Psychosocial care in dementia in European higher education: Evidence from the SiDECar ("Skills in DEmentia Care") project.

In dementia care, psychosocial interventions can increase people's quality of life with dementia and their caregivers. Despite their effectiveness, their translation into practice lacks the desirable systematicity. Systematic educational programs on psychosocial interventions in dementia will improve this translation, as it prepares professionals to face the complexity of dementia care. This study aimed to systematically map out the extent to which higher education programs in Europe include teaching activities about psychosocial care of dementia. We collected quantitative and qualitative data about 303 higher education teaching activities on psychosocial care in dementia across Europe. The analysis revealed that the number of teaching activities focusing on psychosocial care in dementia was relative. Although the results reflected UNESCO indications, the teaching activities on psychosocial care in dementia appeared less systematized than optimal. As world health agencies recommend, international higher education systems should consider more psychosocial care topics because they can prepare professionals to respond timely and effectively to dementia patients and caregivers' needs.

Plasma levels of adipokines in patients with Alzheimer's disease - where is the "breaking point" in Alzheimer's disease pathogenesis?

Peripheral insulin resistance is associated with decreasing adiponectin and increasing leptin plasma levels, and also with cognitive decline. The effects of adipokines on brain function have been published from both animal and human studies. In particular, the influence of leptin and adiponectin on the development of Alzheimer's disease (AD) has been extensively investigated. However, the association between adipsin and AD is as yet unknown. In 37 patients with AD and 65 controls that followed the same study protocol, we tested whether adiponectin, leptin, and adipsin could be used as biomarkers in the early stages of AD. In contrast with conclusions of cognition studies in insulin resistant states, our study found a correlation of impaired neuropsychological performance with increasing adiponectin and decreasing leptin in AD patients. Nevertheless, no significant differences between patients and controls were found. AD women had significantly increased adipsin compared to controls, and there was a positive correlation of adipsin with age and disease duration. Although adipokines do not appear to be suitable biomarkers for early AD diagnosis, they certainly play a role in the pathogenesis of AD. Further studies will be needed to explain the cause of the adipokine "breaking point" that leads to the pathogenesis of overt AD.

Associations of polymorphisms in the candidate genes for Alzheimer's disease BIN1, CLU, CR1 and PICALM with gestational diabetes and impaired glucose tolerance.

Alzheimer's disease (AD) is the most common type of dementia, with a prevalence that is rising every year. AD is associated with type 2 diabetes mellitus (T2DM) and insulin resistance, and is therefore sometimes called "type 3 diabetes mellitus". The aim of this study was to examine whether the variants of some candidate genes involved in the development of AD, namely BIN1 (rs744373), CLU (rs11136000), CR1 (rs3818361), and PICALM (rs3851179), are related to several disorders of glucose metabolism-gestational diabetes (GDM), T2DM and impaired glucose tolerance (IGT). Our study included 550 women with former GDM and 717 control women, 392 patients with T2DM and 180 non-diabetic controls, and 117 patients with IGT and 630 controls with normal glucose tolerance. Genotyping analysis was performed using specially-designed TaqMan assays. No significant associations of the genetic variants rs744373 in BIN1, rs11136000 in CLU, or rs3818361 in CR1 were found with GDM, T2DM or IGT, but rs3851179 in PICALM was associated with an increased risk of GDM. The frequency of the AD risk-associated C allele was significantly higher in the GDM group compared to controls: OR 1.21; 95% CI (1.03-1.44). This finding was not apparent in T2DM and IGT; conversely, the C allele of the PICALM SNP was protective for IGT: OR 0.67; 95% CI (0.51-0.89). This study demonstrates an association between PICALM rs3851179 and GDM as well as IGT. However, elucidation of the possible role of this gene in the pathogenesis of GDM requires further independent studies.

Assessment of Diagnostics Tools for Sarcopenia Severity Using the Item Response Theory (IRT).

OBJECTIVE: To use the item response theory (IRT) methods to examine the degree to which the four selected tools reflect sarcopenia and to arrange them according to their ability to estimate sarcopenia severity. DESIGN: A cross-sectional study aimed at verifying the possibilities of using diagnostic tools for sarcopenia. SETTING AND PARTICIPANTS: The study included residents living in an assisted living unit at the Senior Centre in Blansko (South Moravia, Czech Republic) (n=77). Sarcopenia was estimated according to the proposals of the European Working Group on Sarcopenia in Older People (EWGSOP) using calf circumference, the EWGSOP algorithm, hand grip strength, and the Short Physical Performance Battery (SPPB). RESULTS: The results from the IRT model showed that these four methods indicate strong unidimensionality so that they measure the same latent variable. The methods ranked according to the discrimination level ranging from high to low discrimination where the calf circumference was the most discriminatory (Hi = 0.86) and the SPPB together with hand grip strength were the least discriminatory (both Hi = 0.44). CONCLUSION: We are recommending to identify mild sarcopenia by SPPB or hand grip strength, moderate sarcopenia by the EWGSOP algorithm and severe sarcopenia by the calf circumference.

Reduced sulfotransferase SULT2A1 activity in patients with Alzheimer's disease.

Steroids are important components in the pathophysiology of Alzheimer's disease (AD). Although their role has been studied, the corresponding metabolomic data is limited. In the present study we evaluate the role of steroid sulfotransferase SULT2A1 in the pathophysiology of AD on the basis of circulating steroids (measured by GC-MS), in which the sulfation catalyzed by SULT2A1 dominates over glucuronidation (pregnenolone/sulfate, DHEA/sulfate, androstenediol/sulfate and 5alpha-reduced pregnane and androstane catabolites). To estimate a general trend of SUL2A1 activity in AD patients we compared the ratios of steroid conjugates to their unconjugated counterparts (C/U) in controls (11 men and 22 women) and AD patients (18 men and 16 women) for individual circulating steroids after adjustment for age and BMI using ANCOVA model including the factors AD status and gender. Decreased C/U ratio for the C19 steroids demonstrate an association between attenuated sulfation of C19 steroids in adrenal zona reticularis and the pathophysiology of AD.

Relation between cigarette smoking and sarcopenia: meta-analysis.

Cigarette smoking is a risk factor for many diseases. It could be associated with sarcopenia. The aim of this meta-analysis was to determine whether smoking is an isolated risk factor for sarcopenia. We searched PubMed, Web of Science, EBSCO, and Science Direct for articles addressing the relationship between cigarette smoking and sarcopenia. A total of 12 studies containing information on 22,515 participants were included in this meta-analysis. Odds ratio (OR) was calculated for each study group and for all studies together. An OR was also calculated separately for each sex. We used a fixed-effect model in overall estimation and in males, because results of small studies were significantly different from the results of large studies in those cases and in females where the estimation showed only moderate heterogeneity we used a random-effect model. According to proposes of the Cochrane Handbook for Systematic Reviews. The resulting OR in the fixed-effect model was 1.12 (95 % CI 1.03-1.21), OR for each sex was in the fixed-effect model 1.20 (95 % CI 1.06-1.35) in males and in the random-effect model 1.21 (95 % CI 0.92-1.59) in females. The results of this meta-analysis indicate that cigarette smoking as an isolated factor may contribute to the development of sarcopenia. However, the results of the individual studies were largely inconsistent due to different approaches of measuring the main variables which affected the results.

Transforming growth factor beta and soluble endoglin in the healthy senior and in Alzheimer's disease patients.

OBJECTIVES: Senescence of the immune system and of endothelial cells can contribute to age-dependent vascular and neurodegenerative disorders including Alzheimer's disease. The aim of this study is an assessment of putative relationships of serum levels of transforming growth factor beta (TGFß) and soluble endoglin (sCD105) and neurodegeneration, and of changes of these molecules in the course of ageing. DESIGN: The subjects of the study consisted of three groups, the first one was 63 otherwise healthy middle - aged participants, 31 females, 32 males, of average age 35 years. The second group was formed by 58 healthy, self-dependent inhabitants of nursing homes, 44 females and 14 males, average age 83.5 years. The third group comprised of 129 Alzheimer's disease patients, 86 females, 43 males, of average age 80 years, with MMSE score that ranged from 16 to 20. MEASUREMENT: Serum levels of TGF beta and soluble endoglin were measured by the ELISA method in samples of peripheral blood using commercial kits. RESULTS: The serum level of TGFß was 34,339 ± 6,420 pg/ml in the healthy younger group, 37,555 ± 11,944 pg/ml in the healthy seniors, and 29,057 ± 11,455 pg/ml in Alzheimer's disease patients. Compared to healthy seniors, the serum level of TGFß was significantly decreased in Alzheimer's disease patients (p < 0.01). The serum level of endoglin were 4.88 ± 0.95 µg/ml in the healthy younger group; 6.11 ± 1.38 µg/ml in healthy seniors, and 7.20 ± 1.72 µg/ml in patients with Alzheimer's disease, respectively. The serum level of endoglin was significantly higher (p < 0.001) in senescent healthy persons compared to the younger control group. When compared with healthy seniors, patients with Alzheimer's disease had significantly elevated (p < 0.001) serum level of endoglin. CONCLUSIONS: Decreased levels of TGF ß in Alzheimer's disease may result in impairment of cerebral circulation reflected in the increased endoglin levels. These findings may indicate involvement of the immune system in Alzheimer's disease pathogenesis.

The primary care physician and Alzheimer's disease: an international position paper.

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Recommendations on end-of-life care for people with dementia.

OBJECTIVE: To establish, in collaboration with national Alzheimer Societies in Europe, practical and consensual recommendations for the end-of-life care of people with dementia. The aim of these recommendations is to provide a basis for understanding and action with regard to end-of-life care not only for family caregivers but also for professionals, policy makers and anyone with an interest in palliative care. DESIGN: A literature review was carried out by Alzheimer Europe in collaboration with a working group comprised of people from different backgrounds such as family caregivers, physicians, palliative care nurses and members of Alzheimer associations, who also prepared the draft recommendations during 4 sessions. These recommendations were then discussed with external experts and sent to Alzheimer Europe's member associations to be broadly discussed within their countries until a consensus was reached. SETTING: Alzheimer Europe is an umbrella association of European Alzheimer societies with 34 member associations in 30 different countries. SUBJECTS: Not applicable. METHODS: Literature review, workshops, dissemination by e-mail and during conferences, consensus finding. RESULTS: At the end of 2008, Alzheimer Europe prepared written recommendations on good end-of-life care for people with dementia. We are aware that this topic is challenging and that there is therefore a need for further discussion. CONCLUSION: In this article we aim to present these recommendations and to invite professionals to consider these important issues and to contribute towards a broader discussion.

Dignity and palliative care in dementia.

Care for patients with dementia poses multiple challenges to the caretaker, including issues concerning maintaining patient dignity. In this paper, we discuss dignity in the context of patient autonomy, self-respect and appreciation, and explore issues that relate to dignity of patients in dementia care. As patients become incapacitated by the disease, it becomes the caretaker's responsibility to assure that the patient continues to live with dignity. The uniform manifestation of dementia symptoms across individuals allows for implementation of patient-friendly activities to address their special needs and allow them to express the remaining autonomy. In advanced dementia, a beneficial long-term care outcome becomes secondary and should give way to strategies to maintain patient comfort and dignity. Although it may be challenging to stress dignity in a patient with advanced dementia, where multiple serious health problems are likely to co-exist, it remains important to realize that dignity can be, should be and must be supported, maintained and, in some situations, regained.

Business ethics as a novel issue in health care economics.

The problems of health care providing and solutions suggested to solve them should be discussed publicly at all appropriate levels in all developed countries. In this contribution, new approaches to understanding the problems of business ethics in health care are mentioned and recommended for discussion. An application of such principles of business ethics as trust, accountability, solidarity, transparency and social responsibility is considered in the four following areas. First, it is the allocation of limited resources in health care. This is the world-wide problem of the end of 20th century, as the development of medical technologies offers a wide range of new diagnostic and therapeutic procedures. In our country this coincides with the on-going, and still incompleted reform of health care. Second, the other area is that of connecting health-care and social problems, important namely for vulnerable groups such as children, the elderly and chronically ill. The third area is concerned with the privatization of health care, the newly emanating structure and function of the health care system and the role of health care provides in society. The last group contains issues concerning attempts to facilitate communication between health care specialists and general public, as well as attempts to support those institutions of the civic democratic society that are oriented toward health, sickness and health care providing.

Multiprofessional education in social medicine and clinical ethics.

This contribution describes a project of multiprofessional education in social medicine and clinical ethics based on educational experience of 3rd Department of Internal Medicine, First Medical Faculty, Charles University in conjunction with the Centre of Gerontology Prague. This undergraduate program will be offered to medics, stomatologists and health science students including the English course and will invite to participate students from non-medical faculties such as social science, pedagogy, theology, interested in ethics of health care providing. Basic principles of the new project are: education in clinical setting, early student-patient contact, multiprofessional education in common seminars of problem based learning small groups and developing various forms of communication.