Minna Raivio

How do elderly spouse care givers of people with Alzheimer disease experience the disclosure of dementia diagnosis and subsequent care

Objectives: To examine the experiences of spousal care givers of Alzheimer patients to disclosure of dementia diagnosis and subsequent care. Methods: A random sample of 1943 spousal care givers of people receiving medication for Alzheimer disease (AD) was sent a cross-sectional postal survey about their opinions on the disclosure of dementia and follow-up care. A smaller qualitative study (n = 63) included open-ended questions concerning their experiences of the same topics. Results: The response rate for the survey was 77%. Of the respondents, 1214 of 1434 acknowledged themselves as their spouse’s care giver. The mean age of the care givers was 78.2 years, and that of demented spouses, 80.5 years. Of the care givers, 63% were women. The couples had long-lasting marriages (mean 52 years). Of the care givers, 93% reported that dementia had been disclosed openly to their spouse; 97% also preferred that physicians openly inform the patients of the dementia diagnosis, although 55% of their spouses with AD had developed depressive symptoms after the disclosure. Of the care givers, 71% felt they had received sufficient information about dementia. However, only 50% estimated that their spouses’ follow-up care had been well organised. The responses in the qualitative study indicated that many care givers felt grief and anxiety. They also expressed feelings of loneliness and uncertainty about how to deal with follow-up care for dementia. Conclusions: Elderly spousal care givers were quite satisfied with the information given them about dementia. However, the support with regard to the follow-up care of care-giving families failed to meet their needs adequately.

Use of inappropriate medications and their prognostic significance among in-hospital and nursing home patients with and without dementia in Finland.

BackgroundAlthough the Beers criteria have been frequently utilised to describe the use of inappropriate medications in various elderly populations, less is known about the use of such medications among patients with dementia, and nor have many studies dealt with their impact on mortality or use of healthcare services. This study examines the use of inappropriate drugs and their impact on mortality and use of health services among Finnish elderly nursing home and hospital patients. Patients with dementia were studied as a special subgroup.MethodsA total of 425 patients consecutively admitted to seven Finnish nursing homes and two hospitals in 1999–2000 were examined. Details of all medications prescribed and administered were retrieved from medical records and coded according to the Beers 1997 criteria. Mortality data as well as days in acute hospital were obtained from central registers and all area hospitals during 2 years of follow-up.ResultsThe entire population was old and frail (mean age 86 years, 82% females), 60% had dementia and 36.2% received at least one potentially inappropriate drug (PID). No differences existed in the proportion of users of PIDs among those 60% of patients with dementia compared with those without. The most common PID was temazepam, with 14% of all patients on high doses. Other commonly used PIDs were oxybutynin and dipyridamole. Amitriptyline was more commonly used among patients without dementia (4.7%) compared with those with dementia (0.8%). Nevertheless, in this very old and frail study population, use of inappropriate drugs did not predict mortality or use of health services.ConclusionUse of PIDs is common in nursing homes and hospitals in Finland but has no impact on mortality or hospital admissions. Use of high-dose temazepam as a hypnotic accounted for most of the high use of PIDs.

Anticholinergic Drugs and Their Effects on Delirium and Mortality in the Elderly

Aim: To investigate the use of drugs with anticholinergic properties (DAPs) and their associations with delirium and mortality among elderly patients with comorbidities. Methods: 425 patients (≧70 years of age) in geriatric wards and nursing homes were assessed. The use of DAPs was retrieved from their medical records. Delirium was diagnosed according to the DSM-IV criteria. Results: Of the 341 patients (80.2%) treated with multiple DAPs (≧2), 92 patients (27.0%) suffered from delirium, whereas 14 of 84 patients (16.7%) without DAP treatment had delirium (p = 0.050). In a logistic regression analysis with age, gender, and Charlson Comorbidity Index as covariates, DAP treatment did not predict delirium (odds ratio 1.67, 95% confidence interval 0.87–3.21). The 2-year mortality was 49.3% (n = 168) in DAP users and 35.7% (n = 30) in non-users, respectively (p = 0.026). In the Cox proportional hazard model adjusted for age, gender, and comorbidity, DAPs did not predict mortality (hazard ratio 1.12, 95% confidence interval 0.75–1.68). Conclusion: The use of DAPs is very frequent among frail inpatients with comorbidities, but their use has no independent prognostic significance.

Effects of Exercise on Cognition: The Finnish Alzheimer Disease Exercise Trial: A Randomized, Controlled Trial

To examine whether a regular, long‐term exercise program performed by individuals with Alzheimers disease (AD) at home or as group‐based exercise at an adult daycare center has beneficial effects on cognition; to examine secondary outcomes of a trial that has been published earlier.

DISCLOSURE OF DEMENTIA DIAGNOSIS AND THE NEED FOR ADVANCE CARE PLANNING IN INDIVIDUALS WITH ALZHEIMER'S DISEASE

To the Editor: In a recent article in the Journal of the American Geriatrics Society, Carpenter and colleagues found that disclosure of a dementia diagnosis does not prompt a catastrophic emotional reaction in most people with dementiaFnot even in those who are cognitively only mildly impaired. Companions of these patients also remained stable or even declined in their emotional stress immediately after the disclosure of dementia diagnosis. These findings suggest that physicians can provide a dementia diagnosis to a patient without fear of prompting strong emotional reactions. In our experience, the disclosure of a diagnosis of dementia and adjustment to understanding all dimensions related to this information are a long-term process in which the patient’s feelings develop and change over time. We examined the experiences of spousal caregivers of patients with Alzheimer’s disease (AD) with many comorbidities and disabilities regarding the disclosure of dementia diagnosis and the subsequent need for advance care planning (ACP).

Effects of exercise on functional performance and fall rate in subjects with mild or advanced Alzheimer's disease: secondary analyses of a randomized controlled study

Background: Exercise improves functional performance in subjects with dementia. However, whether the benefits of exercise are evident in all stages of dementia remains uncertain. This study examines how people in different stages of Alzheimers disease (AD) benefit from exercise intervention in their physical functioning and risk of falling. Methods: The present study is a subanalysis of a randomized controlled trial examining the effects of exercise intervention (twice a week for 12 months) in AD patients (n = 194). We studied the effects separately in participants with mild dementia and in participants with advanced dementia. Results: In subjects with mild dementia, the deterioration in physical functioning was slower in the intervention group than in the controls. Changes in Functional Independence Measure at 12 months were -2.7 (95% CI -0.5 to -4.9) in the intervention group and -10.1 (95% CI -7.0 to -13.3) in the control group (p < 0.001). The exercise intervention proved effective in preventing falls among patients with advanced AD, with an incidence rate ratio of 0.47 (95% CI 0.37-0.60; p < 0.001). Conclusions: Regular exercise may slow the rate of functional deterioration in mild AD and reduce falls in patients suffering from advanced AD.

The use of legal guardians and financial powers of attorney among home-dwellers with Alzheimer’s disease living with their spousal caregivers

We conducted a cross-sectional survey of a random sample of 1943 spouses of home-dwellers with Alzheimer’s disease (AD) to examine the prevalence of court-appointed guardians or financial powers of attorney for persons with AD, related factors and the need for information about these issues among caregiving families. The questionnaire consisted questions on variables of demographic characteristics, disability, symptoms and care needs of the person with dementia, the strain of caregiving, the use of court-appointed legal guardians or powers of attorney, as well as discussions about these issues—and the need for them—with a doctor. The response rate was 77% and the mean ages of those with AD and caregivers were 80.2 and 78.2 years, respectively. The use of legal guardians was rare (4.3%), while the use of financial powers of attorney was more common (37.8%). Only 9.9% of the couples had discussed these issues with their doctor, whereas 47.9% expressed a need for it. The factors associated with the use of these legal arrangements were related to the severity of dementia, including experiencing dementia symptoms for more than 3 years, poor functioning, incontinence and behavioural symptoms. There is a clear need for information on medico-legal issues related to dementia among caregivers of AD patients. If held soon after the diagnosis, such discussions could support the autonomy of these persons in spite of AD and enable them to plan for the future as they wish.

How Do Community-Dwelling Persons with Alzheimer Disease Fall Falls in the FINALEX Study

Background: People with dementia are at high risk for falls. However, little is known of the features causing falls in Alzheimer disease (AD). Our aim was to investigate how participants with AD fall. Methods: In the FINALEX (Finnish Alzheimer Disease Exercise Trial) study, participants’ (n = 194) falls were followed up for 1 year by diaries kept by their spouses. Results: The most common reason for falls (n = 355) was stumbling (n = 61). Of the falls, 123 led to injuries, 50 to emergency department visits, and 13 to fractures. The participants without falls (n = 103) were younger and had milder dementia than those with 1 (n = 34) or ≥2 falls (n = 57). Participants with a Mini Mental State Examination score of around 10 points were most prone to fall. In adjusted regression models, good nutritional status, good physical functioning, and use of antihypertensive medication (incident rate ratio [IRR] 0.68, 95% confidence interval [CI] 0.54–0.85) protected against falls, whereas fall history (IRR 2.71, 95% CI 2.13–3.44), osteoarthritis, diabetes mellitus, chronic obstructive pulmonary disease, higher number of drugs, drugs with anticholinergic properties, psychotropics, and opioids (IRR 4.27, 95% CI 2.92–6.24) were risk factors for falls. Conclusions: Our study provides a detailed account on how and why people with AD fall, suggesting several risk and protective factors.

Potentially severe drug–drug interactions among older people and associations in assisted living facilities in Finland: a cross-sectional study

Abstract Objective: This study aims to assess potentially severe class D drug–drug interactions (DDDIs) in residents 65 years or older in assisted living facilities with the use of a Swedish and Finnish drug–drug interaction database (SFINX). Design: A cross-sectional study of residents in assisted living facilities in Helsinki, Finland. Setting: A total of 1327 residents were assessed in this study. Drugs were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and DDDIs were coded according to the SFINX. Main outcome measures: Prevalence of DDDIs, associated factors and 3-year mortality among residents. Results: Of the participants (mean age was 82.7 years, 78.3% were females), 5.9% (N = 78) are at risk for DDDIs, with a total of 86 interactions. Participants with DDDIs had been prescribed a higher number of drugs (10.8 (SD 3.8) vs. 7.9 (SD 3.7), p < 0.001). A larger proportion of residents with DDDIs suffered from rheumatoid arthritis or osteoarthritis than those not exposed to DDDIs (24.7% vs. 15.4%, p = 0.030). The most frequent DDDIs were related to the concomitant use of potassium with amiloride (N = 12) or spironolactone (N = 12). Carbamazepine (N = 13) and methotrexate (N = 9) treatments were also frequently linked to DDDIs. During the follow-up, no differences in mortality emerged between the participants exposed to DDDIs and the participants not exposed to DDDIs. Conclusions: Of the residents in assisted living, 5.9% were exposed to DDDIs associated with the use of a higher number of drugs. Physicians should be trained to find safer alternatives to drugs associated with DDDIs. KEY POINTS   Potentially severe, class D drug–drug interactions (DDDIs) have been defined in the SFINX database as clinically relevant drug interactions that should be avoided.  • Of the residents in assisted living, 5.9% were exposed to DDDIs that were associated with the use of a higher number of drugs.  • The most frequent DDDIs were related to the concomitant use of potassium with amiloride or spironolactone. Carbamazepine and methotrexate were also linked to DDDIs.  • No difference in mortality was observed between residents exposed to DDDIs and residents not exposed to DDDIs.

Relationship of Neuropsychiatric Symptoms with Falls in Alzheimer's Disease - Does Exercise Modify the Risk?: NPS and falls in Alzheimer's disease

To explore how neuropsychiatric symptoms (NPS) are associated with number of falls and how exercise modifies the risk of falling in community‐dwelling people with Alzheimers disease (AD) and NPS.