Surrogate decision making for patients with end-stage dementia.

OBJECTIVE: We aim to explore how health surrogates of patients with dementia proceed in decision making, which considerations are decisive, and whether family surrogates and professional guardians decide differently. METHODS: We conducted an experimental vignette study using think aloud protocol analysis. Thirty-two family surrogates and professional guardians were asked to decide on two hypothetical case vignettes, concerning a feeding tube placement and a cardiac pacemaker implantation in patients with end-stage dementia. They had to verbalize their thoughts while deciding. Verbalizations were audio-recorded, transcribed, and analyzed according to content analysis. By experimentally changing variables in the vignettes, the impact of these variables on the outcome of decision making was calculated. RESULTS: Although only 25% and 31% of the relatives gave their consent to the feeding tube and pacemaker placement, respectively, 56% and 81% of the professional guardians consented to these life-sustaining measures. Relatives decided intuitively, referred to their own preferences, and focused on the patient's age, state of wellbeing, and suffering. Professional guardians showed a deliberative approach, relied on medical and legal authorities, and emphasized patient autonomy. Situational variables such as the patient's current behavior and the views of health care professionals and family members had higher impacts on decisions than the patient's prior statements or life attitudes. CONCLUSIONS: Both the process and outcome of surrogate decision making depend heavily on whether the surrogate is a relative or not. These findings have implications for the physician-surrogate relationship and legal frameworks regarding surrogacy. Copyright © 2011 John Wiley & Sons, Ltd.

Approche preventive des pathologies démentietlles [Preventive approaches to dementia].

Prevalence and incidence of dementia increase with demographic aging. Benefits of current antidementia drugs are modest, both in cognitive and functional domains. Therefore, interest is growing to evaluate the effects of interventions aiming at preventing cognitive decline and, ideally, dementia onset. Cognitive training and physical activity seem promising. This paper describes recent studies that assessed the benefits of preventive strategies in the domain of dementia, especially in Alzheimer's disease.

Diabète et démence: tes liaisons dangereuses [Diabetes and dementia: the dangerous liaisons? ].

As population ages, a growing number of older patients present the constellation of diabetes and dementia. Numerous recent studies highlight that diabetes may increase the risk for Alzheimer and vascular dementia. Among patients with previous severe hypoglycemia, that risk may even double. Inversely demented patients have about three times higher risk of hypoglycemia. Given that spiral link between hypoglycemia and dementia, the latter should be considered as a possible complication of diabetes and consistently be screened for among older diabetic patients. Furthermore, the American Diabetes Association and American Geriatric Society consensus recommends a more flexible glycemic treatment goal of AIC among demented patients, with a target range between 8 and 9%.

Hippocampal atrophy predicts conversion to dementia after STN-DBS in Parkinson's disease.

BACKGROUND: Hippocampal atrophy (HA) is a known predictor of dementia in Alzheimer's disease. HA has been found in advanced Parkinson's disease (PD), but no predicting value has been demonstrated yet. The identification of such a predictor in candidates for subthalamic deep brain stimulation (STN-DBS) would be of value. Our objective was to compare preoperative hippocampal volumes (HV) between PD patients who subsequently converted to dementia (PDD) after STN-DBS and those who did not (PDnD). METHODS: From a cohort of 70 consecutive STN-DBS treated PD patients, 14 converted to dementia over 25.6+/-20.2 months (PDD). They were compared to 14 matched controls (PDnD) who did not convert to dementia after 43.9+/-11.7 months. On the preoperative 3D MPRAGE MRI images, HV and total brain volumes (TBV) were measured by a blinded investigator using manual and automatic segmentation respectively. RESULTS: PDD had smaller preoperative HV than PDnD (1.95+/-0.29 ml; 2.28+/-0.33 ml; p<0.01). This difference reinforced after normalization for TBV (3.28+/-0.48, 3.93+/-0.60; p<0.01). Every 0.1 ml decrease of HV increased the likelihood to develop dementia by 24.6%. A large overlap was found between PD and PDnD HVs, precluding the identification of a cut-off score. CONCLUSIONS: As in Alzheimer's disease, HA may be a predictor of the conversion to dementia in PD. This preoperative predictor suggests that the development of dementia after STN-DBS is related to the disease progression, rather then the procedure. Further studies are needed to define a cut-off score for HA, in order to affine its predictive value for an individual patient.

Conduites spéculaires dans les démences: les multiples signes du miroir [Mirror behaviors in dementia: the many mirror signs].

Mirror behaviors in advanced dementia are: the mirror sign of Abely and Delmas, where the patient stares at his face (environment-driven behavior of Lhermitte); non recognition of the self in the mirror (autoprosopagnosia and/or delirious auto-Capgras); mirror agnosia of Ramachandran and Binkofski where the patient do not understand the concept of mirror and its use; the psychovisual reflex, or reflex pursuit of the eyes when passively moving a minrror in front of a patient (intact vision); mirror writing (procedural learning). We describe four demented patients with mirror behaviors assessing brain mechanisms of self recognition, social brain and mental and visuo-spatial manipulation of images and objects.

Association atypique d'une démence sémantique, d'un syndrome cortico-basal et d'une tauopathie 4R = [Atypical association of semantic dementia, corticobasal syndrome and 4R tauopathy]

Enjeu et contexte de la recherche La dégénérescence lobaire fronto-temporale (DLFT) est une pathologie neurodégénérative aussi fréquente que la maladie d'Alzheimer parmi les adultes de moins de 65 ans. Elle recouvre une constellation de syndromes neuropsychiatriques et moteurs dont les caractéristiques cliniques et anatomo-pathologiques se recoupent partiellement. La plupart des cas de démence sémantique ne présentent pas de troubles moteurs et révèlent à l'autopsie des lésions ubiquitine-positives. Son association à un syndrome cortico-basal et à une tauopathie 4R est donc très inhabituelle. Le cas que nous présentons est le premier à disposer d'une description clinique complète, tant sur le plan cognitif que moteur, et d'une analyse génétique et histopathologique. Résumé de l'article Il s'agit d'un homme de 57 ans, sans antécédents familiaux, présentant une démence sémantique accompagnée de symptômes inhabituels dans ce contexte, tels qu'une dysfonction exécutive et en mémoire épisodique, une désorientation spatiale et une dyscalculie. Le déclin physique et cognitif fut rapidement progressif. Une année et demie plus tard, il développait en effet des symptômes moteurs compatibles initialement avec un syndrome de Richardson, puis avec un syndrome cortico-basal. Son décès survint à l'âge de 60 ans des suites d'une pneumonie sur broncho-aspiration. L'autopsie cérébrale mit en évidence une perte neuronale et de nombreuses lésions tau-4R-positives dans les lobes frontaux, pariétaux et temporaux, les ganglions de la base et le tronc cérébral. Aucune mutation pathologique n'a été décelée dans le gène MAPT (microtubule-associated protein tau). L'ensemble de ces éléments sont discutés dans le cadre des connaissances actuelles sur la DLFT. Conclusions et perspectives Ce cas illustre le recoupement important des différents syndromes de la DLFT, parfois appelée le « complexe de Pick ». De plus, la démence sémantique pourrait s'avérer cliniquement moins homogène que prévu. Les définitions actuelles de la démence sémantique omettent la description des symptômes cognitifs extra-sémantiques malgré l'accumulation de preuves de leur existence. La faible prévalence de la démence sémantique, ainsi que des différences dans les examens neuropsychologiques, peuvent expliquer en partie la raison de cette omission. La variabilité histopathologique de chaque phénotype de DLFT peut également induire des différences dans leur expression clinique. Dans un domaine aussi mouvant que la DLFT, la co- occurrence ou la succession de plusieurs syndromes cliniques est en outre probablement la règle plutôt que l'exception.

New diagnoses of dementia among older patients admitted to postacute care

Introduction : bien que la prévalence des syndromes démentiels soit élevée chez les personnes âgées hospitalisées et qu'une proportion non négligeable échappe au diagnostic, la littérature ne fournit que peu de données chez les patients admis en milieu de réadaptation post-aigu. L'objectif principal de ce travail était de déterminer la prévalence des démences, ainsi que la proportion de démences non diagnostiquées dans une population admise dans un centre de réadaptation gériatrique. Ensuite, nous nous sommes intéressés à identifier les caractéristiques des patients associées à une démence non-détectée. Méthode : nous avons utilisé les données de tous les patients âgés de 70 ans et plus admis durant 3 ans dans l'unité de réadaptation du service de gériatrie et réadaptation gériatrique, Centre Hospitalier Universitaire Vtudois, en excluant les patients décédés pendant l'hospitalisation. Lors de l'admission, des données sociodémographiques, médicales, ainsi que des données concernant le status fonctionnel et mental sont récoltées systématiquement. Par ailleurs, les dossiers des patients ont été examinés pour en extraire les informations quant aux performances cognitive (mini-Mental State Exam, MMSE) et au diagnostic de sortie. Résultats : un diagnostic de démence figurait dans la lettre de sortie de 425 des 1764 patients (24.1%), plus de la moitié présentant une démence de type Alzheimer. Pour 301 de ces 425 patients (70.8%), la démence avait été diagnostiquée durant le séjour de réadaptation. La proportion de démences non-détectées auparavant était plus élevée chez les patients provenant des services de chirurgie/orthopédie que de médecine interne (74.8% vs 65.8%, p=.42). Les patients non diagnostiqués comme déments étaient plus âgés, vivaient plus souvent seuls et avaient de meilleures performances fonctionnelles et cognitives que ceux chez qui le diagnostic avait été posé auparavant. Notamment, un tiers d'entre eux avait un score normal au MMSE. Une analyse multi-variée a mis en évidence deux facteurs prédisposant à la non-détection : l'âge (Odds Ratio (OR) : 2.4 pour le groupe d'âge 85 ans et plus par rapport aux plus jeunes, 96%CI : 1.5-4.0, p=.001) et le score au MMSE (OR : 5.9 lors d'un MMSE normal à l'admission, 96%CI : 2.7-12.7, p<.001) Conclusion et perspectives : cette étude montre qu'environ un quart des patients admis en réadaptation gériatrique souffre de démence, et que cette pathologie n'est pas reconnue chez les trois-quarts d'entre eux. Ces résultats soulignent la nécessité d'un dépistage systématique des troubles cognitifs chez les patients âgés. En effet, en l'absence de détection, ces patients ne peuvent bénéficier d'une prise en charge approprié, incluant non seulement des mesures médicales et pharmacologiques, mais surtout l'information du patient et des proches, dans le but de maintenir une qualité de vie acceptable du patient ainsi que de prévenir l'épuisement des proches et des.soignants. Cette étude incite aussi à être attentif aux signes évocateurs de troubles cognitifs lors de l'interprétation du test MMSE, car un score dans les limites de la norme ne permet pas d'exclure une démence.

Pharmacological treatment of behavioral and psychological symptoms of dementia (BPSD) in nursing homes: development of practice recommendations in a Swiss canton

OBJECTIVES: In 2002, the canton of Fribourg, Switzerland, implemented a coordinated pharmaceutical care service in nursing homes to promote rational drug use. In the context of this service, a project was conducted to develop recommendations for the pharmacological management of behavioral and psychological symptoms of dementia (BPSD) in nursing home residents. DESIGN AND METHODS: Selected evidence-based guidelines and meta-analysis sources related to the management of depression, insomnia, and agitation in dementia patients were systematically searched and evaluated. Evidence and controversies regarding the pharmacological treatment of the most common BPSD symptoms were reviewed, and treatment algorithms were developed. RESULTS: Ten evidence-based guidelines and meta-analyses for BPSD management were identified, with none specifically addressing issues related to nursing home residents. Based on this literature, recommendations were developed for the practice of pharmacological management of depression, sleep disturbances, and agitation in nursing home residents. For depression, SSRIs are considered the first choice if an antidepressant is required. No clear evidence has been found for sleep disturbances; the underlying conditions need to be investigated closely before the introduction of any drug therapy. Many drugs have been investigated for the treatment of agitation, and if necessary, antipsychotics could be used, although they have significant side effects. Several areas of uncertainty were identified, such as the current controversy about typical and atypical antipsychotic use or the appropriateness of cholinesterase inhibitors for controlling agitation. Treatment algorithms were presented to general practitioners, pharmacists, and medical directors of nursing homes in the canton of Fribourg, and will now be implemented progressively, using educational sessions, pharmaceutical counseling, and monitoring. CONCLUSION: Based on existing evidence-based studies, recommendations were developed for the practice of pharmacological management of depression, sleep disturbances, and agitation in nursing home residents. It should be further studied whether these algorithms implemented through pharmaceutical care services will improve psychotropic drug prescriptions and prevent drug-related problems in nursing home residents

Impact of physical activity on activity of daily living in moderate to severe dementia: a critical review

The objectives of this study were to describe the different modalities of physical activity programs designed for moderate to severe dementia and to identify their impact on functional independence in activities of daily living (ADL). A critical review of randomized controlled trials related to the impact of physical activity programs in moderately to severely demented persons on ADL performance and meta-analysis of the identified studies were performed. Among the 303 identified articles, five responded to the selection criteria. Four out of the five studies demonstrated limited methodological quality. In one high-quality study, physical activity programs significantly delayed deterioration of ADL performance. The program components and ADL assessment tools vary widely across studies. Although the proposed treatments have not proven their efficiency in improving the ADL status of the patients, they were able to limit the decline in ADL functioning. Future research is warranted in order to identify clinically relevant modalities for physical activity programs for people with moderate to severe dementia.

New diagnoses of dementia among older patients admitted to postacute care.

Objectives: To determine the prevalence of dementia and the proportion of undiagnosed dementia in elderly patients admitted to postacute care, and to identify patients' characteristics associated with undiagnosed dementia. Design: Cross-sectional study. Setting: Academic postacute rehabilitation facility in Lausanne, Switzerland. Participants: Patients (N = 1764) aged 70 years and older. Measurements: Data on socio-demographic, medical, functional, and affective status were collected upon admission. Data on cognitive performance (Mini-Mental State Exam [MMSE]), and cognition-related discharge diagnoses were abstracted through a structured review of discharge summaries. Results: Overall, 24.1% (425/1764) patients had a diagnosis of dementia, most frequently secondary to Alzheimer's disease (260/425, 61.2%). Among dementia cases, 70.8% (301/425) were newly diagnosed during postacute stay. This proportion was lower among patients referred from internal medicine than from orthopedic/surgery services (65.8% versus 74.8%, P = .042). Compared to patients with already diagnosed dementia, those newly diagnosed were older, lived alone more frequently, and had better functional status and MMSE score at admission (all P < .05). In multivariate analysis, previously undetected dementia remained associated with older age (OR = 2.4 for age 85 years and older, 95% CI 1.5-4.0, P = .001) and normal MMSE at admission (OR = 5.9, 95% CI 2.7-12.7, P < .001). Conclusion: Dementia was present in almost a fourth of elderly patients referred to postacute care, but was diagnosed in less than a third before admission. Oldest old patients appear especially at risk for underrecognition. These results emphasize the high diagnostic yield of systematic cognitive assessment in the postacute care setting to improve these patients' management and quality of life.

The validity of clinical diagnoses of dementia in a group of consecutively autopsied memory clinic patients.

BACKGROUND: Epidemiological studies show that up to 10% of individuals aged 65 years and older suffer from dementia, most commonly from dementia of the Alzheimer Type (DAT) (1). Clinicopathological studies are critical to our understanding of this disease and improving the accuracy of clinical diagnoses. OBJECTIVES: Our objectives were to examine the validity of clinical diagnoses of DAT, to determine the prevalence of different forms of dementia in this sample, and to investigate the relationship between age at death and polymorbidity. SUBJECTS AND METHOD: Clinical data were available from 221 patients who had been examined at the Basel Memory Clinic between 1986 and 1996. From this population, 34% (75 patients) were autopsied in the Department of Pathology, University Hospital Basel, and neuropathological examinations were additionally performed on 62 (83%) of these patients. Clinical and neuropathological data were retrospectively compared. RESULTS: 67.8% of the neuropathologically examined patients received a definitive diagnosis of AD (Alzheimer's disease), vascular dementia (VaD) or mixed dementia (AD and VaD). AD alone or with other histopathological hallmarks of dementia was the most prevalent neuropathological diagnosis (63%). VaD was deemed the only cause of dementia in only 4.8% of patients. The sensitivity for DAT was 75.9%, the specificity 60.6%. Increasing age was associated with an increasing number of clinical and neuropathological diagnoses. CONCLUSION: The sensitivity and specificity of the clinical diagnoses of DAT found in our study are similar to previous reports (2-5). Older patients had more etiologies of their dementia than younger patients. This study reaffirms the need for internationally accepted criteria for clinical and neuropathological diagnoses, as well as further clinical-neuropathological investigations to further refine the clinical diagnostic process.

Du delirium au syndrome démentiel: prise en charge médicamenteuse dans les EMS fribourgeois [Management of elderly patients with delirium or dementia in Swiss nursing homes].

Management of elderly patients with delirium or dementia in Swiss nursing homes Dementia and delirium are among the most frequent medical conditions in older nursing home residents. Their management require a coordinated interdisciplinary approach, including for drug prescription. Using a systematic literature review of published meta-analyses and guidelines, prescription algorithms were developed adressing the pharmacological management of cognitive symptoms of dementia and delirium in older nursing home residents in the canton of Fribourg.