Predicting Outcomes in Frail Older Community-Dwellers in Western Australia: Results from the Community Assessment of Risk Screening and Treatment Strategies (CARTS) Programme.

Understanding risk factors for frailty, functional decline and incidence of adverse healthcare outcomes amongst community-dwelling older adults is important to plan population-level health and social care services. We examined variables associated with one-year risk of institutionalisation, hospitalisation and death among patients assessed in their own home by a community-based Aged Care Assessment Team (ACAT) in Western Australia. Frailty and risk were measured using the Clinical Frailty Scale (CFS) and Risk Instrument for Screening in the Community (RISC), respectively. Predictive accuracy was measured from the area under the curve (AUC). Data from 417 patients, median 82 ± 10 years, were included. At 12-month follow-up, 22.5% (n = 94) were institutionalised, 44.6% (n = 186) were hospitalised at least once and 9.8% (n = 41) had died. Frailty was common, median CFS score 6/9 ± 1, and significantly associated with institutionalisation (p = 0.001), hospitalisation (p = 0.007) and death (p < 0.001). Impaired activities of daily living (ADL) measured on the RISC had moderate correlation with admission to long-term care (r = 0.51) and significantly predicted institutionalisation (p < 0.001) and death (p = 0.01). The RISC had the highest accuracy for institutionalisation (AUC 0.76). The CFS and RISC had fair to good accuracy for mortality (AUC of 0.69 and 0.74, respectively), but neither accurately predicted hospitalisation. Home assessment of community-dwelling older patients by an ACAT in Western Australia revealed high levels of frailty, ADL impairment and incident adverse outcomes, suggesting that anticipatory care planning is imperative for these patients.

Comparison of the Six Item Cognitive Impairment Test (6CIT) to Commonly-Used Short Cognitive Screening Instruments in a Memory Clinic Population.

Background: Short cognitive screening instruments (CSI) are required to identify cognitive impairment in busy outpatient clinics. While the Six Item Cognitive Impairment Test (6CIT) is commonly used, its accuracy in those with mild cognitive impairment (MCI) and subjective cognitive decline (SCD) and against more widely-used CSIs is less well established. Objective: To examine the diagnostic accuracy of the 6CIT against the Montreal Cognitive Assessment (MoCA) and Quick Mild Cognitive Impairment (Qmci) screen across the cognitive spectrum in a memory clinic population. Methods: In total, 142 paired assessments were available (21 with SCD, 32 MCI, and 89 with dementia). Consecutive patients underwent a comprehensive assessment and were screened using the 6CIT, Qmci, and MoCA. Accuracy was determined from the area under receiver operating characteristic curves (AUC). Results: The median age of patients was 76 (±11) years; 68% were female. The median 6CIT score was 10/28 (±14). The 6CIT was strongly, negatively, and statistically significantly correlated with the Qmci (r = -0.84) and MoCA (r = -0.86). The 6CIT had good accuracy for separating cognitive impairment (MCI or dementia) from SCD, (AUC:0.88; 0.82-0.94), similar to the MoCA (AUC:0.92; 0.87-0.97, p = 0.308), but statistically lower than the Qmci (AUC:0.96; 0.94-0.99, p = 0.01). The 6CIT was faster to administer, median time 2.05 minutes versus 4.38 and 9.5 for the Qmci and MoCA, respectively. Conclusion: While the Qmci was more accurate than the 6CIT, the shorter administration time of the 6CIT, suggests it may be useful when assessing or monitoring cognitive impairment in busy memory clinics, though larger samples are required to evaluate.

Screening for Cognitive Impairment with the Quick Memory Check: Validation of a Caregiver Administered Cognitive Screen.

BACKGROUND: Self or home-administered cognitive screening instruments (CSIs) can reduce barriers to the early detection of mild cognitive impairment (MCI) and dementia. OBJECTIVE: To examine the acceptability and diagnostic accuracy of a caregiver-administered CSI, the Quick Memory Check (QMC). METHODS: Components of the Quick Mild Cognitive impairment (Qmci) screen (orientation, verbal fluency, and logical memory) were re-weighted to create the QMC, scored out of 100 points. Participants, attending a university hospital memory clinic, were provided administration instructions beforehand. Area under the curve (AUC) scores, adjusted for age and education, were compared with the Qmci screen and Montreal Cognitive Assessment (MoCA). Caregivers or family scored the QMC. RESULTS: In all, 366 participants were recruited; 53 with subjective memory complaints (SMC), 74 with MCI, 193 with dementia, and 46 normal controls. Median QMC scores for controls were 70±13 versus 60±20 for SMC, 52±18 for MCI, and 31±21 for dementia. The QMC had excellent accuracy (AUC 0.97) for cognitive impairment (MCI/dementia from controls), similar to the Qmci screen (AUC 0.98, p = 0.17) and MoCA (AUC 0.95, p = 0.13). At a cut-off of <52/100, the QMC had 83% sensitivity and 100% specificity for cognitive impairment. The QMC had lower accuracy differentiating MCI from SMC (AUC 0.73), albeit similar to the MoCA (AUC 0.70). CONCLUSION: The QMC, administered by caregivers in advance of clinic, compared favorably to established CSIs scored by trained raters. This caregiver, home-administered CSI is acceptable and can identify cognitive impairment, potentially improving efficiency by reducing testing time and patient stress in busy clinical settings.

Prevalence and Predictors of Caregiver Burden in a Memory Clinic Population.

BACKGROUND: Although caregiver burden is common among carers of people with dementia, little is known about its prevalence and predictors among caregivers of patients attending memory clinics. OBJECTIVE: To examine carer and patient-specific characteristics associated with caregiver burden across the cognitive spectrum in a memory clinic population. METHODS: Consecutive patients referred to a university hospital geriatric memory clinic were included. Caregiver burden was scored using the Caregiver Burden Score (CBS), (modified Zarit), with scores≥15/30 suggesting burden. BPSD were measured with the dysfunctional behaviour rating instrument (DBRI). Cognition was screened using the Montreal Cognitive Assessment (MoCA) and Quick Mild Cognitive Impairment (Qmci) screen. RESULTS: In all, 351 patients were included, median age 77 (±11) years; 65.5% were female. The prevalence of caregiver burden was 33.6% overall, increasing from 10.8% in subjective cognitive decline (SCD), to 15% in mild cognitive impairment (MCI) and 43% in dementia; CBS scores were significantly higher in dementia (p < 0.001). Caregivers with burden were significantly younger (p = 0.045) and were more likely to be adult children (p = 0.007). The CBS weakly correlated with the stage of cognitive impairment (r = 0.16) but had moderate correlation with MoCA (r = -0.54) and Qmci scores (r = -0.60). After adjustment for co-variates, DBRI scores alone independently predicted burden (odds ratio 1.23;1.11-1.35, p < 0.001). CONCLUSION: Caregiver burden is associated with the stage of cognitive impairment, with higher prevalence proportions in those with dementia compared with MCI and SCD. Only the severity of neuropsychiatric symptoms independently predicted caregiver burden in this population and its presence should prompt assessment for burden.

Screening for Cognitive Impairment After Stroke: Validation of the Chinese Version of the Quick Mild Cognitive Impairment Screen.

Background: Screening for post-stroke cognitive impairment (PSCI) is necessary because stroke increases the incidence of and accelerates premorbid cognitive decline. The Quick Mild Cognitive Impairment (Qmci) screen is a short, reliable and accurate cognitive screening instrument but is not yet validated in PSCI. We compared the diagnostic accuracy of a Chinese version of the Qmci screen (Qmci-CN) compared with the widely-used Chinese versions of the Montreal Cognitive Assessment (MoCA-CN) and Mini-Mental State Examination (MMSE-CN). Methods: We recruited 34 patients who had recovered from a stroke in rehabilitation unit clinics in 2 university hospitals in China: 11 with post-stroke dementia (PSD), 15 with post-stroke cognitive impairment no dementia (PSCIND), and 8 with normal cognition (NC). Classification was made based on clinician assessment supported by a neuropsychological battery, independent of the screening test scores. The Qmci-CN, MoCA-CN, and MMSE-CN screens were administered randomly by a trained rater, blind to the diagnosis. Results: The mean age of the sample was 63 ± 13 years and 61.8% were male. The Qmci-CN had statistically similar diagnostic accuracy in differentiating PSD from NC, an area under the curve (AUC) of 0.94 compared to 0.99 for the MoCA-CN (p = 0.237) and 0.99 for the MMSE-CN (p = 0.293). The Qmci-CN (AUC 0.91), MoCA-CN (AUC 0.94), and MMSE-CN (AUC 0.79) also had statistically similar accuracy in separating PSD from PSCIND. The MoCA-CN more accurately distinguished between PSCIND and normal cognition than the Qmci-CN (p = 0.015). Compared to the MoCA-CN, the administration times of the Qmci-CN (329s vs. 611s, respectively, p < 0.0001) and MMSE-CN (280 vs. 611s, respectively, p < 0.0001) were significantly shorter. Conclusion: The Qmci-CN is accurate in identifying PSD and separating PSD from PSCIND in patients post-stroke following rehabilitation and is comparable to the widely-used MoCA-CN, albeit with a significantly shorter administration time. The Qmci-CN had relatively poor accuracy in identifying PSCIND from NC and hence may lack accuracy for certain subgroups. However, given the small sample size, the study is under-powered to show superiority of one instrument over another. Further study is needed to confirm these findings in a larger sample size and in other settings (countries and languages).

Comparison of the Greek Version of the Quick Mild Cognitive Impairment Screen and Standardised Mini-Mental State Examination.

INTRODUCTION: Short cognitive screening instruments (CSIs) are widely used to stratify patients presenting with cognitive symptoms. The Quick Mild Cognitive Impairment (Qmci) screen is a new, brief (<5mins) CSI designed to identify mild cognitive impairment (MCI), which can be used across the spectrum of cognitive decline. Here we present the translation of the Qmci into Greek (Qmci-Gr) and its validation against the widely-used Standardised Mini-Mental State Examination (SMMSE). METHODS: Consecutive patients aged ≥55 years presenting with cognitive complaints were recruited from two outpatient clinics in Greece. All patients completed the Qmci-Gr and SMMSE and underwent an independent detailed neuropsychological assessment to determine a diagnostic classification. RESULTS: In total, 140 patients, median age 75 years, were included; 30 with mild dementia (median SMMSE 23/30), 76 with MCI and 34 with subjective memory complaints (SMC) but normal cognition. The Qmci-Gr had similar accuracy in differentiating SMC from cognitive impairment (MCI & mild dementia) compared with SMMSE, area under the curve (AUC) of 0.84 versus 0.79, respectively; while accuracy was higher for the Qmci-Gr, this finding was not significantly different, (p = .19). Similarly, the Qmci-Gr had similar accuracy in separating SMC from MCI, AUC of 0.79 versus 0.73 (p = .23). CONCLUSIONS: The Qmci-Gr compared favorably with the SMMSE. Further research with larger samples and comparison with other instruments such as the Montreal Cognitive Assessment is needed to confirm these findings but given its established brevity, it may be a better choice in busy clinical practice in Greece.

Prevalence of frailty in 62 countries across the world: a systematic review and meta-analysis of population-level studies.

INTRODUCTION: The prevalence of frailty at population level is unclear. We examined this in population-based studies, investigating sources of heterogeneity. METHODS: PubMed, Embase, CINAHL and Cochrane Library databases were searched for observational population-level studies published between 1 January 1998 and 1 April 2020, including individuals aged ≥50 years, identified using any frailty measure. Prevalence estimates were extracted independently, assessed for bias and analysed using a random-effects model. RESULTS: In total, 240 studies reporting 265 prevalence proportions from 62 countries and territories, representing 1,755,497 participants, were included. Pooled prevalence in studies using physical frailty measures was 12% (95% CI = 11-13%; n = 178), compared with 24% (95% CI = 22-26%; n = 71) for the deficit accumulation model (those using a frailty index, FI). For pre-frailty, this was 46% (95% CI = 45-48%; n = 147) and 49% (95% CI = 46-52%; n = 29), respectively. For physical frailty, the prevalence was higher among females, 15% (95% CI = 14-17%; n = 142), than males, 11% (95% CI = 10-12%; n = 144). For studies using a FI, the prevalence was also higher in females, 29% (95% CI = 24-35%; n = 34) versus 20% (95% CI = 16-24%; n = 34), for males. These values were similar for pre-frailty. Prevalence increased according to the minimum age at study inclusion. Analysing only data from nationally representative studies gave a frailty prevalence of 7% (95% CI = 5-9%; n = 46) for physical frailty and 24% (95% CI = 22-26%; n = 44) for FIs. CONCLUSIONS: Population-level frailty prevalence varied by classification and sex. Data were heterogenous and limited, particularly from nationally representative studies making the interpretation of differences by geographic region challenging. Common methodological approaches to gathering data are required to improve the accuracy of population-level prevalence estimates. PROTOCOL REGISTRATION: PROSPERO-CRD42018105431.

Screening for Cognitive Frailty Using Short Cognitive Screening Instruments: Comparison of the Chinese Versions of the MoCA and Qmci Screen.

BACKGROUND: Cognitive frailty describes cognitive impairment associated with physical decline. Few studies have explored whether short cognitive screens identify frailty. We examined the diagnostic accuracy of the Chinese versions of the Quick Mild Cognitive Impairment (Qmci-CN) screen and Montreal Cognitive Assessment (MoCA-CN) in identifying cognitive frailty. METHODS: Ninety-five participants with cognitive symptoms [47 with mild cognitive impairment (MCI), 34 with subjective cognitive disorder, and 14 with dementia] were included from two outpatient rehabilitation clinics. Energy (work intensity) and physical activity levels were recorded. Cognitive frailty was diagnosed by an interdisciplinary team using the IANA/IAGG consensus criteria, stratified on the Clinical Frailty Scale (CFS). Instruments were administered sequentially and randomly by trained assessors, blind to the diagnosis. RESULTS: The mean age of the sample was 62.6 ± 10.2 years; median CFS score was 4 ± 1 and 36 (38%) were cognitively frail. The Qmci-CN had similar accuracy in differentiating the non-frail from cognitively frail compared to the MoCA-CN, AUC 0.82 versus 0.74, respectively (p = 0.19). At its optimal cut-off (≤55/100), the Qmci-CN provided a sensitivity of 83% and specificity of 67% versus 91% and 51%, respectively, for the MoCA-CN (≤23/30). Neither was accurate in separating MCI from cognitive frailty but both accurately separated cognitive frailty from dementia. CONCLUSION: Established short cognitive screens may be useful in identifying cognitive frailty in Chinese adults with cognitive complaints but not in separating MCI from cognitive frailty. The Qmci-CN had similar accuracy to the MoCA-CN and a shorter administration time in this small and under-powered study, necessitating the need for adequately powered studies in different healthcare settings.

Informal caregiving for dementia patients: the contribution of patient characteristics and behaviours to caregiver burden.

OBJECTIVES: The burden often associated with informal caregiving for patients with dementia is associated with negative effects on health, both physiologically and in terms of caregiver cognition. There is wide variation in the level of burden experienced by dementia caregivers. To better understand caregiver burden, it is thus important to understand the factors associated with level of burden. METHODS: In the current study, we collected carer burden and putative associated factors at baseline, 6 and 12 months. Hierarchical regression was used to assess the impact of these factors on caregiver burden. We assessed self-reported carer burden, patient behavioural and safety issues, and level of difficulty associated with providing assistance with activities of daily living (ADL). Patients' age was also recorded, and trained nurses assessed patient cognitive performance using the quick mild cognitive impairment screen. RESULTS: At baseline, patients' age, cognition and ADLs were associated with burden, and safety and challenging behaviour were both significantly associated with burden independent of the other factors. Change in burden was associated with change in carer-reported safety at 6-month follow-up, and with change in safety and change in carer-reported challenging behaviours at 12-month follow-up. CONCLUSIONS: Safety issues and challenging behaviours are associated with carer burden, even after accounting for cognitive and functional impairment in the person with dementia. As dementia progresses, monitoring these factors may help to inform stress-management strategies for caregivers.

Comparison of Frailty Screening Instruments in the Emergency Department.

Early identification of frailty through targeted screening can facilitate the delivery of comprehensive geriatric assessment (CGA) and may improve outcomes for older inpatients. As several instruments are available, we aimed to investigate which is the most accurate and reliable in the Emergency Department (ED). We compared the ability of three validated, short, frailty screening instruments to identify frailty in a large University Hospital ED. Consecutive patients aged ≥70 attending ED were screened using the Clinical Frailty Scale (CFS), Identification of Seniors at Risk Tool (ISAR), and the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 item questionnaire (PRISMA-7). An independent CGA using a battery of assessments determined each patient's frailty status. Of the 280 patients screened, complete data were available for 265, with a median age of 79 (interquartile ±9); 54% were female. The median CFS score was 4/9 (±2), ISAR 3/6 (±2), and PRISMA-7 was 3/7 (±3). Based upon the CGA, 58% were frail and the most accurate instrument for separating frail from non-frail was the PRISMA-7 (AUC 0.88; 95% CI:0.83-0.93) followed by the CFS (AUC 0.83; 95% CI:0.77-0.88), and the ISAR (AUC 0.78; 95% CI:0.71-0.84). The PRISMA-7 was statistically significantly more accurate than the ISAR (p = 0.008) but not the CFS (p = 0.15). Screening for frailty in the ED with a selection of short screening instruments, but particularly the PRISMA-7, is reliable and accurate.

Selecting a Bedside Cognitive Vital Sign to Monitor Cognition in Hospital: Feasibility, Reliability, and Responsiveness of Logical Memory.

Although there is a high prevalence of delirium and cognitive impairment among hospitalised older adults, short, reliable cognitive measures are rarely used to monitor cognition and potentially alert healthcare professionals to early changes that might signal delirium. We evaluated the reliability, responsiveness, and feasibility of logical memory (LM), immediate verbal recall of a short story, compared to brief tests of attention as a bedside "cognitive vital sign" (CVS). Trained nursing staff performed twice-daily cognitive assessments on 84 clinically stable inpatients in two geriatric units over 3-5 consecutive days using LM and short tests of attention and orientation including months of the year backwards. Scores were compared to those of an expert rater. Inter-rater reliability was excellent with correlation coefficients for LM increasing from r = 0.87 on day 1 to r = 0.97 by day 4 (p < 0.0001). A diurnal fluctuation of two points from a total of 30 was deemed acceptable in clinically stable patients. LM scores were statistically similar (p = 0.98) with repeated testing (suggesting no learning effect). All nurses reported that LM was feasible to score routinely. LM is a reliable measure of cognition showing diurnal variation but minimal learning effects. Further study is required to define the properties of an ideal CVS test, though LM may satisfy these.

Sleep Disturbance in Older Patients in the Emergency Department: Prevalence, Predictors and Associated Outcomes.

Impaired sleep is common in hospital. Despite this, little is known about sleep disturbance among older adults attending Emergency Departments (ED), particularly overnight-boarders, those admitted but housed overnight while awaiting a bed. Consecutive, medically-stable patients aged ≥70, admitted through a university hospital ED were evaluated for overnight sleep quality (Richards Campbell Sleep Questionnaire/RCSQ) and baseline sleep (Pittsburgh Sleep Quality Index/PSQI). Additional variables included frailty, functional and cognitive status, trolley location, time in ED and night-time noise levels. Over four-weeks, 152 patients, mean age 80 (± 6.8) years were included; 61% were male. Most (68%) were ED boarders (n = 104) and 43% were frail. The majority (72%) reported impaired sleep quality at baseline (PSQI ≥ 5) and 13% (20/152) had clinical insomnia. The median time spent in ED for boarders was 23 h (Interquartile ± 13). After adjusting for confounders, median RCSQ scores were significantly poorer for ED boarders compared with non-boarders: 22 (± 45) versus 71 (± 34), respectively, (p = 0.003). There was no significant difference in one-year mortality (p = 0.08) length of stay (LOS) (p = 0.84), 30-day (p = 0.73) or 90-day (p = 0.64) readmission rates between boarders and non-boarders. Sleep disturbance is highly prevalent among older adults admitted through ED. ED boarders experienced significantly poorer sleep, without this impacting upon mortality, LOS or re-admission rates.

Comparing the Diagnostic Accuracy of Two Cognitive Screening Instruments in Different Dementia Subtypes and Clinical Depression.

Short but accurate cognitive screening instruments are required in busy clinical practice. Although widely-used, the diagnostic accuracy of the standardised Mini-Mental State Examination (SMMSE) in different dementia subtypes remains poorly characterised. We compared the SMMSE to the Quick Mild Cognitive Impairment (Qmci) screen in patients (n = 3020) pooled from three memory clinic databases in Canada including those with mild cognitive impairment (MCI) and Alzheimer's, vascular, mixed, frontotemporal, Lewy Body and Parkinson's dementia, with and without co-morbid depression. Caregivers (n = 875) without cognitive symptoms were included as normal controls. The median age of patients was 77 (Interquartile = ±9) years. Both instruments accurately differentiated cognitive impairment (MCI or dementia) from controls. The SMMSE most accurately differentiated Alzheimer's (AUC 0.94) and Lewy Body dementia (AUC 0.94) and least accurately identified MCI (AUC 0.73), vascular (AUC 0.74), and Parkinson's dementia (AUC 0.81). The Qmci had statistically similar or greater accuracy in distinguishing all dementia subtypes but particularly MCI (AUC 0.85). Co-morbid depression affected accuracy in those with MCI. The SMMSE and Qmci have good-excellent accuracy in established dementia. The SMMSE is less suitable in MCI, vascular and Parkinson's dementia, where alternatives including the Qmci screen may be used. The influence of co-morbid depression on scores merits further investigation.

Non-pharmacological treatments for sleep disturbance in mild cognitive impairment and dementia: A systematic review and meta-analysis.

No disease-modifying treatments for dementia are available. Sleep disturbance is strongly associated with cognitive impairment. Non-pharmacological treatments targeting sleep may offer an alternative therapeutic approach. We searched PubMed, CINAHL, EMBASE and the Cochrane library for non-pharmacological treatments for sleep disturbance in mild cognitive impairment (MCI) and dementia, published in English from October 1965 to 2018, including all designs, excluding studies of drug therapies. In all, 53 papers representing 48 studies were included. Participant age ranged from 67.3 to 89.4 years. Most studies (79%) had small samples (<50 participants, range 1-173) and were conducted in long-term/residential care (62%). The majority (85%) recruited participants with moderate-severe dementia; mean MMSE scores ranged from 0 to 28.3/30. Four studies examined MCI. Light therapy delivered over 1-10 weeks was the most studied stand-alone intervention (n = 27), and the majority (81.5%) of these studies found improvements on objective or subjective sleep measures, though the evidence was inconclusive with significant clinical and methodological heterogeneity. Seven multi-modal intervention studies were identified, all incorporating light exposure, and six of these reported improved sleep. Other interventions included electrotherapy stimulation (n = 4), physical exercises/activities (n = 4), acupressure/acupuncture (n = 3) and mindfulness/cognitive behavioural therapy (n = 3). Those examining MCI utilised different mono-modal approaches. A meta-analysis of data from randomised controlled trials showed a statistically significant (mean difference = 3.44, 95% CI: 0.89-5.99, I2=0%; p = 0.008) improvement in sleep efficiency between interventions and controls, favouring the pooled interventions (bright light, multi-domain and other therapies). No other significant differences in sleep or non-sleep outcomes were found. While evidence is available for non-pharmacological sleep interventions, particularly multi-domain approaches, studies were diverse and had small samples. More research examining multi-modal interventions, community-dwellers and those with MCI is required.

Validity of the Japanese Version of the Quick Mild Cognitive Impairment Screen.

Early detection of dementia provides opportunities for interventions that could delay or prevent its progression. We developed the Japanese version of the Quick Mild Cognitive Impairment (Qmci-J) screen, which is a performance-based, easy-to-use, valid and reliable short cognitive screening instrument, and then we examined its validity. Community-dwelling adults aged 65⁻84 in Niigata prefecture, Japan, were concurrently administered the Qmci-J and the Japanese version of the standardized Mini-Mental State Examination (sMMSE-J). Mild cognitive impairment (MCI) and dementia were categorized using established and age-adjusted sMMSE-J cut-offs. The sample (n = 526) included 52 (9.9%) participants with suspected dementia, 123 (23.4%) with suspected MCI and 351 with likely normal cognition. The Qmci-J showed moderate positive correlation with the sMMSE-J (r = 0.49, p < 0.001) and moderate discrimination for predicting suspected cognitive impairment (MCI/dementia) based on sMMSE-J cut-offs, area under curve: 0.74, (95%CI: 0.70⁻0.79), improving to 0.76 (95%CI: 0.72 to 0.81) after adjusting for age. At a cut-off of 60/61/100, the Qmci-J had a 73% sensitivity, 68% specificity, 53% positive predictive value, and 83% negative predictive value for cognitive impairment. Normative data are presented, excluding those with any sMMSE-J < 27. Though further research is required, the Qmci-J screen may be a useful screening tool to identify older adults at risk of cognitive impairment.

Effect of Visit-to-Visit Blood Pressure Variability on Cognitive and Functional Decline in Mild to Moderate Alzheimer's Disease.

BACKGROUND: Visit-to-visit blood pressure (BP) variability (VVV) is increasingly recognized as a marker of cardiovascular risk. Although implicated in cognitive decline, few studies are currently available assessing its effects on established dementia. OBJECTIVE: To investigate if VVV is associated with one-year rate of decline in measures of cognition and function in patients with mild to moderate Alzheimer's disease (AD) in the Doxycycline And Rifampicin for Alzheimer's Disease study. METHODS: Patients were included if ≥3 BP readings were available (n = 392). VVV was defined using different approaches including the coefficient of variation (CV) in BP readings between visits. Outcomes included rates of decline in the Standardized Alzheimer's Disease Assessment Scale-Cognitive Subscale (SADAS-cog), Standardized MMSE, Clinical Dementia Rating Scale, the Quick Mild Cognitive Impairment screen and the Lawton-Brody activities of daily living (ADL) scale. RESULTS: Half of the patients (196/392) had a ≥4-point decline in the SADAS-cog over one-year. Using this cut-off, there were no statistically significant associations between any measures of VVV, for systolic or diastolic BP, with and without adjustment for potential confounders including treatment allocation, history of hypertension and use of anti-hypertensive and cognitive enhancing medications. Multiple regression models examining the association between systolic BP CV by quartile and decline over one-year likewise showed no clinically significant effects, apart from a U-shaped pattern of ADL decline of borderline clinical significance.∥Conclusions: This observational study does not support recent research showing that VVV predicts cognitive decline in AD. Further studies are needed to clarify its effects on ADL in AD.

Urinary and Faecal Incontinence: Point Prevalence and Predictors in a University Hospital.

Incontinence is common and associated with adverse outcomes. There are insufficient point prevalence data for incontinence in hospitals. We evaluated the prevalence of urinary (UI) and faecal incontinence (FI) and their predictors among inpatients in an acute university hospital on a single day. Continence status was recorded using the modified Barthel Index (BI). Baseline characteristics, Clinical Frailty Scale (CFS) and ward type were recorded. In all, 435 patients were assessed, median age 72 ± 23 years and 53% were male. The median CFS score was 5 ± 3. The point prevalence of UI was 26% versus 11% for FI. While UI and FI increased with age, to 35.2% and 21.1% respectively for those ≥85, age was not an independent predictor. Incontinence also increased with frailty; CFS scores were independently associated with both UI (p = 0.006) and FI (p = 0.03), though baseline continence status was the strongest predictor. Patients on orthopaedic wards had the highest prevalence of incontinence. Continence assessments were available for only 11 (2%) patients. UI and FI are common conditions affecting inpatients; point prevalence increases with age and frailty status. Despite this, few patients receive comprehensive continence assessments. More awareness of its high prevalence is required to ensure incontinence is adequately managed in hospitals.

Screening for cognitive impairment in an Australian aged care assessment team as part of comprehensive geriatric assessment.

Accurate detection of mild cognitive impairment (MCI) is important to stratify and address risk. Yet, few short cognitive screening instruments are validated for this. . In Australia, all clients referred to an Aged Care Assessment Team (ACAT) receive comprehensive geriatric assessment (CGA) including the Standardized Mini-Mental State Examination (SMMSE). We compared the accuracy of the quick mild cognitive impairment (Qmci) screen to the SMMSE in 283 participants: 195 with dementia, 47 with MCI, and 41 with subjective cognitive decline (SCD) in an Australian community-based ACAT. Both had similar accuracy in identifying dementia, AUC of 0.86 for the Qmci versus 0.93 for the SMMSE (p = 0.10), but the Qmci was more accurate than the SMMSE in differentiating MCI from SCD, AUC of 0.84 versus 0.71, respectively, p = 0.046. These suggest that the new, short (3-5 min) Qmci screenis appropriate for use in an ACAT or other units conducting CGA.

Nilvadipine in mild to moderate Alzheimer disease: A randomised controlled trial.

BACKGROUND: This study reports the findings of the first large-scale Phase III investigator-driven clinical trial to slow the rate of cognitive decline in Alzheimer disease with a dihydropyridine (DHP) calcium channel blocker, nilvadipine. Nilvadipine, licensed to treat hypertension, reduces amyloid production, increases regional cerebral blood flow, and has demonstrated anti-inflammatory and anti-tau activity in preclinical studies, properties that could have disease-modifying effects for Alzheimer disease. We aimed to determine if nilvadipine was effective in slowing cognitive decline in subjects with mild to moderate Alzheimer disease. METHODS AND FINDINGS: NILVAD was an 18-month, randomised, placebo-controlled, double-blind trial that randomised participants between 15 May 2013 and 13 April 2015. The study was conducted at 23 academic centres in nine European countries. Of 577 participants screened, 511 were eligible and were randomised (258 to placebo, 253 to nilvadipine). Participants took a trial treatment capsule once a day after breakfast for 78 weeks. Participants were aged >50 years, meeting National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's disease Criteria (NINCDS-ADRDA) for diagnosis of probable Alzheimer disease, with a Standardised Mini-Mental State Examination (SMMSE) score of ≥12 and <27. Participants were randomly assigned to 8 mg sustained-release nilvadipine or matched placebo. The a priori defined primary outcome was progression on the Alzheimer's Disease Assessment Scale Cognitive Subscale-12 (ADAS-Cog 12) in the modified intention-to-treat (mITT) population (n = 498), with the Clinical Dementia Rating Scale sum of boxes (CDR-sb) as a gated co-primary outcome, eligible to be promoted to primary end point conditional on a significant effect on the ADAS-Cog 12. The analysis set had a mean age of 73 years and was 62% female. Baseline demographic and Alzheimer disease-specific characteristics were similar between treatment groups, with reported mean of 1.7 years since diagnosis and mean SMMSE of 20.4. The prespecified primary analyses failed to show any treatment benefit for nilvadipine on the co-primary outcome (p = 0.465). Decline from baseline in ADAS-Cog 12 on placebo was 0.79 (95% CI, -0.07-1.64) at 13 weeks, 6.41 (5.33-7.49) at 52 weeks, and 9.63 (8.33-10.93) at 78 weeks and on nilvadipine was 0.88 (0.02-1.74) at 13 weeks, 5.75 (4.66-6.85) at 52 weeks, and 9.41 (8.09-10.73) at 78 weeks. Exploratory analyses of the planned secondary outcomes showed no substantial effects, including on the CDR-sb or the Disability Assessment for Dementia. Nilvadipine appeared to be safe and well tolerated. Mortality was similar between groups (3 on nilvadipine, 4 on placebo); higher counts of adverse events (AEs) on nilvadipine (1,129 versus 1,030), and serious adverse events (SAEs; 146 versus 101), were observed. There were 14 withdrawals because of AEs. Major limitations of this study were that subjects had established dementia and the likelihood that non-Alzheimer subjects were included because of the lack of biomarker confirmation of the presence of brain amyloid. CONCLUSIONS: The results do not suggest benefit of nilvadipine as a treatment in a population spanning mild to moderate Alzheimer disease. TRIAL REGISTRATION: Clinicaltrials.gov NCT02017340, EudraCT number 2012-002764-27.