Managing employees with dementia: a systematic review.

BACKGROUND: The experience of developing dementia while in employment has been explored from the point of view of the employee, but less is known about the perspectives, experiences and needs of employers. AIMS: To review systematically literature about the management of employees who develop dementia whilst in employment. METHODS: Databases searched included MEDLINE, EMBASE, PsycINFO, CINAHL, BNI, ABI Inform, ISI Web of Science, Open Grey and dementia journals database; 44 documents were identified for inclusion in the review: 22 journal papers, one PhD thesis and 21 articles, reports and webpages from the grey literature. As all documents were qualitative in nature a thematic synthesis of their content was undertaken. RESULTS: Three main themes and ten sub-themes were identified. The main themes concerned early presentation and identification in the workplace; reasonable adjustments for people with working age dementia; and the provision of information to raise awareness and facilitate informed choice. The evidence suggested that there is a lack of awareness about working age dementia and that this may impact negatively on employees. Guidance for employers offered suggestions for good practice. CONCLUSIONS: Guidance for employers is increasingly available although it rarely refers to the evidence base. There is a need for future studies that explore the effectiveness of guidance and training initiatives for employers. Examples of good practice where employees with dementia have been well supported in the workplace and who have been able to leave the workforce with dignity, would be helpful.

Screening for dementia--is it a no brainer?

As people are living longer, dementia is becoming a significant issue for society. Dementia is now recognised as a major concern in society, and the numbers of people estimated to have dementia in the UK population appear to have stabilised at around 700,000 . Globally, 35.6 million people are estimated to meet criteria for dementia, a number predicted to double every 20 years . Given the absence of treatments that significantly alter the natural history of the clinical syndrome of dementia, there has been increased emphasis on early diagnosis, with research exploring assessment tools and biomarkers that might predict with certainty a particular clinical outcome. At the same time, there has been pressure to focus on biomedical profiles, which assume a very close link between the pathobiology and the manifest clinical syndrome.

Perception, attention, and working memory are disproportionately impaired in dementia with Lewy bodies compared with Alzheimer's disease.

OBJECTIVE: To test the hypotheses that visuoperceptual and attentional ability are disproportionately impaired in patients having dementia with Lewy Bodies (DLB) compared with Alzheimer's disease (AD). METHODS: A comprehensive battery of neuropsychological tasks designed to assess working, episodic, and semantic memory, and visuoperceptual and attentional functions was given to groups of patients with DLB (n=10) and AD (n=9), matched for age, education, and mini mental state examination (MMSE), and to normal controls (n=17). RESULTS: Both patient groups performed equally poorly on tests of episodic and semantic memory with the exception of immediate and delayed story recall, which was worse in the AD group. Digit span was by contrast spared in AD. The most striking differences were on tests of visuoperceptual/spatial ability and attention. Whereas patients with AD performed normally on several subtests of the visual object and space perception battery, the DLB group showed substantial impairments. In keeping with previous studies, the AD group showed deficits in selective attention and set shifting, but patients with DLB were more impaired on virtually every test of attention with deficits in sustained, selective, and divided attention. CONCLUSIONS: Patients with DLB have substantially greater impairment of attention, working memory, and visuoperceptual ability than patients with AD matched for overall dementia severity. Semantic memory seems to be equally affected in DLB and AD, unlike episodic memory, which is worse in AD. These findings may have relevance for our understanding of the genesis of visual hallucinations, and the differential diagnosis of AD and DLB.

Population norms for the MMSE in the very old: estimates based on longitudinal data. Mini-Mental State Examination.

OBJECTIVE: To report the percentile distribution of Mini-Mental State Examination (MMSE) scores in older people by age, sex, and education level, estimated from longitudinal data, after correcting for loss due to dropout. METHODS: The Cambridge City over 75 Cohort is a population-based study of a cohort of 2106 subjects age 75 years and older at study entry followed up over 9 years. At each of the four waves, cognitive function was assessed using MMSE. Based on these data, the relationship between age and MMSE score was modeled. Percentile distributions by age, sex, and education level were provided using inverse probability weighting to correct for dropouts. RESULTS: Performance on MMSE was related to age in men and women. In women, at age 75, MMSE score ranged from 21 (10th percentile) to 29 (90th percentile). At age 95, the range was 10 (10th percentile) to 27 (90th percentile). The upper end of MMSE distribution was slightly modified with age, whereas the lower end of the distribution was very sensitive to age effect. A similar pattern was observed in both sexes. CONCLUSION: These findings provide norms for MMSE scores in subjects age 75 years and older from longitudinal population-based data. Such norms can be used as reference values to determine where an individual's score lies in relation to his or her age, sex, and education level.

Decline across different domains of cognitive function in normal ageing: results of a longitudinal population-based study using CAMCOG.

Dementia is an important cause of disability in the elderly. There is evidence that cognitive impairment in dementia is on a continuum with cognitive impairment in the non-demented elderly. In order to investigate this possibility, we need detailed knowledge about the population distribution of cognitive function and change in cognitive function. The aim of this study is to describe the change in different domains of cognitive function over 4 years in a population-based sample of non-demented elderly people, and to investigate the effect of sociodemographic variables and baseline cognitive function on change in each of the cognitive domains. Respondents from two group general practice lists (n = 503) were interviewed using the Cambridge Cognitive Examination (CAMCOG) at the incidence wave of the Cambridge City Over-75 Cohort Study and after a mean time period of 3.9 years. One hundred and thirty five of 212 non-demented subjects seen at follow-up completed the CAMCOG at both interviews. The annual rate of change in total CAMCOG score was -1.6 points per year (p < 0.001). There was statistically significant decline in all of the CAMCOG subscales. Greater decline in the Memory subscale was associated with less education (p = 0.03). Greater decline in the Attention/Calculation subscale was associated with manual social class (p = 0.05). Greater decline in the Perception subscale was associated with older age (p = 0.03). Decline in specific cognitive domains may indicate a reversible phase of cognitive impairment and deserves further investigation.

Cognitive function in UK community-dwelling African Caribbean and white elders: a pilot study.

In recent years there has been interest in risk of cognitive impairment and dementia in populations of African origin. Little is known about this risk in older African Caribbean residents in the UK. One difficulty is lack of consensus over an adequate cognitive test battery for this community. Forty-five African Caribbean and 45 age and gender matched white community residents were recruited by household enumeration of an inner London electoral ward. These participants were administered the MMSE during a screening interview. Where possible, this was followed up by tests from the CERAD and CAMCOG neuropsychological batteries, a medical examination, and a structured interview with an informant. Based on these data, a psychiatrist blind to ethnicity independently rated 86 of these participants (41 of the African Caribbeans, all 45 of the whites) as cognitively normal, cognitively impaired, or demented. Of 41 African Caribbeans, 18 (44%) were rated as cognitively normal, 9 (22%) were rated as cognitively impaired, and 14 (34%) were rated as demented. Of the 45 whites, 39 (87%) were rated as cognitively normal, 4 (9%) were rated as cognitively impaired, and 2 (4%) were rated as demented. African Caribbeans scored significantly lower than whites in most cognitive test scores, which was not accounted for by their lower educational and occupational attainment, or their higher frequency of cardiovascular risk factors. African Caribbean elders in the UK appear to be at high risk of cognitive impairment and dementia. However, the influence of potential confounding factors such as socio-economic position and ill-health, and the effect of cultural test bias, cannot be ruled out.

Very old drivers: findings from a population cohort of people aged 84 and over.

BACKGROUND: Increases in longevity will involve a significant increase among the number of drivers in the very old, who are at greater risk of being involved in road accidents. Data are thus needed from studies of older populations to characterize those still driving, the reasons for giving up and to help formulate appropriate policies for dealing with the problems faced and created by an increase in older drivers. METHODS: A driving questionnaire was administered to surviving members of a cohort comprising a representative sample of individuals aged >/=84, the Cambridge City over 75 Cohort. Out of 546 survivors 404 completed the driving questionnaire at the 9-year follow-up. In addition, subjects were assessed, at baseline and at each follow-up, for cognitive performance using the Mini-Mental State Examination (MMSE) and for physical impairment using the Instrumental of Activities in Daily Living (IADL) scale. RESULTS: Of the sample, 37% had driven in the past, and 8.4% were still driving, the majority regularly. The drivers tended to be younger (mean age 86.6 years), men (71%) and to be married (67.7%). Although physical disability and cognitive impairment are common in this age group, current drivers had few physical limitations on their daily activities and were not impaired on MMSE. None of the current drivers had visual impairment and 22.6% had hearing loss. Of those who had given up driving, 48.5% had given up at the age of >/=80. The commonest reasons for giving up driving were health problems (28.6%), and loss of confidence (17.9%). One-third reported giving up driving on advice. CONCLUSION: A process of self-selection takes place among older drivers. People over the age of 84 who are still driving have generally high levels of physical fitness and mental functioning, although some have some sensory loss. Given the likely increase in the number of older drivers over the next decades, safety will be improved most by strategies aimed at the entire driving population with older drivers in mind, rather than relying on costly screening programmes to identify the relatively small numbers of impaired older people who continue to drive.

Estimating the true extent of cognitive decline in the old old.

OBJECTIVE: To measure cognitive change using a brief measure over a period of 9 years and to adjust for attrition in the sample. DESIGN: The Cambridge City over 75 Cohort (CC75C), a complete sample of the 75 years and older age group from five group general practices in the city of Cambridge with a systematic one-third of a further practice, all followed on four occasions. SETTING: Cambridge city, UK, the respondents' place of residence. PARTICIPANTS: A total of 2106 subjects were included at study entry. MEASUREMENTS: A brief interview, administered by a trained interviewer, containing a short cognitive scale and the Mini-Mental State Examination (MMSE) at baseline, 2.4 years, 6 years, and 9 years. RESULTS: Decline in MMSE scores occurred across the population and was greater in the oldest age groups. Attrition at later stages of the follow-up was associated with greater decline at earlier stages. Adjusting the results for loss to the sample leads to considerably higher estimates of decline, with the older age groups declining faster from lower levels. CONCLUSIONS: To date, cognitive decline in the very old has been considerably underestimated by longitudinal studies. If studies of population samples are to reflect the health and social needs of this frail group accurately, adjustments for the effect of attrition must be included before true decline can be estimated.

Apo E and Apo CI loci are associated with dementia in younger but not older late-onset cases.

Numerous groups have confirmed that apolipoprotein E allelic variation accounts for a proportion of the genetic risk for late-onset Alzheimer's disease (AD). However, there is a paucity of data on the impact of this locus on the overall risk of dementia (as opposed to AD) in the elderly. Most studies have ascertained specifically AD cases from hospital clinics or brain banks and many demented cases have vascular dementia or mixed AD and vascular pathology. We have examined the closely linked apo E and apo CI loci in demented cases and non-demented controls from two community-based aged Cambridgeshire populations: the rural Ely population (cohort 1) comprised 60 pairs of demented and non-demented elderly individuals, with a mean age of 84.2 years (SD = 6.11); the Cambridge city population (cohort 2) comprised 81 pairs all aged over 84 with a mean age of 87.7 years (SD = 2.9). The younger Ely cohort showed significant allelic associations with dementia at the apo E and apo CI loci, which were not replicated in the older Cambridge cohort. These data suggest the possibility of age-dependent penetrance for different candidate genes in late-onset dementia. We propose a number of explanations to account for the stronger associations we observed between dementia and apo CI, compared to the neighbouring apo E locus. Our data are compatible with the possibility that specific alleles or genotypes may confer different risks for overall dementia, compared to AD.

Lithium in the over-65s: who is taking it and who is monitoring it? A survey of older adults on lithium in the Cambridge Mental Health Services catchment area.

OBJECTIVES: To determine the prevalence of lithium therapy in the over-65s in the Cambridge Mental Health Services catchment area, to obtain a profile of this group and to find out how well and by whom lithium treatment is being monitored. METHODS: A census was carried out of patients over the age of 65 in the Cambridge Mental Health Services catchment area who were on lithium therapy on 1 February 1995. The records of these patients were examined retrospectively for demographic details, details of lithium therapy, information about lithium monitoring and risk factors associated with lithium treatment. RESULTS: One hundred and forty-eight patients were identified representing a point prevalence of 0.27%. GPs carried out lithium monitoring for the majority of this group and 47% had not been seen by a psychiatrist in the 12 months leading up to the census date. Thirty-two per cent of the group were on thyroxine treatment or had raised TSH levels. CONCLUSIONS: The prevalence of lithium therapy in this study was greater than the prevalences reported in studies of patients of all ages. Standards of monitoring varied widely and were not always better where psychiatrists monitored the treatment, although psychiatrists were more likely than GPs to monitor renal function. There was a high rate of thyroid dysfunction in the study group.

Changes in self-rated health, disability and contact with services in a very elderly cohort: a 6-year follow-up study.

OBJECTIVES: To study the relationships between global self-rated health, reported physical symptoms and depressive symptoms and the receipt of community services by very elderly people, and to examine changes in these variables over time. DESIGN: Three-wave study with follow-up at 2.4 and 6 years after first interview. Structured interview, incorporating cognitive examination (Mini-Mental State Examination) and enquiring specifically about overall self-rated health, physical symptoms and depressive symptoms. SETTING: Community setting in city of Cambridge, UK. PARTICIPANTS: 2609 were initially recruited: all patients aged 75 years and over from lists of six general practices (and one in three from a seventh practice). At 2.4 years, 1173 individuals re-examined and at 6 years 628 individuals. MEASUREMENTS: General health self-rated in comparison to others of similar age and individual physical and depressive symptoms self-rated as present or absent. Symptoms were added to produce physical health and depressive symptom scores. Data presented from cross-sectional analysis of 6-year sample; also examined longitudinal data from all three waves of study for ageing and cohort effects. Finally the effect of health variables on the receipt of services was examined. Statistics used included chi(2) and non-parametric statistics for continuous data, also odds ratios for likelihood of receiving services. RESULTS: At 6 years, 70% rated their overall health as good or very good. Overall self-rated health showed both ageing and cohort effects, improving with increasing age and especially with more recent cohort. Reported physical symptoms increased with ageing. Depression scores also increased with ageing but the relationship between depressive symptoms and ageing was less clear-cut. Receipt of services was associated with poor self-rated health and reported physical symptoms as well as with ageing. Higher depression scores at 2.4 years were associated with increased service receipt at 6 years, indicating a lag between the symptoms and the service response. Individuals in the more recent cohort were less likely to receive services, but those who did so received more frequent contact. CONCLUSIONS: Although very elderly people have a high prevalence of reported physical symptoms, they often rate their overall health as good. There was a stronger relationship between ageing and physical symptoms than with depressive symptoms. Symptoms of both kinds influenced the likelihood of receiving services, although there was a lag between depressive symptoms and service response. Cohort effects on service receipt may reflect changes in public service policy.

The role of carers in evaluating mental health services for older people.

OBJECTIVES: To examine, using the published literature and local service experience, the contributions that carers can make to the development and evaluation of specialist mental health services for the elderly. METHODS: MEDLINE search for relevant papers about carers and the elderly, especially with mental disorders; review of recent experience of service planning, implementation and evaluation in the Cambridge area. RESULTS: Increased emphasis on the role of carers in recent literature, extending into acknowledgement of the carer perspective in official publications; few papers on the role of carers specifically in evaluating services, with only one study looking solely at an old age psychiatry service. CONCLUSIONS: There is considerable scope for involving carers in the development and evaluation of services, though there are also some potential concerns, not least that carers and users may have different perspectives. These issues are discussed, along with possible future developments, such as the need for a standardized assessment of carer satisfaction.

Attitudes toward death: a community study of octoagenarians and nonagenarians.

Attitudes to death were explored in 125 community residents aged 81 and older. Those people who thought about dying had less frequent contact with their interview informant; those who thought about death more frequently showed less severe cognitive impairment, a greater severity of depressive symptoms, and were more likely to be unmarried and were more commonly reported to be depressed by their interview informant. Worries about dying showed no association with sociodemographic or clinical variables. The commonest category of response from spontaneous comments was concerning the circumstances of dying. The results are discussed in light of other research findings, and emphasize the influence of low mood and social factors on death attitudes. This may have implications for closer examination of such attitudes in the assessment of depression and suicidal risk as well as in the care of the dying.

Analysis of alpha-1 antichymotrypsin, presenilin-1, angiotensin-converting enzyme, and methylenetetrahydrofolate reductase loci as candidates for dementia.

The genetic factors which predispose individuals to dementia in old age have not been fully defined. Although the apolipoprotein E4 allele accounts for a proportion of the genetic risk for late-onset Alzheimer disease (AD), it is neither necessary nor sufficient to cause this disease. Recent suggestions that other loci are involved in dementia risk have been supported by findings of associations of genotypes at the alpha-1 antichymotrypsin (ACT) and presenilin-1 (PS-1) loci with AD. We investigated these loci in two community-based aged Cambridgeshire populations: the rural Ely population (cohort 1) comprised 60 pairs of demented and nondemented elderly individuals, with a mean age of 84.2 years; and the Cambridge city population (cohort 2) comprised 81 pairs all over age 84, with a mean age of 87.3 years. Since vascular risk factors are likely to impact on dementia risk, we also examined the angiotensin-converting enzyme (ACE) and methylenetetrahydrofolate reductase (MTHFR) genes as candidates. ACE, ACT, PS-1, and MTHFR genotype and allele frequencies were not significantly different in cases and matched controls. These data support the doubts which have been raised about the involvement of the PS-1 and ACT polymorphisms in late-onset dementia.

Analysis of the apo E/apo C-I, angiotensin converting enzyme and methylenetetrahydrofolate reductase genes as candidates affecting human longevity.

Genetic factors are likely to affect human survival, since twin studies have shown greater concordance for age of death in monozygotic compared to dizygotic twins. Coronary artery disease is an important contributor to premature mortality in the UK. Accordingly, we have chosen genes associated with cardiovascular risk, apo E/apo C-I, angiotensin converting enzyme (ACE) and methylenetetrahydrofolate reductase (MTHFR), as candidates which may affect longevity/survival into old age. An association study was performed by comparing allele and genotype frequencies at polymorphic loci associated with these genes in 182 women and 100 men aged 84 years and older with 100 boys and 100 girls younger than 17 years. MTHFR allele and genotype frequencies were similar in the elderly and young populations. Apo C-I allele and genotype frequencies were significantly different in the elderly women compared to the younger sample (P < 0.05). No difference was observed in the elderly men. At the neighbouring apo E gene, we only observed a difference between genotypes in the elderly women and the young sample; however, this did not retain significance when the genotype frequencies of the young sample were adjusted to values expected from the allele frequencies on the basis of Hardy-Weinberg equilibrium and compared to observed genotypes in elderly men and women. In contrast to previous studies, apo E2 was not overrepresented in the elderly men or women. Thus, the proposition that apo E2, E3 and E4 protein isoforms are themselves functionally associated with increasing risks for early death, may be too simplistic. The I/I ACE was depleted in the elderly males but not the elderly females. Furthermore, significant differences were observed between ACE genotypes in elderly men and elderly women. These data suggest that the penetrance of loci which influence survival may vary according to sex. The depletion of the ACE I/I genotype in elderly men is generally consistent with a previous study which found decreased frequencies of the I allele in French centenarians compared to younger controls. However, these results are apparently paradoxical, since others have suggested that the I allele is associated with increased cardiovascular risk. Clarification of the overall effect of a genotype on survival will be vital if therapies are to be considered which target specific genetic variants.

Suicidal thinking in community residents over eighty.

MAIN OBJECTIVE: to study the relationship between suicidal thinking and both cognitive impairment and depression. DESIGN: Random sample selected for interview, all of whom were a cohort in a pre-existing epidemiological study of dementia. SETTING: Community residents. PATIENTS AND OTHER PARTICIPANTS: Participants aged over 81. Study excluded the following: moved out of area/died/ too frail/severe communication difficulties/refused interview, refusal by GP/family/carers, 300 names selected at random from database. 170 eligible participants approached: 31 refused, 125 interviewed, 125 informants approached for interview; 118 interviewed. MAIN OUTCOME MEASURES: CAMDEX, 15-item Geriatric Depression Scale (GDS), and Scale for Suicidal Ideation (SSI) (including informant versions of latter 2 scales). RESULTS: 9 people showed suicidal thinking, all women: 6 had clinical evidence of cardiovascular/cerebrovascular disease. Those with suicidal thinking showed higher CAMDEX depression scores, weaker strength of the wish to go on living, higher rates of expressing wish to die and higher rates of depressive illness and mixed DAT/multi-infarct dementia as primary psychiatric diagnoses. No significant associations between suicidal thinking and GDS scores, Alzheimer-type dementia alone, awareness of memory difficulties or severity of dementia. CONCLUSIONS: Results show association between suicidal thinking and both depression and mixed DAT/multi-infarct dementia, but do not support an association between suicidal thinking and awareness of memory problems/severity of dementia. Given the methodological limitations, the significance of the results should be viewed with caution. Further exploration of the role of cerebrovascular disease in depressive disorder is suggested.

The tRNA(Gln) 4336 mitochondrial DNA variant is not a high penetrance mutation which predisposes to dementia before the age of 75 years.

The genetic factors that predispose to Alzheimer's disease (AD) are heterogeneous. Two recent reports have suggested that a mitochondrial DNA mutation within the tRNAGln gene, located at position 4336, may be a risk factor for AD, as it was found in 10/256 (3.9%) cases with AD confirmed by necropsy. Although low prevalences of this mutation were detected in non-demented subjects in both of these studies, the controls were not carefully matched with the AD cases. We have investigated the frequency of this mutation in two community based elderly cohorts in Cambridgeshire, who have participated in longitudinal studies of cognitive function. The 4336 mitochondrial mutation was detected in 8/ 443 people examined. These people were found to be non-demented at ages 74, 81, 84, 86, 89, 90, 91, and 102 years, in contrast to the previously described cases whose onset of dementia occurred between 60 and 76 years (mean 68). Accordingly, we believe that this mitochondrial variant is not a high penetrance mutation which predisposes to dementia before the age of 76 years.