Factors affecting usage patterns of memantine in Alzheimer disease.

Memantine is approved by the US Food and Drug Administration for the treatment of moderate to severe Alzheimer disease (AD). We investigated the frequency and variables associated with its use in mild to moderate/severe AD as defined by criteria involving the Mini-Mental Status Examination (MMSE) and Clinical Dementia Rating (CDR) scale. Consecutive possible and probable AD patients seen at our research center from November 2003 to December 2006 were included. Individuals were classified as mild dementia either by CDR=1 or MMSE >or=15, using criteria derived in part from the pivotal trials of memantine used for its approval by the Food and Drug Administration. Of 117 patients, 37% of those with mild AD by MMSE criterion (total N=94), and 38% of those with mild AD by CDR criterion (total N=86) used memantine. Logistic regression was used to simultaneously estimate the odds ratios (ORs) of the likelihood of memantine usage associated with a set of predictor variables. Lower MMSE was associated with a greater likelihood of using memantine independent of CDR [ORMMSE=7.45, 95% confidence interval (CI)=1.50-37.05]; CDR was not significantly related to memantine use. Controlling both MMSE and CDR, Whites were more likely to use memantine than African Americans (OR=6.47, 95% CI=1.25-33.39). Patients who used other antidementia medications were more likely to use memantine than those who did not (OR=3.15, 95% CI=0.995-9.97). Eight other patient characteristics were not significant predictors. Use of memantine in mild AD was common. Patterns of memantine usage are complex and deserve further study in a larger sample because of their implications for medical system cost, equitable access to care, and risk of drug interactions.

Health state valuation in mild to moderate cognitive impairment: feasibility of computer-based, direct patient utility assessment.

BACKGROUND: Most patients with dementia will, at some point, need a proxy health care decision maker. It is unknown whether persons with various degrees of cognitive impairment can reliably report their health-related preferences. METHODS: The authors performed health state valuations (HSVs) of current and hypothetical future health states on 47 pairs of patients with mild to moderate cognitive impairment and their caregivers using computer-based standard gamble, time tradeoff, and rating scale techniques. RESULTS: Patients' mean (SD) age was 74.6 (9.3) years. About half of the patients were women (48%), as were most caregivers (73%), who were on average younger (mean age= 66.2 years, SD= 12.2). Most participants were white (83%); 17% were African American. The mean (SD) Mini-Mental State Examination (MMSE) score of patients was 24.2 (4.6) of 30. All caregivers and 77% of patients (36/47) completed all 18 components of the HSV exercise. Patients who completed the HSV exercise were slightly younger (mean age [SD]= 74.1 [8.5] v. 75.9 [11.8]; P = 0.569) and had significantly higher MMSE scores (mean score [SD] = 25.0 [4.3] v. 21.4 [4.4]; P = 0.018). Although MMSE scores below 20 did not preclude the completion of all 18 HSV ratings, being classified as having moderate cognitive impairment was associated with a lower likelihood of completing all scenario ratings (44% v. 82%). Patient and caregiver responses showed good consistency across time and across techniques and were logically consistent. CONCLUSION: Obtaining HSVs for current and hypothetical health states was feasible for most patients with mild cognitive impairment and many with moderate cognitive impairment. HSV assessments were consistent and reasonable.

Recognizing apathy in Alzheimer's disease.

Apathy has been increasingly recognized as a neuropsychiatric symptom in many neurologic disorders. In this paper, we review the clinical features of apathy in Alzheimer's disease. We also review screening, the differential diagnosis including depression, medical illnesses, and mild cognitive impairment, and treating modalities and issues. It must also be recognized that apathy per se almost never occurs as an isolated syndrome, so it must be viewed in the context of an individual's entire behavioral and cognitive status.

ADCS Prevention Instrument Project: quality of life assessment (QOL).

Information about quality of life (QOL) is valuable in evaluating pharmaceutical agents but it is not adequately assessed in many dementia drug trials. In prevention trials, following participants to conversion to AD requires QOL scales appropriate for both normal and cognitively impaired individuals. Our objective was to evaluate the utility of several scales for subject or informant QOL assessment: Quality of Life-AD; Quality of Life Activity Inventory; SF-36; SF-12 (a shortened version of the SF-36); and Satisfaction with Life Scale. Measurements were collected from 644 subject-study partner pairs, half of whom completed the instruments at the clinic and half at home. Three-month test-retest data were collected. Scales administered at home or in clinic did not differ significantly. Subject self-ratings showed a wide range for all scales. Test-retest intraclass coefficients ranged from 0.67 to 0.77. Moderately high interscale associations suggest that the scales are measuring common aspects of QOL but are not equivalent. Furthermore, they differed with respect to associations with demographic variables and QOL determinants. We conclude that the QOL scores at baseline show sufficient range and reliability to suggest they will have utility in tracking QOL through conversion to dementia.

ADCS Prevention Instrument Project: pilot testing of a book club as a psychosocial intervention and recruitment and retention strategy.

Both psychosocial and biologic interventions may delay or prevent Alzheimer disease. Staying mentally active may help older people maintain their cognitive abilities. In the Alzheimer Disease Cooperative Study Prevention Instrument Project a book club was introduced as a recruitment and retention device. A 3-arm study was designed and included: a nonrandomized, self-selected group (n=211) who chose not to participate in the book club, and 2 groups randomly assigned to receive 2 books per year in individual self-improvement (n=210) or community involvement (n=207) categories. Participants reported their reactions to the selections and other reading behaviors. Results from the first 2 years revealed that most book club participants agreed with Likert-type statements indicating the readings were enjoyable (P<0.001), had an impact on their thinking (P=0.01), and were shared by them with others (P=0.002). Respondents in the community involvement group agreed more strongly with these statements than those in the self-improvement category. Comments from participants in response to open-ended questions in the reader survey revealed such themes as developing plans for successful aging and reflecting on attitudes and behaviors in their own lives. Further longitudinal analyses are planned to determine whether the book club influenced retention and whether participation was associated with slowing cognitive decline.