tactics Scale (MCTS) for detecting clinically significant abuse. METHODS: We interviewed 220 family carers of people consecutively referred to psychiatric services with dementia in Essex and London (U.K.), using the MCTS to measure abuse. We defined abuse cases using (1) the MCTS conventional scoring system; (2) the Pillemer criteria; and (3) clinical judgment of an expert panel. RESULTS: Our panel judged that 15 (6.8%) of carers reported potentially clinical concerning abusive behavior; but 47 (21%) were cases according to the Pillemer criteria and 74 (34%) using the MCTS conventional scoring system. We developed a weighted MCTS scoring system, with high sensitivity and specificity for detecting clinically concerning abuse. CONCLUSIONS: The MCTS could be used routinely in clinical practice with carers of people with dementia to detect clinically concerning cases of abuse, many of which are currently being missed.

Mental capacity to consent to treatment and admission decisions in older adult psychiatric inpatients.

OBJECTIVES: There is little information about older adult psychiatric inpatients' capacity to consent to clinical decisions. In younger adults, lack of capacity is associated with poor insight and psychosis rather than cognitive impairment. We assessed the prevalence and predictors of mental capacity to make treatment and admission decisions in older psychiatric inpatients, and asked their views about who should make these decisions. METHODS: We interviewed 99 participants using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in three geographical locations. RESULTS: Fifty-two (52.5%) participants had capacity for admission and 38 (38.4%) for treatment decisions. Capacity was associated with not having dementia, and higher levels of insight and cognition. Those with depression were more likely to have capacity than those with psychosis. 75% of patients without capacity for admission were not detained legally. CONCLUSIONS: Patients can have capacity to make decisions in one area but not in others. Many people are admitted and treated in a way that is contrary to the human rights legislation. The new Deprivation of Liberty Safeguards in England and Wales are likely to apply to a significant proportion of older inpatients. Most people wanted doctors to make treatment and admission decisions and very few wanted their family to make decisions on their behalf.

The TE4D-Cog: a new test for detecting early dementia in English-speaking populations.

BACKGROUND: The screening test usually used to detect dementia (Mini Mental State Examination, MMSE) is limited by a ceiling effect and high false positive rates, as are other similar instruments. There is therefore a need for a more sensitive and specific screening tool to aid early detection and diagnosis of dementia. OBJECTIVE: The hypothesis of the study was that the TE4D-Cog would be more sensitive and specific than the MMSE in detecting mild cognitive impairment in patients with AD. METHOD: The TE4D (Test for the Early Detection of Dementia from Depression) was adapted from its original German version for English-speaking populations. This new scale (the TE4D-Cog) was then administered together with the MMSE and the cognitive subscale of the Alzheimer's disease Assessment Scale (ADAS-Cog) to 178 people with a diagnosis of Alzheimer's disease and 25 cognitively intact comparators. The sensitivity and specificity in detecting dementia of the TE4D-Cog and the MMSE were compared in those with mild dementia and those without dementia. RESULTS: The TE4D-cog had high sensitivity with an acceptable specificity and low false positive rate. It also had good concurrent validity, high inter-rater reliability, good internal consistency and strong predictive validity. CONCLUSIONS: The TE4D-Cog is easy to administer, short and acceptable. Results are independent of age, gender and level of education. The TE4D-Cog may therefore be a useful alternative to the MMSE as a dementia screening instrument.