Kathleen A. Smyth

Patients with Alzheimer's disease have reduced activities in midlife compared with healthy control-group members

The development of Alzheimers disease (AD) later in life may be reflective of environmental factors operating over the course of a lifetime. Educational and occupational attainments have been found to be protective against the development of the disease but participation in activities has received little attention. In a case-control study, we collected questionnaire data about 26 nonoccupational activities from ages 20 to 60. Participants included 193 people with probable or possible AD and 358 healthy control-group members. Activity patterns for intellectual, passive, and physical activities were classified by using an adaptation of a published scale in terms of “diversity” (total number of activities), “intensity” (hours per month), and “percentage intensity” (percentage of total activity hours devoted to each activity category). The control group was more active during midlife than the case group was for all three activity categories, even after controlling for age, gender, income adequacy, and education. The odds ratio for AD in those performing less than the mean value of activities was 3.85 (95% confidence interval: 2.65–5.58, P < 0.001). The increase in time devoted to intellectual activities from early adulthood (20–39) to middle adulthood (40–60) was associated with a significant decrease in the probability of membership in the case group. We conclude that diversity of activities and intensity of intellectual activities were reduced in patients with AD as compared with the control group. These findings may be because inactivity is a risk factor for the disease or because inactivity is a reflection of very early subclinical effects of the disease, or both.

Complex visual disturbances in Alzheimer's disease

Although Alzheimers disease (AD) involves visual association cortex, previous studies have not systematically investigated complex visual disturbances in AD. We examined 30 community-based AD patients, 13 (43%) of whom had complex visual complaints, and compared them with 30 controls on 7 types of complex visual tasks. Despite preserved visual acuity and color recognition, the AD patients were impaired in the visual evaluation of common objects, famous faces, spatial locations, and complex figures. In the AD patients, we found that all 30 had disturbances in figure-ground analysis; 17 (57%) had difficulties visually recognizing actual objects (“agnosia”); those with worse dementia disability had the most complex visual disturbances; and a subgroup (6) with Balints syndrome performed the most poorly on the complex visual tasks. This study demonstrates that a range of complex visual disturbances are common in AD and suggests that they may result from the known neuropathology in the visual association cortex.

Assessment of behavioral and affective symptoms in Alzheimer's disease

Noncognitive behavioral symptoms occurring during the prior week were studied in 34 Alzheimers disease (AD) patients and 21 spousal control subjects via caregiver and patient interviews using the Behavioral Pathology in Alzheimers Disease Rating Scale and the Cornell Scale for Depression in Dementia. Delusional or paranoid features were reported in 13 subjects (38%) and hallucinations in six (18%); patients with these psychoticlike symptoms had lower scores on the Folsteins Mini-Mental State Examination. Other behavioral symptoms reported in AD patients included anxiety (50%) and activity disturbances (44%). Six AD subjects (18%) and two controls (10%) showed mild to moderate symptoms of depression ; AD subjects were more likely than controls to show behavioral signs and symptoms of depression, but the two groups did not differ in terms of mood-related, cyclical, or physical signs and symptoms. (J Geriatr Psychiatry Neurol 1990;3:21-30).

ComputerLink: electronic support for the home caregiver.

Computers have become ubiquitous in contemporary society, as has the demand for home care for the elderly. Caregiving is recognized as a normal experience across the life span, and nurses must develop innovative responses to support caregivers. Computer networks offer caregivers access to a wide range of services such as communication, information, and decision support. Presented here is an interim report of a randomized field experiment demonstrating the feasibility of computer networks as a mechanism for delivering nursing services to caregivers of persons with Alzheimers disease. Caregivers can and do use the computer network in home care.

Worker functions and traits associated with occupations and the development of AD

Objective: To investigate the association between Alzheimer disease (AD) and worker functions and traits associated with occupations. Background: Studies have reported that occupational attainment is related to AD. However, most have not identified specific worker functions and traits (i.e., occupational demands) of occupations that may explain the association, nor have they accounted for changing occupational demands over time. Methods: Within- and between-group differences in mental, motor, physical, and social occupational demands of 122 AD cases and 235 control subjects were compared across four decades of life (20s, 30s, 40s, and 50s) using repeated-measures analyses of covariance adjusted for race, gender, year of birth, and education. Results: Overall, mental occupational demands were significantly lower and physical occupational demands were significantly higher for cases than for control subjects. Case/control differences in mental demand scores were not found in their 20s but only in later decades. Differences in physical demands were found in all decades but their 30s. Social and motor demands did not differ between cases and control subjects. Among cases only, there were no significant occupational demand score differences across decades. In contrast, mental and social demand scores of control subjects increased in later decades, and motor demand scores declined. Like cases, physical demand scores of control subjects remained stable across the decades. Conclusions: The authors’ results may indicate a relatively early influence of Alzheimer disease neuropathology on capacity to pursue mentally demanding occupations. However, results also are consistent with the notion that mentally demanding occupations have a direct influence on Alzheimer disease neuropathology.

Disturbances of person identification in Alzheimer's disease : a retrospective study

Person identification disturbances in Alzheimers disease (AD) add to the suffering of both patients and caregivers. We assessed the prevalence of person identification disturbances in the records of 217 outpatients with AD. These disturbances occurred in 25.4% (N = 55) and included transient misidentifications of familiar persons (N = 34), the Capgras syndrome (N = 11), misidentification of themselves in mirrors (N = 5), prosopagnosia (N = 3), misidentification of unfamiliar persons as familiar (N = 1), and misidentiflcation of another person as oneself (N = 1). Transient misidentifications were easily corrected misperceptions, and the Capgras syndrome and mirror difficulties were associated with suspiciousness/paranoia and delusions. In AD, these findings suggest that misidentifications of familiar persons result from misinterpretations due to cognitive impairments, and the Capgras syndrome and mirror difficulties ensue when these misinterpretations are elaborated by paranoid delusions.

Associations between dementia/mild cognitive impairment and cognitive performance and activity levels in youth

Objectives: To study the associations between dementia/mild cognitive impairment (MCI) and cognitive performance and activity levels in youth.

Assessment of functional ability in Alzheimer disease: a review and a preliminary report on the Cleveland Scale for Activities of Daily Living.

SummaryAssessment of activities of daily living (ADL) in Alzheimer disease (AD) is critical in establishing the diagnosis, monitoring disease progression, evaluating the efficacy of treatment interventions, and determining the need for health and social services. The proper method to measure ADL depends on the purposes to which the scale is to be put. Existing ADL scales differ as to the type of behaviors assessed, the nature of the observations made, and the manner in which the observations are quantified. These scales were not specifically designed to evaluate changes in the nature and extent of the broad spectrum of functional difficulties seen in individuals with AD. We describe the Cleveland Scale for Activities of Daily Living (CSADL), an informant-based instrument designed to expand upon the capacity of existing physical and instrumental ADL scales by assessing both premorbid and current component acts (e.g., initiation versus implementation) of daily living functions.

Participation in novelty-seeking leisure activities and Alzheimer's disease

The objective was to study the associations between participation in different types of mentally stimulating leisure activities and status as Alzheimer’s disease (AD) case or normal control. Research suggests that participation in leisure activities, especially mentally stimulating activities, is associated with a lower risk for AD. However, no study has yet evaluated associations between AD and different types of mental leisure activities, especially those involving “novelty seeking.” The authors used a case-control design to compare participation in activities across the life span in persons with AD and normal controls. Cases (n = 264) were recruited from clinical settings and from the community. Controls were drawn from 2 populations. Control group A members (n = 364) were the friends or neighbors of the cases or members of the same organizations to which the cases belonged. Control group B members (n = 181) were randomly drawn from the community. The 2 control groups did not differ in their responses to most activity questions, so they were combined. Factor analysis of activity questions identified 3 activity factors: (1) novelty seeking; (2) exchange of ideas; and (3) social. Logistic regression analysis indicated that, adjusting for control variables, greater participation in novelty-seeking and exchange-of-ideas activities was significantly associated with decreased odds of AD. The odds of AD were lower among those who more often participated in activities involving exchange of ideas and were lower yet for those who more frequently participated in novelty-seeking activities. We conclude that participation in a variety of mental activities across the life span may lower one’s chances of developing AD.

Cost Effectiveness of Facility-Based Care, Home-Based Care and Mobile Clinics for Provision of Antiretroviral Therapy in Uganda

AbstractBackground: Stakeholders in HIV/AIDS care currently use different programmes for provision of antiretroviral therapy (ART) in Uganda. It is not known which of these represents the best value for money. Objective: To compare the cost effectiveness of home-based care (HBC), facility-based care (FBC) and mobile clinic care (MCC) for provision of ART in Uganda. Methods: Incremental cost-effectiveness analysis was performed using decision and Markov modeling of adult AIDS patients in WHO Clinical Stage 3 and 4 from the perspective of the Ugandan healthcare system. The main outcome measures were cost (year 2008 values), life expectancy in life-years (LY) and the incremental cost-effectiveness ratio (ICER) measured as cost per QALY or LY gained over 10 years. Results: Ten-year mean undiscounted life expectancy was lowest for FBC (3.6 LY), followed by MCC (4.3 LY) and highest for HBC (5.3 LY), while the mean discounted QALYs were also lowest for FBC (2.3), followed by MCC (2.9) and highest for HBC (3.7). The 10-year mean costs per patient were lowest for FBC (