Noorhazlina Ali

New DSM-V Neurocognitive Disorders Criteria and Their Impact on Diagnostic Classifications of Mild Cognitive Impairment and Dementia in a Memory Clinic Setting

OBJECTIVE To examine diagnostic agreement between Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) Neurocognitive Disorders (NCDs) criteria and DSM, Fourth Edition (DSM-IV) criteria for dementia and International Working Group (IWG) criteria for mild cognitive impairment (MCI) and DSM-Vs impact on diagnostic classifications of NCDs. The authors further examined clinical factors for discrepancy in diagnostic classifications between the different operational definitions. METHODS Using a cross-sectional study in tertiary memory clinic, the authors studied consecutive new patients aged 55 years or older who presented with cognitive symptoms. Dementia severity was scored based on the Clinical Dementia Rating scale (CDR). All patients completed neuropsychological evaluation. Agreement in diagnostic classifications between DSM-IV/IWG and DSM-V was examined using the kappa test and AC1 statistic, with multinomial logistic regression for factors contributing to MCI reclassification as major NCDs as opposed to diagnostically concordant MCI and dementia groups. RESULTS Of 234 patients studied, 166 patients achieved concordant diagnostic classifications, with overall kappa of 0.41. Eighty-six patients (36.7%) were diagnosed with MCI and 131 (56.0%) with DSM-IV-defined dementia. With DSM-V, 40 patients (17.1%) were classified as mild NCDs and 183 (78.2%) as major NCDs, representing a 39.7% increase in frequency of dementia diagnoses. CDR sum-of-boxes score contributed independently to differentiation of MCI patients reclassified as mild versus major NCDs (OR: 0.01; 95% CI: 0-0.09). CDR sum-of-boxes score (OR: 5.18; 95% CI: 2.04-13.15), performance in amnestic (OR: 0.14; 95% CI: 0.06-0.34) and language (Boston naming: OR: 0.52; 95% CI: 0.29-0.94) tests, were independent determinants of diagnostically concordant dementia diagnosis. CONCLUSION The authors observed moderate agreement between the different operational definitions and a 40% increase in dementia diagnoses with operationalization of the DSM-V criteria.

Worry about performance: a unique dimension of caregiver burden.

BACKGROUND Recent studies that describe the multidimensionality of the Zarit Burden Interview (ZBI) challenge the traditional dual-factor paradigm of personal and role strains (Whitlatch et al., 1991). These studies consistently reported a distinct dimension of worry about caregiver performance (WaP) comprising items 20 and 21.The present study aims to compare WaP against conventional ZBI domains in a predominantly Chinese multi-ethnic Asian population. METHODS We studied 130 consecutive dyads of family caregivers and patients. Factor analysis of the 22-item ZBI revealed four factors of burden. We compared WaP (factor 4) with the other three factors, personal strain, and role strain via: internal consistency; inter-factor correlation; item-to-total ratio across Clinical Dementia Rating (CDR) stages; predictors of burden; and interaction effect on total ZBI score using two-way analysis of variance. RESULTS WaP correlated poorly with the other factors (r = 0.05-0.21). It had the highest internal consistency (Cronbachs α = 0.92) among the factors. Unlike other factors, WaP was highly endorsed in mild cognitive impairment and did not increase linearly with disease severity, peaking at CDR 1. Multiple regression revealed younger caregiver age as the major predictor of WaP, compared with behavioral and functional problems for other factors. There was a significant interaction between WaP and psychological strain (p = 0.025). CONCLUSION Our results corroborate earlier studies that WaP is a distinct burden dimension not correspondent with traditional ZBI domains. WaP is germane to many Asian societies where obligation values to care for family members are strongly influential. Further studies are needed to better delineate the construct of WaP.

Cost of informal care for community-dwelling mild-moderate dementia patients in a developed Southeast Asian country.

BACKGROUND Cost of informal care constitutes an important component of total dementia care cost. It also reflects resource utilization by patients and caregivers. We aim to quantify the informal cost of care for mild to moderate dementia patients. METHODS We recruited 165 patient-caregiver dyads with mild to moderate dementia. Informal care burden was assessed using the Resource Utilization in Dementia (RUD)-Lite instrument. A generalized linear model was fitted for association between cost of informal care and cognitive impairment, taking into account patient demographics, disease factors, and use of paid domestic help. Marginal estimates were obtained from the model for the purpose of illustration and discussion. RESULTS Total hours of informal care by primary caregiver doubled in moderate dementia patients, with 57.9% having paid domestic help to assist in care. Functional factors and use of paid domestic help were significantly associated with informal care costs. Costs were consistently higher for patients without paid domestic help for mild- and moderate dementia. CONCLUSION This study demonstrates the informal care costs of caring for mild-moderate dementia patients in Singapore, with the unique cost savings provided by live-in paid domestic help, and potentially may aid policy-makers in allocation of resources and support to caregivers.

Caregiver Burden: Looking Beyond the Unidimensional Total Score.

The Zarit Burden Interview allows caregiver burden to be interpreted from a total score. However, recent studies propose a multidimensional Zarit Burden Interview model. This study aims to determine the agreement between unidimensional (UD) and multidimensional (MD) classification of burden, and differences in predictors among identified groups. We studied 165 dyads of dementia patients and primary caregivers. Caregivers were dichotomized into low-burden and high-burden groups based upon: (1) UD score using quartile cutoffs; and (2) MD model via exploratory cluster analysis. We compared UD versus MD 2×2 classification of burden using &kgr; statistics. Caregivers not showing agreement by either definition were classified as “intermediate” burden. We performed binary logistic regression to ascertain differences in predictive factors. The 2 models showed moderate agreement (&kgr;=0.72, P<0.01), yielding 104 low, 20 intermediate (UD “low burden”/MD “high burden”), and 41 high-burden caregivers. Neuropsychiatric symptoms [odds ratio (OR)=1.27, P=0.003], coresidence (OR=6.32, P=0.040), and decreased caregiving hours (OR=0.99, P=0.018) were associated with intermediate burden, whereas neuropsychiatric symptoms (OR=1.21, P=0.001) and adult children caregivers (OR=2.80, P=0.055) were associated with high burden. Our results highlight the differences between UD and MD classification of caregiver burden. Future studies should explore the significance of the noncongruent intermediate group and its predictors.

A Combined Cognitive Stimulation and Physical Exercise Programme (MINDVital) in Early Dementia: Differential Effects on Single- and Dual-Task Gait Performance

Background: Gait disorders are common in early dementia, with particularly pronounced dual-task deficits, contributing to the increased fall risk and mobility decline associated with cognitive impairment. Objective: This study examines the effects of a combined cognitive stimulation and physical exercise programme (MINDVital) on gait performance under single- and dual-task conditions in older adults with mild dementia. Methods: Thirty-nine patients with early dementia participated in a multi-disciplinary rehabilitation programme comprising both physical exercise and cognitive stimulation. The programme was conducted in 8-week cycles with participants attending once weekly, and all participants completed 2 successive cycles. Cognitive, functional performance and behavioural symptoms were assessed at baseline and at the end of each 8-week cycle. Gait speed was examined under both single- (Timed Up and Go and 6-metre walk tests) and dual-task (animal category and serial counting) conditions. A random effects model was performed for the independent effect of MINDVital on the primary outcome variable of gait speed under dual-task conditions. Results: The mean age of patients enroled in the rehabilitation programme was 79 ± 6.2 years; 25 (64.1%) had a diagnosis of Alzheimers dementia, and 26 (66.7%) were receiving a cognitive enhancer therapy. There was a significant improvement in cognitive performance [random effects coefficient (standard error) = 0.90 (0.31), p = 0.003] and gait speed under both dual-task situations [animal category: random effects coefficient = 0.04 (0.02), p = 0.039; serial counting: random effects coefficient = 0.05 (0.02), p = 0.013], with reduced dual-task cost for gait speed [serial counting: random effects coefficient = -4.05 (2.35), p = 0.086] following successive MINDVital cycles. No significant improvement in single-task gait speed was observed. Improved cognitive performance over time was a significant determinant of changes in dual-task gait speed [random effects coefficients = 0.01 (0.005), p = 0.048, and 0.02 (0.005), p = 0.003 for category fluency and counting backwards, respectively]. Conclusion: A combined physical and cognitive rehabilitation programme leads to significant improvements in dual-task walking in early dementia, which may be contributed by improvement in cognitive performance, as single-task gait performance remained stable.

Association of nutrition and immune-endocrine dysfunction with muscle mass and performance in cognitively impaired older adults

BACKGROUND With lean mass declining early in Alzheimers disease, muscle quality beyond quantity is relevant to physical performance. We sought to identify potentially modifiable factors for the differential loss of muscle mass (pre-sarcopenia) and its performance (sarcopenia) in older adults with mild cognitive impairment (MCI) and mild-to-moderate Alzheimers disease (AD). METHODS This is a cross-sectional study of 108 community-dwelling older adults with MCI and mild-to-moderate AD. Participants were categorized as: (i) No sarcopenia (normal muscle mass), (ii) Pre-sarcopenia (low muscle mass without weakness or slowness), (iii) Sarcopenia (low muscle mass AND weak grip strength and/or slow gait speed) using Asian cut-offs. Muscle quality was defined as the ratio of grip and knee extension strength to average arm and leg lean mass respectively. We measured cognitive, functional and physical (Short Physical Performance Battery, SPPB) performance; physical activity level; nutritional status; and blood biomarkers of inflammation and endocrine dysfunction. RESULTS SPPB (p=0.033) and activity level (p=0.010) were highest in the pre-sarcopenic group. Pre-sarcopenic group had highest arm muscle quality [10.6 (7.7-12.2) vs 13.9 (12.6-15.7) vs 11.3 (9.7-12.8), p<0.001], despite significantly lower appendicular lean mass than non-sarcopenic group. In multi-nomial logistic regression reference to non-sarcopenic group, malnutrition independently increased risk for both pre-sarcopenia (Relative risk=7.53, 95% C.I 1.20-47.51, p=0.032) and sarcopenia (Relative risk=11.91, 95% C.I 2.85-49.77, p=0.001). A combined pro-inflammatory and endocrine deficient state significantly increased the risk of sarcopenia (Relative risk=5.17, 95% C.I 1.31-20.37, p=0.019). CONCLUSION Malnutrition is a precursor for progressive loss of muscle mass, but a pro-inflammatory and endocrine deficient state may potentially aggravate decline in muscle quality to culminate in frank sarcopenia.

Burden among Family Caregivers of Dementia in the Oldest-Old: An Exploratory Study

Background With >85 years, the fastest growing age segment in developed countries, dementia in the oldest-old is projected to increase exponentially. Being older, caregivers of dementia in oldest-old (CDOO) may experience unique challenges compared with younger-age groups. Thus, we aim to explore demographic characteristics and burden pattern among CDOO. Methods We studied 458 family caregiver-patient dyads attending an outpatient memory clinic. We classified patients into three age-groups: <75, 75–84, and ≥85 years. We measured caregiver burden using the Zarit Burden Interview (ZBI) 4-factor structure described by Cheah et al. (1). We compared care recipient characteristics, caregiver demographics, and ZBI total/factors scores between the three age-groups, and performed 2-way analysis of variance (ANOVA) to ascertain the effect of age-group by disease severity interaction. Results Oldest-old care recipients were more impaired in cognitive function and instrumental ADL; there was no difference in behavior and basic ADL. Compared with the other two age-groups, CDOO were older (mean age: 50.4 vs 55.5 vs 56.8 years, P < 0.01), and overwhelmingly adult children (85.9%) as opposed to spouses (5.3%). CDOO also had higher ZBI total score, role strain, and personal strain (all P < 0.05). However, there was no difference in worry about performance scores. 2-way ANOVA did not reveal significant age-group by disease severity interaction for ZBI total and factor scores, although distinctive differences were seen between role/personal strain with worry about performance in mild cognitive impairment and very mild dementia. Conclusion Our study highlighted that CDOO were mainly older adult children who experienced significant role and personal strain independent of disease severity while caring for their family member with more impaired cognitive and physical function. These results pave the way for targeted interventions to address the unique burden faced by this rapidly growing group of caregivers.

The dignity in advanced dementia (diadem) study: Developing an integrated geriatric palliative homecare program

Background: The prevalence of dementia is rising globally. Many patients suffer from the burdensome complications of advanced dementia as they are still poorly addressed. Aims: To describe the development of an interdisciplinary palliative homecare program for patients with advanced dementia and to develop a workflow that delineates the seamless continuation of care between the hospital and community with the homecare program. Design: Palliative care needs of patients and caregivers were established through a qualitative review of the literature. Appraisal tools were chosen based on their validity and feasibility in the homecare setting. Gaps in the healthcare system were identified and addressed as part of the integration of care between the hospital and the community. Setting/participants: Patients at Functional Assessment Staging (FAST) 7 with pneumonia, albumin level <35 g/L and/or enteral feeding were enrolled from a tertiary care hospital into the homecare program. Results: Patients’ symptom burden and quality of life were assessed. Caregivers were engaged in the planning of patients’ care. With the homecare program, patients and caregivers received support at home. Two physicians, seven nurses, and three social work professionals were educated about advanced dementia palliative care and medical information was communicated between different healthcare sites. Preliminary analysis of 306 patients revealed the presence of pain and neuropsychiatric behaviors. Impact of caregiving was mild to moderately severe. Conclusion: Advanced dementia is under-recognized as a terminal illness requiring specialized palliative intervention. Integrating a homecare palliative program into advanced dementia care is the first step towards palliating suffering at the end-of-life.

Evaluation of an integrated primary care-led dementia shared care program in Singapore: An effectiveness and cost-effectiveness study: Primary care dementia clinic in Singapore

With an aging Singapore population, there is an increasing demand for dementia care. The present study aimed to evaluate the effectiveness and cost‐effectiveness of the Primary Care Dementia Clinic (PCDC) in comparison with the Memory Clinic (MC; hospital‐based) and other polyclinics.

NEUROPSYCHIATRIC SYMPTOMS IN PERSONS WITH MILD COGNITIVE IMPAIRMENT AND ITS IMPACT ON CAREGIVER BURDEN

Background: Persons with Mild Cognitive Impairment (MCI) have been shown to manifest milder severity neuropsychiatric symptoms (NPS). However, there are limited studies looking at the impact of NPS on their caregivers. We seek to characterise the neuropsychiatric profile of persons with MCI and its impact on the various aspects of caregiver burden. Methods: 141 persons with MCI and caregiver pairs were recruited consecutively. Demographic data and functional parameters of persons with MCI were collected, whilst Neuropsychiatric Inventory Questionnaire (NPI-Q), Neuropsychiatric Caregiver Distress (NPI-D) and Zarit caregiver burden interview (ZBI) were administered to caregivers. Results of NPI-Q and NPI-D were analysed in symptom clusters of affective symptoms, psychosis, psychomotor symptoms, apathy, sleep disturbances and eating disorders. ZBI scores were analysed in a validated factor analysis of 4 factors of a) high demands of care and social impact (DoC), b) low confidence and control over situation (CC), c) high personal strain (PS) and d) high worry about performance (WaP). Descriptive statistics were performed to identify frequencies of NPI-Q clusters and corresponding NPI-D. Partial correlations were performed for NPS clusters with ZBI factors. Results: Mean age of persons with MCI was 72.54, and that of caregivers was 53.03. NPS of highest frequencies were that of psychomotor symptoms (56.4%) and closely followed by affective symptoms (52.5%). Correspondingly, the 2 highest frequencies of caregiver distress were due to psychomotor symptoms and affective symptoms (40% and 34.3% respectively). Looking at partial correlations, affective symptoms (r1⁄40.232, p1⁄40.013), psychomotor symptoms (r1⁄4370, p1⁄40.00), apathy (r1⁄40.241, p1⁄40.010) were significantly positively correlated with high total ZBI scores. In particular, psychomotor symptoms were significantly correlated with all 4 factors of caregiver burden: high DoC (r1⁄4 0.371, p1⁄40.00), low CC (r1⁄40.194 p1⁄40.039), high PS (p1⁄40.416, p1⁄40.00) and highWaP (r1⁄40.197, p1⁄40.036). Conclusions:Our study has shown that neuropsychiatric symptoms of affective symptoms and psychomotor symptoms are fairly prevalent amongst persons with MCI and cause significant caregiver burden. Knowledge of aspects of caregiver burden affected in specific clusters of NPS is useful in developing targeted strategies of counselling and utilising of resources to help caregivers of persons with MCI.