Now is the Time to Improve Cognitive Screening and Assessment for Clinical and Research Advancement.

Wang et al. analyze Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment accuracy as screening tests for detecting dementia associated with Alzheimer's disease (AD). Such tests are at the center of controversy regarding recognition and treatment of AD. The continued widespread use of tools such as MMSE (1975) underscores the failure of advancing cognitive screening and assessment, which has hampered the development and evaluation of AD treatments. It is time to employ readily available, efficient computerized measures for population/mass screening, clinical assessment of dementia progression, and accurate determination of approaches for prevention and treatment of AD and related conditions.

The Geriatric Forensic Psychiatry Rotation at University of Chicago: Utilization and Educational Benefit of a Subspecialty Rotation in Psychiatric Residency Training.

Ten years ago, the University of Chicago Department of Psychiatry and Behavioral Neuroscience established a geriatric forensic psychiatry rotation for 4th-year psychiatry residents as one option in a required experience in forensic psychiatry. The rotation's primary emphasis was to learn about cases of testamentary capacity and undue influence. The program was supervised by a senior faculty member, an experienced clinician who was board-certified in Geriatric Psychiatry. RESULTS: Over the past decade, three of the 11 residents have pursued career paths in forensic psychiatry, while another has become a geriatric psychiatrist. More than half of the respondents have pursued geriatric and/or forensic work following their graduations, and all believe that what they learned in the rotation applied to their general practice work. All 11 indicated that the rotation increased their interest in and understanding of forensic work. Ten "strongly agreed" that the geriatric forensic psychiatry rotation was a valuable learning experience; one "agreed." On average, trainees worked on 4.64 forensic cases over the course of the rotation and attended 2-3 trials or depositions. Over the last 3 years of the program, all three of the participating residents have chosen to complete a forensic fellowship following the rotation. CONCLUSION: Residents affirm that a geriatric forensic psychiatry rotation is a valuable learning experience, one that has utility after their graduation. The University of Chicago Department of Psychiatry and Behavioral Neuroscience is committed to continuing this rotation as an important part of their forensic experience in resident education and to encourage more interest in the area of geriatric psychiatry.

Genetic Risk of Alzheimer's Disease: Three Wishes Now That the Genie is Out of the Bottle.

The availability and increasing popularity of direct-to-consumer genetic testing for the presence of an APOE4 allelle led the Alzheimer's Foundation of America Medical, Scientific and Memory Screening Advisory Board to identify three critical areas for attention: 1) ensure consumer understanding of test results; 2) address and limit potential negative consequences of acquiring this information; and 3) support linking results with positive health behaviors, including potential clinical trial participation. Improving access to appropriate sources of genetic counseling as part of the testing process is critical and requires action from clinicians and the genetic testing industry. Standardizing information and resources across the industry should start now, with the input of consumers and experts in genetic risk and health information disclosure. Direct-to-consumer testing companies and clinicians should assist consumers by facilitating consultation with genetic counselors and facilitating pursuit of accurate information about testing.

Findings from the National Memory Screening Day program.

OBJECTIVES: To report experience with a large, nation-wide public memory screening program. DESIGN: Descriptive study of community-dwelling elderly adults. SETTING: Local community sites (48 sites agreed to provide data) throughout the United States participating in National Memory Screening Day in November 2010. PARTICIPANTS: Of 4,369 reported participants, 3,064 had complete data records and are included in this report. MEASUREMENTS: Participants completed a questionnaire that included basic demographic information and a question about subjective memory concerns. Each site selected one of seven validated cognitive screening tests: Mini-Cog, General Practitioner assessment of Cognition, Memory Impairment Screen, Kokmen Short Test of Mental Status, Mini-Mental State Examination, Montreal Cognitive Assessment, Saint Louis University Mental Status Examination. RESULTS: Overall, 11.7% failed one of the seven screening tests. As expected, failure rates were higher in older and less-educated participants (P's < .05). Subjective memory concerns were associated with a 40% greater failure rate for persons of similar age and education but no memory concerns (odds ratio = 1.4, 95% confidence interval = 1.07-1.78), although only 11.9% of those who reported memory concerns (75% of all participants) had detectible memory problems. CONCLUSION: Screening for cognitive impairment in community settings yielded results consistent with expected effects of age and education. The event attracted a large proportion of individuals with memory concerns; 88.1% were told that they did not have memory problems detectible with the tests used. Further studies are needed to assess how participants respond to and use screening information, whether this information ultimately influences decision-making or outcomes, and whether memory screening programs outside healthcare settings have public health value.

Testamentary capacity and delirium.

BACKGROUND: With the aging of the population there will be a substantial transfer of wealth in the next 25 years. The presence of delirium can complicate the evaluation of an older person's testamentary capacity and susceptibility to undue influence but has not been well examined in the existing literature. METHODS: A subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to review how to assess prospectively and retrospectively testamentary capacity and susceptibility to undue influence in patients with delirium. RESULTS: The subcommittee identified questions that should be asked in cases where someone changes their will or estate plan towards the end of their life in the presence of delirium. These questions include: was there consistency in the patient's wishes over time? Were these wishes expressed during a "lucid interval" when the person was less confused? Were the patient's wishes clearly expressed in response to open-ended questions? Is there clear documentation of the patient's mental status at the time of the discussion? CONCLUSIONS: This review with some case examples provides guidance on how to consider the question of testamentary capacity or susceptibility to undue influence in someone undergoing an episode of delirium.

Contemporaneous assessment of testamentary capacity.

BACKGROUND: Challenges to wills on the basis of lack of testamentary capacity and/or undue influence are likely to increase over the next generation. Since contemporaneous assessment of testamentary capacity can be a powerful influence on the outcome of such challenges, there will be an associated increase in requests for expert assessment of testamentary capacity. There is a need to provide such potential experts with the knowledge and guidelines necessary to conduct assessments that will be helpful to the judicial system. METHODS: A subcommittee of the International Psychogeriatric Association (IPA) task force on "Testamentary Capacity and Undue Influence" was formed to establish guidelines for contemporaneous assessment of testamentary capacity. RESULTS: The task-specific criteria for testamentary capacity as outlined by Lord Chief Justice Cockburn in the well-known Banks v. Goodfellow case are described. Additional issues are identified for probing and documentation. This is designed to determine whether the testator can formulate a coherent, rational testamentary plan that connects his/her beliefs, values and relationships with the proposed disposition of assets. Rules of engagement by the expert assessor are defined as well as an approach to the clinical examination for testamentary capacity resulting in a clear and relevant report. CONCLUSION: Guidelines for experts who are asked to provide a contemporaneous opinion on testamentary capacity should help to inform disputes resulting from challenges to wills. A consistent clinical approach will help the courts to make their determinations.

E-care: a telecommunications technology intervention for family caregivers of dementia patients.

OBJECTIVE: This study evaluated the effectiveness of a technology-based psychoeducational intervention for family caregivers of dementia patients. An additional objective was to determine if the intervention could be implemented by a community-based social service agency. METHODS: Forty-six caregivers were randomly assigned to either a technology-based intervention or an information-only control condition. RESULTS: Caregivers assigned to the intervention condition reported a significant decrease in burden postintervention and those who evidenced high depression at baseline experienced a significant decline in depression. CONCLUSION: This study provides evidence that technology offers a cost-effective and practical method for delivering interventions to caregivers.

Sleep: a marker of physical and mental health in the elderly.

OBJECTIVE: The objective of this study was to determine the occurrence and recognition of common sleep-related problems and their relationship to health-related quality-of-life measures in the elderly. METHOD: A total of 1,503 participants with a mean age of 75.5 (+/- 6.8, range: 62-100) years from 11 primary care sites serving primarily elderly patients were interviewed. Subjects completed a five-item sleep questionnaire and the SF-12. A Physical Component Summary (PCS-12) and Mental Component Summary (MCS-12) score was calculated. A systematic medical chart review was conducted to determine whether sleep problems were identified by the healthcare providers. RESULTS: A total of 68.9% of patients reported at least one sleep complaint and 40% had two or more. Participants most commonly endorsed (45%) that they had "difficulty falling asleep, staying asleep, or being able to sleep." The number and type of sleep problems endorsed was associated with both physical and mental health quality-of-life status. Excessive daytime sleepiness was the best predictor of poor mental and physical health-related quality of life. Even when all five sleep questions were endorsed, a sleep complaint was only reported in the chart 19.2% of the time. CONCLUSIONS: When elicited, sleep complaints predicted the general physical and mental health-related quality-of-life status in elderly populations with comorbid medical and mental illnesses. Yet, questions regarding sleep are not an integral component of most clinical evaluations. Given the growing evidence of a relationship between sleep and health, identification of sleep disorders could lead to improved management of common age-related chronic illnesses and quality of life of elderly patients.

Risperidone treatment in elderly patients with dementia: relative risk of cerebrovascular events versus other antipsychotics.

BACKGROUND: The possibility that low-dose antipsychotic treatment is associated with increased risk of cerebrovascular events (CVEs) in elderly patients with dementia has been raised. The objective was to determine whether risperidone is associated with an increased risk of CVEs relative to other commonly considered alternative treatments. METHODS: An analysis of Medicaid data from 1999 to 2002, representing approximately 8 million enrollees from multiple states, was conducted. The primary outcome was the incidence of acute inpatient admission for a CVE within 3 months following initiation of treatment with atypical antipsychotics (risperidone, olanzapine, quetiapine, or ziprasidone), haloperidol, or benzo-diazepines. RESULTS: Descriptive analyses found similar rates of incident CVEs across evaluated agents. Multivariate analyses found no differences in comparisons of risperidone with olanzapine or quetiapine. Risperidone and other antipsychotics as a group were also not associated with a higher odds ratio (OR) of incident CVE than either haloperidol or benzodiazepines. With risperidone as the reference group: olanzapine, OR = 1.05, 95% CI 0.63-1.73; quetiapine, OR = 0.66, 95% CI 0.23-1.87; haloperidol, OR = 1.91, 95% CI 1.02-3.60; benzodiazepines, OR = 1.97, 95% CI 1.30-2.98. With benzodiazepines as the reference group, the OR of incident CVE for all antipsychotics as a class was 0.49, 95%CI 0.35-0.69. CONCLUSIONS: This study found no significant difference in the incidence of CVEs between patients taking risperidone and those taking other atypical antipsychotics. Risperidone and all atypical antipsychotics were not associated with higher risk than two common treatment alternatives (haloperidol and benzodiazepines). These findings do not support the conclusion that risperidone is associated with a higher risk of CVE than other available treatment alternatives. The data also suggest that patient characteristics other than antipsychotic use are more significant predictors of CVEs. Given the relatively low rates of incident CVEs, a larger sample of patients with groups closely balanced on a wide spectrum of potential risk factors could provide a more precise assessment of risk.

Undertreatment of patients with Alzheimer's disease in an elderly United States population.

BACKGROUND: The aim of this study was to assess the undertreatment of elderly mild to moderate Alzheimer's disease (AD) patients in the United States utilizing baseline data from a community-based trial that has established comparability to national survey samples on demographic characteristics. METHODS: Baseline data were used from an open-label, 12-week, postapproval study of compliance with galantamine, an AChEI and nicotinic receptor modulator, and vitamin E. A total of 2,114 patients from 406 community-based US practices in which physicians had previously treated patients with acetylcholinesterase inhibitors (AChEIs) were included in the study. This population reflects a large, ethnically diverse patient pool consistent with the demographics of the elderly population in the United States, atypical of those enrolled in most AD trials. RESULTS: The majority of patients (64.5%) were described by either themselves or their caregivers as not having received prior AChEI treatment. Positive associations were found between past AChEI treatment and longer time since diagnosis, white race, higher education, medical care by a neurologist, and older caregivers. The likelihood of having received previous AChEI treatment was higher among white patients (61.9%) than among those from other ethnic groups combined (25.8%). CONCLUSIONS: The similarity of patient demographic characteristics to the 2000 US Census figures for the population aged >65 years makes this data set a potentially powerful tool for planning public health initiatives. Findings suggest that patients with mild to moderate AD are undertreated and that specialist and nonspecialist organizations should discuss and implement ways to optimize management of this disease.

Effects of rivastigmine on behavioral and psychological symptoms of dementia in Alzheimer's disease.

BACKGROUND: The presence of certain behavioral and psychological symptoms (eg, paranoia, hallucinations, aggression, activity disturbances) in Alzheimer's disease (AD) may predict faster cognitive and functional decline; therefore, such symptoms represent an important treatment target. Behavioral and psychological symptoms of dementia (BPSD) may be caused at least in part by cholinergic deficits. Regulatory studies of rivastigmine in AD were not designed to evaluate effects on BPSD, but further investigation of rivastigmine in AD was prompted by later studies demonstrating behavioral benefits in other types of dementia. OBJECTIVE: The primary aim of this article was to review available data on the behavioral benefits of rivastigmine in patients with AD. METHODS: Relevant data were identified through a MEDLINE search for studies published in peer-reviewed journals through January 2004. The search terms were Alzheimer, behavior, psychosis, and rivastigmine. Data presented at international scientific congresses were also reviewed to ensure that the most recent data were considered. RESULTS: A meta-analysis of three 6-month, placebo-controlled trials of rivastigmine in mild to moderate AD indicated that rivastigmine 6 to 12 mg/d may improve or prevent disruptive BPSD (P < 0.05 vs placebo). In patients with more advanced AD, 2 open-label studies of up to 12 months' duration found that improvements in BPSD were accompanied by a decrease in the use of psychotropic medications. Rivastigmine demonstrated behavioral benefits in patients with dementia with Lewy bodies (DLB) in a double-blind, placebo-controlled study (P < 0.05). In open-label extension studies, rivastigmine provided sustained effects (up to 2 years) in patients with mild to moderate AD or DLB. CONCLUSIONS: The available dats suggest that rivastigmine may be a well-tolerated treatment option for improving or preventing psychotic and nonpsychotic symptoms associated with AD. Prospective, double-blind studies are needed to evaluate these preliminary findings.

A randomized, placebo-controlled study of the efficacy and safety of sertraline in the treatment of the behavioral manifestations of Alzheimer's disease in outpatients treated with donepezil.

OBJECTIVE: To examine the safety and efficacy of sertraline augmentation therapy in the treatment of behavioral manifestations of Alzheimer's disease (AD) in outpatients treated with donepezil. METHODS AND MATERIALS: Patients with probable or possible AD, and a Neuropsychiatric Inventory (NPI) total score >5 (with a severity score > or =2 in at least one domain), were treated with donepezil (5-10 mg) for 8 weeks, then randomly assigned to 12 weeks of double-blind augmentation therapy with either sertraline (50-200 mg) or placebo. Primary efficacy measures were the 12-item Neuropsychiatric Inventory (NPI) and the Clinical Global Impression Improvement (CGI-I) and Severity (CGI-S) scales. RESULTS: 24 patients were treated with donepezil+sertraline and 120 patients with donepezil+placebo. There were no statistically significant differences at endpoint on any of the three primary efficacy measures. However, a linear mixed model analysis found modest but statistically significantly greater improvements in the CGI-I score on donepezil+sertraline. Moreover, in a sub-group of patients with moderate-to-severe behavioral and psychological symptoms of dementia, 60% of patients on sertraline vs 40% on placebo (p = 0.006) achieved a response (defined as > or = 50% reduction in a four-item NPI-behavioral subscale). One adverse event (diarrhea) was significantly (p < 0.05) more common in the donepezil+sertraline group compared to the donepezil+placebo group. CONCLUSION: Sertraline augmentation was well-tolerated in this sample of AD outpatients. In addition, post hoc analyses demonstrated a modest but statistically significant advantage of sertraline over placebo augmentation in mixed model analyses and a clinically and statistically significant advantage in a subgroup of patients with moderate-to-severe behavioral and psychological symptoms of dementia.

Morning or evening activity improves neuropsychological performance and subjective sleep quality in older adults.

STUDY OBJECTIVES: Sleep disturbances and decline in neuropsychological performance are common in older adults. Reduced social and physical activity is likely a contributing factor for these age-related changes in sleep and cognition. We previously demonstrated that a program of structured social and physical activity, with 2 daily activity sessions, 1 in the morning and 1 in the evening for a relatively short period of 2 weeks, improved sleep and neuropsychological performance in community-dwelling older adults. The goals of this pilot study were to determine whether a single daily morning or evening activity session for 2 weeks would also improve sleep and neuropsychological function and whether these effects were dependent on the timing of the activity sessions. DESIGN: We compared the effect of morning or evening structured activity sessions in a repeated-measures crossover design. Subjective mood, neuropsychological performance tasks, and subjective and objective measures of sleep were assessed at baseline and after the intervention. SETTING: All procedures took place in the participant's residence. PARTICIPANTS: Twelve older men and women (74.6 +/- 5.5 years of age). INTERVENTIONS: Subjects participated in 14 days of structured activity sessions in the morning (9:00-10:30 am) or evening (7:00-8:30 pm). Sessions consisted of stretching, low-impact aerobics, and game playing. MEASUREMENTS AND RESULTS: Exposure to either morning or evening activity significantly improved performance on a neuropsychological test battery. Morning activity sessions increased throughput on 4 of 8 performance tasks, while evening activity sessions improved throughput on 7 of the 8 performance tasks. Subjective sleep-quality ratings, measured by the Pittsburg Sleep Quality Index, improved following activity sessions in either the morning or the evening. Objective measures of sleep did not improve when measured by actigraphy or polysomnography. CONCLUSIONS: These results suggest that short-term exposure to either morning or evening social and physical activity improves objective measures of neuropsychological performance and subjective sleep quality in the elderly. Increasing exposure to social and physical activity may be a useful intervention to improve sleep quality and daytime function in older adults.

Dementia patients in primary care. Care managers offer a solution to providing ongoing care.

The structure of our healthcare system does not take into consideration the many psychological and social needs of older patients. For a patient like Mr. G, who has mild-to-moderate dementia, a critical aspect of primary medical care is determining the patient's non-medical needs. These needs often bear directly on medical care. Cost is one reason primary care offices do not have more care managers. Yet, in the seven intervention sites participating in the Council for Jewish Elderly study, six have arranged to continue with the social worker or have made substantial efforts to come up with the funding to do so. As we continue to look at our changing demographics and the needs of our increasingly older population, public policy planners must look at care management in primary care settings as an important clinical provision of care. To find a care manager in your area, log on to www.caremanager.org, which is the web site of the National Association of Professional Geriatric Care Managers. Click on the "Find a Care Manager" link and fill out the search form.

Cognitive screening in the primary care setting. The role of physicians at the first point of entry.

There are many reasons why it is important to conduct the cognitive assessment and arrive at a preliminary diagnosis within the primary care setting. In addition to starting the patient on anti-cholinesterase medications, the physician must discuss with the family (and often the patient) issues related to financial matters and self-care. Alzheimer's patients who live alone may be targets for financial and personal exploitation, and are at risk for self-neglect. Community support or provision might be needed to assist with medication compliance, provide nutritional services by shopping for prepared foods or through Meals on Wheels, housekeeping to maintain cleanliness, adult day services to provide social and recreational activities, live-in companions, and assistance with other instrumental activities of daily living. Sometimes more structured or institutional living is necessary. Generally, the primary care practice is not set up to coordinate these additional services, as well as to provide ongoing care. We will discuss potential solutions to providing ongoing care in next month's column.