Rory H. Fisher

The NINCDS‐ADRDA Work Group criteria for the clinical diagnosis of probable Alzheimer's disease A clinicopathologic study of 57 cases

Neuropathologic confirmation is required to validate the NINCDS-ADRDA Work Group criteria for the clinical diagnosis of Alzheimers disease (AD). Neuropathologic inclusion and exclusion criteria for AD, however, are not uniform. The purpose of this investigation was to examine the confirmation rate for the Work Group criteria against differing neuropathologic criteria for AD. The sample consisted of 57 cases, 22 of which had received a clinical diagnosis of AD. Nine neuropathologic criteria for AD were applied in a blind fashion to each of the 57 cases. Our results indicated that, depending on the neuropathologic criteria applied, the clinicopathologic agreement ranged from 64% to 86%. These findings demonstrate the need for universally accepted neuropathologic and clinical criteria for AD.

Fatty acid analysis of blood plasma of patients with Alzheimer's disease, other types of dementia, and cognitive impairment.

Fatty acid differences, including docosahexaenoic acid (DHA; 22:6n-3) have been shown in the brains of Alzheimers patients (AD) as compared with normal age-matched individuals. Furthermore, low serum DHA is a significant risk factor for the development of AD. The relative concentration of DHA and other fatty acids, however, in the plasma of AD patients compared with patients with other kinds of dementias (other dementias; OD), patients who are cognitively impaired but nondemented (CIND), or normal patients is not known. In this study we analyzed the total phospholipid, phosphatidylcholine (PC), phosphatidylethanolamine (PE), and lysophosphatidylcholine (lysoPC) fractions of plasma from patients diagnosed with AD, OD, or CIND and compared them with a group of elderly control subjects with normal cognitive functioning. Plasma phospholipid and PC levels of 20:5n-3, DHA, total n-3 fatty acids, and the n-3/n-6 ratio were lower in the AD, OD, and CIND groups. Plasma phospholipid 24:0 was lower in the AD, OD, and CIND groups as compared with the group of control patients, and total n-6 fatty acid levels were higher in the AD and CIND groups only. In the plasma PE fraction, levels of 20:5n-3, DHA, and the total n-3 fatty acid levels were significantly lower in the AD, OD, and CIND groups. DHA levels were lower in the lysoPC fraction of CIND individuals only. There were no other differences in the fatty acid compositions of the different phospholipid fractions. Therefore, in AD, OD, and CIND individuals, low levels of n-3 fatty acids in the plasma may be a risk factor for cognitive impairment and/or dementia. Interestingly, a decreased level of plasma DHA was not limited to the AD patients but appears to be common in cognitive impairment with aging.

Risk Factors for Harm in Cognitively Impaired Seniors Who Live Alone: A Prospective Study

Objectives: To identify risk factors for harm due to self‐neglect or behaviors related to disorientation in cognitively impaired seniors who live alone that can be used in primary care.

The Clinical Case Against Tube Feeding in Palliative Care of the Elderly

The terminal stages of many neurological illnesses occurring in the elderly produce feeding and swallowing problems. These difficulties lead to ethical, religious, philosophical, and medico‐legal conflicts when decisions about starting or stopping tube feedings are considered. We present the case against all forms of tube feeding in a particular subset of elderly palliative patients. These are individuals who are in the end‐stage of a progressive neurological disease who are noncommunicative, and spend all or most of their time in a recumbent position. We discuss the physiological phenomena existing in these patients that make the probability of aspiration pneumonia as great or possibly greater than with careful spoon feeding. If tube feeding results in the outcome that it is thought to prevent (ie, aspiration pneumonia) then decisions regarding nutritional support in these patients become clinically clearer.

A randomized double-blind trial of the effects of hormone therapy on delayed verbal recall in older women

We examined whether estradiol and norethindrone hormone therapy (HT) prevented decline in delayed verbal recall in older women with normal to mildly impaired memory functioning. This was a 2-year, randomized, double-blind, placebo-controlled trial of 142 women aged 61-87, randomly assigned to receive 1 mg 17-beta estradiol daily and 0.35 mg norethindrone 3 days/week or daily placebo for 2 years. The primary outcome was short-delay verbal recall of the California Verbal Learning Test (CVLT). To look for differences in response to HT by baseline short-delay recall, we examined the primary outcome in participants grouped according to whether their baseline scores were below average for the age group or greater than or equal to this score and according to whether they met criteria for Mild Cognitive Impairment (MCI) or not. 133 women completed 1 year of the trial and 128 completed 2 years. Prespecified covariates in all repeated measures analyses of covariance (RANCOVA) included age, education, APOE epsilon4, and prior HT use. RANCOVA showed no overall significant treatment effects at year 1 or year 2. After testing for an interaction, which was significant (p=0.02), we found that women in the HT group who scored at or above the average showed significantly less decline than the placebo group in short-delay verbal recall after 1 year, p=0.007 and 2 years, p=0.01. No treatment effects were found in women below the average in either year. When grouped according to whether the participant met criteria for MCI, the interaction between treatment group and MCI subgroup was not significant. These results suggest that benefits of estrogen exposure may be limited to those with average to above average scores on the delayed verbal recall. HT dose and formulation may have contributed to these beneficial outcomes. Replication is warranted before recommendations can be made in the clinical setting.

Use of the Rey Auditory Verbal Learning Test in Differentiating Normal Aging from Alzheimer's and Parkinson's Dementia.

Elderly control subjects (n = 38) performed better than did patients with moderate Alzheimers disease (AD; n = 18), severe AD (n = 33), or Parkinsons dementia (PD; n = 12) on all measures of the Rey Auditory Verbal Learning Test (RAVLT). The moderate-AD group performed better than did the severe-AD group on the 5 learning trials of List A. Unlike the controls and PD patients, both AD groups showed a greater recency than primacy effect, and both performed equally poorly on recall of List A after List B had been presented. The PD group showed poorer recall on List B than did the moderate-AD group but had better recognition scores than did both AD groups

WAIS-R Test-retest reliability in a normal elderly sample

We examined the 1-year test-retest reliability of WAIS-R Verbal, Performance, and Full-Scale IQs in a sample of 101 older normal individuals (mean age = 67.1). The respective Pearson rs were .86, .85, and .90. The median retest reliability coefficient for the WAIS-R subtests was .71. The test-retest reliability for the Verbal-Performance Discrepancy was .69. These data indicate that IQ scores are reliable in older normal individuals for this retest interval, but less confidence can be placed in the reliability of subtest scores and the Verbal-Performance Discrepancy.

Educationally influential physicians: The need for construct validation

Introduction: Educational influential physicians may be a valuable resource in continuing medical education. Although the idea driving this research—informal learning—converges with research in adult education, organizational learning, marketing, and knowledge diffusion, the results of interventions hare proven inconclusive. To actualize the promise of the educationally influential physician (EIP) construct, it is argued that researchers must return to the “classic” studies in this area and resume the process of validating the meaning of the construct. Methods: A literature review and the occasion of an educationally influential physician identification survey provided an opportunity to contribute to development of this construct. We compared three identification rules used to study 212 physicians. Result: Each rule may identify different people as EIPs. Discussion: To improve the use of educational influentials, research must be completed to validate their role in informal learning.

Oro-esophageal tube feeding: An alternative to nasogastric or gastrostomy tubes

Some elderly, dysphagic patients refuse to accept conventional methods of enteral feeding, presenting caregivers with a considerable dilemma. The ability to offer an alternative then becomes important. For the past four years, we have used, for selected patients, a method of oro-esophageal tube feeding, developed by the principal author. This method has been successfully used by patients who refuse nasogastric or gastrostomy tubes.

End of Life Care: The Experience of Seniors and Informal Caregivers

As Canadas elderly population grows, an increasing number of seniors will require care as they face the end of life. Relatively little research attention, however, has been given to end-of-life issues, including those related to treatment and care for persons who are both old and dying. Families and health care providers have little direction and guidance to ensure an optimum quality of life for seniors prior to death and during the period of bereavement. This article presents an abbreviated summary of the literature regarding end-of-life issues and challenges for seniors who face a life threatening illness and are at, or near, the end of their lives. The article is also informed by a series of focus groups with elderly and other informal caregivers regarding the giving of help and getting support while caring for persons who are dying. It concludes with a response to this evidence by making a series of recommendations aimed at ensuring optimal end-of-life care for seniors who are dying and their families.