Charles Scerri

Strategic roadmap for an early diagnosis of Alzheimer's disease based on biomarkers

The diagnosis of Alzheimers disease can be improved by the use of biological measures. Biomarkers of functional impairment, neuronal loss, and protein deposition that can be assessed by neuroimaging (ie, MRI and PET) or CSF analysis are increasingly being used to diagnose Alzheimers disease in research studies and specialist clinical settings. However, the validation of the clinical usefulness of these biomarkers is incomplete, and that is hampering reimbursement for these tests by health insurance providers, their widespread clinical implementation, and improvements in quality of health care. We have developed a strategic five-phase roadmap to foster the clinical validation of biomarkers in Alzheimers disease, adapted from the approach for cancer biomarkers. Sufficient evidence of analytical validity (phase 1 of a structured framework adapted from oncology) is available for all biomarkers, but their clinical validity (phases 2 and 3) and clinical utility (phases 4 and 5) are incomplete. To complete these phases, research priorities include the standardisation of the readout of these assays and thresholds for normality, the evaluation of their performance in detecting early disease, the development of diagnostic algorithms comprising combinations of biomarkers, and the development of clinical guidelines for the use of biomarkers in qualified memory clinics.

Mediterranean diet and dementia of the Alzheimer type.

Dementia of the Alzheimer type is the most common form of dementia affecting mostly the elderly population. It is a progressive and fatal neurodegenerative disorder with characteristic neuropathology and clinical symptomology. In the coming years, the number of individuals with Alzheimers disease (AD) will increase as the elderly population worldwide is expected to grow significantly thus putting an added strain on national health care systems as well as caregivers who will inevitably carry most of the care burden. Thus it has been suggested that early intervention strategies which delay or halt the disease progression will have a strong impact on clinical outcomes. Changes in lifestyle habits such as diet modification or supplementation have been indicated as probable protective factors for a number of chronic conditions including AD. Particular attention has recently been devoted to the Mediterranean diet which is rich in the antioxidants Vitamins C and E, polyunsaturated fatty acids and polyphenolic compounds. Several in vitro, animal and population-based studies reported a positive effect between adherence to a Mediterranean diet and AD prevention, although contrasting views remain. This review will focus on the latest developments and findings in the ongoing research investigating the relationship between Mediterranean diet and its major constituents in AD onset and progression.

Practices in diagnosis, disclosure and pharmacotherapeutic management of dementia by general practitioners--a national survey.

Objectives: To explore the practice patterns of general practitioners (GPs) for the diagnosis, disclosure and pharmacological management of individuals with dementia. We also investigated whether the number of years working in general practice is a determinant factor associated with the responses obtained. Method: A national survey was sent to all registered GPs in the Maltese islands. The return rate was 54.2% with the majority of respondents having 15 years or more working experience in general practice. Chi-square analysis of variance was used to determine any relationship effects. Results: Although the majority of GPs indicated lack of competence in diagnosing dementia, only a small percentage showed a preference towards specialist referral. Lack of training was mostly envisaged by physicians with the least number of years in general practice. Significant differences in pharmacotherapeutic prescribing were noted depending on the stage of disease progression and the number of years working as a GP. Disease disclosure was not routinely carried out even though GPs were aware of the fact that disclosure may help individuals with dementia and their caregivers or relatives with future planning. Conclusion: The findings show notable shortcomings in various aspects of dementia management by GPs. This highlights the need of providing continued educational support and training opportunities to enhance not only GPs’ clinical competence, but also their role as key players in providing quality support to individuals with dementia in the primary care setting.

The organisation of dementia care by families in Malta : the experiences of family caregivers

This paper discusses the experiences of dementia family caregivers in Malta. The study design was essentially exploratory as this is the first funded social research on dementia in the island of Malta. In-depth semi-structured interviews were conducted in October 2008 with 17 caregivers. Identification of caregivers was through their relatives’ attendance at a hospital based outpatient memory clinic. Interviews were recorded, transcribed and when required, phrases were translated from Maltese to English. A thematic analysis was guided by the questions; What are the experiences of family caregiving in Malta? And what impact does caregiving have for individual/family life? Three key findings are discussed, namely: the organization of family care in Malta; the use of formal services; and the dislocation of dementia caregiving experiences from wider community life. This paper raises questions about support mechanisms currently available in Malta while presenting cross-national learning opportunities to apply established knowledge to the Maltese context.

Nicotine modifies in vivo and in vitro rat hippocampal amyloid precursor protein processing in young but not old rats

Previous studies have shown that administration of nicotine modifies the expression and secretion of amyloid precursor protein (APP) in various cell lines. The present study investigated the extent to which chronic subcutaneous nicotine administration influences APP levels and processing in cerebral cortex, striatum and hippocampus of young and old rat brains. The results showed that constant nicotine infusion (0.25 or 4.00mg/kg/day) increased the levels of particulate APP (APPp) but not secreted APP (APPs) in the hippocampus of young rats in vivo. This response to nicotine was not observed in the striatum or cerebral cortex of young rats or in any of the brain regions examined in old animals. Subsequent in vitro analysis demonstrated that nicotine enhanced the release of APPs from hippocampal slice preparations and that this increase was attenuated by mecamylamine, a non-selective nicotinic acetylcholine receptor (nAChR) antagonist. The in vitro effect of nicotine on APPs was age-related, being only detected from hippocampal slices derived from the young but not the older animals. These results suggest that nicotine modulates APP expression and secretion in the hippocampus and that the responses observed to the drug are age-dependent being only detected in younger rats.

Using appreciative inquiry to implement person-centred dementia care in hospital wards

The quality of care of persons with dementia in hospitals is not optimal and can be challenging. Moreover, staff may find difficulty in translating what they have learned during training into practice. This paper report the development and evaluation of a set of workshops using an appreciative inquiry approach to implement person-centred dementia care in two hospital wards. Staff worked collaboratively to develop a ward vision and to implement a number of action plans. Using appreciative inquiry approach, staff attitudes towards persons with dementia improved, inter-professional collaboration was enhanced and small changes in staff practices were noted. Dementia care in hospitals can be enhanced by empowering staff to take small but concrete actions after they engage in appreciative inquiry workshops, during which they are listened to and appreciated for what they can contribute.

Teamwork in healthcare organisations

The concept of teamwork represents the basis of a new paradigm and a shift from the traditional inter-professional boundaries. A questionnaire was developed to analyse potential benefits and/or limitations of teamwork, and to determine the importance and existence of this notion with the Maltese public healthcare organisation. Of the 200 questionnaires distributed through email amongst employees within the Ministry of Health, 92 responses were received, giving a response rate of 46.5%. Whereas 40.2% stated that teamwork does exist locally, a slight majority remarked that teamwork doesn’t exist. Approximately 98% affirmed that it would be beneficial for a healthcare organisation to embrace the concept of teamwork. The majority believe that barriers are a reality that inhibit effective teamwork and deem that intraprofessional learning would aid health professionals to work and provide care together. The results indicate that teamwork is an important issue within the contemporary healthcare organisation.

Outcomes in knowledge, attitudes and confidence of nursing staff working in nursing and residential care homes following a dementia training programme

ABSTRACT Objectives: Dementia training programmes for staff working in long-term care settings have been found to be effective in improving staff outcomes. This study investigated the impact of a dementia training programme for all Maltese nursing staff working in public nursing/residential homes on their knowledge, attitudes and confidence. Additionally, we identified the predictors of these domains before and after the programme. Method: A 14-hour training programme focusing on dementia management, care and policy was developed for all nursing staff working in public nursing and residential homes in Malta. A pretest-posttest design was used to evaluate the participants’ knowledge of dementia, attitudes and confidence in working with residents with dementia using validated tools. Demographic variables were measured and compared with each staff domain. Results: The majority of nursing staff attended the training programme with 261 fully completed questionnaires being collected pre-training and 214 post-training. The programme significantly improved nursing staff knowledge, attitudes and confidence. Stepwise regression analysis of each staff domain showed that the strongest predictor in all models at pre-training was the intensity of previous training programmes. Furthermore, staff who attended previous training continued to improve in their attitudes and confidence following programme completion. Conclusion: The study continues to shed further evidence on the impact of dementia training programs on staff outcomes. It also indicated that the intensity of previous participation in dementia training programmes was related to the participants’ knowledge, attitudes and confidence and that continual exposure to training had a cumulative effect.

Non-coding RNA influences in dementia

Dementia is a complex clinical syndrome characterised by progressive decline in cognitive function. It usually presents itself as impairment in memory, loss of judgement, abstract thinking and other disturbances that are severe enough to interfere with activities of daily living. It has long been considered as one of the major challenges at present posing an ever-increasing demand on global health and social care systems. Of all the different forms of dementia, Alzheimers disease (AD) is the most common. The term non-coding RNA (ncRNA) refers to RNA sequences which do not have the ability to be translated into proteins and therefore mainly fall within the realm of the recently acknowledged ‘dark matter’ of the genome. This genomic dark matter encompasses a whole spectrum of differing ncRNA families such as microRNAs (miRNAs), long non-coding RNAs (lncRNAs), PIWI-interacting RNAs (piRNAs), transfer RNAs (tRNAs), small nuclear RNAs (snoRNAs) and circular RNAs (circRNAs), to name but a few. Consequently, due to the widespread influences of miRNAs and lncRNAs across all disease pathways, it is of critical importance for researchers in the field of dementia to focus their attention on possible ncRNA-induced pathogeneses, with the ultimate goal of identifying novel diagnostic procedures and drug targets, together with the development of novel therapies to control such a devastating mental condition in the patient population.

Training Older Adults about Alzheimer's Disease--Impact on Knowledge and Fear.

ABSTRACT Although the impact of Alzheimer’s disease training programs directed to informal and formal caregivers has been extensively studied, programs for older adults who do not have the disease are relatively few. Moreover, increased knowledge increases fear of the disease, even though there is little empirical evidence to support this. This study investigated the impact of an Alzheimer’s disease training program for older persons on their knowledge and fear of the condition. Participants consisted of 110 older adults who voluntarily applied for a 16-hour course as part of the University of the Third Age. A questionnaire, consisting of two validated tools (Alzheimer’s Disease Knowledge Scale and the Fear of Alzheimer’s Disease Scale), was distributed pre- and posttraining to the participants. Sixty-six questionnaires (response rate = 60%) were collected at the start of the program and 46 at the end (response rate = 42%). Participants’ fear at pretraining was significantly related to their current knowledge of the disease. Training significantly improved knowledge of the disease, but the participants’ perceived fear did not change. The study indicated that an Alzheimer’s disease training program for older persons can increase their knowledge, but it does not necessarily increase their fear. Training programs aimed at raising awareness of Alzheimer’s disease should target more effectively this age cohort who may be concerned and are seeking learning opportunities to know more about the condition.