McKee J. McClendon

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.

Psychosocial Resources as Moderators of the Impact of Spousal Dementia Caregiving on Depression

This study examines the relationship of personal mastery and perceived emotional support to depressive symptoms for spousal dementia caregivers (CGs) and noncaregiver (NCG) spouses. Although it is well known that caring for a spouse with dementia is stressful and that personal mastery and emotional support may reduce stress, the authors hypothesize that these resources are more important for reducing stress in the difficult situation of dementia care than in everyday life for older persons. In bivariate comparisons, CG levels of perceived support and mastery were lower and depression was higher than for NCGs. Consistent with prior research, a hierarchical multiple regression with combined data shows that CG status was a significant predictor of depressive symptoms. A significant interaction of CG status with personal mastery indicates greater impact of mastery on depression among CGs than among NCGs. This unique finding strongly supports interventions focusing on enhancement of mastery among spousal CGs.

Effects of educational attainment on the clinical expression of Alzheimer's disease: Results from a research registry:

The “reserve” hypothesis suggests that education should affect the clinical expression of Alzheimers disease (AD), but results from studies examining this idea are not consistent. In a single study, we evaluated the effects of educational attainment on three aspects of the clinical expression of AD: age at symptom onset, rate of cognitive decline, and survival. Subjects were 258 persons with mild-or moderate-stage Alzheimers, drawn from our AD Research Registry. With statistical adjustment for confounding variables present in a clinic-based design, we found that higher educational attainment was associated with slightly earlier reports of symptom onset and a slower rate of cognitive decline on the Mini-Mental State Exam (MMSE). Education did not affect time of survival until death. We conclude that, for subjects in our sample, education had modest effects on aspects of the clinical expression of AD. These effects were not fully consistent with predictions derived from the “reserve” hypothesis.

Pharmacological treatment of Alzheimer's disease: effect of race and demographic variables.

Existing research shows differences in medication use for Alzheimers disease (AD) based on demographics such as race, ethnicity, and geographical location. To determine individual and community characteristics associated with differences in acetylcholinesterase inhibitor (AChEI) and memantine use in AD, 3,049 AD subjects were drawn from 30 centers and evaluated using the Uniform data set (UDS). Cases were evaluated at the individual level within the context of 31 communities (one center encompassed two separate geographical regions). Multivariate analysis was used to determine the significance of individual variables on medication use. Compared to non-Hispanic Whites, Blacks were less likely to use AChEI and memantine with odds ratios (OR) of 0.59 (95% CI 0.46-0.76) and 0.43 (95% CI 0.32-0.57), respectively. Compared to non-Hispanic Whites, non-Black Hispanics were less likely to use memantine (OR=0.69 (95% CI 0.49-0.98)). No association was found between the proportion of Blacks or non-Black Hispanics versus non-Hispanic Whites at an Alzheimer Disease Center and individual use of AChEI or memantine. Other significant variables include gender, age, marital status, dementia severity, source of referral, AChEI use, and education. Education and age somewhat mitigated disparity. Significant racial and ethnic differences in AChEI and memantine use exist at the individual level regardless of the racial and ethnic composition of the individuals community. Research and initiatives at the societal level may be an important consideration toward addressing these differences.

Relationships Among Caregivers' Demographic Characteristics, Social Support Ratings, and Expectations of Computer-Mediated Support Groups

Computer-mediated support groups (CMSG) for family caregivers are proliferating; however, actual social support needs of potential CMSG users and their expectations regarding CMSG use have not been studied. The authors used path analysis to investigate how the responses of 118 family caregivers to scales measuring the importance to them of four dimensions of social support (CASS-I), their expectations regarding three dimensions of CMSG technology (CATS-E) and their demographic characteristics were interrelated. Caregiver gender and race were related to two of four CASS-I scores; caregiver education, gender, and race were directly related to two of the three CATS-E scores; and gender and race also were indirectly related to two of three CATS-E scores through their impact on CASS-I scores. Results suggest that CASS-I and CATSE assessments might be helpful in customizing CMSG to meet particular subgroup needs, in understanding and influencing patterns of CMSG use, and in evaluating impacts of CMSG use.

Does depression prior to caregiving increase vulnerability to depressive symptoms among caregivers of persons with Alzheimer's disease?

Based on the vulnerability model of depression, this study tested the hypothesis that caregivers with prior depression are more likely to be depressed during caregiving than caregivers without prior depression. We further hypothesized an interaction effect in which caregivers with prior depression would be affected more by care-recipient dependency in activities of daily living and care-recipient depressive symptoms than those without prior depression. In a sample of 111 caregivers of persons with Alzheimers disease, in an additive regression model, neither ‘prior depressive symptoms’ nor the clinically more serious ‘prior depressive syndrome’ was related to depressive symptoms during caregiving. In an interaction model, for caregivers with either ‘no prior depression’ or ‘prior depressive symptoms,’ the greater the care-recipient dependencies in instrumental activities of daily living (IADL), the greater were the depressive symptoms during caregiving. For caregivers with a ‘prior depressive syndrome’, however, the greater the IADL dependency, the fewer were the depressive symptoms during caregiving. This unexpected finding suggests that caregivers with a history of clinically significant depression are not necessarily more prone to depressive symptoms when caregiving responsibilities, at least for instrumental activities, are high. This result questions the vulnerability model of depression when applied to older caregivers.

Memantine and acetylcholinesterase inhibitor treatment in cases of CDR 0.5 or questionable impairment.

The biological meaning of uncertain dementia ratings (CDR 0.5) and its treatment implications are unclear. Our study examines the frequency of anti-dementia medication use in individuals with CDR 0.5 and the cognitive, behavioral, and demographic factors associated with memantine and acetylcholinesterase inhibitor (AChEI) use. Subjects were drawn from the National Alzheimer Coordinating Center database, which collects data from 30 Alzheimer Disease Centers. There were 2,512 subjects with the following diagnoses: Normal, 11.8%; Mild cognitive impairment, 44.6%; Alzheimers disease, 34.9%; and other dementias, 8.7%. Overall, 35% used AChEIs and 13% used memantine. AChEI and memantine use was greater in subjects who were referred by clinics and diagnosed with Alzheimers disease. AChEI use was associated with being married, younger, male, and more educated while memantine use was associated with less severe apathy and other dementia diagnosis. Non-Hispanic whites were more likely to use AChEI and memantine than non-Hispanic blacks (OR = 2.2, 2.5). Hispanics were more likely to use AChEI than non-Hispanic blacks. It appears anti-dementia medication use in CDR 0.5 is frequent and represents evidence for extensive off label usage. Diagnosis, severity of impairment, and race, among other variables, affect the likelihood of AChEI and memantine use in this population.

Factors affecting usage patterns of memantine in Alzheimer disease.

Memantine is approved by the US Food and Drug Administration for the treatment of moderate to severe Alzheimer disease (AD). We investigated the frequency and variables associated with its use in mild to moderate/severe AD as defined by criteria involving the Mini-Mental Status Examination (MMSE) and Clinical Dementia Rating (CDR) scale. Consecutive possible and probable AD patients seen at our research center from November 2003 to December 2006 were included. Individuals were classified as mild dementia either by CDR=1 or MMSE ≥15, using criteria derived in part from the pivotal trials of memantine used for its approval by the Food and Drug Administration. Of 117 patients, 37% of those with mild AD by MMSE criterion (total N=94), and 38% of those with mild AD by CDR criterion (total N=86) used memantine. Logistic regression was used to simultaneously estimate the odds ratios (ORs) of the likelihood of memantine usage associated with a set of predictor variables. Lower MMSE was associated with a greater likelihood of using memantine independent of CDR [ORMMSE=7.45, 95% confidence interval (CI)=1.50-37.05]; CDR was not significantly related to memantine use. Controlling both MMSE and CDR, Whites were more likely to use memantine than African Americans (OR=6.47, 95% CI=1.25-33.39). Patients who used other antidementia medications were more likely to use memantine than those who did not (OR=3.15, 95% CI=0.995-9.97). Eight other patient characteristics were not significant predictors. Use of memantine in mild AD was common. Patterns of memantine usage are complex and deserve further study in a larger sample because of their implications for medical system cost, equitable access to care, and risk of drug interactions.

Early-Stage Cognitive Impairment: A Social Work Practice and Research Agenda:

With the current emphasis on early diagnosis of mild cognitive impairment or dementia such as Alzheimers disease, it is increasingly common to receive the diagnosis of impairment before functioning is seriously compromised. People in the early stages of cognitive loss experience distress related to their current and future functioning and yet are capable of participating in psychosocial treatment or support. Although most published studies deal with services for caregivers rather than direct practice with the cognitively impaired person, there is a growing body of clinical and research reports on psychosocial interventions offered directly to people with early cognitive loss. These interventions are aimed at alleviating the stress, depression, and anxiety while promoting a positive outlook. Gerontological social work practitioners and researchers are well positioned to further develop, implement, and evaluate these promising intervention approaches with early-stage cognitive loss.