Evaluation of a Web-based decision aid for people considering the APOE genetic test for Alzheimer risk.

PURPOSE: With the increasing interest in apolipoprotein E (APOE) genetic testing to estimate the risk of developing late-onset Alzheimer disease, new educational tools are needed to help people make the best decision for themselves about whether to undergo this test. This study evaluated an online tool to assist in this decision process. METHODS: A prototype decision aid was studied in a two-part survey that collected data from participants before and after they examined the decision aid. Both surveys had multiple-choice options and opportunities for open-ended responses, yielding quantitative and qualitative information. The responses before and after use of the aid were compared for each participant. RESULTS: A total of 1,262 individuals completed both surveys. The overall effectiveness of the decision aid was shown by three measures: 94% found the decision aid very helpful or somewhat helpful; general knowledge was increased; and some people changed their minds about APOE genetic testing, with 35% shifting to a higher likelihood of undergoing the test and 20% to a lower likelihood. Suggestions for improvements were noted and incorporated into the online tool. CONCLUSION: This decision aid can provide useful educational assistance to many individuals as they consider APOE genetic testing as well as facilitate further discussions with their health-care providers.Genet Med advance online publication 03 November 2016.

End-of-Life Care of Persons with Alzheimer's Disease and Other Dementias.

End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).

Case reports of neuroleptic malignant syndrome in context of quetiapine use.

A retrospective analysis was followed on 20 case reports covering the possible correlation between the atypical antipsychotic, quetiapine, and neuroleptic malignant syndrome (NMS), determined by the study of 7 different NMS criteria guidelines. A great majority (19) of the case studies did not meet the requirements of all 7 guidelines, frequently due to unreported information. Nor was quetiapine proven to be the sole cause of the possible NMS in the two age groups investigated. Only one case was found to have no other medication or medical conditions confounding the relationship of quetiapine and NMS symptoms, and that case was in the context of a significant quetiapine overdose. The other 19 cases demonstrated the difficulty of identifying the cause of NMS when polypharmacy and other medical conditions are involved. The authors note the need for caution in deciding both the presence of NMS and the causal factors of the symptoms.

Caring for Patients With Dementia at End of Life.

Care of the dementia patient continues to be challenging. It is a terminal condition that many times goes undiagnosed leading to improper evidence-based interventions. Healthcare professionals (HCPs) should initiate goals of care conversations early with patients and their families in order to align treatment preferences. Early integration of palliative medicine is an important intervention that can lead to better manage symptoms and lessen the strain on loved ones. Additionally, early enrollment into hospice should be encouraged with loved ones to promote quality of life as defined by the patient.

End-of-Life Care of Persons With Alzheimer Disease: An Update for Clinicians.

While end-of-life (EOL) care has been a relatively common option for patients with terminal cancer, the utilization of EOL care in Alzheimer disease and other dementias has become available more recently. By the time end-stage dementia is present, the clinicians and caregivers become faced with multiple clinical issues-their inability to provide subjective complaints of pain and discomfort, behavioral symptoms, delirium, food refusal, and so on. In addition to providing quality EOL care to the patients, clinicians need to work with their families in an open and empathic manner, assuring that their loved ones will receive supportive measures to keep them comfortable.

Does a wander garden influence inappropriate behaviors in dementia residents?

BACKGROUND: The effect on resident behaviors of adding a wander garden to an existing dementia facility was investigated. METHODS: 34 male residents were observed for 12 months before and after opening the garden. Behaviors were assessed using the Cohen-Mansfield Agitation Inventory Short Form (CMAI), incident reports, as needed medications (pro re nata [PRN]), and surveys of staff and residents' family members as indices of affect. RESULTS: Final CMAI scores and total PRNs employed were lower than baseline values with a trend for residents who used the garden more often to have less agitated behavior. Verbal inappropriate behaviors did not change significantly whereas physical incidents increased. Staff and family members felt that the wander garden decreased inappropriate behaviors and improved mood and quality of life of the dementia residents. CONCLUSIONS: Study design characteristics and garden management may have affected behaviors both positively and negatively. Additional studies are needed to explore the benefits of wander gardens for dementia residents.

Drug-induced movement disorders in older adults: an overview for clinical practitioners.

OBJECTIVE: To provide an overview of some of the most common drug-induced movement disorders (DIMD) seen in the elderly by the primary care clinician. The epidemiology, clinical presentation, differential diagnosis, treatment, risk factors, and preventive measures are presented for each DIMD. DATA SOURCES: Medical literature and research article search utilizing PubMed (National Library of Medicine), Psych INFO (American Psychological Association), CINAHL Database (CINAHL Information Systems), the Library of Congress Catalogue, and the Internet. STUDY SELECTION: Reviews and articles from 1954 to 2005 concerning various movement disorders associated with medication in older adults. DATA EXTRACTIONS: Data on movement disorders associated with medications ranging from possible or controversial to well-established. DATA SYNTHESIS: With the aging of populations in the United States and other countries, the use of medications with potential risk of precipitating movement disorders is increasing. The majority of these iatrogenic problems will be first seen in the geriatric patient in various clinical settings, typically in a primary care setting. To a large extent they will be observed in patients with mild cognitive impairment or dementia having impaired recall and reduced capacity to participate in the diagnostic interview. The challenge to clinicians is complicated by the sizable number of medications that may be involved.

PTSD in Combat Veterans With Cognitive Decline.

Patients may exhibit posttraumatic stress disorder symptoms prior to the onset of dementia or uncover long quiescent symptoms of the disease, adding to the challenge of treating this population.

Focused supervision of high-risk fall dementia patients: a simple method to reduce fall incidence and severity.

Dementia units in nursing homes have a disproportionately high number of demographic risk factors for falls. Many residents have a previous history of falls, the inability to call for assistance, and the inability to remember safety instructions. For interdisciplinary falls review committees, this population may be the most difficult to manage. The Virginia Veterans Care Center (VVCC) Dementia Unit Interdisciplinary Fall Team instituted a novel practice for reducing the number and severity of falls among the highest risk group of dementia patients. Certified nursing assistants (CNAs) were assigned to high-risk residents for focused supervision. The patients received consistent supervision by selected CNAs during the day and evening shifts. Eight residents identified as high risk who continued to have falls despite multiple interventions were selected for the study. A comparison of four months of intervention with the four months prior to the intervention revealed a significant (p = 0. 024) fall reduction during the intervention months. Individually, seven of the eight participants had reduced falls during the intervention period. A 5-point scale for fall severity demonstrated an overall reduction in fall severity during that period. Individually, five of the eight patients had a decreased fall severity, and one had no change. Two patients experienced an increase in fall severity due to ongoing medical problems. While the small number of patients in the study limits the power of the results, this novel intervention of using designated CNAs to supervise high-risk fall residents with dementia may prove helpful for staff in other nursing facilities.

Risk factors for Alzheimer's disease: an overview for clinical practitioners.

OBJECTIVE: To review current information on various risk factors of Alzheimer's disease (AD) for clinicians so that they may educate patients or their families in a clinical setting. DATA SOURCES: Published medical literature and research articles from MEDLINE. STUDY SELECTION: Reviews and articles from 1985 to 2003 concerning risk factors associated with AD. DATA EXTRACTION: Data on risk factors ranging from possible or controversial to well established. DATA SYNTHESIS: AD is an irreversible, progressive neurodegenerative disorder. AD is currently known to be the most common cause of dementia in the United States. Over the last several decades, different levels of risk factors associated with AD have been identified. With more information available to the public via various resources, there is greater need for clinical practitioners to provide up-to-date information on risk factors in a meaningful way. This article discusses advanced age, family history, gender, low education, apolipoprotein E e4, head injury, cardiovascular conditions, and aluminum. CONCLUSION: Since there currently is no cure or preventive measure for AD, it is important to educate patients and their families about risk factors of AD in clinical practice.

Donepezil for alcohol-related dementia: a case report.

A 75-year old man with a 40-year history of alcoholism was admitted to the hospital for intoxication and inability to care for himself. He had been admitted frequently in the past for detoxification and rehabilitation. The patient had no family history of Alzheimer's disease, no history of head injury, and single-photon emission computed tomography showed no typical findings of Alzheimer's disease. His cognitive function was impaired. He was treated with donepezil for alcohol-related dementia, and 3 months later, his cognitive function had improved. More research is needed to confirm donepezil's role in treating alcohol-related dementia.

Treatment of delirium in older adults with quetiapine.

Delirium is a neuropsychiatric syndrome characterized by impairment of consciousness, changes in cognition, or perceptual disturbances. In addition, delirium is often accompanied by delusions, hallucinations, and agitation. In this study, 12 older patients with delirium were treated for neuropsychiatric symptoms with quetiapine. The mean duration for stabilization was 5.91 +/- 2.22 days, and the mean dose was 93.75 +/- 23.31 mg/day. None of the 12 patients developed extrapyramidal symptoms. There were significant improvements on all measures used in this study. Interestingly, the Delirium Rating Scale scores along with scores of the Mini-Mental State Examination and Clock Drawing Test continued to improve throughout the 3-month study period. In our study, we found that quetiapine was a safe and effective treatment in hospitalized older patients with delirium.

Percutaneous endoscopic gastrostomy in cognitively impaired older adults: a geropsychiatric perspective.

The increasing use of percutaneous endoscopic gastrostomy (PEG) in cognitively compromised elderly presents complex treatment-related and ethical questions. Approximately half of all dementia patients will be unable to feed themselves within eight years of their diagnosis. Moreover, 85 percent of dementia patients have demonstrated refusal to eat. Geropsychiatry is often employed to evaluate these cognitively impaired patients either prior to or following PEG tube placement. This manuscript presents three cases to illustrate the most commonly encountered general dementia presentations: the ability to communicate with decisional capacity, the ability to communicate without decisional capacity, and severe verbal aphasia without decisional capacity. The study discusses ethical issues and treatment strategies for pre- and post-PEG tube placement consultations, including environmental interventions, in order to improve quality of life for this population.

Providing quality palliative care in end-stage Alzheimer disease.

Providing quality palliative care is a daunting task profoundly impacted by diminished patient capacity at the end of life. Alzheimer disease (AD) is a disorder that erases our memories and is projected to increase dramatically for decades to come. By the time the patients with AD reach the end stage of the disease, the ability of patients to provide pertinent subjective complaints of pain and discomfort would have vanished. Historical perspectives of palliative care, exploration of the AD process, ethical issues, and crucial clinical considerations are provided to improve the understanding of disease progression and quality of care for patients with end-stage AD.

Grief experiences of 3 caregiving wives of veterans with dementia.

Three wives share their experiences of caregiving for husbands with dementia. The 3 husbands, aged 51, 71, and 84, developed dementia following years of devoted military service. To present lived experiences of caregiving wives', meanings attributed to caregiving are investigated, variations in caregiving and grieving experiences are explored, and therapeutic implications are offered. Through case study approach and with issues of caregiver grief considered, we introduce life course and ambiguous loss theoretical perspectives. Emergent qualitative themes and quantitative inventory ratings indicate significant differences in caregiver grief response depend on care-recipient age. Practice implications and directions for future care recipient, age-related research are presented.

Relationship of physical and functional independence and perceived quality of life of veteran patients with Alzheimer disease.

Alzheimer disease not only affects the cognitive function but also impacts one's abilities to perform daily tasks. This study evaluated for correlation between the quality of life of patients with Alzheimer disease (QoL-AD) and the level of independence and to evaluate the statistical difference between patients' quality of life and proxy perception of quality of life by utilizing the Katz activities of daily living and QoL-AD on patients and QoL-AD on caregivers. There was a small positive correlation (r = .13) between the levels of physical and functional independence and the perceived QoL. Also, patient consistently had higher QoL-AD than their caregiver counterparts. These findings provide some insight into our need to acknowledge factors that may influence QoL and illustrate the importance of monitoring for executive dysfunction and the safety risk.