Home-Based Electronic Cognitive Therapy in Patients With Alzheimer Disease: Feasibility Randomized Controlled Trial.

BACKGROUND: Can home-based computerized cognitive training programs be a useful tool to sustain cognition and quality of life in patients with Alzheimer disease (AD)? To date, the progressive nature of the disease has made this question difficult to answer. Computerized platforms provide more accessibility to cognitive trainings; however, the feasibility of long-term, home-based computerized programs for patients with AD dementia remains unclear. OBJECTIVE: We aimed to investigate the feasibility of a 24-week home-based intervention program using the Constant Therapy app and its preliminary efficacy on cognition in patients with AD. Constant Therapy is a program developed for patients with speech and cognitive deficits. We hypothesized that patients with AD would use Constant Therapy daily over the course of the 24-week period. METHODS: Data were collected over a 48-week period. We recruited participants aged between 50 and 90 years with a diagnosis of mild cognitive impairment due to AD or mild AD dementia. Participants were randomly assigned to either the Constant Therapy (n=10) or active control (n=9) group. The Constant Therapy group completed a tablet-based training during the first 24 weeks; the second 24 weeks of computerized training were optional. The active control group completed paper-and-pencil games during the first 24 weeks and were invited to complete an optional Constant Therapy training during the second 24 weeks. Every 6 weeks, the participants completed the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The participants independently accessed Constant Therapy using an Apple iPad. Our primary feasibility outcomes were the rate of adherence and daily use of Constant Therapy over 24 weeks. Our secondary outcomes were Constant Therapy performance over 24 weeks and change in RBANS scores between the 2 experimental groups. RESULTS: Feasibility analyses were computed for participants who completed 24 weeks of Constant Therapy. We found that long-term use of the Constant Therapy program was feasible in patients with AD over 24 weeks (adherence 80%; program use 121/168 days, for 32 minutes daily). These participants showed an overall improvement in accuracy and latency (P=.005) in the Constant Therapy scores, as well as specific improvements in visual and auditory memory, attention, and arithmetic tasks. The Constant Therapy group showed improvement in the RBANS coding subtest. No unexpected problems or adverse events were observed. CONCLUSIONS: Long-term (eg, 24 weeks) computerized cognitive training using Constant Therapy is feasible in patients with AD in the mild cognitive impairment and mild dementia stages. Patients adhered more to Constant Therapy than to the paper-and-pencil training over 24 weeks and improved their performance over time. These findings support the development of future randomized controlled trials that will investigate the efficacy of Constant Therapy to sustain cognitive function in patients with AD. TRIAL REGISTRATION: ClinicalTrials.gov NCT02521558; https://clinicaltrials.gov/ct2/show/NCT02521558.

Impact of amyloid PET in the clinical care of veterans in a tertiary memory disorders clinic.

Introduction: We aimed to characterize the clinical impact of amyloid PET (APET) in a veteran population with cognitive decline by comparing differences in management between those who did and did not have an APET. Methods: This was a retrospective observational study. Poisson regressions and logistic regression were used for comparisons. Results: Out of 565 veterans, 197 underwent APET; positivity rate was 36.55%. Having an APET was associated with longer follow-up, and increased diagnostic variability; it was not associated with number of additional studies, cholinesterase inhibitors prescription, or referrals to research. A positive APET was associated with less diagnostic variability, fewer additional tests, greater cholinesterase inhibitor prescriptions, and more research referrals. Discussion: In a medically complex, real-world population, APET yielded lower positivity rates and was not associated with classical clinical utility variables when comparing patients with and without an APET. APET may be used more to "rule out" rather than to confirm Alzheimer's disease. Highlights: Amyloid PET was associated with longer follow-up, and higher diagnostic variability.No association was seen with cholinesterase inhibitors prescription, or referrals to research.In complex patients, expected amyloid PET positivity rates are lower than previously described.Amyloid PETs were used to "rule out" AD than to confirm the diagnosis of AD.

Amyloid PET ordering practices in a memory disorders clinic.

Introduction: This study assessed the ordering of amyloid positron emission tomography (PET) scans in a Veterans Affairs (VA) memory disorders clinic as part of routine clinical care, with possible implications for the extent to which ordering may occur outside of the VA in the future if covered by insurance. Methods: Clinical features predictive of ordering amyloid PET scans were retrospectively assessed; the percentage of patients who met appropriate use criteria were evaluated. Results: Among 565 veterans, 34.9% of received an amyloid PET scan and 98.0% of these were consistent with appropriate use criteria. Patients with a PET were younger and more likely to have an initial diagnosis of Alzheimer's disease (AD). Of patients without an amyloid PET scan ordered, 64.4% would have met appropriate use criteria for amyloid PET. Discussion: The majority of scans ordered were consistent with appropriate use criteria and more patients were eligible than received a scan. The current study's findings that approximately one-third of patients in a memory disorders clinic received an amyloid PET scan has implications for memory disorders clinics inside and outside of the US Veterans Health Administration.

Head Injury Exposure in Veterans Presenting to Memory Disorders Clinic: An Observational Study of Clinical Characteristics and Relationship of Event-Related Potentials and Imaging Markers.

Objective: Traumatic brain injury (TBI) and repetitive head impacts (RHI) related to blasts or contact sports are commonly reported among military service members. However, the clinical implications of remote TBI and RHI in veterans remains a challenge when evaluating older veterans at risk of neurodegenerative conditions including Alzheimer's disease (AD) and Chronic Traumatic Encephalopathy (CTE). This study aimed to test the hypothesis that veterans in a memory disorders clinic with remote head injury would be more likely to have neurodegenerative clinical diagnoses, increased rates of amyloid PET positivity, higher prevalence of cavum septum pellucidi/vergae, and alterations in event-related potential (ERP) middle latency auditory evoked potentials (MLAEPs) and long latency ERP responses compared to those without head injuries. Methods: Older veterans aged 50-100 were recruited from a memory disorders clinic at VA Boston Healthcare system with a history of head injury (n = 72) and without head injury history (n = 52). Patients were classified as reporting prior head injury including TBI and/or RHI exposure based on self-report and chart review. Participants underwent MRI to determine presence/absence of cavum and an ERP auditory oddball protocol. Results: The head injury group was equally likely to have a positive amyloid PET compared to the non-head injury group. Additionally, the head injury group were less likely to have a diagnosis of a neurodegenerative condition than those without head injury. P200 target amplitude and MLAEP amplitudes for standard and target tones were decreased in the head injury group compared to the non-head injury group while P3b amplitude did not differ. Conclusions: Veterans with reported remote head injury evaluated in a memory disorders clinic were not more likely to have a neurodegenerative diagnosis or imaging markers of neurodegeneration than those without head injury. Decreased P200 target and MLAEP target and standard tone amplitudes in the head injury group may be relevant as potential diagnostic markers of remote head injury.