Cynthia Barton

Potentially Inappropriate Medication Use in Older Adults With Mild Cognitive Impairment

BACKGROUND Patients with mild cognitive impairment (MCI) may be especially vulnerable to the side effects of potentially inappropriate medications (PIMs), especially those that impair cognition. METHODS We conducted a cross-sectional study to determine the prevalence of PIM use among 689 patients with MCI. We used the 2003 Beers Criteria for cognitive impairment to identify PIMs. We then determined if certain patients were more likely to use PIMs. RESULTS There were 143 (20.8%) patients with MCI taking a PIM: 108 (15.7%) patients were taking one PIM and 35 (5.1%) patients were taking two or more PIMs. The most common PIMs were anticholinergics (35.7%) and benzodiazepines (31.5%). Patients were more likely to be taking PIMs if they were women and were taking a greater number of medications and less likely if they had a history of myocardial infarction. CONCLUSIONS Patients with MCI are frequently taking PIMs that may negatively affect cognition. Future research is needed to assess whether cognitive impairment symptoms are improved if PIM use is reduced.

Video-Telemedicine in a Memory Disorders Clinic: Evaluation and Management of Rural Elders with Cognitive Impairment

OBJECTIVE Telemedicine is increasingly being used to provide consultation for healthcare in rural areas. Little work has been done with dementia although preliminary research suggests that clinical diagnosis performed via telemedicine consultation is valid. We implemented a program to provide multidisciplinary, state-of-the-art diagnosis of cognitive impairment by video-telemedicine (VTM) integrated into a clinical setting. METHODS Patients at a rural veterans community clinic were referred by their local provider for evaluation of memory complaints by the multidisciplinary team of the San Francisco Veterans Administration (SFVA) Memory Disorders Clinic (MDC). The evaluation was integrated into the usual clinic structure and included a neurological evaluation and neuropsychological testing by the MDC team via video assisted by a remote clinician at the community clinic. RESULTS We evaluated 15 new patients referred to our multidisciplinary clinic. In each case, the VTM format permitted the MDC team to arrive at a working diagnosis; 12 patients with dementia, two with mild cognitive impairment, and one cognitively normal. Relevant treatment recommendations were made to the patients and caregivers. The evaluation results were discussed with providers who joined the MDC postclinic conference via VTM. In the majority of cases, recommendations were followed and there was satisfaction with VTM by providers and patients. CONCLUSIONS VTM is emerging as an effective way to provide consultation and care to rural residents who may not have access to specialty services and can be integrated into current clinical settings.

Treatment Practices of Mild Cognitive Impairment in California Alzheimer's Disease Centers

OBJECTIVES: To examine “real world” treatments for patients with mild cognitive impairment (MCI).

The Experience of Caregiving: Differences Between Behavioral Variant of Frontotemporal Dementia and Alzheimer Disease

OBJECTIVE To examine caregiver strain, depression, perceived sense of control, and distress from patient neuropsychiatric symptoms in family caregivers of persons with Alzheimer disease (AD) and behavioral variant of frontotemporal dementia (bvFTD) and determine whether group differences exist. METHODS Family caregivers were recruited from the Memory and Aging Center in San Francisco, California. Analyses of cross-sectional data on 53 family caregivers (AD = 31, bvFTD = 22) were performed. The Mann-Whitney U test was used to contrast groups. RESULTS There were statistically significant differences between the AD and bvFTD caregivers in strain, distress, and perceived control but not in depression. On average, bvFTD caregivers experienced greater strain and distress, more depressive symptoms, and lower perceived control. CONCLUSIONS Findings support that experiences of AD and bvFTD caregivers may differ. Further study is needed to identify possible explanatory factors for these group differences.

Functional deficits among patients with mild cognitive impairment.

Diagnostic criteria for mild cognitive impairment (MCI) include no significant functional decline, but recent studies have suggested that subtle deficits often exist. It is not known whether these differ by MCI type. We investigated the level and type of functional impairment among patients with MCI.

Implementation of advanced practice nurse clinic for management of behavioral symptoms in dementia: A dyadic intervention (innovative practice)

Behavioral symptoms are common in all types of dementia and often result in significant caregiver stress and illness, institutionalization of the patient, and reduced quality of life for the patient and caregiver. Health care practitioners often lack the expertise or time to adequately assess behavioral symptoms or counsel caregivers about interventions. Our goal was to implement a specialty clinic managed by advanced practice nurses to assess and manage behavioral symptoms associated with dementia. The clinic evaluations consisted of an assessment of the patient by the Nurse Practitioner during the time that the family caregiver(s) was interviewed by the Clinical Nurse Specialist and focused on an assessment of the cognitive and functional abilities of the patient, identification of triggers for the problematic behaviors, and assessment of caregiver coping. We evaluated 66 dyads since implementation in February 2010. The patients were primarily female, Caucasian, 74.3 years of age with Alzheimer’s disease. The majority of caregivers were spouses (n = 44) followed by adult children (n = 20) and then siblings (n = 2). Targeted interventions were developed and caregiver counseling, support, and education were an integral part of the consultation and included written information, video instruction, and internet resources. Evaluations indicated caregivers and referring providers found the appointment helpful in managing behavioral symptoms and caregiver stress.

Evaluation of the diagnosis and management of cognitive impairment in long-term care.

&NA; The objective was to determine the prevalence of screening for cognitive impairment and its effect on diagnosis and management of cognitive impairment in a long‐term care setting, especially in comparison to depressive and behavioral symptoms. The study was a prospective cohort study of medical records of 60 patients admitted to the 120 bed Veterans Administration Nursing Home in San Francisco. Screening was determined by documented results on the Mini‐Mental Status Examination, Geriatric Depression Scale, and Minimum Data Set. Diagnosis and management were determined by review of medical records for provider documentation. Strategies for management were broad, including interventions such as pharmacological therapy, education, behavioral strategies, or caregiver interventions. Screening was conducted routinely for cognitive impairment (95%), depressive symptoms (95%), and behavioral symptoms (85%). Cognitive status was uncertain in 8 patients; 23 (44%) met criteria for cognitive impairment. Twelve (52%) had a differential diagnosis of cognitive impairment and 11 (48%) had evidence of strategies for management. Depressive and behavioral symptoms were equally or almost as common as cognitive impairment (44% and 25%, respectively), but evidence of a management plan was more frequently present (80% and 100%; p = 0.002 vs. with cognitive impairment). Although depressive and behavioral symptoms were frequently diagnosed and interventions initiated, the diagnosis and management of cognitive impairment were often imprecise or absent. Further research is needed to identify barriers to diagnosis and management so that greater numbers of patients can benefit from recommended strategies.

Profiles of apathy: Different features among patients with frontotemporal lobar degeneration and Alzheimer's disease

with Alzheimer’s disease identified through an innovative case-finding program in 5 community in Indo-Nepal Border, we obtained information on the range of care arrangements, attitudes towards care giving roles and sources of strain. Results: The majority of caregivers were young women, often daughters-in-law of women with dementia. The principal sources of caregiver strain were behavioural problems associated with the dementia syndrome, and incontinence. Strain was exacerbated by the lack of supportive response by local health services, and by lack of support and, sometimes, criticism from other family members. Family conflict was commonly encountered. The majority of caregivers experienced significant deterioration in their mental health. One caregiver unfortunately committed suicide after the death of her husband. Conclusions: There is a clear need for more education, advice and support for families affected by dementia. Community services in developing countries should consider training existing domiciliary outreach services, the community-based multi-purpose health workers, to identify and support family caregivers, which is urgent need in developing country.