Test Accuracy of the Montreal Cognitive Assessment in Screening for Early Poststroke Neurocognitive Disorder: The Nor-COAST Study.

BACKGROUND AND PURPOSE: We determined the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) for poststroke neurocognitive disorder defined according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria in a prospective observational study. METHODS: Consecutive participants able to complete a cognitive test battery and MoCA 3 months poststroke were included. The reference standard of neurocognitive disorder was defined as a score of ≥1.5 SD below the normative mean in ≥1 cognitive domain on the cognitive test battery. RESULTS: Among 521 participants (43.6% women; mean age/SD, 71.5/12.0 years; mean education/SD, 12.4/3.8 years), the area under the receiver operating characteristic curve of MoCA for neurocognitive disorder was 0.80 (95% CI, 0.76-0.84). Using the standard MoCA cutoff <26, sensitivity was 0.71 (0.69-0.79) with specificity of 0.73 (0.66-0.76). MoCA cutoff of <27 gave higher sensitivity (0.82 [0.77-0.85]) at the expense of specificity (0.60 [0.53-0.66]). DISCUSSION: MoCA has reasonable accuracy for poststroke neurocognitive disorder diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02650531.

Quality of Life in People with Young-Onset Dementia: A Nordic Two-Year Observational Multicenter Study.

BACKGROUND: Cross-sectional studies of quality of life (QOL) of people with young-onset dementia show diverging results. OBJECTIVE: To identify factors associated with QOL in people with young-onset Alzheimer's (AD) and frontotemporal dementia (FTD) and explore development in QOL over a two-year period, including differences between the two subtypes. METHODS: A two-year cohort study of 88 community-dwelling people with young-onset AD and FTD recruited from Nordic memory clinics. QOL was assessed using the proxy version of the Quality of Life - Alzheimer's Disease questionnaire, dementia severity was rated with the Clinical Dementia Rating scale, depressive symptoms by the Cornell Scale for Depression in Dementia, awareness with the Reed anosognosia scale, and needs using the Camberwell Assessment of Needs in the Elderly questionnaire. Factors associated with QOL and development in QOL over time were explored with growth mixture model trajectories and mixed model analyses. RESULTS: We identified two groups of people following trajectories with better (n = 35) versus poorer (n = 53) QOL. People with more depressive symptoms at baseline had higher odds of belonging to poorer QOL group, OR 1.2 (CI 1.1; 1.5, p = 0.011). Having Alzheimer's disease was associated with significantly better QOL (p = 0.047 at baseline, p = 0.009 at T1 and p = 0.033 at T2). Increasing number of unmet needs was significantly associated with poorer QOL at baseline (p = 0.007), but not later in follow-up. CONCLUSION: Early assessment and treatment based on dementia subtype, depression, and individual needs may enhance quality of life in young-onset dementia.

Nursing care needs and services utilised by home-dwelling elderly with complex health problems: observational study.

BACKGROUND: In Norway, as in many Western countries, a shift from institutional care to home care is taking place. Our knowledge is limited regarding which needs for nursing interventions patients being cared for in their home have, and how they are met. We aimed at assessing aspects of health and function in a representative sample of the most vulnerable home-dwelling elderly, to identify their needs for nursing interventions and how these needs were met. METHODS: In this observational study we included patients aged 75+ living in their own homes in Oslo, who received daily home care, had three or more chronic diagnoses, received daily medication, and had been hospitalized during the last year. Focused attention and cognitive processing speed were assessed with the Trail Making Test A (TMT-A), handgrip strength was used as a measure of sarcopenia, mobility was assessed with the "Timed Up-and-Go" test, and independence in primary activities of daily living by the Barthel Index. Diagnoses and medication were collected from electronic medical records. For each diagnosis, medication and functional impairment, a consensus group defined which nursing service that the particular condition necessitated. We then assessed whether these needs were fulfilled for each participant. RESULTS: Of 150 eligible patients, 83 were included (mean age 87 years, 25% men). They had on average 6 diagnoses and used 9 daily medications. Of the 83 patients, 61 (75%) had grip strength indicating sarcopenia, 27 (33%) impaired mobility, and 69 (83%) an impaired TMT-A score. Median amount of home nursing per week was 3.6 h (interquartile range 2.6 to 23.4). Fulfilment of pre-specified needs was >60% for skin and wound care in patients with skin diseases, observation of blood glucose in patients taking antidiabetic drugs, and in supporting food intake in patients with eating difficulties. Most other needs as defined by the consensus group were fulfilled in <10% of the patients. CONCLUSIONS: We identified a very frail group of home-dwelling patients. For this group, resources for home nursing should probably be used in a more flexible and pro-active way to aim for preserving functional status, minimize symptom burden, and prevent avoidable hospitalisations.

Cooperation between geriatricians and general practitioners for improved pharmacotherapy in home-dwelling elderly people receiving polypharmacy - the COOP Study: study protocol for a cluster randomised controlled trial.

BACKGROUND: Polypharmacy and inappropriate drug use is associated with negative health outcomes among older people. Various interventions for improving drug treatment have been evaluated, but the majority of studies are limited by the use of surrogate outcomes or suboptimal design. Thus, the potential for clinically significant improvements from different interventions is still unclear. The main objective of this study is therefore to evaluate the effect upon patient-relevant endpoints of a cooperation between geriatricians and general practitioners on complex drug regimens in home-dwelling elderly people. METHODS: This is a cluster randomised, single-blind, controlled trial where general practitioners are invited to participate with patients from their lists. The patients must be 70 years or older, use at least seven different medications and have their medications administered by the home nursing service. We plan to recruit 200 patients, with randomisation at physician level. The intervention consists of three main parts: (1) clinical geriatric assessment of the patient, combined with a thorough review of their medications; (2) a meeting between the geriatrician and general practitioner, where the two physicians combine their competence and knowledge and discuss the drug list systematically; (3) clinical follow-up, depending on the medication changes that have been done. The study period is 24 weeks, and the patients are assessed at baseline, 16 and 24 weeks. The primary outcome measure is health-related quality of life according to the 15D instrument. Secondary outcome measures include physical and cognitive functioning, medication appropriateness, falls, carer burden, use of health services (hospital or nursing home admissions, use of home nursing services) and mortality. DISCUSSION: Our choice of patient-relevant outcome measures will hopefully provide new knowledge on the potential for clinical improvements after performing comprehensive medication reviews in home-dwelling elderly people receiving polypharmacy. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02379455 . Registered on 27 February 2015.

Determinants of quality of life in young onset dementia - results from a European multicenter assessment.

BACKGROUND: Promoting adaptation, improving well-being and maintaining an optimal quality of life (QOL) is an important aspect in dementia care. The purpose of this study was to identify determinants of QOL in young onset dementia, and to assess differences in QoL domains between people with Alzheimer's disease (AD) and frontotemporal dementia (FTD). METHODS: In total 135 persons with AD and 58 persons with FTD were included from two prospective cohort studies. QOL was assessed with the proxy reported quality of life in Alzheimer's disease questionnaire (QoL-AD). Possible determinants were explored using multiple linear regression and included sociodemographic variables, diagnosis, dementia severity, disease awareness, neuropsychiatric symptoms, met and unmet needs and hours of personal and instrumental care. Differences between QOL domains in people with AD and FTD were calculated using Mann-Whitney U tests. RESULTS: Lower QOL was associated with more depressive symptoms, lower disease awareness, and a higher amount of needs, both met and unmet. People with AD scored lower on the memory and higher on the friends' subscale. No differences were found for the other items. CONCLUSION: This study demonstrates a unique set of determinants of QOL in AD and FTD. Interventions directed towards these specific factors may improve QOL.

The Memory Clinic--outpatient assessment when dementia is suspected.

The patients who are assessed at Oslo University Hospital's Memory Clinic are young--half of them are under 65 years of age. Most are suffering from mild cognitive impairment or dementia at a very early phase while others come to get a second opinion. The assessment takes 2 - 3 hours and is conducted by a doctor and a nurse. It includes a clinical investigation, cognitive testing, an MRI scan with measurement of the medial temporal lobes, a lumbar puncture and single-photon-emission tomography (SPECT of the brain).

Outcome after femoral neck fractures: a comparison of Harris Hip Score, Eq-5d and Barthel Index.

INTRODUCTION: The objective of this study was to evaluate the discriminatory ability and responsiveness of the Harris Hips Score, the Barthel Index and the Eq-5d (Euroqol) in an unselected population of patients with displaced femoral neck fracture. METHODS: Data were collected at 4 and 12 months after surgery from a population of 222 patients. Patients with complete data sets who suffered a serious complication (n=23) were compared with patients with no complication (n=56). The assessment scales' ability to discriminate between the groups was calculated, as was the change score and the standardised response mean. RESULTS: All scales were able to discriminate between the complications group and the non-complications group at 4 months, but only Harris Hip Score had independent explanatory ability in a logistic regression analysis. All scales showed a positive change score for the complications group from 4 to 12 months. The standardised response mean was 0.75 for Harris Hip Score, 0.40 for Barthel Index, 0.46 for the Eq-5d index score, and 0.57 for the Eq-5d visual analogue scale. Barthel Index had a marked ceiling effect with 51/79 (65%) scoring 19 or 20 at 4 months. The response rate was 71-87% for Eq-5d and 96-98% for Harris Hip Score and Barthel Index. CONCLUSION: All the scales may be used for this patient group, but Harris Hip Score performed better than the other scales.

A one-year randomized controlled psychosocial intervention study among family carers of dementia patients--effects on patients and carers.

OBJECTIVE: To test the effect of a short-term psychosocial intervention programme for family carers of patients with dementia and identify characteristics of carers and patients that responded positively. METHODS: The study was a multi-centre randomized controlled trial. Carers of 180 patients suffering from dementia recruited at 7 memory clinics at geriatric or psychiatric departments participated in the study. Carers of the intervention group were educated about dementia and in 6 group meetings taught how to use structured problem-solving. The control group received treatment as usual. The effect on patients was measured with the Neuropsychiatric Inventory and on carers with the Relatives' Stress Scale (RSS). RESULTS: The intention-to-treat efficacy analysis included 171 carer/patient dyads. The intervention did not have any effect on the primary outcome variables. The burden measured by the RSS increased in both groups; however, more carers of the control group converted from a low-burden group to a medium- or high-burden group after 4.5 months. In a subgroup analysis we found a statistically significant difference in the Neuropsychiatric Inventory score in favour of the intervention group among female patients. CONCLUSION: The predominately negative result of this study emphasizes the need of individually tailored interventions for carers and the use of narrow inclusion criteria when performing group-based interventions, such as the extent of burden as well as gender and kinship.

High score on the Relative Stress Scale, a marker of possible psychiatric disorder in family carers of patients with dementia.

OBJECTIVE: To compare the scores on the Relative Stress Scale (RSS) with those on the General Health Questionnaire (GHQ) and the Geriatric Depression Scale (GDS), and to establish a cut-off score for RSS in order to distinguish carers with symptoms of psychiatric disorders from those without. METHODS: One hundred and ninety-four carers of 194 patients suffering from dementia according to ICD-10 were included in the study. Burden of care was assessed by the 15-items RSS, and psychiatric symptoms by means of the GHQ-30 and the 30-items GDS. A case score above 5 on GHQ and above 13 on GDS were used to define carers with probable psychiatric morbidity. Sensitivity (SS), specificity (SP), accuracy and likelihood ratio for a positive test (LR+) were calculated for different cut-points of the RSS. RESULTS: Fifty-six percent of the carers had a GHQ score above 5, and 22% had a GDS score above 13. A two-step cluster analysis using 192 of the 194 carers, identified three groups of carers; a low risk group for psychiatric morbidity (LRG), 82 carers with GHQ < or = 5 and GDS < or = 13; a medium risk group (MRG), 69 carers with GHQ > 5 and GDS < or = 13; and a high-risk group (HRG), 40 carers with GHQ > 5 and GDS > 13. The optimal RSS cut-off to distinguish between the LRG and the others was > 23 (SS 0.72, SP 0.82, accuracy 0.76, LR + 4.0), whereas the optimal cut-off to separate the HRG from the others was >30 (SS 0.74, SP 0.87, accuracy 0.84, LR + 5.7). CONCLUSION: The RSS is a useful instrument to stratify carers according to their risk of psychiatric morbidity.

Emotional well-being of close relatives to stroke survivors.

OBJECTIVE: To compare the well-being of stroke patients' relatives with that of a reference group, and to identify variables related to the well-being of the relatives. DESIGN: Cross-sectional study. SETTING: Outpatient hospital department and patients' and relatives' own homes. SUBJECTS: Fifty-four patients one year after a stroke and their closest relatives. A reference population consisted of 419 elderly people drawn at random from the census files. OUTCOME MEASURES: Emotional well-being was assessed with the General Health Questionnaire (GHQ-20), and the perceived burden attributed to the care of the patient with the Caregiver Strain Index (CSI). The personal and instrumental activities of daily life (PADL and IADL), motor and cognitive functions of the patients were assessed with standardized tests. RESULTS: The relatives rated their well-being lower than the reference group rated theirs, the odds ratio (OR) being 5.6 (95% confidence interval (CI) 3.1-10) adjusted for age and gender. No association was found between the relatives' well-being and the motor, cognitive, PADL, IADL or other characteristics of the patients. Strong relationships were found between the CSI and the GHQ scores of the relatives, the OR (95% CI) for a poor GHQ score being 2.4 (1.6-3.7) for each unit increase in CSI, adjusted for gender. CONCLUSIONS: Emotional well-being is influenced when a close relative gets a stroke. This seems to relate more strongly to the perceived burden of care than to objective characteristics of the patient.