Anton Svendrovski

Effects of centrally acting angiotensin converting enzyme inhibitors on functional decline in patients with Alzheimer's disease.

BACKGROUND Centrally acting angiotensin converting enzyme inhibitors (CACE-Is) are associated with reduced rates of cognitive decline in patients with dementia. CACE-Is may also improve exercise tolerance in functionally impaired older adults with normal cognition, suggesting that CACE-Is may positively influence activities of daily living (ADL) in dementia. OBJECTIVE To compare rates of decline in patients with mild to moderate Alzheimers disease (AD) receiving CACE-Is to those not currently treated with CACE-Is (NoCACE-I), included in the Doxycycline and Rifampicin for Alzheimers Disease study (n = 406). METHODS Patients were included if baseline and end-point (twelve months apart) scores were available for measures including the Standardized Alzheimers Disease Assessment Scale - Cognitive Subscale; Quick Mild Cognitive Impairment screen; Clinical Dementia Rating Scale (CDR-SB), and Lawton-Brody ADL Scale. RESULTS There was a significant, 25% difference (median one-point) in the 12-month rate of decline in ADL scores in patients taking CACE-Is (n = 91), compared to the NoCACE-I group (n = 274), p = 0.024. This remained significant after adjusting for age, gender, education, and blood pressure, p = 0.034. When individual CACE-Is were compared to the NoCACE-I group, a significant reduction in the rate of decline in ADLs (median one versus four points), were only observed for perindopril, p = 0.01. The CDR-SB was also reduced (median one-point) for the perindopril compared to the NoCACE-I group, p = 0.04. CONCLUSION This observational study suggests that CACE-Is, and potentially perindopril in particular, are associated with a reduced rate of functional decline in patients with AD, without an association with mood or behavior. This suggests that CACE-Is may slow disease progression in AD.

The Quick Mild Cognitive Impairment screen correlated with the Standardized Alzheimer's Disease Assessment Scale–cognitive section in clinical trials

OBJECTIVES The Alzheimers Disease Assessment Scale-cognitive section and its standardized version (SADAS-cog) are the current standard for assessing cognitive outcomes in clinical trials of dementia. This study compares a shorter cognitive instrument, the Quick Mild Cognitive Impairment (Qmci) screen, with the SADAS-cog as outcome measures in clinical trials. STUDY DESIGN AND SETTING The SADAS-cog, Qmci, Clinical Dementia Rating (CDR) scale, and the Lawton-Brady activities of daily living (ADL) scale were assessed at multiple time points, over 1 year in a multicenter randomized clinical trial of 406 patients with mild to moderate Alzheimers dementia. Correlations were estimated using regression at each time point, all time points, and mean values across time. Responsiveness was assessed using the standardized response mean (SRM). RESULTS Regression for pooled time points showed strong and significant correlation between the SADAS-cog and Qmci (r = -0.75, P < 0.001). Correlations remained strong for mean values across time and at each time point. The SADAS-cog and Qmci also correlated with CDR and ADL scores. There was no difference in SRMs between the SADAS-cog and Qmci [t(357) = -0.32, P = 0.75]. CONCLUSION The Qmci correlated strongly with the SADAS-cog and both were equally responsive to deterioration. We suggest that clinicians and investigators can substitute the shorter Qmci for the SADAS-cog.

Validation of the Turkish Version of the Quick Mild Cognitive Impairment Screen

Background: The objective of this study was to validate the Turkish version of the Quick Mild Cognitive Impairment (Qmci-TR) screen. Methods: In total, 100 patients aged ≥65 years referred to a geriatric outpatient clinic with memory loss were included. The Qmci was compared to the Turkish versions of the standardized Mini-Mental State Examination and the Montreal Cognitive Assessment (MoCA). Results: The Qmci-TR had higher accuracy than the MoCA in discriminating subjective memory complaints (SMCs) from cognitive impairment (mild cognitive impairment [MCI] or dementia), of borderline significance after adjusting for age and education (P = .06). The Qmci-TR also had higher accuracy than the MoCA in differentiating MCI from SMC, which became nonsignificant after adjustment (P = .15). A similar pattern was shown for distinguishing MCI from dementia. Test reliability for the Qmci-TR was strong. Conclusion: The Qmci-TR is a reliable and useful screening tool for discriminating MCI from SMC and dementia in a Turkish population.

The Community Assessment of Risk Instrument: Investigation of Inter-Rater Reliability of an Instrument Measuring Risk of Adverse Outcomes.

BACKGROUND Frailty is increasingly common in community dwelling older adults and increases their risk of adverse outcomes. Risk assessment is implicit in the Aged Care Assessment Teams process, but few studies have considered the factors that influence the assessors decision making or explored the factors that may contribute to their interpretation of risk. OBJECTIVE to examine the inter-rater reliability of the Community Assessment of Risk Instrument (CARI), which is a new risk assessment instrument. DESIGN A cohort study was used. SETTING AND PARTICIPANTS A sample of 50 community dwelling older adults underwent comprehensive geriatric assessment by two raters: a geriatrician and a registered nurse. Procedure and measurements: Each participant was scored for risk by the two raters using the CARI. This instrument ranks risk of three adverse outcomes, namely i) institutionalisation, ii) hospitalisation and iii) death within the next year from a score of 1, which is minimal risk to 5, which is extreme risk. Inter-rater reliability was assessed with Gamma, Spearman correlation and Kappa statistics. Internal consistency was assessed with Cronbachs alpha. RESULTS There were 30 female (mean age 82.23 years) and 20 male (mean age 81.75 years) participants. Items within domains showed good-excellent agreement. The gamma statistic was >0.77 on 6/7 Mental State items, 14/15 items in the Activities of Daily Living domain. In the Medical domain, 6/9 items had Gamma scores >0.80. The global domain scores correlated well, 0.88, 0.72 and 0.87. Caregiver network scores were 0.71, 0.73 and 0.51 for the three domains. Inter-rater reliability scores for global risk scales were 0.86 (institutionalisation) and 0.78 (death). The gamma statistic for hospitalisation was 0.29, indicative of lower inter-rater reliability. Cronbachs alpha was 0.86 and 0.83 for the Activities of Daily Living domain, 0.51 and 0.42 for the Mental state domain and 0.23 and 0.10 for the Medical state domain. CONCLUSIONS Overall, the instrument shows good inter-rater reliability. Poor correlations on some items relate to poor communication of clinical data and variable interpretation based on professional background. Lack of internal consistency in the medical condition domain confirms the discrete nature of these variables.

Comparison of the Quick Mild Cognitive Impairment (Qmci) screen to the Montreal Cognitive Assessment (MoCA) in an Australian geriatrics clinic

The Montreal Cognitive Assessment (MoCA) accurately differentiates mild cognitive impairment (MCI) from mild dementia and normal controls (NC). While the MoCA is validated in multiple clinical settings, few studies compare it with similar tests also designed to detect MCI. We sought to investigate how the shorter Quick Mild Cognitive Impairment (Qmci) screen compares with the MoCA.

The Community Assessment of Risk and Treatment Strategies (CARTS): An Integrated Care Pathway to Manage Frailty and Functional Decline in Community Dwelling Older Adults

The Community Assessment of Risk & Treatment Strategies (CARTS) is an evolving integrated care pathway for community-dwelling older adults, designed to screen for and prevent frailty through the use of innovative, novel targeted risk screening instruments, comprehensive geriatric assessment, tailored interventions and integrated patient-centred multi-disciplinary monitoring. This multimodal service aims to positively affect risk and frailty transitions, to reduce adverse healthcare outcomes and achieve the European Innovation Partnerships on Active and Healthy Ageing’s (EIP-AHA) goal of improved healthy life years. The CARTS programme builds on the activities and deliverables defined within Action Plan A3 of the EIP-AHA ‘Prevention and early diagnosis of frailty, both physical and cognitive, in older people’, aiming to use information and communications technology (ICT) to facilitate its implementation in clinical practice. The CARTS instruments have been piloted in Ireland as well as in Portugal, Spain and Australia. An update on the research conducted to date and future plans are presented.

Screening for cognitive impairment in an Australian aged care assessment team as part of comprehensive geriatric assessment

ABSTRACT Accurate detection of mild cognitive impairment (MCI) is important to stratify and address risk. Yet, few short cognitive screening instruments are validated for this. . In Australia, all clients referred to an Aged Care Assessment Team (ACAT) receive comprehensive geriatric assessment (CGA) including the Standardized Mini-Mental State Examination (SMMSE). We compared the accuracy of the quick mild cognitive impairment (Qmci) screen to the SMMSE in 283 participants: 195 with dementia, 47 with MCI, and 41 with subjective cognitive decline (SCD) in an Australian community-based ACAT. Both had similar accuracy in identifying dementia, AUC of 0.86 for the Qmci versus 0.93 for the SMMSE (p = 0.10), but the Qmci was more accurate than the SMMSE in differentiating MCI from SCD, AUC of 0.84 versus 0.71, respectively, p = 0.046. These suggest that the new, short (3–5 min) Qmci screenis appropriate for use in an ACAT or other units conducting CGA.

Measuring staff perception of end-of-life experience of older adults in long-term care

BACKGROUND Quality of dying and death receive far less attention than quality of life. Measuring the quality of care at end-of-life (EOL) in long-term care (LTC) is essential, to ensure high standards. METHODS A questionnaire measuring staff perception of their patients end of life experience (SPELE) was developed. Content validity (CVI) was assessed by a panel of experts, and piloting was conducted with dyads of healthcare assistants (n=15) and nurses (n=15). RESULTS The SPELE captures facets of the quality of the death and dying experience from healthcare staffs perspective. Good group inter-rater reliability was observed among subscales. One exception was the pain and symptom experience scale. Kappa values showed little agreement between nurses and healthcare assistants for certain symptoms, including pain. CONCLUSION Further testing of the questionnaire is required. However it is described as a useful mechanism to enable researchers and clinicians to explore quality of care at EOL.

The inter-rater reliability of the Risk Instrument for Screening in the Community

Predicting risk of adverse healthcare outcomes is important to enable targeted delivery of interventions. The Risk Instrument for Screening in the Community (RISC), designed for use by public health nurses (PHNs), measures the 1-year risk of hospitalisation, institutionalisation and death in community-dwelling older adults according to a five-point global risk score: from low (score 1,2) to medium (3) to high (4,5). We examined the inter-rater reliability (IRR) of the RISC between student PHNs (n=32) and expert raters using six cases (two low, medium and high-risk), scored before and after RISC training. Correlations increased for each adverse outcome, statistically significantly for institutionalisation (r=0.72 to 0.80, p=0.04) and hospitalisation (r=0.51 to 0.71, p<0.01) but not death. Training improved accuracy for low-risk but not all high-risk cases. Overall, the RISC showed good IRR, which increased after RISC training. That reliability fell for some high-risk cases suggests that the training programme requires adjustment to improve IRR further.