Kannayiram Alagiakrishnan

Evaluation and management of oropharyngeal dysphagia in different types of dementia: A systematic review

INTRODUCTION Dysphagia, or swallowing impairment, is a growing concern in dementia and can lead to malnutrition, dehydration, weight loss, functional decline, and fear of eating and drinking as well as a decrease in quality of life (QOL). OBJECTIVE The aim of this article is to do a systematic review of the literature to determine the patterns of swallowing deficits in different types of dementia and to look at the usefulness of different diagnostic and management strategies. METHODS An electronic literature search was done using five electronic databases from 1990 to 2011. One thousand and ten records were identified and 19 research articles met the inclusion criteria. These studies were heterogeneous in design and methodology, type of assessment and outcomes, so only descriptive analysis (narrative reporting) was possible. RESULTS Prevalence of swallowing difficulties in patients with dementia ranged from 13 to 57%. Dysphagia developed during the late stages of frontotemporal dementia (FTD), but it was seen during the early stage of Alzheimers dementia (AD). Limited evidence was available on the usefulness of diagnostic tests, effect of postural changes, modification of fluid and diet consistency, behavioral management and the possible use of medications. Use of Percutaneous Endoscopic Gastrostomy (PEG) tubes in advanced dementia, did not show benefit with regards to survival, improvement in QOL, or reduction in aspiration pneumonia. Significant gaps exist regarding the evidence for the evaluation and management of dysphagia in dementia.

Sexually inappropriate behaviour in demented elderly people.

Aim: To determine the prevalence, aetiology, and treatment profile of abnormal sexual behaviour in subjects with dementia in psychogeriatric practices. Methods: A retrospective cross sectional study was conducted in a long term care psychiatry consultation service, community based geriatric psychiatry service, and an inpatient dementia behavioural unit in Edmonton, Canada. Results: Forty one subjects (1.8%) had sexually inappropriate behaviour. Of those cognitively impaired subjects with sexually inappropriate behaviour, 20 (48.8%) were living in nursing homes and the rest, 21 (51.2%) in the community. Of these subjects, 53.7% had vascular dementia, 22% had Alzheimer’s, and 9.8% had mild cognitive impairment. History of alcohol misuse and psychosis were reported in 14.6% and 9.8% of subjects respectively. Twenty seven (65.7%) had verbally inappropriate behaviour and 36 (87.8%) had physically inappropriate behaviour. In this study, verbally inappropriate behaviour was more commonly seen in the community sample (81%) than in the nursing home sample (50%) (p = 0.04). Behavioural treatment was also more commonly seen in the community sample (81%) than in the nursing home sample (45%) (p = 0.01). Conclusion: In this study sexually inappropriate behaviour was seen in all stages of dementia, more commonly associated with subjects of vascular aetiology, and is as commonly seen in community dwelling subjects with dementia as in nursing home subjects.

Treating vascular risk factors and maintaining vascular health: Is this the way towards successful cognitive ageing and preventing cognitive decline?

Dementia is a progressive disorder that typically worsens with time and from which recovery is unlikely. The incidence of dementia increases exponentially with ageing and is an important public health challenge. There is now growing evidence for the role of vascular factors in Alzheimer’s disease, mixed dementia (Alzheimer’s disease with cerebrovascular disease), and of course vascular dementia. With the rising prevalence of vascular disease, there are increasing numbers of people who are identified to be at risk of cognitive impairment. By changing modifiable vascular risk factors, there is emerging evidence that it may be possible to prevent or delay the expression and progression of dementia.

Montreal Cognitive Assessment Is Superior to Standardized Mini-Mental Status Exam in Detecting Mild Cognitive Impairment in the Middle-Aged and Elderly Patients with Type 2 Diabetes Mellitus

Aim. This study compares the usefulness of Montreal Cognitive Assessment (MoCA) to Standardized Mini-Mental Status Exam (SMMSE) for diagnosing mild cognitive impairment (MCI) in Type 2 diabetes mellitus (DM) population. Methods. This prospective pilot study enrolled 30 community dwelling adults with Type 2 DM aged 50 years and above. Subjects were assessed using both the SMMSE and MoCA for MCI. In all subjects, depression and dementia were ruled out using the DSM IV criteria, and a functional assessment was done. MCI was diagnosed using the standard test, the European consortium criteria. Sensitivity and specificity analysis, positive and negative predictive values, likelihood ratios and Kappa statistic were calculated. Results. In comparison to consortium criteria, the sensitivity and specificity of MoCA were 67% and 93% in identifying individuals with MCI, and SMMSE were 13% and 93%, respectively. The positive and negative predictive values for MoCA were 84% and 56%, and for SMMSE were 66% and 51%, respectively. Kappa statistics showed moderate agreement between MoCA and consortium criteria (kappa = 0.4) and a low agreement between SMMSE and consortium criteria (kappa = 0.07). Conclusion. In this pilot study, MoCA appears to be a better screening tool than SMMSE for MCI in the diabetic population.

Update on diastolic heart failure or heart failure with preserved ejection fraction in the older adults

Nearly half of all heart failure (HF) patients have diastolic HF (DHF) or clinical HF with normal or near-normal left ventricular ejection fraction (LVEF). Although the terminology has not been clearly defined, it is increasingly being referred to as HF with preserved ejection fraction (HFPEF). The prevalence of HFPEF increases with age, especially among older women. Identifying HFPEF is important because the etiology, pathogenesis, prognosis, and optimal management may differ from that for systolic HF (SHF) or HF with reduced ejection fraction. The clinical presentation of HF is similar for both SHF and HFPEF. As in SHF, HFPEF is a clinical diagnosis. Once a clinical diagnosis of HF has been made, the presence of HFPEF can be established by confirming a normal or near-normal LVEF, often by an echocardiogram. HFPEF is often associated with a history of hypertension, concentric left ventricular hypertrophy, vascular stiffness, and left ventricular diastolic dysfunction. As in SHF, HFPEF is also associated with poor outcomes. While therapies with angiotensin-converting enzyme inhibitors and beta-blockers improve outcomes in SHF, there is currently no such evidence of their benefits in older HFPEF patients. In this review recent advances in the diagnosis and management of HFPEF in older adults are discussed.

Psychiatric Disorders Presenting in the Elderly With Type 2 Diabetes Mellitus

Diabetes mellitus (DM) is one of the major health problems of the elderly. Developed countries face an epidemic of Type 2 DM. Healthcare providers should be aware of the frequent coexistence of psychiatric conditions in elderly patients with DM. Dementia, depression, and anxiety are commonly seen in addition to other psychiatric conditions. The relationship between diabetes and psychiatric disorders is complex. Evidence suggests that common mechanisms may play a role in both the pathogenesis of DM and several psychiatric illnesses. Possible mechanisms, diagnosis, and management options are reviewed and discussed. Common mechanisms of psychiatric illness involving brain-derived neurotrophic factor, insulin resistance, and inflammatory cytokines are throwing new light that these psychiatric illnesses could be due to the complications of Type 2 DM. Periodic screening should be done in DM patients to identify the psychiatric complications. Healthcare professionals should routinely screen for psychiatric complications of DM in addition to the microvascular and macrovascular complications of DM. It is important to screen all diabetic elderly patients for mental health issues as these may interfere with self-care and the overall management of DM. Recognition and management of psychiatric disorders will help to optimize the diabetes management. Good diabetes control can also reduce the mental health complications in these patients.

The cure of ageing: vitamin D—magic or myth?

Vitamin D was initially thought only to function in calcium homeostasis. However, it has multiple roles in human health, including neuromuscular and immune modulation. Recently, its deficiency is increasingly implicated in many diseases. This discovery has led both popular culture and research to find ways that vitamin D can either treat or prevent many diseases. Since vitamin D not only affects the expression of many genes, but also has intra-individual pharmacokinetic variation, a simplistic cause and effect between vitamin D deficiency and illnesses should not be expected. Older adults pose a challenge not only because diseases become more prevalent with ageing, but they also are often complicated with other comorbidities. This article reviews the link of vitamin D deficiency and the associated medical conditions in middle aged and older adults. It also examines the variability in testing vitamin D values and evaluates dosing recommendations based on current evidence.

Genetics and epigenetics of Alzheimer's disease

Alzheimers disease (AD) is a highly prevalent condition that predominantly affects older adults. AD is a complex multifactorial disorder with a number of genetic, epigenetic and environmental factors which ultimately lead to premature neuronal death. Predictive and susceptibility genes play a role in AD. Early-onset familial AD is a rare autosomal dominant disorder. Genome-wide association studies have identified many potential susceptibility genes for late-onset AD, but the clinical relevance of many of these susceptibility genes is unclear. The genetic variation by susceptibility genes plays a crucial role in determining the risk of late-onset AD, as well as the onset of the disease, the course of the AD and the therapeutic response of patients to conventional drugs for AD. The newer understanding of the epigenetics in AD has also been highlighted. Recent advances in genetics, epigenetics and pharmacogenetics of AD pose new challenges to the future management of AD.

Impairment of activities of daily living and incident heart failure in community‐dwelling older adults

Instrumental activities of daily living (IADLs) are tasks that are necessary for independent community living. These tasks often require intact physical and cognitive function, the impairment of which may adversely affect health in older adults. In the current study, we examined the association between IADL impairment and incident heart failure (HF) in community‐dwelling older adults.

Simple cognitive testing (Mini-Cog) predicts in-hospital delirium in the elderly

control group (2.2 0.3 pg/mL before and after treatment). Serum IL-6 remained unchanged in both groups. In the Hochuekkito-treated group, serum prealbumin level, a marker of nutritional status, increased from 23.6 1.1 mg/dL to 26.6 1.2 mg/dL, whereas it was unchanged in the control group. These data suggest that Hochuekkito improves systemic inflammation and nutritional status in older patients with moderate to severe COPD, although the mechanisms of Hochuekkito have not been defined. Systemic inflammation, in addition to nutritional status, is a determinant of quality of life and prognosis in COPD patients. Further larger studies on its effects and mechanisms of action will be needed, although Hochuekkito has a long history of use in patients with COPD and weakness, and its safety has been clinically established.