Daniel W. O'Connor

The efficacy of psychosocial approaches to behaviour disorders in dementia: a systematic literature review

Objective: This paper provides a systematic review of research findings published between 1989 and 1998 concerning non-pharmacological strategies to alleviate behavioural disturbances in elderly persons with dementia. Method: Data collection strategies included computer literature searches, manual searches of selected journals and checks of references listed in previous reviews. To warrant inclusion, studies were required to include some measure of behaviour before and after the introduction of an intervention. Papers were appraised in the following domains: design, sampling technique, setting, behaviours studied, measurement tools, data collection methods, type of interventions and feasibility. An overall validity rating was assigned to each article using predetermined rules. Results: Forty-three studies met criteria for inclusion including five randomised controlled trials. Validity ratings were as follows: one strong, 15 moderate, and 27 weak. Areas of scientific weakness included small numbers of subjects, inadequate descriptions of study participants, imprecise data collection methods, high attrition rates and insufficient statistical analysis. Despite this, there is evidence to support the efficacy of activity programs, music, behaviour therapy, light therapy, carer education and changes to the physical environment. The evidence in favour of multidis-ciplinary teams, massage and aromatherapy is inconclusive. Conclusions: It was easier to interpret the results of rigorously designed studies that focused on a single behaviour or single intervention tailored to the needs of individuals and carers. Future studies should seek to replicate the findings outlined here, improving methodologies where necessary and including outcome measures that encompass the interests of people with dementia, family caregivers and health professionals.

Vascular Risks and Incident Dementia: Results from a Cohort Study of the Very Old

The contribution of vascular pathology to the manifestation of dementia and the importance of vascular risk to measures of cognitive function is being increasingly recognized. In particular, confirmation of this risk points towards approaches for prevention in large sections of the population. Information on determinants of incident dementia is increasing, but still relatively few studies of risk have been based on incident cases of dementia in very elderly populations. In this study based on incident cases of dementia in a population aged 75 and over, vascular risks were obtained from informants of the respondents with incident dementia. When compared with controls the factors associated with incident dementia were history of heart attack (odds ratio 2.9), transient ischaemic attacks (4.8), cerebrovascular accidents (3.4), family history of first-degree relatives with dementia (4.0), and occupational exposure to vibrating instruments (1.4). If only Alzheimer’s disease, clinically diagnosed, was included, diabetes (1.4) and a history of dementia in first-degree relatives (6.6) emerged. Thus, vascular risk continues to be of importance in the oldest age groups.

Population norms for the MMSE in the very old Estimates based on longitudinal data

Objective To report the percentile distribution of Mini-Mental State Examination (MMSE) scores in older people by age, sex, and education level, estimated from longitudinal data, after correcting for loss due to dropout. Methods The Cambridge City over 75 Cohort is a population-based study of a cohort of 2106 subjects age 75 years and older at study entry followed up over 9 years. At each of the four waves, cognitive function was assessed using MMSE. Based on these data, the relationship between age and MMSE score was modeled. Percentile distributions by age, sex, and education level were provided using inverse probability weighting to correct for dropouts. Results Performance on MMSE was related to age in men and women. In women, at age 75, MMSE score ranged from 21 (10th percentile) to 29 (90th percentile). At age 95, the range was 10 (10th percentile) to 27 (90th percentile). The upper end of MMSE distribution was slightly modified with age, whereas the lower end of the distribution was very sensitive to age effect. A similar pattern was observed in both sexes. Conclusion These findings provide norms for MMSE scores in subjects age 75 years and older from longitudinal population-based data. Such norms can be used as reference values to determine where an individuals score lies in relation to his or her age, sex, and education level.

Neuropathological Findings in the Very Old: Results from the First 101 Brains of a Population-based Longitudinal Study of Dementing Disorders

Abstract: We report a unique longitudinal epidemiological study of cognitive decline in the elderly population of the city of Cambridge, UK. A population sample of people aged 75 and over was surveyed between 1984–1996 (n= 2,616) and followed 2.4, 6, and 9 years later. CAMDEX diagnostic criteria were used for clinical assessment, and the neuropathological protocol (in 101 cases) was based on the CERAD method, with additional features to allow Braak staging of neurofibrillary pathology. The main findings are of the heterogeneity of lesions to be found in very old populations, and the existence of considerable overlap in the pathologies found in the demented and nondemented. It seems that white matter (ischemic) pallor an amyloid angiopathy, as well as neuritic plaques, neurofibrillary tangles and Lewy body formation are all lesions that increase the likelihood of dementia.

Estimating the true extent of cognitive decline in the old old

OBJECTIVE: To measure cognitive change using a brief measure over a period of 9 years and to adjust for attrition in the sample.

Do older Australians truly have low rates of anxiety and depression? A critique of the 1997 National Survey of Mental Health and Wellbeing

This paper sets out to critically evaluate reports from the Australian-wide National Survey of Mental Health and Wellbeing of very low rates of ICD-10 anxiety and depressive disorders in community resident older Australians. Data from the National Survey, which relied on the Composite International Diagnostic Interview (CIDI) were re-computed and re-analysed to address concerns about population sampling, interview response patterns and alternate measures of mental health. Rates of anxiety and depressive disorders fell to low levels after 65 years and continued to fall thereafter. This is at odds with findings from gerontological surveys that used assessment tools better suited to frail older people. Scores on mental health scales, together with diagnostic algorithms that obviated CIDI skip patterns, showed much less change in mental wellbeing across generations. It is argued that sampling and case ascertainment bias combined to reduce rates of anxiety and depression in very old people, especially when adjustments are made for the high morbidity levels encountered in aged residential facilities. Functional mental disorders almost certainly rise in frequency in advanced old age, often in conjunction with dementia.

Correlates of aggressive behavior in dementia

BACKGROUND AND OBJECTIVE A review of current literature was undertaken in order to summarize some of the possible biopsychosocial contributions to the development of aggressive behavior in elderly people with dementia. It was intended that such a summary would provide a useful clinical aid when assessing patients with behavioral symptoms and a starting point for undertaking research in this area. METHOD Information was gathered from literature searches conducted on several occasions between 1995 and 2001 using 3 databases (Medline, CINHAL and PsycINFO), as well as journals and books available from the libraries of the authors and from Monash University, Melbourne, Australia. RESULTS Associations between various conditions and the development of aggressive behavior were found, including the contributions of degrees of cognitive impairment, personality, sensory change, physical illness, language impairment, brain pathology, affective and psychotic disorders. The role of gender, sexuality and disruption of circadian rhythms is also discussed, as is the importance of environmental factors. CONCLUSION Identification of correlates of aggressive behavior may assist clinicians to understand and manage aggressive behavior more effectively.

Efficacy of Psychosocial Treatments for Noisemaking in Severe Dementia

Noisemaking is one of the most disturbing behavior disorders associated with dementia. Standard management practices, including pharmacological interventions, are not very successful in treating the behavior. Very little research has been carried out to evaluate innovative treatments or to determine the etiology of noisemaking. In this article, we report on a series of 12 case studies in which we tested the efficacy of some psychosocial interventions in reducing the frequency of noisemaking in long-term-care residents with severe dementia. Interventions were contingent reinforcement of quiet behavior and environmental stimulation tailored to individual preferences. Of the 12 patients recruited into the study, 2 died during the course of observations, 3 were not observed to be as noisy as reported by staff, and 3 showed a clear reduction in noise during the intervention period. Four patients did not show any overall reduction in noisemaking during psychosocial interventions. Future research could differentiate between types of interventions in successful cases and attempt to control further for the consistent application of interventions by long-term-care staff.

Apolipoprotein E Genotype in the Prediction of Cognitive Decline and Dementia in a Prospectively Studied Elderly Population

An increased apolipoprotein E (ApoE) type epsilon 4 allele frequency is associated with both sporadic and familial late-onset Alzheimers disease (AD). The age of onset of disease in patients homozygous for the epsilon 4 allele appears to be decreased by approximately 15 years compared with E2/3 individuals. In order to assess the influence of this allele on both dementia and cognitive decline in the elderly we have determined the ApoE genotype of 150 individuals over the age of 75 years who have taken part in a longitudinal study. Homozygosity for the epsilon 4 allele was rare. Of the 2 homozygotes, 1 was severely demented but the other did not receive a clinical diagnosis of dementia. The latter individual did demonstrate marked cognitive decline over a 28-month period. There was a consistent association between the presence of an epsilon 4 allele and both the clinical diagnosis of dementia and cognitive decline. These findings confirm a genetic heterogeneity in late-onset sporadic AD and prompt caution in the use of ApoE genotype to predict an elderly individuals susceptibility to either dementia or cognitive decline.

Mental health scales and psychiatric diagnoses: Responses to GHQ-12, K-10 and CIDI across the lifespan

BACKGROUND Surveys based on complex interviews like CIDI report very low rates of affective disorder in older people, perhaps because the lengthy, convoluted questions present a special challenge to aged respondents. By contrast, mental health scales like the GHQ-12 and K-10 show much less change in score with age. Before concluding that scales present a fairer picture of aged mental health, it is important to check if scores are inflated by items that might reflect normal involutional changes in cognition, energy and social role. METHODS Secondary analysis of an Australian national survey of 10,641 adults. RESULTS GHQ-12 and K-10 scores declined with age to a relatively minor degree. When scores were bisected, the proportion of respondents scoring above the cutpoints fell with age but to a lesser degree than with ICD-10 diagnoses. Scores on GHQ-12 and K-10 items relating to cognition, energy and social role rose with age but, on factor analysis, these items loaded similarly in a two-factor model. CONCLUSION No evidence emerged of age-related bias in either GHQ-12 or K-10. Items concerning cognition, energy and social role were associated with affect in older people, just as they were in younger ones. It seems unlikely therefore that the different trajectories over the lifespan of CIDI diagnoses and scores on GHQ-12 and K-10 are due to limitations within the scales. The possibility that CIDI minimizes affective disorder in older age-groups cannot be discounted. LIMITATIONS Residents of aged care facilities and those with low cognitive scores were excluded.