Lori A. Daiello

A longitudinal study of drivers with Alzheimer disease

Objective: The goal of this study was to define the natural progression of driving impairment in persons who initially have very mild to mild dementia. Methods: We studied 128 older drivers, including 84 with early Alzheimer disease (AD) and 44 age-matched control subjects without cognitive impairment. Subjects underwent repeated assessments of their cognitive, neurologic, visual, and physical function over 3 years. Self-reports of driving accidents and traffic violations were supplemented by reports from family informants and state records. Within 2 weeks of the office evaluation, subjects were examined by a professional driving instructor on a standardized road test. Results: At baseline, subjects with AD had experienced more accidents and performed more poorly on the road test, compared to controls. Over time, both groups declined in driving performance on the road test, with subjects with AD declining more than controls. Survival analysis indicated that while the majority of subjects with AD passed the examination at baseline, greater severity of dementia, increased age, and lower education were associated with higher rates of failure and marginal performance. Conclusions: This study confirms previous reports of potentially hazardous driving in persons with early Alzheimer disease, but also indicates that some individuals with very mild dementia can continue to drive safely for extended periods of time. Regular follow-up assessments, however, are warranted in those individuals.

Dementia of the Alzheimer Type

Dementia of the Alzheimer type is a progressive, fatal neurodegenerative condition characterized by deterioration in cognition and memory, progressive impairment in the ability to carry out activities of daily living, and a number of neuropsychiatric symptoms. This narrative review summarizes the literature regarding descriptive epidemiology, clinical course, and characteristic neuropathological changes of dementia of the Alzheimer type. Although there are no definitive imaging or laboratory tests, except for brain biopsy, for diagnosis, brief screening instruments and neuropsychiatric test batteries used to assess the disease are discussed. Insufficient evidence exists for the use of biomarkers in clinical practice for diagnosis or disease management, but promising discoveries are summarized. Optimal treatment requires both nonpharmacological and pharmacological interventions, yet none have been shown to modify the diseases clinical course. This review describes the current available options and summarizes promising new avenues for treatment. Issues related to the care of persons with dementia of the Alzheimer type, including caregiver burden, long-term care, and the proliferation of dementia special care units, are discussed. Although advances have been made, more research is needed to address the gaps in our understanding of the disease.

Effect of a Pharmacist-Led Multicomponent Intervention Focusing on the Medication Monitoring Phase to Prevent Potential Adverse Drug Events in Nursing Homes

OBJECTIVES: To determine the extent to which the use of a clinical informatics tool that implements prospective monitoring plans reduces the incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

Association of fish oil supplement use with preservation of brain volume and cognitive function

The aim of this study was to investigate whether the use of fish oil supplements (FOSs) is associated with concomitant reduction in cognitive decline and brain atrophy in older adults.

Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia

BACKGROUND Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimers disease. However, there has been little previous study of the outcomes associated with discontinuing these medications. OBJECTIVE The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy. METHODS This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged > or =60 years with a diagnosis of Alzheimers disease or non-Alzheimers dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS. RESULTS The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged > or =85 years, and the sample was predominantly female. A diagnosis of Alzheimers disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (-0.01; 95% CI, -0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, -0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (-0.26; 95% CI, -0.50 to -0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65). CONCLUSION Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.

Association of dementia with early rehospitalization among Medicare beneficiaries

Preventable hospital readmissions have been recognized as indicators of hospital quality, a source of increased healthcare expenditures, and a burden for patients, families, and caregivers. Despite growth of initiatives targeting risk factors associated with potentially avoidable hospital readmissions, the impact of dementia on the likelihood of rehospitalization is poorly characterized. Therefore, the primary objective of this retrospective cohort study was to investigate whether dementia was an independent predictor of 30-day readmissions. Administrative claims data for all admissions to Rhode Island hospitals in 2009 was utilized to identify hospitalizations of Medicare fee-for-service beneficiaries with a diagnosis of Alzheimers Disease or other dementias. Demographics, measures of comorbid disease burden, and other potential confounders were extracted from the data and the odds of 30-day readmission to any United States hospital was calculated from conditional logistic regression models. From a sample of 25,839 hospitalizations, there were 3908 index admissions of Medicare beneficiaries who fulfilled the study criteria for a dementia diagnosis. Nearly 20% of admissions (n=5133) were followed by a readmission within thirty days. Hospitalizations of beneficiaries with a dementia diagnosis were more likely to be followed by a readmission within thirty days (adjusted odds ratio (AOR) 1.18; 95% CI, 1.08, 1.29), compared to hospitalizations of those of without dementia. Controlling for discharge site of care did not attenuate the association (AOR 1.21; 95% CI, 1.10, 1.33).

Microdosing of scopolamine as a “cognitive stress test”: Rationale and test of a very low dose in an at-risk cohort of older adults

Abnormal β‐amyloid (Aβ) is associated with deleterious changes in central acetylcholinergic tone in the very early stages of Alzheimers disease (AD), which may be unmasked by a cholinergic antagonist. We aimed to establish an optimal “microdose” of scopolamine for the development of a “cognitive stress test.”

Association of β-Blockers With Functional Outcomes, Death, and Rehospitalization in Older Nursing Home Residents After Acute Myocardial Infarction

Importance Although &bgr;-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit. Objective To study the association of &bgr;-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older. Design, Setting, and Participants This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with &bgr;-blocker use before AMI were excluded. Propensity score–based methods were used to compare outcomes in people who did vs did not initiate &bgr;-blocker therapy after AMI hospitalization. Main Outcomes and Measures Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living. Results The initial cohort of 15 720 patients (11 140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83 [8] years) included 8953 new &bgr;-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of &bgr;-blockers and an equal number of nonusers for a total cohort of 10 992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84 [8] years). Users of &bgr;-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, &bgr;-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from &bgr;-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to &bgr;-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P = .03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P = .06 for effect modification). Mortality benefits of &bgr;-blockers were similar across all subgroups. Conclusions and Relevance Use of &bgr;-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of &bgr;-blockers yielded a considerable mortality benefit in all groups.

Antipsychotic Use and the Risk of Diabetes in Nursing Home Residents with Dementia

BACKGROUND Growing evidence suggests an association between antipsychotic use and diabetes onset in schizophrenia, but little is known about this association among patients with dementia. OBJECTIVE The aim of this study was to quantify the association between antipsychotic use and the risk of diabetes onset among nursing home residents with dementia. METHODS We conducted a nested case-control study in 29,203 long-stay Medicaid-eligible residents living in nursing homes in California, Florida, Illinois, New York, and Ohio between January 2001 and December 2002 who were at least 65 years old with a dementia diagnosis and no record of diabetes within 90 days of nursing home admission. We identified 762 incident cases of diabetes and randomly selected up to 5 controls, matched on nursing home and quarter of minimum data set (MDS) assessment (N = 2646). Cases of incident diabetes were identified from MDS assessments and Medicaid claims, medication use was ascertained from Medicaid pharmacy files, and resident characteristics were obtained from MDS assessments. RESULTS Relative to non-users of antipsychotics, use of atypical antipsychotics was not associated with diabetes onset (adjusted odds ratio [AOR] = 1.03; 95% CI, 0.84-1.27) and risk of diabetes did not increase with length of time on treatment. Conventional antipsychotic treatment was associated with diabetes onset, particularly when treatment duration was <30 days (AOR = 2.70; 95% CI, 1.57-4.65). CONCLUSIONS Among nursing home residents with dementia, conventional antipsychotic therapy, particularly short-term therapy, increased their risk of developing diabetes. Atypical antipsychotic use was not associated with an increased risk of diabetes onset.

Effects of cholinesterase inhibitors on visual attention in drivers with Alzheimer disease

Objective: We conducted a combined observational cohort and case-control study in patients with Alzheimer disease (AD) to assess the effects of acetylcholinesterase inhibitor (ChEI) treatment on cognitive functions important for driving. Methods: Performance of 24 outpatients with newly diagnosed (untreated) early-stage AD was compared before beginning ChEI (pre-ChEI) and after 3 months of therapy (post-ChEI) on a set of computerized tests of visual attention and executive function administered under both single-task and dual-task conditions. To address the limitation of a lack of an untreated control group in this observational cohort study, performance of 35 outpatients with newly diagnosed (untreated) early-stage AD (ChEI nonusers) were also compared with a demographically matched group of AD patients treated with stable doses of a ChEI (ChEI users) on these tasks. Results: Performance was consistently worse under dual-task than single-task conditions regardless of ChEI treatment status. However, ChEI treatment consistently affected specific components of attention within each test across both sets of comparisons: ChEI treatment enhanced simulated driving accuracy and was associated with significantly better visual search target detection accuracy and response time in both pre-ChEI-post-ChEI and users-nonusers treatment comparisons. Cholinesterase inhibitor treatment also improved overall time to complete a set of mazes while not affecting accuracy of completion. Conclusions: Cholinesterase inhibitor treatment was associated with improvements in tests of executive function and visual attention. These findings could have important implications for patients who continue to drive in the early stages of AD.