Prevalence, management and outcomes of unrecognized delirium in a National Sample of 1,493 older emergency department patients: how many were sent home and what happened to them?

BACKGROUND: Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium. OBJECTIVES: To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes. METHODS: Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls). RESULTS: We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2-6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4-66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2-72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort. CONCLUSION: Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.

Tolcapone Treatment for Cognitive and Behavioral Symptoms in Behavioral Variant Frontotemporal Dementia: A Placebo-Controlled Crossover Study.

BACKGROUND: There are currently no disease-targeted treatments for cognitive or behavioral symptoms in patients with behavioral variant frontotemporal dementia (bvFTD). OBJECTIVE: To determine the effect of tolcapone, a specific inhibitor of Catechol-O-Methyltransferase (COMT), in patients with bvFTD. METHODS: In this randomized, double-blind, placebo-controlled, cross-over study at two study sites, we examined the effect of tolcapone on 28 adult outpatients with bvFTD. The primary outcome was reaction time on the N-back cognitive test. As an imaging outcome, we examined differences in the resting blood oxygen level dependent (BOLD) functional magnetic resonance imaging (fMRI) signal intensity between subjects on placebo versus tolcapone performing the N-back test. Secondary outcomes included measures of cognitive performance and behavioral disturbance using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Neuropsychiatric Inventory-Questionnaire (NPI-Q), and Clinical Global Impressions scale (CGI). RESULTS: Tolcapone was well tolerated and no patients dropped out. The most frequent treatment-related adverse event during tolcapone treatment was elevated liver enzymes (21%). There were no significant differences between tolcapone treatment and placebo in the primary or imaging outcomes. However, there were significant differences between RBANS total scores (p < 0.01), NPI-Q total scores (p = 0.04), and CGI total scores (p = 0.035) between treatment conditions which were driven by differences between baseline and tolcapone conditions. Further, there was a trend toward significance between tolcapone and placebo on the CGI (p = 0.078). CONCLUSIONS: Further study of COMT inhibition and related approaches with longer duration of treatment and larger sample sizes in frontotemporal lobar degeneration-spectrum disorders may be warranted.

Scoring algorithms for a computer-based cognitive screening tool: An illustrative example of overfitting machine learning approaches and the impact on estimates of classification accuracy.

Computerized cognitive screening tools, such as the self-administered Computerized Assessment of Memory Cognitive Impairment (CAMCI), require little training and ensure standardized administration and could be an ideal test for primary care settings. We conducted a secondary analysis of a data set including 887 older adults (M age = 72.7 years, SD = 7.1 years; 32.1% male; M years education = 13.4, SD = 2.7 years) with CAMCI scores and independent diagnoses of mild cognitive impairment (MCI). A study by the CAMCI developers used a portion of this data set with a machine learning decision tree model and suggested that the CAMCI had high classification accuracy for MCI (sensitivity = 0.86, specificity = 0.94). We found similar support for accuracy (sensitivity = 0.94, specificity = 0.94) by overfitting a decision tree model, but we found evidence of lower accuracy in a cross-validation sample (sensitivity = 0.62, specificity = 0.66). A logistic regression model, however, discriminated modestly in both training (sensitivity = 0.72, specificity = 0.80) and cross-validation data sets (sensitivity = 0.69, specificity = 0.74). Evidence for strong accuracy when overfitting a decision tree model and substantially reduced accuracy in cross-validation samples was replicated across 500 bootstrapped samples. In contrast, the evidence for accuracy of the logistic regression model was similar in the training and cross-validation samples. The logistic regression model produced accuracy estimates consistent with other published CAMCI studies, suggesting evidence for classification accuracy of the CAMCI for MCI is likely modest. This case study illustrates the general need for cross-validation and careful evaluation of the generalizability of machine learning models. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Sex Differences in Depression as a Risk Factor for Alzheimer's Disease: A Systematic Review.

BACKGROUND AND OBJECTIVES: Depression is an important risk factor for Alzheimer's disease (AD) but little is known about the mechanisms of this association. Given sex differences in both AD and depression, we sought to conduct a systematic review and meta-analysis to examine whether there are sex differences in their association, as this may improve understanding of underlying mechanisms. RESEARCH DESIGN AND METHODS: MEDLINE, PsycINFO, and Cochrane Reviews were searched for observational studies including both sexes and examining the association between history of depression and AD. RESULTS: Forty studies, including 62,729 women and 47,342 men, were identified. Meta-analysis was not possible because only 3 studies provided sufficient data. Seven studies provided information about the influence of sex for a qualitative synthesis. Two found an association in men only, 2 in women only, and 3 reported no sex differences. The 2 studies finding an association in women only were unique in that they had the shortest follow-up periods, and were the only clinic-based studies. DISCUSSION AND IMPLICATIONS: The findings of our systematic review show that there are important methodological differences among the few studies providing data on the influence of sex on depression as a risk factor for AD. Had all 40 studies provided sex-segregated data, these methodological differences and their impact on sex effects could have been examined quantitatively. We encourage researchers to report these data, as well as potential moderating factors, so that the role of sex differences can be better understood.

The Comprehensive Assessment of Neurodegeneration and Dementia: Canadian Cohort Study.

BACKGROUND: The Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) cohort study of the Canadian Consortium on Neurodegeneration in Aging (CCNA) is a national initiative to catalyze research on dementia, set up to support the research agendas of CCNA teams. This cross-country longitudinal cohort of 2310 deeply phenotyped subjects with various forms of dementia and mild memory loss or concerns, along with cognitively intact elderly subjects, will test hypotheses generated by these teams. METHODS: The COMPASS-ND protocol, initial grant proposal for funding, fifth semi-annual CCNA Progress Report submitted to the Canadian Institutes of Health Research December 2017, and other documents supplemented by modifications made and lessons learned after implementation were used by the authors to create the description of the study provided here. RESULTS: The CCNA COMPASS-ND cohort includes participants from across Canada with various cognitive conditions associated with or at risk of neurodegenerative diseases. They will undergo a wide range of experimental, clinical, imaging, and genetic investigation to specifically address the causes, diagnosis, treatment, and prevention of these conditions in the aging population. Data derived from clinical and cognitive assessments, biospecimens, brain imaging, genetics, and brain donations will be used to test hypotheses generated by CCNA research teams and other Canadian researchers. The study is the most comprehensive and ambitious Canadian study of dementia. Initial data posting occurred in 2018, with the full cohort to be accrued by 2020. CONCLUSION: Availability of data from the COMPASS-ND study will provide a major stimulus for dementia research in Canada in the coming years.

Évaluation complète d'une étude de cohorte canadienne portant sur la démence et la neuro-dégénérescence. Contexte : L'évaluation globale de la neuro-dégénérescence et de la démence (COMPASS-ND), étude de cohorte du Consortium canadien en neuro-dégénérescence associée au vieillissement (CCNV), représente une initiative nationale visant à promouvoir la recherche portant sur la démence et à soutenir les programmes de recherche des équipes du CCNV. Totalisant 2310 sujets recrutés partout au pays, cette cohorte longitudinale regroupe des individus fortement « phénotypés ¼ qui présentent diverses formes de démence et de pertes de mémoire légères. En plus de sujets âgés dont les fonctions cognitives sont intactes, ces 2310 sujets ont permis de valider les hypothèses formulées par les équipes du CCNV. Méthodes : Nous avons utilisé de nombreux documents pour décrire cette étude : le protocole de la COMPASS-ND ; la demande initiale de subvention ; le cinquième rapport d'étape semi-annuel du CCNV soumis aux Instituts de recherche en santé du Canada (IRSC) en décembre 2017 ; ainsi que d'autres documents produits à la suite de modifications consécutives à la mise en œuvre de ce projet. Résultats: L'étude de cohorte COMPASS-ND du CCNV inclut des participants de partout au Canada dont les divers états cognitifs sont associés à des maladies neurodégénératives ou au risque d'en souffrir. Ils feront l'objet d'un large éventail d'examens expérimentaux, cliniques, génétiques et d'imagerie afin d'aborder de manière spécifique les causes, le diagnostic, le traitement et la prévention de ces états cognitifs chez les personnes âgées. Les données obtenues à la suite d'évaluations cliniques et cognitives, ainsi que celles issues d'échantillons biologiques, d'imagerie cérébrale, de tests génétiques et de dons de cerveaux, seront utilisées pour tester les hypothèses générées par les équipes de recherche du CCNV et d'autres chercheurs canadiens. Cette étude constitue donc à ce jour l'étude canadienne la plus complète et la plus ambitieuse au sujet de la démence. La présentation des données initiales ayant eu lieu en 2018, la cohorte devrait atteindre sa taille maximale d'ici à 2020.Conclusion : La disponibilité des données de l'étude COMPASS-ND stimulera considérablement la recherche sur la démence au Canada au cours des prochaines années.

Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium.

OBJECTIVES: Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) "serious game" to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention. DESIGN: Prospective observational study. SETTING: ED of a Canadian tertiary care center. PARTICIPANTS: We included ED patients, aged 70 years and older, with a minimum 4-hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment. MEASUREMENTS: Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT). RESULTS: We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%-100.0%) and 59.7% specificity (95% CI = 52.3%-66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77-0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT. CONCLUSION: Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370-2375, 2019.

Cognitive profile of non-demented Parkinson's disease: Meta-analysis of domain and sex-specific deficits.

INTRODUCTION: Better awareness of the cognitive domains affected in non-demented Parkinson's Disease (PD) should improve understanding of cognitive disease mechanisms. A complete understanding of the cognitive areas impaired in non-demented PD is hindered because most studies use small clinical samples without comparison to healthy controls. This meta-analysis examined cumulative evidence across studies to determine if there were impairments in non-demented PD in the three cognitive domains thought to be most widely affected in PD: frontal executive, visuospatial, and verbal memory. Because there are well-documented sex differences in PD, a second objective was to explore sex differences in these findings. METHODS: MEDLINE, EMBASE and PsycINFO databases were searched (1988-March 2017). Random effects models were used to compute and compare effect sizes of differences between PD patients and controls within cognitive domains. Sex differences in effect sizes were also examined in these comparisons. Moderating factors including age, disease duration, motor symptom severity, levodopa dosage, and depression were examined through meta-regression. RESULTS: PD patients showed deficits of moderate effect sizes in all three cognitive domains relative to controls. Significant sex differences were observed only for frontal executive abilities, with male PD patients showing greater deficits than female PD patients relative to controls. No moderators of effect sizes were identified in the domain specific overall or sex-segregated meta-analyses. CONCLUSIONS: Results indicate that non-demented PD patients have deficits of moderate magnitude in frontal executive, verbal memory, and visuospatial abilities. Our findings of greater frontal executive deficits in males warrant further confirmation.

Meta-analysis of Driving Cessation and Dementia: Does Sex Matter?

Objectives: The number of drivers with dementia is expected to increase over the coming decades. Because dementia is associated with a higher risk of crashes, driving cessation becomes inevitable as the disease progresses, but many people with dementia resist stopping to drive. This meta-analysis examines whether there are sex differences in the prevalence and incidence of driving cessation among drivers with dementia and compares the pattern of sex differences in drivers with dementia to those without dementia. Method: MEDLINE, PsycINFO, Scopus, and CINAHL were searched in July 2015 for observational studies of sex differences in driving cessation. Meta-analyses were performed using a random-effects model. Results: Twenty studies provided data on sex differences in driving cessation in older adults with or without dementia. Driving cessation was significantly more prevalent in women with dementia than men (odds ratio [OR] = 2.11, 95% confidence interval [CI] = 1.50-2.98), and the same pattern was found in women without dementia (OR = 2.74, 95% CI = 1.85-4.06). Discussion: Our findings suggest that the patterns of driving cessation differ between men and women with dementia, and this may have implications for sex-specific approaches designed to support drivers with dementia both before and after driving cessation.

Computerized Cognitive Testing in Primary Care: A Qualitative Study.

Computerized cognitive assessment tools may facilitate early identification of dementia in the primary care setting. We investigated primary care physicians' (PCPs') views on advantages and disadvantages of computerized testing based on their experience with the Computer Assessment of Mild Cognitive Impairment (CAMCI). Over a 2-month period, 259 patients, 65 years and older, from the family practice of 13 PCPs completed the CAMCI. Twelve PCPs participated in an individual interview. Generally, PCPs felt that the relationship between them and their patients helped facilitate cognitive testing; however, they thought available paper tests were time consuming and not sufficiently informative. Despite concerns regarding elderly patients' computer literacy, PCPs noticed high completion rates and that their patients had generally positive experiences completing the CAMCI. PCPs appreciated the time-saving advantage of the CAMCI and the immediately generated report, but thought the report should be shortened to 1 page and that PCPs should receive training in its interpretation. Our results suggest that computerized cognitive tools such as the CAMCI can address PCPs' concerns with cognitive testing in their offices. Recommendations to improve the practicality of computerized testing in primary care were suggested.

Integrating sex and gender into neurodegeneration research: A six-component strategy.

INTRODUCTION: Despite important sex differences, there remains a paucity of studies examining sex and gender differences in neurodegeneration. The Canadian Consortium on Neurodegeneration in Aging (CCNA), a national network of researchers, provides an ideal platform to incorporate sex and gender. METHODS: CCNA's Women, Gender, Sex and Dementia program developed and implemented a six-component strategy involving executive oversight, training, research collaboration, progress report assessment, results dissemination, and ongoing manuscript review. The inclusion of sex and gender in current and planned CCNA projects was examined in two progress reporting periods in 2016. RESULTS: Sex and gender research productivity increased substantially for both preclinical (36%-45%) and human (56%-60%) cohorts. The main barrier was lack of funding. DISCUSSION: The Women, Gender, Sex and Dementia strategy resulted in a major increase of sex and gender into research on neurodegenerative disorders. This best practice model could be utilized by a wide variety of large multidisciplinary groups.

Sex differences in the prevalence of genetic mutations in FTD and ALS: A meta-analysis.

OBJECTIVE: To conduct a meta-analysis that investigates sex differences in the prevalence of mutations in the 3 most common genes that cause amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD)-chromosome 9 open reading frame 72 (C9orf72), progranulin (GRN), or microtubule-associated protein tau (MAPT)-in patients clinically diagnosed with these conditions. METHODS: MEDLINE, EMBASE, and PsycINFO databases were searched (inception to June 30, 2016). Studies of patients with FTD or ALS that reported the number of men and women with and without mutations of interest were selected. Female to male pooled risk ratios (RR) and 95% confidence intervals (CI) for each mutation were calculated using random-effects models. RESULTS: Thirty-two articles reporting 12,784 patients with ALS (including 1,244 C9orf72 mutation carriers) revealed a higher prevalence of female patients with C9orf72-related ALS (RR 1.16, 95% CI 1.04-1.29). Twenty-three articles reporting 5,320 patients with FTD (including 488 C9orf72 mutation carriers) revealed no sex differences in C9orf72-related FTD (RR 0.95, 95% CI 0.81-1.12). Thirty-six articles reporting 3,857 patients with FTD (including 369 GRN mutation carriers) revealed a higher prevalence of female patients with GRN-related FTD (RR 1.33, 95% CI 1.09-1.62). Finally, 21 articles reporting 2,377 patients with FTD (including 215 MAPT mutation carriers) revealed no sex difference in MAPT-related FTD (RR 1.21, 95% CI 0.95-1.55). CONCLUSIONS: Higher female prevalence of C9orf72 hexanucleotide repeat expansions in ALS and GRN mutations in FTD suggest that sex-related risk factors might moderate C9orf72 and GRN-mediated phenotypic expression.

Exploring the nexus of Alzheimer's disease and related dementias with cancer and cancer therapies: A convening of the Alzheimer's Association & Alzheimer's Drug Discovery Foundation.

Recent population studies suggest an intriguing inverse relationship between several types of cancer and neurodegenerative diseases, including Alzheimer's disease. Understanding the intersection of the underlying biology for these two distinct families of diseases with one another may offer novel approaches to identify new therapeutic approaches and possible opportunities to repurpose existing drug candidates. The Alzheimer's Association and the Alzheimer's Drug Discovery Foundation convened a one-day workshop to delve into this discussion. Workshop participants outlined research focus areas, potential collaborations, and partnerships for future action.

The Effects of Computerized Cognitive Testing of Older Patients on Primary Care Physicians' Approaches to Care: A Canadian Study.

BACKGROUND: We evaluated effects of providing primary care physicians (PCPs) with reports of their patients' results on the Computer Assessment of Mild Cognitive Impairment (CAMCI) by examining their documented care approaches after receipt of the report. METHODS: Patients were 65 years and above, without a diagnosis or previous workup for dementia, seen consecutively over 2 months by one of 13 PCPs. PCPs indicated whether they, patients, or families had concerns about patients' cognition. A total of 259 patients individually completed the CAMCI and results were provided to the PCP. Two raters blind to CAMCI results recorded care approaches documented by PCPs at the first visit within 3 months of report (n=181). RESULTS: In total, 28 different care approaches were grouped as related to Cognition or Safety/Self-Care. Negative binomial regression revealed that the number of care approaches was significantly associated with performance on the CAMCI for both Cognition and Safety/Self-care domains. These findings remained significant when covariates included PCPs' cognitive concern before CAMCI results, and patients' age, sex, number of comorbidities, and living arrangements. CONCLUSIONS: Our findings indicate that PCPs documented more care approaches in patients with greater cognitive impairment based on the CAMCI results and this was independent of their, the patients', or families' prior concerns about their patients' cognition.

Sex differences in the prevalence and incidence of mild cognitive impairment: A meta-analysis.

OBJECTIVE: More women have Alzheimer's disease (AD) than men. Understanding sex differences in mild cognitive impairment (MCI) may further knowledge of AD etiology and prevention. We conducted a meta-analysis to examine sex differences in the prevalence and incidence of MCI, which included amnestic and non-amnestic subtypes. METHOD: Systematic searches were performed in July 2015 using MEDLINE/PubMed, Scopus, and PsycINFO for population-or community-based studies with MCI data for men and women. Random-effects model were used. RESULTS: Fifty-six studies were included. There were no statistically significant sex differences in prevalence or incidence of amnestic MCI. There was a significantly higher prevalence (p=0.038), but not incidence, of non-amnestic MCI among women. There were no sex differences in studies that combined both subtypes of MCI. CONCLUSION: The only statistically significant finding emerging from this study was that women have a higher prevalence of non-amnestic MCI. To better understand sex differences in the preclinical stages of dementia, studies must better characterize the etiology of the cognitive impairment.

Test-Retest Reliability of a Serious Game for Delirium Screening in the Emergency Department.

Introduction: Cognitive screening in settings such as emergency departments (ED) is frequently carried out using paper-and-pencil tests that require administration by trained staff. These assessments often compete with other clinical duties and thus may not be routinely administered in these busy settings. Literature has shown that the presence of cognitive impairments such as dementia and delirium are often missed in older ED patients. Failure to recognize delirium can have devastating consequences including increased mortality (Kakuma et al., 2003). Given the demands on emergency staff, an automated cognitive test to screen for delirium onset could be a valuable tool to support delirium prevention and management. In earlier research we examined the concurrent validity of a serious game, and carried out an initial assessment of its potential as a delirium screening tool (Tong et al., 2016). In this paper, we examine the test-retest reliability of the game, as it is an important criterion in a cognitive test for detecting risk of delirium onset. Objective: To demonstrate the test-retest reliability of the screening tool over time in a clinical sample of older emergency patients. A secondary objective is to assess whether there are practice effects that might make game performance unstable over repeated presentations. Materials and Methods: Adults over the age of 70 were recruited from a hospital ED. Each patient played our serious game in an initial session soon after they arrived in the ED, and in follow up sessions conducted at 8-h intervals (for each participant there were up to five follow up sessions, depending on how long the person stayed in the ED). Results: A total of 114 adults (61 females, 53 males) between the ages of 70 and 104 years (M = 81 years, SD = 7) participated in our study after screening out delirious patients. We observed a test-retest reliability of the serious game (as assessed by correlation r-values) between 0.5 and 0.8 across adjacent sessions. Conclusion: The game-based assessment for cognitive screening has relatively strong test-retest reliability and little evidence of practice effects among elderly emergency patients, and may be a useful supplement to existing cognitive assessment methods.

Identification of Physician-Diagnosed Alzheimer's Disease and Related Dementias in Population-Based Administrative Data: A Validation Study Using Family Physicians' Electronic Medical Records.

BACKGROUND: Population-based surveillance of Alzheimer's and related dementias (AD-RD) incidence and prevalence is important for chronic disease management and health system capacity planning. Algorithms based on health administrative data have been successfully developed for many chronic conditions. The increasing use of electronic medical records (EMRs) by family physicians (FPs) provides a novel reference standard by which to evaluate these algorithms as FPs are the first point of contact and providers of ongoing medical care for persons with AD-RD. OBJECTIVE: We used FP EMR data as the reference standard to evaluate the accuracy of population-based health administrative data in identifying older adults with AD-RD over time. METHODS: This retrospective chart abstraction study used a random sample of EMRs for 3,404 adults over 65 years of age from 83 community-based FPs in Ontario, Canada. AD-RD patients identified in the EMR were used as the reference standard against which algorithms identifying cases of AD-RD in administrative databases were compared. RESULTS: The highest performing algorithm was "one hospitalization code OR (three physician claims codes at least 30 days apart in a two year period) OR a prescription filled for an AD-RD specific medication" with sensitivity 79.3% (confidence interval (CI) 72.9-85.8%), specificity 99.1% (CI 98.8-99.4%), positive predictive value 80.4% (CI 74.0-86.8%), and negative predictive value 99.0% (CI 98.7-99.4%). This resulted in an age- and sex-adjusted incidence of 18.1 per 1,000 persons and adjusted prevalence of 72.0 per 1,000 persons in 2010/11. CONCLUSION: Algorithms developed from health administrative data are sensitive and specific for identifying older adults with AD-RD.

Endocrine treatment-associated cognitive impairment in breast cancer survivors: evidence from published studies.

Endocrine-based treatments are the mainstay of therapy for postmenopausal women with breast cancer; yet concern has been raised about potential adverse cognitive effects. We performed a systematic review of the published literature to evaluate whether endocrine-based treatments for breast cancer are associated with changes in cognitive domains and whether these effects are more pronounced with advanced age. An electronic database search was performed. Original investigations that examined the effects of endocrine treatment on cognitive function were identified. Data were abstracted and studies were assessed for risk of bias. A total of 21 unique studies (n = 2398) were identified. Ten were short-term (duration ≤ 2 years) and 11 were long-term (duration > 2 years). Nine (43 %) studies had a sample size ≤100 subjects; 9 (43 %) were longitudinal, with baseline measurement before treatment initiation. No studies were primary randomized clinical trials. While there was heterogeneity in the neuropsychological measures used, tests could be grouped into the cognitive domains that they assessed. Compared to breast cancer or healthy controls, endocrine therapy was associated with impaired performance on neuropsychological testing. No study explored the association between age and changes in cognitive performance. Overall, endocrine therapies were associated with greater cognitive deficits compared to surgical and healthy controls; yet, lack of randomized trial data and heterogeneity in design of many studies limited any definitive conclusions. Despite older women being at highest risk for the development of cognitive impairment, advanced age has not been adequately explored.

A Serious Game for Clinical Assessment of Cognitive Status: Validation Study.

BACKGROUND: We propose the use of serious games to screen for abnormal cognitive status in situations where it may be too costly or impractical to use standard cognitive assessments (eg, emergency departments). If validated, serious games in health care could enable broader availability of efficient and engaging cognitive screening. OBJECTIVE: The objective of this work is to demonstrate the feasibility of a game-based cognitive assessment delivered on tablet technology to a clinical sample and to conduct preliminary validation against standard mental status tools commonly used in elderly populations. METHODS: We carried out a feasibility study in a hospital emergency department to evaluate the use of a serious game by elderly adults (N=146; age: mean 80.59, SD 6.00, range 70-94 years). We correlated game performance against a number of standard assessments, including the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Confusion Assessment Method (CAM). RESULTS: After a series of modifications, the game could be used by a wide range of elderly patients in the emergency department demonstrating its feasibility for use with these users. Of 146 patients, 141 (96.6%) consented to participate and played our serious game. Refusals to play the game were typically due to concerns of family members rather than unwillingness of the patient to play the game. Performance on the serious game correlated significantly with the MoCA (r=-.339, P <.001) and MMSE (r=-.558, P <.001), and correlated (point-biserial correlation) with the CAM (r=.565, P <.001) and with other cognitive assessments. CONCLUSIONS: This research demonstrates the feasibility of using serious games in a clinical setting. Further research is required to demonstrate the validity and reliability of game-based assessments for clinical decision making.

Self-report measures of well-being predict incident harm due to self-neglect in cognitively impaired seniors who live alone.

BACKGROUND: Primary care physicians (PCPs) increasingly must identify which of their cognitively impaired patients who live alone are at greatest risk of harm due to self-neglect. OBJECTIVES: To determine whether brief patient self-report measures could accurately do this. METHODS: Participants were ≥65 years, lived alone, and recruited from PCPs' practices, community agencies, a hospital emergency department, and acute care medical units. All had cognitive impairment (≤130 on the Dementia Rating Scale) and all had a PCP. Baseline self-report measures included: Geriatric Depression Scale (GDS), a social resources scale, a single item health rating scale, and the Quality of Life-Alzheimer's Disease Scale. We adjusted for baseline demographic, health, and mental status differences. We prospectively captured incidents of harm involving self-neglect or disorientation, resulting in physical injury, property loss, or damage, and requiring emergency services. These were obtained over a one-year longitudinal period, at 3-month intervals, from PCPs and caregivers. Emergency service records were obtained and reviewed for each incident. Proportional hazards modeling estimated how well the self-report measures predicted time to the first incident harm. RESULTS: 190 women and 34 men were followed. Based on the agreement of three medical raters, 23 participants (10%) experienced harmful outcomes. Being depressed on the GDS and rating one's health as fair or poor were the only two measures that significantly shortened time to first harmful outcome. CONCLUSION: GDS and self-rated health are simple measures to administer in the primary care setting and may be useful to PCPs in the earlier identification of those at greatest risk of harm in this vulnerable group of patients.

Feasibility and validity of the self-administered computerized assessment of mild cognitive impairment with older primary care patients.

We investigated whether a validated computerized cognitive test, the Computerized Assessment of Mild Cognitive Impairment (CAMCI), could be independently completed by older primary care patients. We also determined the optimal cut-off for the CAMCI global risk score for mild cognitive impairment against an independent neuropsychological reference standard. All eligible patients aged 65 years and older, seen consecutively over 2 months by 1 family practice of 13 primary care physicians, were invited to participate. Patients with a diagnosis or previous work-up for dementia were excluded. Primary care physicians indicated whether they, the patient, or family had concerns about each patient's cognition. A total of 130 patients with cognitive concerns and a matched sample of 133 without cognitive concerns were enrolled. The CAMCI was individually administered after instructions to work independently. Comments were recorded verbatim. A total of 259 (98.5%) completed the entire CAMCI. Two hundred and forty-one (91.6%) completed it without any questions or after simple acknowledgment of their question. Lack of computer experience was the only patient characteristic that decreased the odds of independent CAMCI completion. These results support the feasibility of using self-administered computerized cognitive tests with older primary care patients, given the increasing reliance on computers by people of all ages. The optimal cut-off score had a sensitivity of 80% and specificity of 74%.