Individual and Interactive Effects of Housing and Neighborhood Quality on Mental Health in Hong Kong: A Retrospective Cohort Study.

Existing literature has widely explored the individual roles of housing and neighborhood quality, and there is limited research examining their interactive effects on mental health. This 3-year cohort study utilized a longitudinal design to investigate the individual and interactive effects of housing and neighborhood quality on mental health among 962 community-dwelling adults in Hong Kong. Participants were asked to rate their residential qualities over the 3-year period. Mental health outcomes, including levels of psychological distress and common mental disorders (CMD), were assessed using the Revised Clinical Interview Schedule (CIS-R). Logistic regression and generalized linear models were used to examine the association between housing and neighborhood quality and CMD/psychological distress, adjusting for sociodemographic and residential characteristics and baseline mental disorders. Housing quality was associated with the 3-year CMD (adjusted OR 0.95; 95% CI 0.91 to 0.98). Likewise, neighborhood quality was associated with CMD over 3 years (adjusted OR 0.92; 95% CI 0.87 to 0.96). In a separate model including both quality measures, the effect of housing quality on CMD was attenuated, whereas the neighborhood impact remained significant (adjusted OR 0.92; 95% CI 0.87 to 0.98). Generalized linear models indicated that for participants residing in substandard housing, those with high neighborhood quality had lower CIS-R scores at follow-up compared to those with low neighborhood quality (p = 0.041). Better neighborhood quality alleviated the detrimental effects of poor housing quality on mental health. Planning for an enhanced neighborhood would improve population mental health in an urban environment.

Development and validation of cognitive ageing risk score (CARS) for early detection of subtle cognitive deficits in older people.

BACKGROUND: Early cognitive deficits commonly seen in older people have not been well defined and managed in primary care. The objectives are (1) to develop and validate a new risk score to estimate the risk of dementia in Chinese older population; and (2) to evaluate the use of risk score in conjunction with cognitive screening in detecting early cognitive deficits in community older people. METHODS: A development cohort of 306 cognitive healthy older adults aged 60 or above were followed for 6 years. A CARS was constructed using the estimated coefficients of risk factors associated with dementia at follow up. Validation was carried out in another five-year cohort of 383 older adults. The usefulness of CARS in detecting early cognitive deficits was evaluated. RESULTS: Risk factors include older age, male gender, low level of education, poorly controlled diabetes, prolonged sleep latency, fewer mind body or light exercise, loneliness, and being apolipoprotein e4 carriers. A cutoff of CARS at -1.3 had a sensitivity of 83.9% and a specificity of 75.4% to predict dementia. The area under curve was 82.5% in the development cohort. Early cognitive deficits were characterized by impaired retention (p <.001, 95% CI 0.2-0.9) and attention (p =.012, 95% CI 0.1-0.8). CONCLUSION: The CARS can be used as a standard risk assessment of dementia or in conjunction with a computerized cognitive screening to evaluate a full cognitive profile for detecting early cognitive deficits. The result put forward the integration of risk algorithm into smart healthcare system to provide personalized lifestyle interventions.

Dementia literacy in an ageing world.

AIMS: This discursive article aims to capture and explore the most pertinent nursing aspects of dementia literacy (DL). BACKGROUND: Older people constitute a rapidly increasing proportion of the global population, experiencing higher risk of developing chronic disease, including dementia. It is important that older adults receive and understand reliable health-related information, as age-related changes may affect the level of health literacy in an older person. It has been suggested that older adults may have poorer health literacy than younger adults, associated with poorer health outcomes. Health literacy, how people receive, interpret and act on health information, play a significant role in dementia-related disorders, both as a possible predicter of onset of dementia and as a potential modifier of cognitive decline. Dementia literacy constitutes one aspect of health literacy in relation to nursing care, related to knowledge of dementia-related disorders and approaches towards older people with dementia. DESIGN: This discursive article explores the importance of DL for the nursing profession, including dementia-related assessment, education and interventions. METHOD: This article is informed by analysis of relevant descriptive and empirical literature and policy documents related to DL, an increasingly important aspect of dementia-related nursing care. Valid assessment tools that can accurately assess aspects an individuals' DL are examined; these have the potential to help nurses detect dementia-related symptoms. With early detection and prevention of dementia, older people may have better chance of benefiting from evolving treatment options. CONCLUSION: Greater attention needs to be given to the issue of DL in older people, especially in terms of nursing assessment and care. Globally, increased DL-related education is urgently required to improve knowledge of this concept; this includes public awareness initiatives to better understanding this chronic condition. IMPLICATION NURSING PRACTICE: Enhancing DL has the potential to empower older people to have greater access to healthcare services and to make more informed decisions about their health care. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as this is a discursive article.

Clinical and radiomic features for predicting the treatment response of repetitive transcranial magnetic stimulation in major neurocognitive disorder: Results from a randomized controlled trial.

Image-guided repetitive transcranial magnetic stimulation (rTMS) has shown clinical effectiveness in senior adults with co-occurring depression and cognitive impairment, yet the imaging markers for predicting the treatment response are less investigated. In this clinical trial, we examined the efficacy and sustainability of 10 Hz rTMS for the treatment of depression and cognitive impairment in major neurocognitive disorder (NCD) patients and tested the predictive values of imaging-informed radiomic features in response to rTMS treatment. Fifty-five major NCD patients with depression were randomly assigned to receive a 3-week rTMS treatment of either active 10 Hz rTMS (n = 27) or sham rTMS (n = 28). Left dorsolateral prefrontal cortex (DLPFC) was the predefined treatment target. Based on individual structural magnetic resonance imaging scans, surface-based analysis was conducted to quantitatively measure the baseline radiomic features of left DLPFC. Severity of depression, global cognition and the serum brain-derived neurotrophic factor (BDNF) level were evaluated at baseline, 3-, 6- and 12-week follow-ups. Logistic regression analysis revealed that advanced age, higher baseline cognition and randomized group were associated with the remission of depression. Increased cortical thickness and gyrification in left DLPFC were the significant predictors of clinical remission and cognitive enhancement. A 3-week course of 10 Hz rTMS is an effective adjuvant treatment for rapid ameliorating depressive symptoms and enhancing cognitive function. Pre-treatment radiomic features of the stimulation target can predict the response to rTMS treatment in major NCD. Cortical thickness and folding of treatment target may serve as imaging markers to detect the responders. ChiCTR-IOR-16008191, registered on March 30, 2016.

Are Care-Recipient Outcomes Attributable to Improved Caregiver Well-Being? A Cluster-Randomized Controlled Trial of Benefit-Finding Intervention.

OBJECTIVES: The benefit-finding therapeutic (BFT) intervention, training cognitive reappraisal, and alternative thinking to construct positive aspects of caregiving have been found to reduce caregiver depression. This study examines BFT effects on care-recipient outcomes via reduced caregiver depression. DESIGN: Cluster-randomized double-blind controlled trial. SETTING: Social centers and clinics. PARTICIPANTS: A total of 129 caregivers. Inclusion criteria were 1) primary caregiver aged 18+, 2) without cognitive impairment, 3) providing ≥14 care hours weekly to a relative with mild-to-moderate Alzheimer's disease, and 4) scoring ≥3 on the Hamilton Depression Rating Scale. Exclusion criterion was care-recipient having Parkinsonism or other forms of dementia. INTERVENTIONS: BFT was evaluated against two forms of psychoeducation-standard and simplified (lectures only) psychoeducation. MEASUREMENTS: Care-recipient outcomes included neuropsychiatric symptoms (NPS), functional impairment, and global dementia severity (Clinical Dementia Rating sum-of-box), measured at baseline, postintervention, and 4- and 10-month follow up. RESULTS: Mixed-effects regressions showed a significant effect on NPS when compared with simplified psychoeducation only, with BFT participants reporting fewer NPS (especially mood symptoms) at 4-month follow-up (d = -0.52). Furthermore, longitudinal path analysis (using changes in caregiver depression scores at postintervention to predict changes in care-recipient NPS at follow-up) found that this effect was mediated by improved caregiver depression. No other intervention or mediation effects were found or were consistent across analyses. CONCLUSIONS: Less depressed caregivers may be able to provide better care and more positive interactions, leading to reduced NPS in care-recipients. However, this benefit of BFT was limited to the comparison with simplified psychoeducation only.

Is sleep quality a potential predictor of neurocognitive disorders? A 6-year follow-up study in Chinese older adults.

OBJECTIVE: To investigate the longitudinal association of sleep quality with incidence of neurocognitive disorders in 6 years. METHODS: This was a 6-year follow-up study of community-living older adults who scored a Clinical Dementia Rating (CDR) of 0 at baseline. Sleep quality was assessed by the self-rated Pittsburgh Sleep Quality Index (PSQI) questionnaire, where higher scores indicated poorer sleep quality, and a cutoff score of 5 or above was suggestive of sleep disorder. The study outcome was incident neurocognitive disorders in 6 years, as identified by a CDR of 0.5 or above. Poisson regression analysis was conducted to test if baseline sleep quality was independently associated with risk of incident neurocognitive disorders in 6 years. RESULTS: Of the 290 participants in this study, 166 (57.2%) developed neurocognitive disorders in 6 years. They had poorer sleep quality (mean [SD] total PSQI score: 6.2 [3.8] vs. 4.9 [3.2], p = 0.001) and higher prevalence of sleep disorder (100 [60.2%] vs. 56 [45.2%], p = 0.01) at baseline than those who remained free of neurocognitive disorder. After controlling for age, gender, education, and physical and psychiatric morbidities, the risk ratios (RRs) for incident neurocognitive disorders were 1.05 (95% confidence interval (CI) = 1.00-1.11, p < 0.05) for PSQI total score and 1.50 (95% CI = 1.05-2.14, p = 0.03) for sleep disorder at baseline. CONCLUSIONS: Sleep quality might predict the development of neurocognitive disorders. From a clinical perspective, enquiry of sleep quality and screening for sleep disorder should be promoted as part of the neurocognitive disorder risk assessment in older adults.

The 12-month prevalence of psychotic experiences and their association with clinical outcomes in Hong Kong: an epidemiological and a 2-year follow up studies.

BACKGROUND: The relationship between the subtypes of psychotic experiences (PEs) and common mental health symptoms remains unclear. The current study aims to establish the 12-month prevalence of PEs in a representative sample of community-dwelling Chinese population in Hong Kong and explore the relationship of types of PEs and common mental health symptoms. METHOD: This is a population-based two-phase household survey of Chinese population in Hong Kong aged 16-75 (N = 5719) conducted between 2010 and 2013 and a 2-year follow-up study of PEs positive subjects (N = 152). PEs were measured with Psychosis Screening Questionnaire (PSQ) and subjects who endorsed any item on the PSQ without a clinical diagnosis of psychotic disorder were considered as PE-positive. Types of PEs were characterized using a number of PEs (single v. multiple) and latent class analysis. All PE-positive subjects were assessed with common mental health symptoms and suicidal ideations at baseline and 2-year follow-up. PE status was also assessed at 2-year follow-up. RESULTS: The 12-month prevalence of PEs in Hong Kong was 2.7% with 21.1% had multiple PEs. Three latent classes of PEs were identified: hallucination, paranoia and mixed. Multiple PEs and hallucination latent class of PEs were associated with higher levels of common mental health symptoms. PE persistent rate at 2-year follow-up was 15.1%. Multiple PEs was associated with poorer mental health at 2-year follow-up. CONCLUSIONS: Results highlighted the transient and heterogeneous nature of PEs, and that multiple PEs and hallucination subtype of PEs may be specific indices of poorer common mental health.

Increasing the Utilization of Moderate Sedation Services for Pediatric Imaging.

Performing motion-free imaging is frequently challenging in children. To bridge the gap between examinations performed in children who are awake and in those under general anesthesia, a moderate sedation program was implemented at our institution but was seldom used despite substantial eligibility. In conjunction with a 5-month quality improvement (QI) course, a multidisciplinary team was assembled and, by using an A3 approach, sought to address the most important key drivers of low utilization, namely the need for clear moderate sedation eligibility criteria, reliable protocol routing order, consistent moderate sedation screening performed by registered nurses (RNs), and enhanced visibility of moderate sedation services to ordering providers. Initial steps focused on developing better-defined criteria and protocoling standard work for technologists and RNs, with coaching and audits. Modality-specific forecasting was then implemented to reroute profiles of patients who were awaiting scheduling or already scheduled for an examination with general anesthesia to the moderate sedation queue to identify more eligible patients. These manual efforts were coupled with higher reliability but more protracted electronic health record changes, facilitating automated protocol routing on the basis of moderate sedation eligibility and order entry constraints. As a result, scheduled imaging examinations requiring moderate sedation increased from a mean of 1.2 examinations per week to a sustained 6.1 examinations per week (range, 4-8) over the 5-month period, exceeding the team SMART (specific, measurable, achievable, relevant, and time bound) goal to achieve an average of five examinations per week by the QI course end. By targeting the most high-impact yet modifiable process deficiencies through a multifaceted team approach and initially investing in manual efforts to gain cultural buy-in while awaiting higher-reliability interventions, the project achieved success and may serve as a more general model for workflow change when there is organizational resistance. ©RSNA, 2021.

Dynamic changes of region-specific cortical features and scalp-to-cortex distance: implications for transcranial current stimulation modeling.

BACKGROUND: Transcranial current stimulation in rehabilitation is a fast-growing field featured with computational and biophysical modeling. Cortical features and scalp-to-cortex distance (SCD) are key variables for determining the strength and distribution of the electric field, yet longitudinal studies able to capture these dynamic changes are missing. We sought to investigate and quantify the ageing effect on the morphometry and SCD of left primary motor cortex (M1) and dorsolateral prefrontal cortex (DLPFC) in normal ageing adults and mild cognitive impairment (MCI) converters. METHODS: Baseline, 1-year and 3-year follow-up structural magnetic resonance imaging scans from normal ageing adults (n = 32), and MCI converters (n = 22) were drawn from the Open Access Series of Imaging Studies. We quantified the changes of the cortical features and SCDs of left M1 and DLPFC, including grey matter volume, white matter volume, cortical thickness, and folding. Head model was developed to simulate the impact of SCD on the electric field induced by transcranial current stimulation. RESULTS: Pronounced ageing effect was found on the SCD of left DLPFC in MCI converters. The SCD change of left DLPFC from baseline to 3-year follow-up demonstrated better performance to discriminate MCI converters from normal ageing adults than the other morphometric measures. The strength of electric field was consequently decreased with SCD in MCI converters. CONCLUSION: Ageing has a prominent, but differential effect on the region-specific SCD and cortical features in older adults with cognitive impairments. Our findings suggest that SCD, cortical thickness, and folding of the targeted regions could be used as valuable imaging markers when conducting transcranial brain stimulation in individuals with brain atrophy.

Higher psychogeriatric admissions in COVID-19 than in severe acute respiratory syndrome.

OBJECTIVES: To examine whether psychogeriatric admissions increased after COVID-19, independent of seasonal variation; whether the increase was comparable with that seen in severe acute respiratory syndrome (SARS); and which factors were associated with such increase. METHODS: All psychiatric admissions aged 65 or older in the 3 months before and after COVID-19 (from November 2019 to April 2020), in the previous 2 years (from November 2017 to April 2018 and from November 2018 to April 2019), and in the year of SARS (from November 2002 to April 2003) in a major gazette inpatient psychiatric unit in Hong Kong, which serves a catchment population of 1.4 million, were anonymously reviewed. The number of psychogeriatric admissions between different timeframes was compared, and factors that might explain the increase in admissions following COVID-19 were examined. RESULTS: Psychogeriatric admissions increased by 21.4% following the COVID-19 outbreak. This increase was not explained by seasonal variation and was greater and lasted longer than that in SARS. A rising trend in admissions for older adults living in residential care homes was observed. The increase in admissions was associated with fewer outpatient attendance, fewer home visits by nurses, and more older adults with dementia requiring inpatient care. CONCLUSIONS: Our findings highlight the impact of COVID-19 on older adults' mental health, greater demand for inpatient psychogeriatric services in COVID-19 than in SARS, and the importance of maintaining support for community-living older adults, in particular those with dementia, and their caregivers in reducing the needs for inpatient psychiatric treatment during the pandemic. Clinicaltrials.gov # ChiCTR2000033317.

Pathways to care for people with dementia: An international multicentre study.

OBJECTIVE: The aim of the present study was to characterize the clinical pathways that people with dementia (PwD) in different countries follow to reach specialized dementia care. METHODS: We recruited 548 consecutive clinical attendees with a standardized diagnosis of dementia, in 19 specialized public centres for dementia care in 15 countries. The WHO "encounter form," a standardized schedule that enables data concerning basic socio-demographic, clinical, and pathways data to be gathered, was completed for each participant. RESULTS: The median time from the appearance of the first symptoms to the first contact with specialist dementia care was 56 weeks. The primary point of access to care was the general practitioners (55.8%). Psychiatrists, geriatricians, and neurologists represented the most important second point of access. In about a third of cases, PwD were prescribed psychotropic drugs (mostly antidepressants and tranquillizers). Psychosocial interventions (such as psychological counselling, psychotherapy, and practical advice) were delivered in less than 3% of situations. The analyses of the "pathways diagram" revealed that the path of PwD to receiving care is complex and diverse across countries and that there are important barriers to clinical care. CONCLUSIONS: The study of pathways followed by PwD to reach specialized care has implications for the subsequent course and the outcome of dementia. Insights into local differences in the clinical presentations and the implementation of currently available dementia care are essential to develop more tailored strategies for these patients, locally, nationally, and internationally.

Validation of a computerized Hong Kong - vigilance and memory test (HK-VMT) to detect early cognitive impairment in healthy older adults.

Objectives: Hong Kong - Vigilance and Memory Test (HK-VMT) is developed to distinguish early cognitive impairment in the pre-symptomatic phase from normal cognitive ageing in older adults. The objectives were to validate HK-VMT to differentiate mild cognitive impairment (MCI) and healthy control (HC), and to explore the cut-off scores for different educational levels.Method: A total of 606 older adults underwent the HK-VMT and conventional cognitive tests. HK-VMT is a 15 minutes cognitive battery that assesses episodic memory, attention, and visuospatial ability. The HK-VMT total is the sum of accuracy of all subtests with a range of 0 to 40. Differences in socio-demographic and clinical characteristics between groups were explored. Receiver operating characteristic (ROC) analyses were used to compare HK-VMT and Cantonese Mini Mental State Examination (CMMSE). A sample of 50 participants repeated the HK-VMT in 1 month to evaluate test-retest reliability.Results: ROC analysis of Area Under Curve (AUC) demonstrated that HK-VMT (AUC 0.793) was comparable to CMMSE (AUC 0.748) in differentiating MCI from HC in a matched sample. A cutoff at 21/22 was chosen yielding a sensitivity of 86.1% and a specificity of 75.3% for differentiating MCI and HC. Test-retest reliability of HK-VMT total was 0.71 (p<.001) in a month time.Conclusion: HK-VMT has demonstrated satisfactory validity in detecting cognitive impairment with good test-retest reliability in local older adults. It also performed favourably in the highly educated group when compared to CMMSE.

Tackling challenges in care of Alzheimer's disease and other dementias amid the COVID-19 pandemic, now and in the future.

We have provided an overview on the profound impact of COVID-19 upon older people with Alzheimer's disease and other dementias and the challenges encountered in our management of dementia in different health-care settings, including hospital, out-patient, care homes, and the community during the COVID-19 pandemic. We have also proposed a conceptual framework and practical suggestions for health-care providers in tackling these challenges, which can also apply to the care of older people in general, with or without other neurological diseases, such as stroke or parkinsonism. We believe this review will provide strategic directions and set standards for health-care leaders in dementia, including governmental bodies around the world in coordinating emergency response plans for protecting and caring for older people with dementia amid the COIVD-19 outbreak, which is likely to continue at varying severity in different regions around the world in the medium term.

Determinants of cognitive performance and decline in 20 diverse ethno-regional groups: A COSMIC collaboration cohort study.

BACKGROUND: With no effective treatments for cognitive decline or dementia, improving the evidence base for modifiable risk factors is a research priority. This study investigated associations between risk factors and late-life cognitive decline on a global scale, including comparisons between ethno-regional groups. METHODS AND FINDINGS: We harmonized longitudinal data from 20 population-based cohorts from 15 countries over 5 continents, including 48,522 individuals (58.4% women) aged 54-105 (mean = 72.7) years and without dementia at baseline. Studies had 2-15 years of follow-up. The risk factors investigated were age, sex, education, alcohol consumption, anxiety, apolipoprotein E ε4 allele (APOE*4) status, atrial fibrillation, blood pressure and pulse pressure, body mass index, cardiovascular disease, depression, diabetes, self-rated health, high cholesterol, hypertension, peripheral vascular disease, physical activity, smoking, and history of stroke. Associations with risk factors were determined for a global cognitive composite outcome (memory, language, processing speed, and executive functioning tests) and Mini-Mental State Examination score. Individual participant data meta-analyses of multivariable linear mixed model results pooled across cohorts revealed that for at least 1 cognitive outcome, age (B = -0.1, SE = 0.01), APOE*4 carriage (B = -0.31, SE = 0.11), depression (B = -0.11, SE = 0.06), diabetes (B = -0.23, SE = 0.10), current smoking (B = -0.20, SE = 0.08), and history of stroke (B = -0.22, SE = 0.09) were independently associated with poorer cognitive performance (p < 0.05 for all), and higher levels of education (B = 0.12, SE = 0.02) and vigorous physical activity (B = 0.17, SE = 0.06) were associated with better performance (p < 0.01 for both). Age (B = -0.07, SE = 0.01), APOE*4 carriage (B = -0.41, SE = 0.18), and diabetes (B = -0.18, SE = 0.10) were independently associated with faster cognitive decline (p < 0.05 for all). Different effects between Asian people and white people included stronger associations for Asian people between ever smoking and poorer cognition (group by risk factor interaction: B = -0.24, SE = 0.12), and between diabetes and cognitive decline (B = -0.66, SE = 0.27; p < 0.05 for both). Limitations of our study include a loss or distortion of risk factor data with harmonization, and not investigating factors at midlife. CONCLUSIONS: These results suggest that education, smoking, physical activity, diabetes, and stroke are all modifiable factors associated with cognitive decline. If these factors are determined to be causal, controlling them could minimize worldwide levels of cognitive decline. However, any global prevention strategy may need to consider ethno-regional differences.

Phase 1/2 study of fractionated dose lutetium-177-labeled anti-prostate-specific membrane antigen monoclonal antibody J591 (177 Lu-J591) for metastatic castration-resistant prostate cancer.

BACKGROUND: Prostate cancer is radiosensitive. Prostate-specific membrane antigen (PSMA) is selectively overexpressed on advanced, castration-resistant tumors. Lutetium-177-labeled anti-PSMA monoclonal antibody J591 (177 Lu-J591) targets prostate cancer with efficacy and dose-response/toxicity data when delivered as a single dose. Dose fractionation may allow higher doses to be administered safely. METHOD: Men with metastatic castration-resistant prostate cancer refractory to or refusing standard treatment options with normal neutrophil and platelet counts were enrolled in initial phase 1b dose-escalation cohorts followed by phase 2a cohorts treated at recommended phase 2 doses (RP2Ds) comprising 2 fractionated doses of 177 Lu-J591 2 weeks apart. 177 Lu-J591 imaging was performed after treatment, but no selection for PSMA expression was performed before enrollment. Phase 2 patients had circulating tumor cell (CTC) counts assessed before and after treatment. RESULTS: Forty-nine men received fractionated doses of 177 Lu-J591 ranging from 20 to 45 mCi/m2 ×2 two weeks apart. The dose-limiting toxicity in phase 1 was neutropenia. The RP2Ds were 40 mCi/m2 and 45 mCi/m2 ×2. At the highest RP2D (45 mCi/m2 ×2), 35.3% of patients had reversible grade 4 neutropenia, and 58.8% of patients had thrombocytopenia. This dose showed a greater decrease in prostate-specific antigen (PSA) levels and longer survival (87.5% with any PSA decrease, 58.8% with >30% decrease, 29.4% with >50% decrease; median survival, 42.3 months [95% confidence interval, 19.9-64.7]). Fourteen of 17 (82%) patients with detectable CTCs experienced a decrease in CTC count. Overall, 79.6% of patients had positive PSMA imaging; those with less intense PSMA imaging tended to have poorer responses. CONCLUSION: Fractionated administration of 177 Lu-J591 allowed higher cumulative radiation dosing. The frequency and depth of PSA decrease, overall survival, and toxicity (dose-limiting myelosuppression) increased with higher doses.

Long-Term Outcomes of the Benefit-Finding Group Intervention for Alzheimer Family Caregivers: A Cluster-Randomized Double-Blind Controlled Trial.

OBJECTIVES: To examine the effects of the group benefit-finding therapeutic intervention (BFT) for Alzheimer family caregivers up to 10-month follow-up. METHODS: This was a cluster-randomized double-blind controlled trial in social centers and clinics. Participants included 129 caregivers. Inclusion criteria were 1) primary caregiver aged 18 years and older and without cognitive impairment, 2) providing 14 or more care hours per week to a relative with mild-to-moderate Alzheimer disease, and 3) scoring 3 or more on the Hamilton Depression Rating Scale. Exclusion criterion was care-recipient having parkinsonism or other forms of dementia. BFT (using cognitive reappraisal to find positive meanings) was evaluated against two forms of psychoeducation as controls-standard and simplified (lectures only) psychoeducation. All interventions had eight weekly sessions of 2 hours each. Primary outcome was depressive symptoms, whereas secondary outcomes were global burden, role overload, and psychological well-being. Measures were collected at baseline, postintervention, and 4- and 10-month follow-up. RESULTS: Mixed-effects regression showed that BFT's effect on depressive symptoms conformed to a curvilinear pattern, in which the strong initial effect leveled out after postintervention and was maintained up to 10-month follow-up; this was true when compared against either control group. The effect on global burden was less impressive but moderate effect sizes were found at the two follow-ups. For psychological well-being, there was an increase in the BFT group at 4-month follow-up and a return to baseline afterward. No effect on role overload was found. CONCLUSION: Benefit-finding reduces depressive symptoms as well as global burden in the long-term and increases psychological well-being in the medium-term.

Noneffectiveness of electroacupuncture for comorbid generalized anxiety disorder and irritable bowel syndrome.

BACKGROUND AND AIM: Comorbid generalized anxiety disorder and irritable bowel syndrome are common and therapeutically challenging. We aimed to assess the effectiveness of electroacupuncture in relieving anxiety and bowel symptoms in Chinese adults with this form of comorbidity. METHODS: In a single-blind randomized sham-controlled trial, subjects with comorbid generalized anxiety disorder and irritable bowel syndrome were randomly assigned to receive 10 weekly sessions of electroacupuncture or sham electroacupuncture. Patients were assessed at baseline, immediately after intervention and at 6-week follow-up. Primary outcome was anxiety (7-item Patient Health Questionnaire section for anxiety). Secondary outcomes included bowel symptoms (bowel symptoms questionnaire), depressive symptoms (9-item Patient Health Questionnaire), somatic symptoms (15-item Patient Health Questionnaire), and health-related quality of life (EuroQol-5 Dimensions). RESULTS: Eighty subjects, 40 in each arm, were randomized. All but two in the sham group completed 10 weekly sessions. There was no significant difference in the proportion of patients experiencing significant (≥ 50%) reduction of anxiety symptoms between the two groups immediately after intervention (32.4% vs 21.6%, P = 0.06) and at 6-week follow-up (25.7% in electroacupuncture vs 27% in sham, P = 0.65). Anxiety, depressive symptom, and bowel symptom severity did not differ significantly between electroacupuncture and sham groups. CONCLUSIONS: Findings failed to support the effectiveness of electroacupuncture for comorbid generalized anxiety disorder and irritable bowel syndrome. Further studies are needed to identify effective acupuncture treatment protocols for such comorbidity.

Higher dementia incidence in older adults with type 2 diabetes and large reduction in HbA1c.

BACKGROUND: although type 2 diabetes increases risk of dementia by 2-fold, whether optimizing glycemic level in late life can reduce risk of dementia remains uncertain. We examined if achieving the glycemic goal recommended by the American Diabetes Association (ADA) within a year was associated with lower risk of dementia in 6 years. METHODS: in this population-based observational study, we examined 2246 community-living dementia-free Chinese older adults with type 2 diabetes who attended the Elderly Health Centres in Hong Kong at baseline and followed their HbA1c level and cognitive status for 6 years. In line with the ADA recommendation, we defined the glycemic goal as HbA1c < 7.5%. The study outcome was incident dementia in 6 years, diagnosed according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) or Clinical Dementia Rating of 1-3. RESULTS: those with HbA1c ≥ 7.5% at baseline and HbA1c < 7.5% in 1 year were associated with higher rather than lower incidence of dementia, independent of severe hypoglycemia, glycemic variability and other health factors. Sensitivity analyses showed that a relative reduction of ≥10%, but not 5-10%, in HbA1c within a year was associated with higher incidence of dementia in those with high (≥8%) and moderate (6.5-7.9%) HbA1c at baseline. CONCLUSION: a large reduction in HbA1c could be a potential predictor and possibly a risk factor for dementia in older adults with type 2 diabetes. Our findings suggest that optimizing or intensifying glycemic control in this population requires caution.

A brief measure of predeath grief in dementia caregivers: the Caregiver Grief Questionnaire.

OBJECTIVE: The study of predeath grief is hampered by measures that are often lengthy and not clearly differentiated from other caregiving outcomes, most notably burden. We aimed to validate a new 11-item Caregiver Grief Questionnaire (CGQ) assessing two dimensions of predeath grief, namely relational deprivation and emotional pain. DESIGN: Cross-sectional survey. SETTING: Community and psychogeriatric clinics. PARTICIPANTS: 173 Alzheimer (AD) caregivers who cared for relatives with different degrees of severity (63 mild, 60 moderate, and 50 severe). MEASUREMENTS: Besides the CGQ, measures of caregiver burden and depressive symptoms, and care-recipients' neuropsychiatric symptoms and functional impairment were assessed. RESULTS: Confirmatory factor analysis supported the hypothesized 2-factor over the 1-factor model, and both subscales were only moderately correlated with burden. Two-week test-retest reliabilities were excellent. Caregivers for mild AD reported less grief than those caring for more severe relatives. Z tests revealed significantly different correlational patterns for the two dimensions, with emotional pain more related to global burden and depressive symptoms, and relational deprivation more related to care-recipients' functional impairment. Both dimensions were mildly correlated with neuropsychiatric symptoms (especially disruptive behaviors and psychotic symptoms) of the care-recipient. CONCLUSIONS: Results supported the reliability and validity of the two-dimensional measure of predeath grief. As a brief measure, it can be readily added to research instruments to facilitate study of this important phenomenon along with other caregiving outcomes.

Loneliness interacts with family relationship in relation to cognitive function in Chinese older adults.

ABSTRACTObjectives:Loneliness and social networks have been extensively studied in relation to cognitive impairments, but how they interact with each other in relation to cognition is still unclear. This study aimed at exploring the interaction of loneliness and various types of social networks in relation to cognition in older adults. DESIGN: a cross-sectional study. SETTING: face-to-face interview. PARTICIPANTS: 497 older adults with normal global cognition were interviewed. MEASUREMENTS: Loneliness was assessed with Chinese 6-item De Jong Gierverg's Loneliness Scale. Confiding network was defined as people who could share inner feelings with, whereas non-confiding network was computed by subtracting the confiding network from the total network size. Cognitive performance was expressed as a global composite z-score of Cantonese version of mini mental state examination (CMMSE), Categorical verbal fluency test (CVFT) and delayed recall. Linear regression was used to test the main effects of loneliness and the size of various networks, and their interaction on cognitive performance with the adjustment of sociodemographic, physical and psychological confounders. RESULTS: Significant interaction was found between loneliness and non-confiding network on cognitive performance (B = .002, ß = .092, t = 2.099, p = .036). Further analysis showed a significant interaction between loneliness and the number of family members in non-confiding network on cognition (B = .021, ß = .119, t = 2.775, p = .006). CONCLUSIONS: Results suggested that a non-confiding relationship with family members might put lonely older adults at risk of cognitive impairment. Our study might have implications on designing psychosocial intervention for those who are vulnerable to loneliness as an early prevention of neurocognitive impairments.