Keiichi Kumai

Fear of falling and cognitive impairments in elderly people with hip fractures

Background/Aim: The purpose of this study was to investigate the estimated prevalence of dementia and the relationship between cognitive impairment and fear of falling in patients with hip fractures. Methods: Analysis 1 included 100 patients with hip fractures. Analysis 2 included a subgroup of subjects with ≥75 years of functional independence: 46 patients with hip fractures and 46 control subjects without hip fractures, and presence or absence of dementia. We used an informant-rated questionnaire including the AD8 for screening for dementia, the Barthel Index for assessing activities of daily living, and the Short Falls Efficacy Scale-International (FES-I) for assessing fear of falling. Results: The estimated prevalence of dementia was 66% in patients with hip fractures. There were significant fracture and dementia effects, with significant covariate effects of age and gender on the Short FES-I scores. Conclusion: Our results suggested that more than two-thirds of patients with hip fractures had dementia. Fear of falling may reflect not only physical functions but also cognitive impairments.

Disturbed social recognition and impaired risk judgement in older residents with mild cognitive impairment after the Great East Japan Earthquake of 2011: the Tome Project.

After the Great East Japan Earthquake of 2011, we investigated the safety of residents in the affected communities. Most of the people requiring help were elderly and had previously been assessed as Clinical Dementia Rating (CDR) 0.5 (i.e. as having mild cognitive impairment (MCI)). We examined how well they understood the television news and whether they could make appropriate decisions.

Improved learning of sequential behaviour during cane gait training or stair climbing after femoral neck fracture: an implication for donepezil for very mild Alzheimer's disease.

An 82-year-old, right-handed woman showed decreased learning of sequential behaviours after a right femoral neck fracture. After graduating from high school, the patient worked as a primary school teacher. There were no remarkable past medical history. She maintained her ability to perform activities of daily living and walked independently. She exhibited no apparent signs of dementia and took care of her household duties. Furthermore, she volunteered at a town office to prepare meals for elderly people living alone. One day, she drove to deliver dinner to an elderly woman living alone in the community and fell on the icy pavement when she got out of the car. She experienced a right femoral neck fracture and underwent bipolar hip arthroplasty (X = time of fracture, X + 3 month = 3 months after fracture, and so on). She began to use a walker on the 6 days after starting rehabilitation. No neurological findings were observed. The patient began rehabilitation involving range-of-motion training with a physical therapist, lower-limb muscle training, basic activities training, gait training with a T-cane, and climbing up and down stairs. The training programmes specific to sequential behaviours for T-cane gait on level ground and climbing up and down stairs using a T-cane and handrail (2 steps/1 stair) were unsuccessful. The sequential behaviour for T-cane gait on level ground was performed as follows: (i) T-cane; (ii) affected leg; and (iii) unaffected leg in case. The sequential behaviour for climbing up and down stairs was as follows: (i) T-cane up a step; (ii) unaffected leg up a step; (iii) affected leg up a step; (iv) T-cane down a step; (v) affected leg down a step; and (vi) unaffected leg down a step. However, the patient appeared to not understand the order and took 45 days to achieve the supervision level with gait training on level ground and the aid-requiring level in climbing up and down stairs. Usually, it takes patients fewer than 30 days to learn these behaviours. At discharge (X + 1.5 months), the Barthel Index was 85/100. In addition, the sequential movement of climbing up and down stairs with a T-cane remained insufficient. These findings indicated that the patient was still at risk of fall. One month after discharge (X + 2.5 months), the patient visited the hospital alone by bus without appointment. According to a physical therapist who did not treat the patient, ‘As she tried to climb up and down the stairs by herself, I asked her to stop the training for a while because she was likely to fall down the stairs’. However, the patient disagreed with the staff. Moreover, the patient explained that she visited the hospital without appointment because her niece had discussed her going to the hospital with her care manager 2 days earlier. She said with anger, ‘They forced me to go to a day care that I did not want to go to, and I felt sad’. In addition, she said, ‘I fell from a bus step when I got off the bus, but it did not hurt me’. We again warned her that she was at risk of fall because she had not completely mastered the movement of climbing up and down stairs, and she understood. When we confirmed the incident at a later date, the patient said, ‘I walked 40–50 min to the bus stop, which was approximately 1.5 km from my house. I then got on a bus and fell again when getting off the bus’. She explained that she undertook this trip because she wanted to know how if she was able to do so. Overestimating her physical ability, she scored 100 on the Barthel Index. The patient could prepare meals, but the daily menu was virtually the same and undernutrition was observed. She was certified as Needed Support 1, Impairment Level of Dementia I, Disability Level A2

A Case of Right Frontal Lobe Dysfunction with Risk Behaviors, Despite Normal General and Risk Cognition: Misunderstood as Cheerful, Active, and Careless Character?

Some older community residents can exhibit baffling behaviors in daily life, despite their memory and general cognitive functions being normal. Thus, they may be superficially suspected to have a psychiatric disease. We experienced a case in which risk behaviors related to fire, consumer damage, fall, etc. and hyperactivity were observed in daily life; despite general cognitive function being within a normal range. Her abnormal behaviors were summarized by behavioral neurology, as follows: 1) hyperactivity caused by right hemisphere damage, 2) decreased right frontal lobe function caused by right frontal lobe damage, and 3) confabulation caused by disinhibition of the left frontal lobe. Thus, we performed neuroimaging examinations, and found right basal ganglia infarction (MRI) and decreased blood flow to the right frontal lobe (single photon emission computed tomography [SPECT], remote effect). After a service representatives meeting, where the physician in charge provided an explanation, the patient, who did not like drug administration by nature, and had thus refused recommendations from her home doctor, began to be conscious about her disease and agreed to undergo drug treatment. It is not easy to explain the relationship between cerebral infarction in a strategically important region and daily life (behavior). This is the specialty of dementia medicine. When a disease is found to exhibit cerebral injury, the patient will be able to correctly understand the disease, and appropriate care will be promoted under the health management and collaboration between medical and nursing care.

Lifetime Expectancy in Dementia with Lewy Bodies: Effects of Donepezil Administration and Special Nursing Home Replacement. A Retrospective Analysis in the Tajiri Project

Objective: Cholinesterase inhibitors (ChEIs) can delay the progression of Alzheimer disease (AD). We previously demonstrated a positive effect of donepezil (DNP) administration and a Special Nursing Home (SNH) replacement on lifetime expectancy after the onset of AD. Recently DNP has been indicated for use in the treatment of dementia with Lewy Bodies (DLB); however, the effect on lifetime expectancy remains unclear. Herein, we analyzed the effects of DNP on DLB. Methods: All outpatients at the Tajiri Clinic with available medical records and death certificates from 1999- 2012 were included in this retrospective analysis. The entry criteria were a diagnosis of dementia based on DSM-IV criteria and diagnosis of DLB using the international consensus criteria; medical treatment for more than 3 months and follow up to less than 1 year before death. Results: We identified 510 subjects based upon medical records and death certificates, of which 360 had a diagnosis of dementia that met the entry criteria. Of 51 patients diagnosed with DLB, 23 had taken DNP and 28 patients had not undergone drug treatment due to treatment prior to the introduction of DNP in 1999 in Japan. The lifetime expectancies after onset were 6.4 years in the DNP group and 3.6 years in the non-DNP group; with a significant drug effect. However, in contrast with the previous AD data, no significant effect of SNH residency was noted. Conclusion: Although this report has the limitation that all analyses were retrospective and lacked randomization, we found a positive effect of DNP on lifetime expectancy after the onset of DLB. The lower life expectancy compared with that of AD and the lack of an effect of SNH residency suggest the cholinergic deficiency in DLB is greater than that in AD.

STEPPING ABILITY OF THE RIGHT FOOT ON THE ACCELERATOR OR BRAKE AS AN IMPORTANT FUNCTION FOR DRIVING: AN ORIGINAL POSNER PARADIGM TEST FOR THE FOOT

using validated neuropsychological tests. Data extraction and assessment of quality were performed by two independent reviewers and data were summarized using a narrative review. Results: Twelve studies met the inclusion criteria, with a high degree of heterogeneity relating to the nature of the dietary intervention and cognitive outcomes measured, thus making comparisons difficult and precluded pooling of studies formeta-analysis. For methodological quality, n1⁄47 studies were allocated a low to moderate quality score (Jadad et al., 1996).Overall, it was evident that the findings were inconsistent across the studies and do not provide clear evidence to support the effect of diet on cognition in MCIpatients. Supplementationwith eitherVitaminEorGinkgoBiloba, hadno significant effect on progression fromMCI to dementia and/or AD. For cognitive function, there were some improvements in cognitive performance, particularly in the domain of memory, with the most consistent results shown by B vitamin, folic acid and cocoa flavonol supplementation. Furthermore, therewere indications that the use of neuroimaging and biomarker outcomemeasuresmayprovide amore sensitive approach to detect changes in cognitive function and dietary change in comparison to clinical tests.Conclusions:This systematic review highlighted that to date, there is insufficient clinical trial data on the effect of diet on cognitive outcomes in MCI patients. There is need for further well-designed RCTs, with standardised and robust measures of cognition to further explore the role of diet in cognitive decline.

MONITORING OF DRUG TREATMENT AND PSYCHOSOCIAL INTERVENTION WITH THE EZIS SYSTEM ( 99M TC-ECD SPECT) FOR AD PATIENTS: THE OSAKI-TAJIRI PROJECT

P2-418 METHODOLOGICAL AND LOGISTIC STRATEGIES FOR A LARGE MULTICENTER b-AMYLOID PET EUROPEAN PROJECT: AMYLOID IMAGING TO PREVENTALZHEIMER’S DISEASE (AMYPAD) Juan Domingo Gispert, Chris Foley, Adriaan A. Lammertsma, Bart N. M. van Berckel, Maqsood M. Yaqub, M. Jorge Cardoso, Pawel Markiewicz, Marc Modat, Chris J. Buckley, Anja Mett, Santiago Bullich, Nigel Banton, Elisabetta Grecci, John Hall, Derek L. Hill, Pierre Payoux, Alexander Drzezga, Craig W. Ritchie, Mark E. Schmidt, Gill Farrar, Frederik Barkhof, Barcelonabeta Brain Research Center, Barcelona, Spain; GE Healthcare, Amersham, United Kingdom; Neuroscience Campus Amsterdam, Amsterdam, Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, VU University Medical Center, Amsterdam, Netherlands; Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, Netherlands; Translational Imaging Group, Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, UCL, London, United Kingdom; Translational Imaging Group, UCL Centre for Medial Image Computing, London, United Kingdom; Piramal Imaging GmbH, Berlin, Germany; Piramal Imaging, Havant, United Kingdom; IXICO PLC, London, United Kingdom; IXICO, London, United Kingdom; Universit e de Toulouse, Toulouse, France; University Hospital Cologne, Cologne, Germany; University of Edinburgh, Edinburgh, United Kingdom; Janssen Research and Development, Beerse, Belgium; Translational Imaging Group, Centre for Medical Image Computing, University College London, London, United Kingdom. Contact e-mail: jdgispert@fpmaragall.org

BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD) IN ALZHEIMER DISEASE IS “COGNITIVE” SYMPTOMS? THE OSAKI-TAJIRI PROJECT

MINT (68) 62 (2.1) 61 (3.3) 59 (4.0) 60.8 (2.4) 45.2 (8.5) 0.01y Nouns denomination (16) 15.6 (0.5) 12.4 (6.3) 15.6 (0.8) 15 (0.7) 7.4 (6.4) 0.04y Verbs denomination (16) 13.3 (2.8) 10.4 (15.9) 13 (1.8) 13.2 (0.8) 4.4 (5.3) 0.04y Northwestern Anagrams (10) 9.6 (0.6) 9.4 (0.8) 10 (0) 6.4 (3.7) 0 <0.01y Sentence’s lecture (5) 4.9 (0.3) 5(0) 5(0) 4.8 (0.4) 1.8 (1.6) 0.017y Sentences’s repetition (5) 5(0) 5(0) 4.6 (0.5) 4.8 (0.4) 1.2 (1.6) <0.01y Animals semantic fluency 19.4 (4.9) 19 (6.8) 17.8 (3.2) 15.2 (6.6) 6.2 (3.7) 0.018y Vegetables semantic fluency 13.2 (4.3) 12.8 (3.6) 11.4 (3.0) 10.4 (4.8) 3.6 (1.5) 0.020y Phonological fluency letter M 11.6 (2.8) 11.4 (5.6) 14.2 (3.7) 10.4 (5.4) 2 (1.2) 0.019y Phonological fluency letter P 11.2 (4.1) 12.4 (8.1) 17.2 (2.5) 14.2 (7.9) 2.8 (1.3) 0.013y Semantic word picture matching test (20) 19.8 (0.6) 19.2 (1.7) 19.8 (0.4) 19.8 (0.4) 18 (1.4) 0.043y

TIMED-UP-AND-GO (TUG) TEST SCORES ARE RELATED TO EXECUTIVE FUNCTION BUT NOT ASSOCIATED WITH FALL ACCIDENT IN THE COMMUNITY: THE WAKUYA PROJECT

Background:Increased physical activity (PA) is associated with better cognitive function. We investigated whether individuals with memory problems and additional cerebrovascular risk factors (CVD) could increase PA in the short-term and maintain adherence to a PA program in the long-term. We also examined factors influencing PA adherence.Methods:The AIBLActive trial recruited participants with mild cognitive impairment (MCI) or subjective memory complaints (SMC) and at least 1 CVD risk factor from The Australian Imaging Biomarkers and Lifestyle Flagship Study of Aging (AIBL). They were randomly assigned to a control or PA group. The control group continued their usual PA throughout the study. The PA group was given a 24-month home-based program with a target of 150 minutes/week of moderate PA and a behavioral intervention. Scheduled group-specific phone calls (n1⁄418) and newsletters (n1⁄417) were administered to both groups over 24 months. The PA group recorded sessions in diaries and adherence was calculated from the number of sessions recorded expressed as the percentage of the sessions prescribed. At baseline, 6, 12 and 24 months participants completed fitness (6-minute walk distance); PA and PA self-efficacy (one’s confidence to be physically active) questionnaires; cognitive and health assessments. Results:The adherence results for the PA group (n1⁄455) comprising of 53% women are reported. At baseline 24% were defined as inactive; men were significantly older than women; 74.7(6SD 5.6) versus 70.1(4.8) years respectively. Five participants did not start the intervention. After 24 months 96% were still in the study. After 6 months mean PA adherence was 83.5% and declined over the trial with mean 24-month adherence being 75.2%. Age, gender andMCI did not significantly influence adherence. Higher baseline self-efficacy (p<0.05) was associated with higher adherence in the first 6months with higher baseline self-efficacy (p<0.05) and fitness (p<0.01) associated with higher 24-month adherence. Positive program enjoyment, helpfulness of the telephone calls and newsletters were reported by 94%; 98% and 93% of participants respectively. Conclusions:The high retention and adherence rates in both the short and long-term demonstrate that this PA program was both achievable and acceptable in this target group.

OLDER RESIDENTS CANNOT OPERATE WELL THE INDUCTION HEATING (IH) COOKERS DUE TO EXECUTIVE DYSFUNCTION: THE WAKUYA PROJECT

Background:Handling errors with household flammables, such as pan burning, may result in serious accidents. The accidents were caused by a decrease in attention or executive function. Themanual for the elderly with dementia of several cities simply suggests the use of Induction Heating (IH) cookers in cases of increased risk of fire. However, the IH cooker contains the complicated button operation and thus may be difficult for older residents to handle. Methods: We examined 105 residents aged 65 years or older in Wakuya, northern Japan, consisted of 57 Clinical Dementia Rating (CDR) 0 (healthy), 41 CDR 0.5 (very mild dementia), and 7 CDR 1+ (dementia) participants. The use rate of IH (Induction Heating) appliance was 29% in the CDR 0 group and 24 % of the CDR 0.5 group. We asked the participants to actually use the IH cooker. Using or without the manual of the cooker, the participants who passed all the procedures were classified as “Good Users,” whereas those failed any procedures were classified as “Poor Users.” Their global cognitive and executive functions were assessed using the Mini-Mental State Examination (MMSE), and Trail Making Test A (TMT-A) and Digit Symbol (DS), respectively. Results: The ratio of “Good Users” in the CDR 0, CDR 0.5, and CDR 1+ groups were 23 (40.4%), 7 (17.1%), and 0 (0%), respectively. For the CDR 0 group, the Good Users had higher scores on the MMSE, TMT-A, and DS compared to the Poor Users (p<0.05). As for the CDR 0.5 group, the Good Users showed higher scores on the DS (p<0.05) compared to the Poor Users. Conclusions:Since the IH cooker contains the complicated button operation, they may be difficult for older residents to handle. Executive function may be more likely to be involved in handling errors with household flammables.