Prodromal or mild Alzheimer's disease: Influence of neuropsychiatric symptoms and premordid personality on caregivers' burden.

OBJECTIVE: In Alzheimer's disease (AD), the burden on caregivers is influenced by various factors, including the stage of disease progression and neuropsychiatric symptoms (NPS). To date, there has been limited research examining how patient's premorbid personality could affect this burden. The objective of this study was to investigate the impact of both premorbid personality and NPS in individuals with prodromal to mild AD on their caregivers' burden. METHOD: One hundred eighty participants with prodromal or mild AD drown from the PACO (in French: Personnalité Alzheimer COmportement) cohort were included. Personality was assessed by the Revised NEO Personality Inventory (NEO-PI-R). Neuropsychiatric symptoms were measured with the short version of the Neuropsychiatric Inventory (NPI-Q), and caregiver burden was evaluated with the Zarit burden scale. Relationships between personality, Neuro-Psychiatric Inventory (NPI) scores, and caregiver burden were determined using multivariate linear regressions controlled for age, sex, educational level, and Mini Mental State Examination. RESULTS: The total NPI score was related to increased burden (beta = 0.45; p < 0.001). High level of neuroticism (beta = 0.254; p = 0.003) et low level of conscientiousness (beta = - 0.233; p = 0.005) were associated higher burden. Extraversion (beta = -0.185; p = 0.027) and conscientiousness (beta = -0.35; p = 0.006) were negatively associated with burden. In contrast, neuroticism, openness and agreeableness were not correlated with burden. When adjusted on total NPI score, the relationship between extraversion and conscientiousness didn't persist. CONCLUSION: Our results suggest that premorbid personality of patients with prodromal to mild Alzheimer influence caregivers's burden, with a protective effect of a high level of extraversion and conscientiousness.

Relationship between anxiety and cognitive performance in an elderly population with a cognitive complaint.

BACKGROUND AND PURPOSE: Almost half of elderly patients being consulted in memory clinics present anxiety disorders, either with or without an associated depressive syndrome. This study investigates the relationship between the level of anxiety and cognitive performance in a population complaining of memory difficulties. METHODS: The study population (n = 149) was selected from the EVATEM cohort, which included subjects aged 65 years or older. All subjects presented memory complaints and patients with depression were excluded. Anxiety level was assessed with the Hamilton Anxiety Rating Scale. A standard neuropsychological battery, including a free and cued episodic memory test, was administered to examine the different processes of verbal episodic memory, visual memory, executive, visuoconstructive and instrumental functions. RESULTS: Subjects with moderate to severe anxiety had worse performance than subjects with no anxiety in retrieval and storage processes of verbal episodic memory (respectively P = 0.004 and P = 0.02) and in visual recognition memory (P = 0.01). No relationship was found between anxiety and executive, visual-constructive or instrumental functions. CONCLUSION: Anxiety impacts several stages of verbal memory, notably the processes of storage and retrieval, and visual recognition memory within a population having cognitive complaints. This study suggests that anxiety should be considered as a factor of memory vulnerability for patients being treated in memory clinics.

Evaluation of a mobile team dedicated to behavioural disorders as recommended by the Alzheimer Cooperative Valuation in Europe joint action: observational cohort study.

BACKGROUND AND PURPOSE: Preventing behavioural crises appears to be crucial to promote quality of life of the patient-caregiver dyad, to reduce inappropriate hospitalizations and to delay institutionalization. The Alzheimer Cooperative Valuation in Europe promotes mobile care to prevent patients from severe behavioural and psychological symptoms in dementia. This study assessed the potential efficacy of a mobile team for Alzheimer's disease on hospitalization sparing and behavioural disorder reduction. METHODS: A cohort study was set up from 1 January 2012 to 31 December 2013 by the Clinical and Research Memory Centre of Lyon (France). It included patients with behavioural and psychological symptoms living at home or in a nursing home. An interview explored the alternative patient pathways used by general practitioners (GPs) if the mobile team had not existed (hospitalization sparing). The Neuropsychiatry Inventory score was assessed at inclusion and 30 days later. The sample included 424 consecutive patients with Alzheimer's disease or related disorders and behavioural disorders at any cognitive and functional stage of the disease, taken in charge by the mobile team. RESULTS: Amongst the 424 patients (84.0 ± 7.2 years), 220 (51.9%) hospitalizations were considered by their GPs and 181 (82.3%) were avoided. The Neuropsychiatric Inventory score declined after mobile team intervention (45.8-29.9, P < 0.001). Sleep and appetite disorders, endangered situation and caregiver burnout were associated with higher risk of hospitalization at 30 days. CONCLUSIONS: The mobile team for Alzheimer's disease allows a high proportion of hospitalizations related to behavioural disorders to be avoided and may help to reduce behavioural disorders.

Performance of cognitive tests, individually and combined, for the detection of cognitive disorders amongst community-dwelling elderly people with memory complaints: the EVATEM study.

BACKGROUND AND PURPOSE: Dementia is a leading cause of dependence amongst the aged population. Early identification of cognitive impairment could help to delay advanced stages of dependence. This study aimed at assessing the performance of three neuropsychological tests to detect cognitive disorders in elderly subjects with memory complaints. METHODS: The EVATEM study is a prospective multicentre cohort with a 1-year follow-up. Subjects with memory complaints were selected during preventive health examinations, and three neuropsychological tests (five-word, cognitive disorders examination, verbal fluency) were administered. Two groups were identified in memory clinics: (i) cognitively healthy individuals (CHI) and (ii) mild cognitive impairment or demented individuals (MCI-DI). Cross-sectional analyses were performed on data at inclusion. The relationship between the diagnosis of MCI-DI/CHI and the neuropsychological tests was assessed using logistic regressions. The performance of the neuropsychological tests, individually and combined, to detect cognitive disorders was calculated. RESULTS: Of 585 subjects, 31.11% had cognitive disorders (MCI, 176 subjects; DI, six subjects). Amongst the three tests studied, the odds ratio for MCI-DI was higher for the five-word test <10 [odds ratio 3.2 (1.81; 5.63)]. The best performance was observed when the three tests were combined: specificity 90.5% and sensitivity 42.4% compared to respectively 89.2% and 28.3% for the five-word test. CONCLUSIONS: Despite the poor sensitivity of the five-word test, it seems to be the most adapted for the diagnosis of MCI-DI in older adults with a memory complaint, in prevention centres, taking into account its high specificity and its rapid administration compared to the other tests.

[Effectiveness of a cognitive-behavioral unit on behavioral and psychological symptoms of dementia]. / Efficacité d'une unité cognitivo-comportementale sur les symptômes psychologiques et comportementaux des démences.

INTRODUCTION: Cognitive-behavioral units (CBUs) have been created in the context of the national Alzheimer plan 2008/2012 for the management of behavioral disorders of patients suffering from Alzheimer's disease or related diseases. The Alzheimer plan promotes the evaluation of these units through the observation of the evolution of behavioral and psychological symptoms of dementia (BPSD). The aim of this study was to assess the effects of the memory center of Lyon (hospices civils de Lyon) CBU on BPSD. PATIENTS: The neuropsychiatric inventory (NPI) was rated by the patients' caregiver (NPI-F) at admission to the CBU and 2 weeks after the discharge. The NPI was also rated by the nursing staff (NPI-NS) 3 days after admission in the CBU and at discharge. RESULTS: All patients admitted in the CBU between July and October 2001 were included in the study for a total of 28 patients. A significant reduction of NPI-F scores between admission (58.93 ± 24.8) and 2 weeks after the discharge (27.07 ± 19.70) (P<0.0001) was observed. Improvement was specifically observed for delusions, agitation, depression, anxiety, disinhibition and aberrant motor activity symptoms. No significant changes were found on NPI-NS scores. CONCLUSION: This study discloses benefits of CBUs in terms of BPSD reduction in patients 2 weeks after CBU discharge. These units have the potential to achieve their principal objective of reducing behavioral problems.

Cognitive complaints, neuropsychological performance and affective disorders in elderly community residents.

BACKGROUND: Previous studies have assessed the relationship between subjective cognitive complaints and objective impairment. While some of them found that cognitive complaints were explained by affective disorders, other researches found a relationship between cognitive complaints and neuropsychological performance. Most of them focused on memory functioning. However, elderly normal adults also display a decline in executive functions. This study aimed to assess the relationship between cognitive complaints, objective memory and executive performance and affective disorders. METHODS: This study was carried out with 937 community-dwelling elderly individuals recruited from the electoral list of the city of Saint-Etienne, France. Cognitive complaints were assessed using the MacNair scale. Cognitive performances were measured via a large battery of memory and executive-performance tests chosen for their capacity to detect subtle cognitive impairment. Anxiety and depressive symptoms were assessed using scales devised by Pichot and Goldberg. RESULTS: Cognitive complaints were associated with lower scores on verbal-memory tests and several executive-performance tests. Moreover, affective disorders were related to some of the executive-performance test scores, but they were not related to scores on the Free and Cued Selective Reminding Test, Digit Symbol Substitution Test and Trail Making B scores. CONCLUSIONS: Cognitive complaints of the elderly can reflect objective memory and executive-performance impairments, independent of affective disorders. Cognitive complaints should be assessed using both memory and executive-performance tests.

Effects of working conditions and sleep of the previous day on cognitive performance.

The study examined the consequences of working conditions on the previous day on cognitive performance the following day. It also addressed the issue of whether this relationship was mediated by sleep and whether it differed as a function of age. The data were taken from the VISAT study (aging, health and work) and concerned the participant's general work schedule, general sleep quality, working conditions on the previous day (content, duration, load and schedule), subsequent sleep length and quality, and cognitive performance. Results showed that both physical activity and working before 6 am or after 10 pm on the previous day were significantly associated with poorer cognitive performance. Significant effects of working conditions on the previous day were also observed on subsequent sleep, but these effects did not mediate the relationship between working conditions and cognitive performance. The observed effect on cognitive performance of atypical work hours on the previous day was similar for all ages, probably because of the healthy worker effect.

Functional impairment in instrumental activities of daily living: an early clinical sign of dementia?

OBJECTIVE: To estimate the predictive value of four IADLs on 3- and 5-year incident dementia. DESIGN: Prospective cohort study. SETTING: A community survey in 37 randomly selected parishes. SUBJECTS: A random sample of French community dwellers aged 65 and older included in the PAQUID study followed-up at 3 (1582 subjects) and 5 years (1283 subjects). MAIN OUTCOME MEASURES: Incidence of dementia at 3 and 5 years, diagnosed by two-step screening: (1) MMS and DSM-III-R; (2) diagnosis of dementia confirmed by a neurologist. RESULTS: A score summing up the number of dependencies at baseline on four IADLs is a predictor of 3-year but not of 5-year incident dementia. Increase in the level of dependence between baseline and 3-year follow-up is associated with an increased risk of incident dementia at 5-year follow-up. CONCLUSION: These four IADLs can help to identify older subjects at high risk of dementia who should then undergo neuropsychological testing.

Neuropsychological correlates of self-reported performance in instrumental activities of daily living and prediction of dementia.

This study examines the relationships between performance on neuropsychological tests and 4 instrumental activities of daily living (IADL) associated with an increased risk of dementia, in 1,792 nondemented elderly people included in the Personnes Agées Quid (PAQUID) study. There was a decline of neuropsychological performance on each test with increasing IADL dependency, in particular between Grades 1 and 2. Performances of the independent participants were very homogeneous. Each IADL had different specific associations with the neuropsychological tests. A principal component analysis showed three main factors explaining 49.6% of variance. The first factor was the common cognitive component of both instrumental tasks and neuropsychological tests. The second factor was specific to three IADL, whereas use of transportation had its main loading on the third factor. Only the first factor was predictive of the risk of incident dementia, suggesting that the predictive value of the 4 IADL was explained by their cognitive component.

Seven-year predictors of self-rated health and life satisfaction in the elderly: the PROOF study.

OBJECTIVES: To investigate the relationship between cognitive performance, affective state, metabolic syndrome and 7-year follow-up self-rated health (SRH) and perceived life satisfaction (PLS). DESIGN: Analysis of a prospective cohort study. SETTING: The PROOF study, including 1011 elderly community residents. PARTICIPANTS: Six hundred and fifty seven subjects completed metabolic syndrome (Met S) variables, neuropsychological and affective measurements at baseline, and then returned a 7-year follow-up questionnaire which included SRH and PLS. MEASUREMENTS: The prospective association between cognitive function, Met S and each of its components, and affective disorders and subsequent subjective health and quality of life was examined. Covariates included educational level and use of tobacco. The analyses were made in men and women separately. RESULTS: In multivariate models, the presence of Met S was significantly associated to weaker SRH (OR = 2.78, p = 0.009 in men and OR = 2.0, p = 0.02 in women). Higher triglycerides rate were associated with weaker SRH in men (OR = 2.23, p = 0.002) and higher fasting glucose in women (OR = 2.54, p = 0.006). Global Met S and abdominal obesity was significantly associated to weaker PLS in women only (respectively OR = 2.70, p = 0.0002 and OR = 1.9, p = 0.02). Depressive symptoms were significantly associated to both weaker SRH and PLS in men (OR = 1.30, p = 0.002; OR = 1.44, p < 0.0001 for SRH and PLS respectively) and in woman (OR = 1.09, p = 0.04; OR = 1.26, p < 0.0001 for SRH and PLS respectively). Anxiety was linked to both weaker SRH and PLS in women (OR = 1.17, p = 0.002 and 0R = 1.11, p = 0.03 for SRH and PLS respectively). Finally, lower executive function was associated with weaker PLS in men (OR = 0.43, p = 0.0005). CONCLUSION: metabolic syndrome and certain of its components, anxiety and depressive symptoms, are independent predictors of poorer subjective health and quality of life as assessed over a period of 7 years in a population of a non-demented aging community. Moreover, executive performance was linked to subsequent quality of life in men. Many of these factors being treatable, our findings point to the necessity of providing preventive care strategies by the management of cardiovascular risk factors and anxio-depressive symptoms.

Cognitive process in preclinical phase of dementia.

Several recent prospective studies have demonstrated the existence of a preclinical stage of dementia, identifiable by neuropsychological assessment showing impairments with a great variety of cognitive tests. However, test scores are often colinear, largely because common cognitive components are involved in different tests; in spite of an apparent heterogeneity, it is still possible that a common cognitive component may be responsible for the deterioration shown in different tests in the preclinical phase. We studied the cognitive performances of 1159 elderly residents in the PAQUID (Personnes Agées quid) cohort, at a fixed lag time of 2 years before the clinical diagnosis of dementia. Seven neuropsychological tests were administered (Mini-Mental Status Examination, Benton Visual Retention Test, Wechsler Paired-Associates Test, Isaacs Set Test, Zazzo's Cancellation Task, Digit Symbol Substitution Test and Wechsler Similarities Test). Among the initially non-demented 1159 subjects, 25 developed a dementia 2 years later, of whom 16 were classified as cases of Alzheimer's disease. In order to dissect the multicolinearity of the tests we used a multivariate approach with principal component analysis (PCA). The patients' loading on each of the first four PCA factors were subsequently correlated with the risk of dementia and Alzheimer's disease 2 years later. The logistic regression with backward stepwise selected only the first factor as an independent predictor of dementia or Alzheimer's disease. Analysis shows that there are good reasons to suspect that the first PCA factor represents a general factor corresponding to aspects of control in the tasks used. Our results therefore seem to show that preclinical deficits in dementia and Alzheimer's disease reflect the deterioration of a general cognitive factor, which may be interpreted as the disturbance of central, control processes.

Occupation during life and risk of dementia in French elderly community residents.

OBJECTIVE: To determine whether principal occupation during life is a risk factor for incident Alzheimer's disease, vascular dementia, or dementia with parkinsonism. METHODS: This study was carried out from the PAQUID (Personnes Agées QUID) cohort, an epidemiological study on normal and pathological aging after 65 years in the south west of France. At baseline, 2950 non-demented people living at home were identified and re-examined 1, 3, 5, 8, and 10 years later with identical standardised neurological and neuropsychological measures. Cox proportional hazards models with delayed entry were used, taking age as the time scale and adjusting for sex, education, tobacco, and wine consumption to estimate the risk ratio (RR) of incident dementia, Alzheimer's disease, vascular dementia, and dementia with parkinsonism associated with occupational category. RESULTS: Of the 2950 subjects, 393 became demented, of whom 251 had Alzheimer's disease, 112 had vascular dementia, and 27 had dementia with parkinsonism. The risk of Alzheimer's disease was not related to a given occupation. However the risk of dementia with parkinsonism seemed to be increased in farmers in comparison with professionals and managerials, particularly among women (RR 7.47; 95%CI, 1.80-31.07). CONCLUSION: The data suggest that occupation does not change the risk of Alzheimer's disease, which seems to be more influenced by cognitive abilities in childhood and adolescence than by occupation in adult life. However, being a farmer may increase the risk of dementia with parkinsonism among women; occupation could act by the way of differences in health behaviour or in exposure to environmental factors.