Isabelle Rouch

Natural history of decline in instrumental activities of daily living performance over the 10 years preceding the clinical diagnosis of dementia: a prospective population-based study.

OBJECTIVES: To study the subtle changes in instrumental activities of daily living (IADLs) over the 10 years preceding the clinical diagnosis of dementia.

Functional Impairment in Instrumental Activities of Daily Living: An Early Clinical Sign of Dementia?

OBJECTIVE: To estimate the predictive value of four IADLs on 3‐ and 5‐year incident dementia.

Occupation during life and risk of dementia in French elderly community residents

OBJECTIVE To determine whether principal occupation during life is a risk factor for incident Alzheimers disease, vascular dementia, or dementia with parkinsonism. METHODS This study was carried out from the PAQUID (Personnes Agées QUID) cohort, an epidemiological study on normal and pathological aging after 65 years in the south west of France. At baseline, 2950 non-demented people living at home were identified and re-examined 1, 3, 5, 8, and 10 years later with identical standardised neurological and neuropsychological measures. Cox proportional hazards models with delayed entry were used, taking age as the time scale and adjusting for sex, education, tobacco, and wine consumption to estimate the risk ratio (RR) of incident dementia, Alzheimers disease, vascular dementia, and dementia with parkinsonism associated with occupational category. RESULTS Of the 2950 subjects, 393 became demented, of whom 251 had Alzheimers disease, 112 had vascular dementia, and 27 had dementia with parkinsonism. The risk of Alzheimers disease was not related to a given occupation. However the risk of dementia with parkinsonism seemed to be increased in farmers in comparison with professionals and managerials, particularly among women (RR 7.47; 95%CI, 1.80–31.07). CONCLUSION The data suggest that occupation does not change the risk of Alzheimers disease, which seems to be more influenced by cognitive abilities in childhood and adolescence than by occupation in adult life. However, being a farmer may increase the risk of dementia with parkinsonism among women; occupation could act by the way of differences in health behaviour or in exposure to environmental factors.

Effects of Anticholinergic Drugs on Verbal Episodic Memory Function in the Elderly

BackgroundAn increasing number of medications that are frequently prescribed to elderly patients have been identified as having weak but definite anticholinergic properties. Few epidemiological studies have evaluated the impact of these drugs on verbal episodic memory using sensitive and specific neuropsychological testing in an elderly population presenting with cognitive impairment.ObjectivesThe aim of this study was to assess the effect of drugs with anticholinergic properties on verbal episodic memory function in elderly patients presenting for memory evaluation.Study DesignWe performed a retrospective, cross-sectional study that included 134 consecutive elderly outpatients who attended the daycare memory unit of Centre Hospitalier Sud, Lyon, France. We searched the MEDLINE database (1973–2008) to identify drugs with anticholinergic properties. All drugs with well known anticholinergic activity, mild reported anticholinergic effects or in vitro anticholinergic activity were included in the study.MeasurementsWe used the Free and Cued Selective Reminding (FCSR) test to evaluate verbal episodic memory.ResultsThe mean±SD number of drugs with anticholinergic properties taken by the subjects was 0.64±0.82. Fifty percent of the subjects (n = 67) had a prescription for at least one drug with anticholinergic properties and 16% (n = 21) had a prescription for two or more. Drugs with anticholinergic properties most frequently prescribed in our cohort were cardiovascular (furosemide, hydrochlorothiazide, digoxin), antidepressant (paroxetine, sertraline, fluoxetine) and antispasmodic (oxybutynin chloride) drugs. The number of drugs with anticholinergic properties that subjects were taking was associated with reduced performance on tasks that assessed verbal memory (p < 0.05). Neuropsychological test batteries revealed a significant unfavourable effect of use of drugs with anticholinergic activity on episodic verbal memory. Tests evaluating other cognitive functions were not affected by use of drugs with anticholinergic activity. These associations remained following multivariate analysis adjusting for age, sex, education level, number of anticholinergic drugs, number of co-morbidities, diagnosis, behavioural symptoms and depressive symptoms.ConclusionClinicians should assess the current use of drugs with anticholinergic properties in the elderly, particularly in patients presenting for memory evaluation. In such cases, use of other therapeutic alternatives should be considered.

Cognitive complaints, neuropsychological performance and affective disorders in elderly community residents

Background. Previous studies have assessed the relationship between subjective cognitive complaints and objective impairment. While some of them found that cognitive complaints were explained by affective disorders, other researches found a relationship between cognitive complaints and neuropsychological performance. Most of them focused on memory functioning. However, elderly normal adults also display a decline in executive functions. This study aimed to assess the relationship between cognitive complaints, objective memory and executive performance and affective disorders. Methods. This study was carried out with 937 community-dwelling elderly individuals recruited from the electoral list of the city of Saint-Etienne, France. Cognitive complaints were assessed using the MacNair scale. Cognitive performances were measured via a large battery of memory and executive-performance tests chosen for their capacity to detect subtle cognitive impairment. Anxiety and depressive symptoms were assessed using scales devised by Pichot and Goldberg. Results. Cognitive complaints were associated with lower scores on verbal-memory tests and several executive-performance tests. Moreover, affective disorders were related to some of the executive-performance test scores, but they were not related to scores on the Free and Cued Selective Reminding Test, Digit Symbol Substitution Test and Trail Making B scores. Conclusions. Cognitive complaints of the elderly can reflect objective memory and executive-performance impairments, independent of affective disorders. Cognitive complaints should be assessed using both memory and executive-performance tests.

Risk Factors of Caregiver Burden Among Patients with Alzheimer's Disease or Related Disorders: A Cross-Sectional Study

BACKGROUND Caregivers play a major role in the care of patients with dementia and are themselves at higher risk of disease. OBJECTIVES We investigate which factors are associated with caregivers burden of outpatients visiting a memory clinic and how functional autonomy and behavioral and psychological symptoms can influence caregiver burden. METHODS The study population was chosen from outpatients with progressive cognitive complaint. The caregiver burden was measured with the short version of the Zarit Burden Interview (ZBI). The relationship was assessed between the ZBI and the patients characteristics, including Neuropsychiatric Inventory (NPI), Instrumental Activities of Daily Living scale (IADL), the Mini-Mental State Examination (MMSE), etiology, and stage of the cognitive impairment. RESULTS In a population of 548 patients, IADL, NPI, antidepressant drugs, and MMSE were found to be related to ZBI, while diagnosed etiology and disease stage were not significant: ZBI decreased by 0.34 point for every unit of IADL, and by 0.03 point for every unit of MMSE; ZBI increased by 0.03 point for every unit of NPI. From the IADL scale, the ability to handle finances, food preparation, responsibility to take medications, mode of transportation, and ability to use the telephone increased the ZBI. Five areas of the NPI increased the ZBI: apathy, agitation, aberrant motor behavior, appetite disorders (p < 0.001), and irritability (p = 0.03). CONCLUSION Caregivers experience a higher burden due to disease symptoms such as impairment of functional autonomy and behavioral and cognitive impairment, whatever the etiology of the cognitive decline.

Autonomic nervous system activity is independently associated with the risk of shift in the non-dipper blood pressure pattern.

An insufficient decrease in nocturnal blood pressure (BP) is a known factor in cardiovascular mortality. We aimed to determine whether autonomic nervous system (ANS) activity and its change over 2 years were associated with a shift to non-dipper status, independently of initial BP, in a general elderly population. From participants in the PROOF study, 600 subjects untreated for hypertension were selected (age at baseline: 65 years, men: 41.5%). Dipper/non-dipper status was defined using repeated measures of 24-h ambulatory BP at baseline and 2 years later. ANS activity was evaluated on the basis of 24-h heart rate variability at both examinations. Among the 454 dipper subjects at baseline, 26.2% became non-dippers. Multivariate analysis showed that a +1 between-subject s.d. increase in the very low frequency at baseline was associated with a decreased odds ratio for the shift to non-dipper status 2 years later (OR=0.61 [0.41–0.91], P=0.02). The within-subject change between the two measurements of day and night systolic BP and day diastolic BP also contributed significantly to the risk of shift to non-dipper status. Our results suggest that impaired ANS activity precedes an insufficient decrease in nocturnal BP independent of hypertension status.

Diabetes, impaired fasting glucose, and cognitive decline in a population of elderly community residents

Background and aims: Diabetes and impaired fasting glucose, as well as cognitive impairment, are common in the elderly. Although several cross-sectional studies have demonstrated the influence of diabetes on cognitive impairment, only a few longitudinal studies have assessed the relationship between diabetes, impaired fasting glucose and cognitive decline in non-demented elderly community dwellers, by means of extensive neuropsychological batteries. The present study assesses the relationship between baseline diabetes, impaired fasting glucose (IFG) and 2-year evolution of memory, attention and executive performance in a sample of non-demented elderly subjects. Methods:Design: Population-based cohort study [(PROgnostic indicator OF cardiovascular and cerebrovascular events (PROOF)]. Participants: One hundred and sixty-three community dwellers aged 65 years without dementia at recruitment. Main outcome measures: Memory, attention and executive performance. Results: A significant association was observed between baseline diabetes mellitus and a higher 2-year decline in the Trial Making Test B and Stroop test exploring attention and executive function. This effect remained significant after adjusting for age, gender, education, anxiety and depressive symptoms, as well as other cardiovascular risk factors (F=2.41; p=0.007). Instead, no relationship was observed between IFG and cognitive decline. Conclusions: Our study showed that, in a sample of elderly non-demented community dwellers, diabetes mellitus (but not IFG) is associated with a higher decline in selective attention and executive functioning. These results emphasize the importance of detecting and managing diabetes and impaired fasting glucose, in order to prevent cognitive impairment and dementia.

Can maintaining cognitive function at 65 years old predict successful ageing 6 years later? The PROOF study

BACKGROUND preservation of cognitive abilities is required to have a good quality of life. The predictive value of cognitive functioning at 65 years old on successful ageing 6 years later is not established. METHODS nine hundred and seventy-six questionnaires were sent by mail to a sample of healthy and voluntary French pensioners. Successful ageing was defined through health status and well-being. Cognitive abilities had been assessed 6 years earlier according to an objective method (Free and Cued Selective Recall Reminding Test (FCSRT), the Benton visual retention test and the similarities subtest of the Wechsler Adult Intelligence Scale-Revised) and a subjective one (Goldbergs anxiety scale, Mac Nairs scale and a Visual Analogue Scale to evaluate memory abilities change in the last 5 years). RESULTS six hundred and eighty-six questionnaires could be analysed. The mean age was 72.9 ± 1.2 years old with 59% of women and 99% lived at home. Well-being was negatively correlated with the FCSRT (r = -0.08, P = 0.0318) but positively related with the Benton (r = 0.09, P = 0.0125) and the similarities tests (r = 0.09, P = 0.0118). There is a negative correlation between anxious and cognitive complaints measured at baseline, and successful ageing indicators 6 years later. CONCLUSION preservation of cognitive abilities at the age of retirement can predict a successful ageing 6 years later. ClinicalTrials.gov Identifier: NCT00759304.

Behavioral and psychological symptoms of dementia and bipolar spectrum disorders: review of the evidence of a relationship and treatment implications.

Dementia is a neuropsychiatric disorder characterized by cognitive impairment and behavioral disturbances. The behavioral and psychological symptoms of dementia (BPSD) are common, contributing to caregiver burden and premature institutionalization. Management of BPSD is complex and often needs recourse to psychotropic drugs. Though widely prescribed, there is a lack of consensus concerning their use, and serious side effects are frequent. This is particularly the case with antidepressant treatment based on the assumption that BPSD is depressive in nature. A better understanding of BPSD etiology could lead to better management strategies. We submit that some BPSD could be the consequence of both dementia and an undiagnosed comorbid bipolar spectrum disorder, or a pre-existing bipolar diathesis pathoplastically altering the clinical expression of dementia. The existence of such a relationship is based on clinical observation, as far as the high frequency of bipolar spectrum disorders in the general population, with a prevalence estimated to be between 5.4% and 8.3%, and the psychopathological similarities between BPSD and mood disorder episodes in bipolar illness. We will review the concept of the bipolar spectrum and explain BPSD before proposing clinical pointers of a possible bipolar spectrum contaminating the phenomenology of dementia, which could lead to the targeted prescription of mood-stabilizing agents in lieu of antidepressant monotherapy. These considerations are of heuristic interest in reconceptualizing the origin of the behavioral manifestations of dementia, with important implications for geriatric practice.