In the Clinic. Dementia.

This issue provides a clinical overview of dementia, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, https://mksap.acponline.org/, and other resources referenced in each issue of In the Clinic.

Estimating severity of illness and disability in Frontotemporal Dementia: Preliminary analysis of the Dementia Disability Rating (DDR).

BACKGROUND: Current measures of severity and disability do not stage or track the progression of disability in frontotemporal dementia (FTD) well. We investigated the reliability of the newly developed Dementia Disability Rating (DDR) in the measurement and staging of illness severity in FTD and dementia of the Alzheimer type (DAT). MATERIAL/ METHODS: We studied 48 consecutive patients of the Johns Hopkins FTD and Young-Onset Dementias Clinic, with diagnoses of DAT, FTD, vascular dementia and "other" cognitive disorder (CDNOS). Cases were scored on the CDR and DDR by three trained raters, based on neuropsychiatric examinations performed at first visit and other assessments performed within the preceding year. Consensus ratings were assigned in conference. RESULTS: Inter-rater correlations of DDR sum of ranks scores for DAT ranged from 0.88 to 0.91, for FTD 0.89-0.96 and for CDNOS 0.85-0.97. Similar correlations were observed of the CDR sum of rank scores for DAT and FTD. Correlations of DDR summary scores for DAT were 0.67-0.91 and for FTD 0.79-0.91, as compared to CDR data: 0.87-0.92 (p<0.0001) and 0.80-0.93 (p<0.0001) for DAT and FTD respectively. In DAT patients the correlation between CDR and DDR summary scores was higher than in FTD patients, whereas correlations based on sum of ranks scores were high in both groups. CONCLUSIONS: These preliminary data indicate the DDR measures disability in DAT and FTD, with reliability comparable to the CDR. Convergent validity was demonstrated for the DDR.

Depression in frontotemporal dementia.

OBJECTIVE: The authors describe mood abnormalities seen in a case series of patients with frontotemporal dementia (FTD). METHOD: Authors provide a structured review of outpatient and inpatient charts of FTD patients. RESULTS: Three distinct depressive syndromes were identified: The first corresponds to DSM-IV major depression. The second is a syndrome of mood lability with prominent responsiveness to the environment. The third is a syndrome of profound apathy, without other evidence of depression. CONCLUSION: A variety of mood disorders are seen in FTD, requiring careful attention to differential diagnosis. FTD should be included in the differential diagnosis during the evaluation of older patients with mood abnormalities.

Surrogate decision makers' understanding of dementia patients' prior wishes for end-of-life care.

OBJECTIVE: This study examines how surrogate decision makers for dementia patients developed an understanding of patient preferences about end-of-life (EOL) care and patient wishes. METHODS: Semistructured interviews were conducted with 34 surrogate decision makers for hospice-eligible nursing home patients with dementia. The data were content analyzed. RESULTS: Most surrogates reported that patients had previously completed an advance directive (59%), discussed preferences for EOL care (56%), or done both (38%). Catalysts for and barriers to completing an advance directive or having EOL care discussions included factors that were both intrinsic and extrinsic to the patient. The most commonly reported wish for EOL care was to not be kept alive by "machines" or "extraordinary measures." DISCUSSION: Health care providers may be able to assist patients and families by normalizing discussions of dying, encouraging advance care planning, helping them identify goals for EOL care, and providing information to support treatment decisions consistent with patients' wishes.

Prevalence and treatment of neuropsychiatric symptoms in advanced dementia.

Neuropsychiatric symptoms (NPS) are common in dementia, although little is known about their prevalence and treatment near the end of life. This study used a retrospective review of the medical records of 123 hospice-eligible nursing home residents with advanced dementia to investigate the prevalence of NPS and NPS-targeted pharmacological and non-pharmacological treatments. The most prevalent NPS were agitation or aggression (50.4%), depression (45.5%), and withdrawal/lethargy (43.1%). Of the 105 (85.4%) residents who exhibited one or more NPS, 90.5% were receiving at least one NPS-targeted treatment, yet 41.9% received no documented nonpharmacological NPS-targeted care. The majority of documented nonpharmacological care focused on safety and explanations or instructions given to residents. Given the high prevalence of comorbidities, associated risks for medication interactions or serious side effects, and potential low-risk benefits of psychobehavioral care, these findings raise concerns about how to best increase the provision and documentation of nonpharmacological care in advanced dementia.

Composite Bonding Pre-Treatment with Laser Radiation of 3 µm Wavelength: Comparison with Conventional Laser Sources.

To use the full potential of composite parts, e.g., to reduce the structural weight of cars or airplanes, a greater focus is needed on the joining technology. Adhesive bonding is considered favorable, superior joining technology for these parts. Unfortunately, to provide a structural and durable bond, a surface pre-treatment is necessary. Due to its high integration potential in industrial process chains, laser radiation can be a very efficient tool for this purpose. Within the BMBF-funded (German Federal Ministry of Education and Research) project GEWOL, a laser source that emits radiation at 3 µm wavelength (which shows significant advantages in theory) was developed for a sensitive laser-based bonding pre-treatment. Within the presented study, the developed laser source was compared with conventional laser sources emitting radiation at 355 nm, 1064 nm, and 10,600 nm in terms of application for a composite bonding pre-treatment. With the different laser sources, composites were treated, analytically tested, subsequently bonded, and mechanically tested to determine the bonding ability of the treated specimens. The results show a sensitive treatment of the surface with the developed laser source, which resulted in a very effective cleaning, high bonding strengths (over 32 MPa), and a good effectiveness compared with the conventional laser sources.

Ethical issues in mobile psychiatric treatment with homebound elderly patients: the Psychogeriatric Assessment and Treatment in City Housing experience.

Unique and challenging ethical difficulties arise during mobile psychiatric treatment of elderly patients. This article outlines and analyzes five of these challenges that have been encountered during nearly 20 years of experience with the Psychogeriatric Assessment and Treatment in City Housing Program in Baltimore, Maryland. The ethical challenges reviewed are: establishing the treatment contract versus the right to refuse treatment, protecting confidentiality versus patient protection, protecting autonomy versus asserting beneficence, treatment termination versus open-ended treatment, and cost versus benefit of care. Ethical challenges with homebound elderly patients are unique because of patient characteristics as well as features of the treatment environment.

Evaluating the clinical impact of involuntary admission to a specialized dual diagnosis ward.

BACKGROUND: We aimed to identify characteristics and outcomes of involuntary and voluntary admissions of dual-diagnosis patients in a single, large mental health center in Israel. METHODS: Using a retrospective chart review methodology, 24 patient records were reviewed spanning a period of five years; clinical and demographic variables of voluntary and involuntary admissions were compared. RESULTS: No significant differences were found in sociodemographic characteristics, admission diagnosis and length of hospitalization between the two types of admission. A smaller proportion of patients discharged from involuntary admissions were in remission compared to those discharged from voluntary admission. Nevertheless, involuntary admissions were associated with longer time to next hospitalization. LIMITATIONS: The data were based on a small number of patients in a single ward, thus the generalizability of the results is uncertain. CONCLUSIONS: The finding of the current study that involuntary admission leads to longer tenure in the community suggests that there may be clinical advantages to involuntary admissions for certain dual diagnosis patients.

Characteristics of immigrant and non-immigrant patients in a dual-diagnosis psychiatric ward and treatment implications.

Two studies were conducted among patients in a male dual diagnosis (severe mental illness [SMI] with substance use) ward. The research examined the following questions: (1) Do immigrant and non-immigrant dual diagnosis patients exhibit similar or different socio-demographic, clinical and criminological characteristics? (2) What are the implications for treatment of immigrant (and non-immigrant) patients? Study one analyzed computerized hospital records of 413 male patients; Study two examined patient files of a subgroup of 141 (70 immigrant) male patients. Alongside similarities, non-immigrant patients reported higher numbers of repeat and involuntary hospitalizations and more drug use while immigrants showed longer hospitalizations, more suicide attempts, more violent suicide attempts, more violent offenses and more alcohol use. Among non-immigrants significant relationships were found between severity of SMI and crime/violence while among immigrants a significant relationship was found between suicidality and crime/violence. Implications for treatment include need for awareness of suicide risk among immigrant dual-diagnosis patients and an understanding of the differential relationship with crime/violence for the two populations.

The role of environmental influences on schizophrenia admissions in Israel.

OBJECTIVE: The role of environmental factors in hospitalization of patients with schizophrenia is incompletely understood. This study attempts to relate the pattern of hospital admissions to environmental variables such as season and to social factors such as nationally celebrated holidays. METHODS: Charts of all adults (n = 4,331) with a discharge diagnosis of schizophrenia admitted to the Abarbanel Mental Health Centre (Bat Yam, Israel) between 1 January 2001 and 31 December 2005 were reviewed. Hospitalizations were classified by gender, first or repeat admission, month and season of admission, and whether or not the admission coincided with a major Jewish holiday period. RESULTS: There was a significant reduction (p < 0.05) in first admissions for men during April, the month corresponding to Passover, the most widely celebrated holiday in Israel. This pattern was not seen for women or for repeat admissions. There was no significant effect of the season upon admission rates, using two different methods of defining the season. CONCLUSIONS: This study demonstrated significant monthly variability in admission rates and a possible protective effect of a widely celebrated public religious holiday. A consistent effect of season upon rates of admission was not found. Future studies need to identify which specific social factors exert a protective or harmful effect and study how knowledge of these effects can be translated into clinical practice.

Quality of life in nursing home residents with advanced dementia.

OBJECTIVES: To examine quality of life (QOL) in nursing home (NH) residents with advanced dementia and identify correlates of QOL near the end of life. DESIGN: Cross-sectional data derived from NH records, interviews with residents' surrogate decision-makers, QOL ratings by NH caregivers, and assessment of residents' cognitive function. SETTING: Three NHs in Maryland. PARTICIPANTS: A cohort of NH residents with dementia (n=119) who were receiving hospice or palliative care or met hospice criteria for dementia and their surrogates. MEASUREMENTS: QOL based on the proxy-rated Alzheimer' Disease-Related Quality of Life (ADRQL) scale administered to NH staff and validated against a single-item surrogate-rated measure of QOL, the Severe Impairment Rating Scale, to measure cognitive function and dichotomous indicators of neuropsychiatric symptoms (behavior problems, mood disorders, psychosis, delusions). RESULTS: Total ADRQL scores, ranging from 12.4 to 95.1 out of 100, were normally distributed and positively correlated (P<.001) with surrogate-rated QOL. Multiple regression analysis of ADRQL scores showed that residents with higher cognitive function (P<.001, 95% confidence interval (CI)=0.97-1.65) and those receiving pain medication (P=.006, 95% CI=3.30-19.59) had higher QOL, whereas residents with behavior problems (P=.01, 95% CI=-11.60 to -1.30) had lower QOL. CONCLUSION: The ADRQL is a valid indicator of QOL in NH residents with advanced dementia. QOL in this population may be improved near the end of life using appropriate assessment and treatment of pain and effective management of behavior problems.

The role of animal models in evaluating reasonable safety and efficacy for human trials of cell-based interventions for neurologic conditions.

Progress in regenerative medicine seems likely to produce new treatments for neurologic conditions that use human cells as therapeutic agents; at least one trial for such an intervention is already under way. The development of cell-based interventions for neurologic conditions (CBI-NCs) will likely include preclinical studies using animals as models for humans with conditions of interest. This paper explores predictive validity challenges and the proper role for animal models in developing CBI-NCs. In spite of limitations, animal models are and will remain an essential tool for gathering data in advance of first-in-human clinical trials. The goal of this paper is to provide a realistic lens for viewing the role of animal models in the context of CBI-NCs and to provide recommendations for moving forward through this challenging terrain.

Treatment decisions regarding hospitalization and surgery for nursing home residents with advanced dementia: the CareAD Study.

BACKGROUND: Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia. METHODS: The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery). RESULTS: Treatment decisions regarding aggressive medical care had been made by 81% of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a 'do not hospitalize' order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity. CONCLUSIONS: Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence of DNH and less so with changeable features of illness or environment.

Medication use in nursing home residents with advanced dementia.

OBJECTIVE: To describe medication usage in nursing home residents with advanced dementia, to identify how this usage changed as patients advanced towards death, and to identify correlates of increased medication usage. METHODS: Prospective cohort study (CareAD) during which data on medication prescription were extracted from medical records at regular intervals using standardized extraction procedures. RESULTS: Patients (n=125) were prescribed a mean of 14.6 medications during the 6 months prior to study enrollment. In a subgroup of patients who died during the study (n=88), as the time of death approached, the total number of medications prescribed did not vary but the types of medications prescribed did change, with an increase in palliative medications such as opiate analgesics and a decrease in other medication classes such as antibiotics, anti-dementia agents, cardiovascular agents, and psychotropic agents, among others. In linear regression analyses, total medication prescription at study entry was associated with study site, antibiotic treatment, presence of cardiovascular disease, and treatment of gastrointestinal or dermatological conditions. CONCLUSIONS: Nursing home residents with advanced dementia are prescribed a large number of medications from numerous medication classes and prescribing patterns change over time. Further study is needed to determine the ideal approach to treating chronic medical problems at the end of life in this patient population.

Neuropsychiatric symptom patterns in hospice-eligible nursing home residents with advanced dementia.

OBJECTIVE: The purpose of this study was to determine whether specific neuropsychiatric symptom patterns could be identified in a cohort of hospice-eligible nursing home residents with advanced dementia. METHODS: Surrogate decision makers gave informed consent to enroll 123 residents from 3 nursing homes. All participating residents met criteria for hospice eligibility and were determined by direct examination at the time of study enrollment to have advanced dementia. Retrospective medical record review was used to collect data on residents' demographics, diagnoses, and the presence of any neuropsychiatric symptoms during the 6 months prior to study enrollment. Latent class analysis (LCA) was used to classify residents based on neuropsychiatric symptom patterns. RESULTS: Overall, 85% of residents exhibited one or more neuropsychiatric symptoms. LCA revealed that these individuals could be classified into 3 groups: one with low symptom frequencies (36%) considered to be the normative class, one characterized by psychosis and agitation or aggression (23%), and a third characterized by withdrawal or lethargy (41%). CONCLUSIONS: These results add to the growing understanding of neuropsychiatric symptom patterns in advanced dementia and have implications for more dimensional classification and treatment approaches.

The physician-patient relationship in dementia care.

Medical care of patients with dementia often occurs within a physician-patient relationship whose features differ from relationships with patients without dementia. Many basic assumptions of the physician-patient relationship may not completely hold true, and certain aspects of the patient role may be shared by others besides the patient. For example, the entire premise of consent to the patient role may be inapplicable to patients who lack insight into their illness. In addition, caring for cognitively impaired patients who do not comprehend the purpose of the physician-patient interaction may render physicians vulnerable to losing empathy with their patients and objectifying them. This can lead to viewing patients as collections of symptoms rather than as humans suffering with illnesses and burdens. The fact that certain medical interventions, such as treatment of neuropsychiatric disturbances that do not trouble the patient, may appear to be initiated for the primary purpose of alleviating caregiver emotional stress also affects the physician-patient relationship. The present review examines how this relationship may be altered and presents a framework within which these alterations can be considered.

A pragmatic approach to teaching psychiatry residents the assessment and treatment of religious patients.

OBJECTIVE: The authors describe a pragmatic and atheoretical frameword for teaching psychiatry residents how to assess and treat religious patients. RESULTS: The psychiatrist's goals in assessing the religious history are clarified. These goals differ between the assessment and treatment phases. During assessment, attention is paid to psychiatric phenomenology and careful history-taking, utilizing knowledgeable outside informants. A framework is presented for engaging religious patients, fostering therapeutic alliance, avoiding pitfalls, and facilitating treatment within the patient's religious context. CONCLUSIONS: Emphasizing knowledge of phenomenology and information gathering skills may be more effective than emphasizing broad knowledge of many religions, except for clinicians practicing within a particular religious community.