Cholinesterase inhibitors for Parkinson's disease dementia

Background - The loss of cholinergic, dopaminergic and noradrenergic innervations seen in Parkinson's Disease Dementia (PDD) suggest a potential role for cholinesterase inhibitors. Concerns have been expressed about a theoretical worsening of Parkinson's disease related symptoms, particularly movement symptoms. Objectives - To assess the efficacy, safety, tolerability and health economic data relating to the use of cholinesterase inhibitors in PDD. Search methods - The trials were identified from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 19 April 2005 using the search term parkinson*. This register contains records from major health care databases and many ongoing trial databases and is updated regularly. Comprehensive searches of abstracts from major scientific meetings were performed. Pharmaceutical companies were approached for information regarding additional and ongoing studies. Selection criteria - Randomized, double-blind, placebo-controlled studies assessing the effectiveness of cholinesterase inhibitors in PDD. Inclusion and exclusion criteria were stated to limit bias. Data collection and analysis - Two reviewers (IM, CF) independently reviewed the quality of the studies utilizing criteria from the Cochrane Collaboration Handbook. Medications were examined separately and as a group. The outcome measures assessed were in the following domains: neuropsychiatric features, cognition, global impression, daily living activities, quality of life, burden on caregiver, Parkinsonian related symptoms, treatment acceptability as determined by withdrawal from trials, safety as determined by the frequency of adverse events, institutionalisation, death and health economic factors. Main results - A detailed and systematic search of relevant databases identified one published randomized, double-blind, placebo-controlled study (Emre 2004) involving 541 patients that compared rivastigmine with placebo. Rivastigmine produced statistically significant improvements in several outcome measures. On the primary cognitive measure, the ADAS-Cog, rivastigmine was associated with a 2.80 point ADAS-Cog improvement [WMD -2.80, 95% Cl -4.26 to -1.34, P = 0.0002] and a 2.50 point ADCS-ADL improvement [95% Cl 0.43 to 4.57, P = 0.02] relative to placebo. Clinically meaningful (moderate or marked) improvement occurred in 5.3% more patients on rivastigmine, and meaningful worsening occurred in 10.1% more patients on placebo. Tolerability appeared to be a significant issue. Significantly more patients on rivastigmine dropped out of the study due to adverse events [62/362 versus 14/179, OR 2.44, 95% Cl 1.32 to 4.48, P = 0.004]. Nausea [20/179 versus 105/362, OR 3.25, 95% Cl 1.94 to 5.45, P < 0.00001], tremor [7/179 versus 37/362, OR 2.80, 95% Cl 1.22 to 6.41, P = 0.01] and in particular vomiting [3/179 versus 60/362, OR 11.66, 95% Cl 3.60 to 37.72, P < 0.0001] were significantly more common with rivastigmine. However, significantly fewer patients died on rivastigmine than placebo [4/362 versus 7/179, OR 0.27, 95% CI 0.08 to 0.95, P = 0.04] Authors' conclusions - Rivastigmine appears to improve cognition and activities of daily living in patients with PDD. This results in clinically meaningful benefit in about 15% of cases. There is a need for more studies utilising pragmatic measures such as time to residential care facility and both patient and carer quality of life assessments. Future trials should involve other cholinesterase inhibitors, utilise tools to analyse the data that limit any bias and measure health economic factors. It is unlikely that relying solely on the last observation carried forward (LOCF) is sufficient. Publication of the observed case data in the largest trial would assist (Emre 2004). Adverse events were associated with the cholinergic activity of rivastigmine, but may limit patient acceptability as evidenced by the high drop out rate in the active arm.

Issues of collaboration, representation, meaning and emotions:utilising participant-led visual diaries to capture the everyday lives of people in mid to later life

In recent years there has been an increasing use of visual methods in ageing research. There are, however, limited reflections and critical explorations of the implications of using visual methods in research with people in mid to later life. This paper examines key methodological complexities when researching the daily lives of people as they grow older and the possibilities and limitations of using participant-generated visual diaries. The paper will draw on our experiences of an empirical study, which included a sample of 62 women and men aged 50 years and over with different daily routines. Participant-led photography was drawn upon as a means to create visual diaries, followed by in-depth, photo-elicitation interviews. The paper will critically reflect on the use of visual methods for researching the daily lives of people in mid to later life, as well as suggesting some wider tensions within visual methods that warrant attention. First, we explore the extent to which photography facilitates a ‘collaborative’ research process; second, complexities around capturing the ‘everydayness’ of daily routines are explored; third, the representation and presentation of ‘self’ by participants within their images and interview narratives is examined; and, finally, we highlight particular emotional considerations in visualising daily life.

Modulation of cholesterol in midlife affords cognitive advantage during ageing - a role for altered redox balance

General practitioners, geriatricians, neurologists and health care professionals all over the world will be facing by 2040 the diagnostic, therapeutic and socioeconomic challenges of over 80 million people with dementia. Dementia is one of the most common diseases in the elderly which drastically affects daily life and everyday personal activities, is often associated with behavioural symptoms, personality change and numerous clinical complications and increases the risk for urinary incontinence, hip fracture, and - most markedly - the dependence on nursing care. The costs of care for patients with dementia are therefore immense. Serum cholesterol levels above 6.5 mmol/L are known to be associated with an increased RR of 1.5 and 2.1 to develop Alzheimeŕs disease, the most common form of dementia, and a reduction of serum cholesterol in midlife is associated with a lowered dementia risk. The aim of this work is to critically discuss some of the main results reported recently in the literature in this respect and to provide the pathophysiological rationale for the control of dyslipidemia in the prevention of dementia onset and progression.

Everyday tactics and spaces of power: the role of informal economies in post-Soviet Ukraine

Utilising de Certeau's concepts of daily life and his delineation between strategies and tactics as everyday practices this paper examines the role of informal economies in post-Ukraine. Based on 700 household surveys and seventy-five in-depth interviews, conducted in three Ukrainian cities, the paper argues that individuals/households have developed a wide range of tactics in response to the economic marginalisation the country has endured since the collapse of the Soviet Union. Firstly, the paper details the importance of informal economies in contemporary Ukraine while highlighting that many such practices are operated out of necessity due to low wage and pension rates and high levels of corruption. This challenges state-produced statistics on the scale of economic marginalisation currently experienced in the country. By exploring a variety of these tactics the paper then examines how unequal power relations shape the spaces in which these practices operate in and how they can be simultaneously sites of exploitation and resistance to economic marginalisation. The paper concludes pessimistically by suggesting that the way in which these economic spaces are shaped precludes the development of state policies which might benefit the economically marginalised.

ALEX:mobile language assistant for low-literacy adults

Basic literacy skills are fundamental building blocks of education, yet for a very large number of adults tasks such as understanding and using everyday items is a challenge. While research, industry, and policy-making is looking at improving access to textual information for low-literacy adults, the literacy-based demands of today's society are continually increasing. Although many community-based organizations offer resources and support to adults with limited literacy skills, current programs have difficulties reaching and retaining those that would benefit most from them. To address these challenges, the National Research Council of Canada is proposing a technological solution to support literacy programs and to assist low-literacy adults in today's information-centric society: ALEX© – Adult Literacy support application for EXperiential learning. ALEX© has been created together with low-literacy adults, following guidelines for inclusive design of mobile assistive tools. It is a mobile language assistant that is designed to be used both in the classroom and in daily life, in order to help low-literacy adults become increasingly literate and independent.

Hidden in plain sight:low-literacy adults in a developed country overcoming social and educational challenges through mobile learning support tools

Illiteracy is often associated with people in developing countries. However, an estimated 50 % of adults in a developed country such as Canada lack the literacy skills required to cope with the challenges of today's society; for them, tasks such as reading, understanding, basic arithmetic, and using everyday items are a challenge. Many community-based organizations offer resources and support for these adults, yet overall functional literacy rates are not improving. This is due to a wide range of factors, such as poor retention of adult learners in literacy programs, obstacles in transferring the acquired skills from the classroom to the real life, personal attitudes toward learning, and the stigma of functional illiteracy. In our research we examined the opportunities afforded by personal mobile devices in providing learning and functional support to low-literacy adults. We present the findings of an exploratory study aimed at investigating the reception and adoption of a technological solution for adult learners. ALEX© is a mobile application designed for use both in the classroom and in daily life in order to help low-literacy adults become increasingly literate and independent. Such a solution complements literacy programs by increasing users' motivation and interest in learning, and raising their confidence levels both in their education pursuits and in facing the challenges of their daily lives. We also reflect on the challenges we faced in designing and conducting our research with two user groups (adults enrolled in literacy classes and in an essential skills program) and contrast the educational impact and attitudes toward such technology between these. Our conclusions present the lessons learned from our evaluations and the impact of the studies' specific challenges on the outcome and uptake of such mobile assistive technologies in providing practical support to low-literacy adults in conjunction with literacy and essential skills training. © 2013 Her Majesty the Queen in Right of Canada.

“Showing off” your mobile device:adult literacy learning in the classroom and beyond

For a very large number of adults, tasks such as reading. understanding, and using everyday items are a challenge. Although many community-based organizations offer resources and support for adults with limited literacy skills. current programs have difficulty reaching and retaining those that would benefit most. In this paper we present the findings of an exploratory study aimed at investigating how a technological solution that addresses these challenges is received and adopted by adult learners. For this, we have developed a mobile application to support literacy programs and to assist low-literacy adults in today's information-centric society. ALEX© (Adult Literacy support application for Experiential learning) is a mobile language assistant that is designed to be used both in the classroom and in daily life in order to help low-literacy adults become increasingly literate and independent. Through a long-term study with adult learners we show that such a solution complements literacy programs by increasing users' motivation and interest in learning, and raising their confidence levels both in their education pursuits and in facing the challenges of their daily lives.