Adherence to Clinical Practice Guidelines during Dementia Work-Up in a Real-World Setting: A Study from the Registry of Dementias of Girona.

BACKGROUND: There are several position statements and clinical practice guidelines (CPG) for diagnosing dementia. OBJECTIVE: Our aims were to evaluate the adherence to CPG among specialists in the 7 memory clinics included in the Registry of Dementias of Girona (ReDeGi), and to compare the results between 2007-2011 and 2012-2015. We also determined the time and number of visits required to achieve a diagnosis, the supplementary tests ordered, and the drugs prescribed according to dementia subtypes. METHODS: Medical charts of a stratified random sample of 475 ReDeGi cases were reviewed. Basic dementia work-up was evaluated using as a reference evidence-based CPG. An Index of Adherence (AI) was calculated using the following items in the medical chart: cognitive symptomatology; functional disability evaluation; physical examination; neurological examination; psychiatric examination; brief cognitive examination; activities of daily living performance examination; blood test; structural neuroimaging (CT-scan or MRI). RESULTS: The mean AI to CPG among specialists was of 8.2 points, and it improved from 7.9 points in 2007-2011 to 8.5 points in 2012-2015 (Cohen's d = 0.46). A lower adherence was detected in the most severe cases. A dementia diagnosis required 3.5 visits, regardless of the subtype of dementia, although milder cases required more time, more visits, and more supplementary tests than severe cases. CONCLUSION: The adherence to CPG in the catchment area of the ReDeGi is high, and an epidemiological surveillance system such as the ReDeGi may help in improving it. Dementia guidelines should establish procedures adapted to clinical practice, with simplified recommendations for most severe cases.

[Cognitive decline in Alzheimer's disease. A follow three or more years of a sample of patients]. / Declive cognitivo en la enfermedad de Alzheimer. Seguimiento de mas de tres años de una muestra de pacientes.

INTRODUCTION: The rates of cognitive decline in patients with Alzheimer's disease show variations due to various factors. AIM. To determine the influence of age, education, gender, activities of daily living (ADL) and acetylcholinesterase inhibitors (IAChE) and memantine in the rhythm and rate of cognitive decline. PATIENTS AND METHODS: Retrospective study of a sample of 383 patients with Alzheimer's disease, with neuropsychological assessments over three years. Cognitive measure was used as the Cambridge Cognitive Examination (CAMCOG). Patients were grouped according to their rate of annual decline (RAD) and performed a bivariate and multivariate regression analysis using as dependent variable the difference in scores on the CAMCOG (baseline-final). RESULTS: The younger age (beta = -0.23; p < 0.001), more educated (beta = 0.26; p < 0.001) and the greater deterioration of ADL (beta = 0.24; p < 0.001) were associated with a greater decline in all patients. The drugs had a beneficial effect (beta = -0.18; p = 0.011) in the group with lower and slower decline (RAD < 5%). CONCLUSIONS: The lower age, higher education and the deterioration of ADL are associated with a greater cognitive decline. The IAChE and memantine had a beneficial effect, slowing the decline in the group of patients with lower RAD.

TITLE: Declive cognitivo en la enfermedad de Alzheimer. Seguimiento de mas de tres años de una muestra de pacientes.Introduccion. Las tasas de declive cognitivo en los pacientes con enfermedad de Alzheimer presentan variaciones debido a diversos factores. Objetivo. Determinar la influencia de la edad, escolaridad, genero, actividades de la vida diaria (AVD) e inhibidores de la acetilcolinesterasa (IAChE) y memantina en el ritmo y tasas de declive cognitivo. Pacientes y metodos. Estudio retrospectivo de una muestra de 383 pacientes con enfermedad de Alzheimer, con evaluaciones neuropsicologicas durante un periodo superior a tres años. Se utilizo como medida cognitiva el Cambridge Cognitive Examination (CAMCOG). Se agruparon los pacientes segun su tasa de declive anual (TDA) y se realizaron analisis bivariante y de regresion lineal multivariante utilizando como variable dependiente la diferencia de puntuaciones en el CAMCOG (basal-final). Resultados. La menor edad (beta = ­0,23; p < 0,001), la mayor escolaridad (beta = 0,26; p < 0,001) y el mayor deterioro de las AVD (beta = 0,24; p < 0,001) estuvieron asociados a un mayor declive en todos los pacientes. Los farmacos tuvieron un efecto benefico (beta = ­0,18; p = 0,011) en el grupo con menor y mas lento declive (TDA < 5%). Conclusiones. La menor edad, la mayor escolaridad y el deterioro de las AVD se relacionan con un mayor declive cognitivo. Los IAChE y la memantina tuvieron un efecto benefico, enlenteciendo el declive en el grupo de pacientes con menor TDA.

Declive cognitivo en la enfermedad de Alzheimer. Seguimiento de más de tres años de una muestra de pacientes / Cognitive decline in Alzheimer’s disease. A follow three or more years of a sample of patients

Introducción. Las tasas de declive cognitivo en los pacientes con enfermedad de Alzheimer presentan variaciones debido a diversos factores. Objetivo. Determinar la influencia de la edad, escolaridad, género, actividades de la vida diaria (AVD) e inhibidores de la acetilcolinesterasa (IAChE) y memantina en el ritmo y tasas de declive cognitivo. Pacientes y métodos. Estudio retrospectivo de una muestra de 383 pacientes con enfermedad de Alzheimer, con evaluaciones neuropsicológicas durante un período superior a tres años. Se utilizó como medida cognitiva el Cambridge Cognitive Examination (CAMCOG). Se agruparon los pacientes según su tasa de declive anual (TDA) y se realizaron análisis bivariante y de regresión lineal multivariante utilizando como variable dependiente la diferencia de puntuaciones en el CAMCOG (basal-final). Resultados. La menor edad (β = –0,23; p < 0,001), la mayor escolaridad (β = 0,26; p < 0,001) y el mayor deterioro de las AVD (β = 0,24; p < 0,001) estuvieron asociados a un mayor declive en todos los pacientes. Los fármacos tuvieron un efecto benéfico (β = –0,18; p = 0,011) en el grupo con menor y más lento declive (TDA < 5%). Conclusiones. La menor edad, la mayor escolaridad y el deterioro de las AVD se relacionan con un mayor declive cognitivo. Los IAChE y la memantina tuvieron un efecto benéfico, enlenteciendo el declive en el grupo de pacientes con menor TDA (AU)

Introduction. The rates of cognitive decline in patients with Alzheimer’s disease show variations due to various factors. Aim. To determine the influence of age, education, gender, activities of daily living (ADL) and acetylcholinesterase inhibitors (IAChE) and memantine in the rhythm and rate of cognitive decline. Patients and methods. Retrospective study of a sample of 383 patients with Alzheimer’s disease, with neuropsychological assessments over three years. Cognitive measure was used as the Cambridge Cognitive Examination (CAMCOG). Patients were grouped according to their rate of annual decline (RAD) and performed a bivariate and multivariate regression analysis using as dependent variable the difference in scores on the CAMCOG (baseline-final). Results. The younger age (β = –0.23; p < 0.001), more educated (β = 0.26; p < 0.001) and the greater deterioration of ADL (β = 0.24; p < 0.001) were associated with a greater decline in all patients. The drugs had a beneficial effect (β = –0.18; p = 0.011) in the group with lower and slower decline (RAD < 5%). Conclusions. The lower age, higher education and the deterioration of ADL are associated with a greater cognitive decline. The IAChE and memantine had a beneficial effect, slowing the decline in the group of patients with lower RAD (AU)

Estrategias no farmacológicas en las demencias / No disponible

Las estrategias no farmacológicas (ENFs) o intervenciones psicosociales se caracterizan por abordar la demencia desde una perspectiva psicosocial tratando tanto los problemas del paciente como de sus familiares. La base teórica de estas estrategias se fundamenta en los conceptos de neuroplasticidad, reserva cerebraly reserva cognitiva. Estas ENFs, también conocidas como «terapias blandas» pueden clasificarse en cinco: terapias de enfoque emocional, terapias de aproximación conductual, terapias de enfoque cognitivo, terapias de estimulación y terapias dirigidas a los cuidadores (AU)

Non-pharmacological Strategies (NPSs)or Psychosocial Interventions are characterized by addressing dementia from a psychosocial perspective, treating the problems of both, the patients and the family. The theoretical basis of these strategies is based on the concepts of neuroplasticity, brain reserve and cognitive reserve. These NPSs, also known as «soft therapies», can be classified into five groups: emotional therapy approach, approximation conduct therapy, cognitive therapy approach, stimulation therapy and therapies aimed at poviding support to caregivers (AU)

Predictors of cognitive decline in Alzheimer's disease and mild cognitive impairment using the CAMCOG: a five-year follow-up.

BACKGROUND: There are discrepant findings regarding which subscales of the Cambridge Cognitive Examination (CAMCOG) are able to predict cognitive decline. The study aimed to identify the baseline CAMCOG subscales that can discriminate between patients and predict cognitive decline in Alzheimer's disease (AD) and mild cognitive impairment (MCI). METHODS: This was a five-year case-control study of patients with cognitive impairment and a control group. Participants were grouped into AD (n = 121), MCI converted to dementia (MCI-Ad, n = 43), MCI-stable (MCI-St, n = 66), and controls (CTR, n = 112). Differences in the mean scores obtained by the four groups were examined. Receiver operating characteristic curves were used to compare subscale scores in the AD and MCI-Ad groups with those of controls. The influence of age, gender, schooling, and depression on baseline subscale scores was assessed. RESULTS: Of the CAMCOG subscales, Orientation and Memory (learning and recent) (OR + MEM) showed the highest discriminant capacity in the baseline analysis of the four groups. This baseline analysis indicated that OR + MEM was the best predictor of conversion to AD in the MCI-Ad group (area under the curve, AUC = 0.81), whereas the predictive capacity of the global MMSE and CAMCOG scores was poor (AUC = 0.59 and 0.53, respectively). CONCLUSIONS: In the baseline analysis, the Orientation and Memory (learning and recent) subscales showed the highest discriminant and predictive capacity as regards both cognitive decline in the AD group and conversion to AD among MCI-Ad patients. This was not affected by age, gender, schooling, or depression.

Valor económico anual de la asistencia informal en la enfermedad de Alzheimer / Annual economic cost of informal care in Alzheimer’s disease

Introducción. El coste indirecto asociado a la atención de los pacientes con enfermedad de Alzheimer (EA) lo asume principalmente la familia. Objetivo. Describir el coste asociado al tiempo de dedicación, su evolución anual, las características y la carga del cuidador asociada. Sujetos y métodos. Pacientes diagnosticados de EA no institucionalizados, seguidos ambulatoriamente en una unidad de diagnóstico y sus cuidadores principales. Estudio prospectivo y observacional de 12 meses de evolución. Se evaluaron las características clínicas del paciente a través del Cambrigde Cognitive Examination Revised, para la capacidad cognitiva; el Disability Assessment in Dementia, para la capacidad funcional, y el inventario neuropsiquiátrico, para los trastornos no cognitivos. Se recogieron los datos sociodemográficos a través del Cambridge Examination for Mental Disorders of the Elderly Revised. Se registró la dedicación del cuidador, sus características sociodemográficas y la carga (a través de la escala de Zarit). Resultados. La muestra estuvo formada por 169 pacientes y 169 cuidadores. El coste en el momento basal fue de 6.364,8 €/año, asociado principalmente al apoyo en actividades instrumentales. A los 12 meses se observó un incremento global del 29% (1.846,8 €/año). El incremento del coste se asoció a la discapacidad física (F = 25,2; gl = 1; p < 0,001), el deterioro cognitivo (F = 8,5; gl = 1; p = 0,004), la edad del paciente (F = 9,2; gl = 1; p = 0,003) y si el cuidador era o no el único (F = 20,4; gl = 1; p < 0,001). El coste de la asistencia explicó el 6,7% de la varianza total de la carga percibida por los cuidadores. Conclusiones. El coste indirecto medio de la atención fue de 6.364,8 €/año, con un incremento del 29% anual que se asoció a la discapacidad física y cognitiva, a la edad del paciente y a tener un solo cuidador (AU)

Introduction. The indirect cost associated with the care of patients with Alzheimer’s disease is taken on primarily by the family. Aim. To describe the cost associated with time dedication, its annual evolution, associated characteristics and related caregiver burden. Subjects and methods. Non-institutionalized patients diagnosed with Alzheimer’s disease who are managed on an outpatient basis in a diagnosis unit and their primary caregivers. Prospective and observational study conducted over 12 months. The patient’s clinical features were assessed using the Cambrigde Cognitive Examination Revised for cognitive capacity, the Disability Assessment in Dementia for functional capacity and the Neuropsychiatric Inventory for non-cognitive disorders. Sociodemographic data were collected by means of the Cambridge Examination for Mental Disorders of the Elderly Revised. The caregiver’s dedication, sociodemographic characteristics and burden (by means of the Zarit interview) were recorded. Results. Sample comprised of 169 patients and 169 caregivers. The cost at baseline was 6364.8 €/year, and was mainly associated with support in instrumental activities. At 12 months, an overall increase of 29% was observed (1846.8 €/year). Cost increase was associated with physical (F = 25.2; df = 1; p < 0.001) and cognitive (F = 8.5; df = 1; p = 0.004) disability, patient age (F = 9.2; df = 1; p = 0.003) and with whether the caregiver was the only caregiver or not (F = 20.4; df = 1; p < 0.001). The cost of care explained 6.7% of the total variance of the burden perceived by caregivers. Conclusions. Care has a mean indirect cost of 6364.2 €/year, with an annual increase of 29% that was associated with physical and cognitive disability, patient age and having one single caregiver (AU)

[Annual economic cost of informal care in Alzheimer's disease]. / Valor económico anual de la asistencia informal en la enfermedad de Alzheimer.

INTRODUCTION: The indirect cost associated with the care of patients with Alzheimer's disease is taken on primarily by the family. AIM: To describe the cost associated with time dedication, its annual evolution, associated characteristics and related caregiver burden. SUBJECTS AND METHODS: Non-institutionalized patients diagnosed with Alzheimer's disease who are managed on an out-patient basis in a diagnosis unit and their primary caregivers. Prospective and observational study conducted over 12 months. The patient's clinical features were assessed using the Cambrigde Cognitive Examination Revised for cognitive capacity, the Disability Assessment in Dementia for functional capacity and the Neuropsychiatric Inventory for non-cognitive disorders. Sociodemographic data were collected by means of the Cambridge Examination for Mental Disorders of the Elderly Revised. The caregiver's dedication, sociodemographic characteristics and burden (by means of the Zarit interview) were recorded. RESULTS: Sample comprised of 169 patients and 169 caregivers. The cost at baseline was 6364.8 euro/year, and was mainly associated with support in instrumental activities. At 12 months, an overall increase of 29% was observed (1846.8 euro/year). Cost increase was associated with physical (F = 25.2; df = 1; p < 0.001) and cognitive (F = 8.5; df = 1; p = 0.004) disability, patient age (F = 9.2; df = 1; p = 0.003) and with whether the caregiver was the only caregiver or not (F = 20.4; df = 1; p < 0.001). The cost of care explained 6.7% of the total variance of the burden perceived by caregivers. CONCLUSIONS: Care has a mean indirect cost of 6364.2 euro/year, with an annual increase of 29% that was associated with physical and cognitive disability, patient age and having one single caregiver.

Syndromic association of behavioral and psychological symptoms of dementia in Alzheimer disease and patient classification.

OBJECTIVES: To identify patient groups with Alzheimer disease (AD) according to the presence of psychological and behavioral syndromes and to determine the clinical differences among these groups. METHODS: Cross-sectional and observational study of 491 patients with probable AD whom were administered the Neuropsychiatric Inventory (NPI) at the baseline visit and reevaluated after 12 months. RESULTS: Principal component analysis (PCA) of baseline NPI data revealed three factors, including a psychosis factor (delusions, hallucinations, and aberrant motor behavior), a depressive factor (depression, anxiety, irritability, agitation, and apathy) and a hypomanic factor (euphoria and disinhibition). Cluster analysis of factor scores indicated the presence of three patient groups: one group was characterized by low scores in factors, a second group including patients with high scores in the depressive factor, and a third group that included patients with high scores in the three factors. The PCA of the NPI scores carried out after 1 year showed the persistence of the three factors. The cluster analysis of their factor scores also showed the presence of the same three patient groups but with a few differences in certain symptoms. A higher frequency of personal psychiatric history but no family history was observed in the cluster with depressive symptoms. CONCLUSIONS: Three neuropsychiatric syndromes have been identified, which have made it possible to classify patients with AD in three distinct large groups. A temporal stability is evidenced among the group with low symptoms. Patients with high scores in depressive factor or in three factors showed greater temporal instability. Certain differences among the groups suggest that different physiopathogenic mechanisms may be involved in neuropsychiatric syndromes.

Perfil cognitivo en la fibromialgia. Comparación con un grupo con deterioro cognitivo leve / Cognitive profile in fibromyalgia. Comparison with a mild cognitive impairment group

Objetivo: Los objetivos de este trabajo fueron realizar una evaluación neuropsicológica de pacientes con fibromialgia (FM) con quejas subjetivas de pérdida de memoria y compararlos con un grupo de deterioro cognitivo leve (DCL) sin FM. Material y método: Estudio retrospectivo. Se evaluó a 32 pacientes con FM y 86 pacientes con DCL sin FM. Se administró una batería neuropsicológica. Se comparó el grupo con FM con un grupo control con DCL (n=86) sin FM. Resultados: Se evidenció un deterioro cognitivo leve en 29 de las 32 mujeres con FM y el patrón neuropsicológico mostró una afectación en atención, memoria y función ejecutiva. Cuando comparamos el perfil neuropsicológico con el grupo con DCL sin FM, observamos que la muestra con FM presenta una mayor afectación en memoria, en función ejecutiva, y una menor afectación en función premotora. Conclusión: La exploración neuropsicológica evidenció una alteración cognitiva leve en la mayoría de las mujeres con FM con quejas subjetivas de pérdida de memoria (90,5%). El patrón neuropsicológico obtenido es de predominio subcortical, con afectación de la memoria y de la función ejecutiva. La muestra con FM presenta unos resultados cognitivos similares al grupo con DCL (AU)

Objective: The neuropsychological assessment of patients with fibromyalgia (FM) and with subjective cognitive complaints was analyzed. The group was compared with a mild cognitive impairment (MCI) group without FM. Material and method: Retrospective study of 32 patients with FM were evaluated and 86 patients with MCI without FM. A neuropsychological test battery was administered. Results were compared with a control group of MCI (n=86) without FM. Results: Evidence of MCI was observed in 29 of 32 women with FM, and the neuropsychological pattern showed a major impairment on attention, memory and executive function. When the neuropsychological pattern was compared with the MCI group without FM, we found that patients with FM presented a higher rate of impairment of memory and executive function, and less impairment of the premotor function. Conclusions: The neuropsychological evaluation showed an MCI in the majority of women with FM with a subjective complaint of memory loss (90,5%). The neuropsychological pattern was predominantly subcortical with impairment of memory and executive function. The sample of patients with FM presented cognitive results similar to the MCI group (AU)

[Cognitive profile in fibromyalgia. Comparison with a mild cognitive impairment group]. / Perfil cognitivo en la fibromialgia. Comparación con un grupo con deterioro cognitivo leve.

OBJECTIVE: The neuropsychological assessment of patients with fibromyalgia (FM) and with subjective cognitive complaints was analyzed. The group was compared with a mild cognitive impairment (MCI) group without FM. MATERIAL AND METHOD: Retrospective study of 32 patients with FM were evaluated and 86 patients with MCI without FM. A neuropsychological test battery was administered. Results were compared with a control group of MCI (n=86) without FM. RESULTS: Evidence of MCI was observed in 29 of 32 women with FM, and the neuropsychological pattern showed a major impairment on attention, memory and executive function. When the neuropsychological pattern was compared with the MCI group without FM, we found that patients with FM presented a higher rate of impairment of memory and executive function, and less impairment of the premotor function. CONCLUSIONS: The neuropsychological evaluation showed an MCI in the majority of women with FM with a subjective complaint of memory loss (90,5%). The neuropsychological pattern was predominantly subcortical with impairment of memory and executive function. The sample of patients with FM presented cognitive results similar to the MCI group.

Comparison of different clinical diagnostic criteria for depression in Alzheimer disease.

OBJECTIVE: Data in the literature show different estimates of the prevalence of depression in patients with Alzheimer disease (AD) when different classification systems are used. This study describes the prevalence and clinical features of depression in AD based on five different depression classification systems. METHODS: This was a cross-sectional, observational study of 491 patients with probable AD. Depression was diagnosed using five classification systems (International Classification of Diseases, 10th Revision [ICD-10], Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV], Cambridge Examination for Mental Disorder of the Elderly [CAMDEX], Provisional Diagnostic Criteria for depression in AD [PDC-dAD], Neuropsychiatric Inventory [NPI]). RESULTS: The prevalence of depression was 4.9% (95% confidence interval [CI]: 3.2-7.1) according to ICD-10 criteria; 9.8% (95% CI: 7.3-12.6) according to CAMDEX; 13.4% (95% CI: 10.6-16.6) according to DSM-IV; 27.4% (95% CI: 23.6-31.5) according to PDC-dAD criteria; and 43.7% (95% CI: 39.4-48.2) when using the screening questions from the NPI depression subscale. The level of agreement between the classification systems was low to moderate (kappa <0.52). The characteristics associated with the most diagnostic disagreement were loss of confidence or self-esteem and irritability. CONCLUSIONS: This study shows that there is a high variability in the prevalence rates of depression in AD depending on the diagnostic criteria used and that there is a low rate of agreement among the diagnostic criteria analyzed. The results suggest that the use of generic diagnostic criteria such as the ICD-10, the CAMDEX, or DSM-IV provides low prevalence rates of depression in patients with AD compared with specific diagnostic criteria such as the PDC-dAD.

[Cost relation between severity of Alzheimer's disease and cognitive and functional impairment]. / Análisis de los costes de la enfermedad de Alzheimer en función del deterioro cognitivo y funcional.

BACKGROUND AND OBJECTIVE: This study aims to identify the relationship between costs of medical and social attention in patients with dementia of Alzheimer disease (AD) type and clinical and sociodemographic data of patients and their caregivers. PATIENTS AND METHOD: It was an analytic observational study in a cohort of patients diagnosed with Alzheimer's disease who received ambulatory attention. Information about the use of health-related resources was collected and costs were estimated from a societal perspective. Indirect costs were calculated using a replacement cost approach. Patients and caregivers were examined with the Mini-Mental State Examination (MMSE), the Rapid Disability Rating Scale (RDRS-2), the Neuropsychiatric Inventory (NPI), the Burden Interview (BI) and the Resource Utilization in Dementia (RUD). Patients were grouped taking into account the score obtained in the MMSE. RESULTS: A cohort of 417 patients, mean age (SD) 75.2 (6.6) years, 71% females, was studied. Disease severity levels were distributed as follows: MMSE, 26% for MMSE > 19, 66% for MMSE = 19-11, and 8% for MMSE < 11. 69% of caregivers were women, with a mean age of 57.1 (15.8) years. The cost per patient and per month was estimated to be 419.3 Euro for MMSE > 19, 641.9 Euro for MMSE = 19-11, and 1150.6 Euro for MMSE < 11. CONCLUSIONS: The societal cost of AD increases dramatically with increasing disease severity. Caregiver burden and sex as well as the marital status of patients are associated with the cost of the disease.