Tobias Luck

Prediction of institutionalization in the elderly. A systematic review

OBJECTIVE in the past decades, many studies have examined predictors of nursing home placement (NHP) in the elderly. This study provides a systematic review of predictors of NHP in the general population of developed countries. DESIGN relevant articles were identified by searching the databases MEDLINE, Web of Science, Cochrane Library and PSYNDEXplus. Studies based on population-based samples with prospective study design and identification of predictors by multivariate analyses were included. Quality of studies and evidence of predictors were determined. RESULTS thirty-six studies were identified; one-third of the studies were of high quality. Predictors with strong evidence were increased age, low self-rated health status, functional and cognitive impairment, dementia, prior NHP and a high number of prescriptions. Predictors with inconsistent results were male gender, low education status, low income, stroke, hypertension, incontinence, depression and prior hospital use. CONCLUSIONS findings suggested that predictors of NHP are mainly based on underlying cognitive and/or functional impairment, and associated lack of support and assistance in daily living. However, the methodical quality of studies needs improvement. More theoretical embedding of risk models of NHP would help to establish more clarity in complex relationships in using nursing homes.

Prediction of Dementia by Subjective Memory Impairment Effects of Severity and Temporal Association With Cognitive Impairment

CONTEXT Subjective memory impairment (SMI) is receiving increasing attention as a pre-mild cognitive impairment (MCI) condition in the course of the clinical manifestation of Alzheimer disease (AD). OBJECTIVES To determine the risk for conversion to any dementia, dementia in AD, or vascular dementia by SMI, graded by the level of SMI-related worry and by the temporal association of SMI and subsequent MCI. DESIGN Longitudinal cohort study with follow-up examinations at 1(1/2) and 3 years after baseline. SETTING Primary care medical record registry sample. PARTICIPANTS A total of 2415 subjects without cognitive impairment 75 years or older in the German Study on Aging, Cognition and Dementia in Primary Care Patients. MAIN OUTCOME MEASURES Conversion to any dementia, dementia in AD, or vascular dementia at follow-up 1 or follow-up 2 predicted by SMI with or without worry at baseline and at follow-up 2 predicted by different courses of SMI at baseline and MCI at follow-up 1. RESULTS In the first analysis, SMI with worry at baseline was associated with greatest risk for conversion to any dementia (hazard ratio [HR], 3.53; 95% confidence interval [CI], 2.07-6.03) or dementia in AD (6.54; 2.82-15.20) at follow-up 1 or follow-up 2. The sensitivity was 69.0% and the specificity was 74.3% conversion to dementia in AD. In the second analysis, SMI at baseline and MCI at follow-up 1 were associated with greatest risk for conversion to any dementia (odds ratio [OR], 8.92; 95% CI, 3.69-21.60) or dementia in AD (19.33; 5.29-70.81) at follow-up 2. Furthermore, SMI at baseline and amnestic MCI at follow-up 1 increased the risk for conversion to any dementia (OR, 29.24; 95% CI, 8.75-97.78) or dementia in AD (60.28; 12.23-297.10), with a sensitivity of 66.7% and a specificity of 98.3% for conversion to dementia in AD. CONCLUSION The prediction of dementia in AD by SMI with subsequent amnestic MCI supports the model of a consecutive 3-stage clinical manifestation of AD from SMI via MCI to dementia.

Age- and gender-specific prevalence of depression in latest-life – Systematic review and meta-analysis

OBJECTIVE The objective of the study is to systematically analyze the prevalence of depression in latest life (75+), particularly focusing on age- and gender-specific rates across the latest-life age groups. DESIGN Relevant articles were identified by systematically searching the databases MEDLINE, Web of Science, Cochrane Library and Psycinfo and relevant literature from 1999 onwards was reviewed. Studies based on the community-based elderly population aged 75 years and older were included. Quality of studies was assessed. Meta-analysis was performed using random effects model. RESULTS 24 studies reporting age- and gender-specific prevalence of depression were found. 13 studies had a high to moderate methodical quality. The prevalence of major depression ranged from 4.6% to 9.3%, and that of depressive disorders from 4.5% to 37.4%. Pooled prevalence was 7.2% (95% CI 4.4-10.6%) for major depression and 17.1% (95% CI 9.7-26.1%) for depressive disorders. Potential sources of high heterogeneity of prevalence were study design, sampling strategy, study quality and applied diagnostics of latest life depression. CONCLUSIONS Despite the wide variation in estimates, it is evident that latest life depression is common. To reduce variability of study results, particularly sampling strategies (inclusion of nursing home residents and severe cognitively impaired individuals) for the old age study populations should be addressed more thoroughly in future research.

Prediction of institutionalisation in dementia. A systematic review.

Background/Aims: In the past decades, a substantial number of studies considered factors influencing institutionalisation of persons with dementia. This study reviews recent work on predictors of actual institutionalisation in dementia. Method: Relevant articles were identified by a systematic search of the literature. Studies were considered which included persons aged 65 and over, and whose results were based on prospective design and on multivariate statistical analyses. Results: Forty-two studies were identified. The rate of institutionalisation increased from 20% in the first year after diagnosis to 50% after 5 years. Median time to institutionalisation was estimated between 30 and 40 months. Predictors of institutionalisation were classified according to a provided conceptual framework in the categories sociodemographic and relationship characteristics of persons with dementia and caregivers, primary stressors, secondary stressors and resources. Conclusion: The overview of research activities in this area showed a lack of methodological strength in a large part of identified studies. Nevertheless, a lot of well-examined and less highlighted predictors could be identified.

AD dementia risk in late MCI, in early MCI, and in subjective memory impairment

To compare the risk of developing Alzheimers disease (AD) dementia in late mild cognitive impairment (LMCI), early MCI (EMCI), and subjective memory impairment (SMI) with normal test performance.

Mild Cognitive Impairment in General Practice: Age-Specific Prevalence and Correlate Results from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)

Background: Although mild cognitive impairment (MCI) represents a high-risk factor for developing dementia, little is known about the prevalence of MCI among patients of general practitioners (GPs). Aims: Estimation of age-specific prevalence for original and modified concepts of MCI and their association with sociodemographic, medical and genetic (apoE Ε4 genotype) factors among patients of GPs. Methods: A GP practice sample of 3,327 individuals aged 75+ was assessed by structured clinical interviews. Results: Prevalence was 15.4% (95% CI = 14.1–16.6) for original and 25.2% (95% CI = 23.7–26.7) for modified MCI. Rates increased significantly with older age. Positive associations were found for apoE Ε4 allele, vascular diseases and depressive symptoms. Conclusion: MCI is frequent in elderly patients of GPs. GPs have a key position in secondary prevention and care of incipient cognitive deterioration up to the diagnosis of dementia.

Incidence of Mild Cognitive Impairment: A Systematic Review

Background/Aims: Subjects with mild cognitive impairment (MCI) constitute a risk population of developing dementia and thus a population of clinical interest. This study reviews recent work on the incidence of MCI in the elderly. Methods: Incidence papers were identified by a systematic literature search. Studies on the incidence of MCI were considered if they identified ‘cognitively mildly impaired’ subjects by application of the MCI criteria, used the ‘person-years-at-risk’ method, and were based on population- or community-based samples. Results: Nine studies were identified. The incidence of amnestic MCI subtypes ranged between 9.9 and 40.6 per 1,000 person-years, and the incidence of non-amnestic MCI subtypes was 28 and 36.3 per 1,000 person-years. Regarding any MCI, incidence rates of 51 and 76.8 per 1,000 person-years were found. A higher risk of incident MCI mainly resulted for higher age, lower education and hypertension. Discussion: The incidence rates of MCI varied widely, and possible risk factors for incident MCI were analysed only to a limited extent. The findings call for an agreement concerning the criteria used for MCI and the operationalisation of these criteria.

Nursing home staff training in dementia care: a systematic review of evaluated programs

Background: We reviewed studies of in-service interventions for caregivers of personswithdementiainnursinghomespublishedbetween1990and2004. The aim was to obtain an overview of the evaluated interventions and to characterize their methodological quality. Methods: A thorough literature search was conducted, including searching electronic databases for selected intervention studies and previous reviews. Selected studies were summarized and compared along certain categories, and methodological quality was assessed. Results: A total of 21 studies were identified, mostly published in the United States. Most were of poor methodological quality. Although nearly all reported positive effects, their results must be interpreted cautiously due to methodological weaknesses. Extensive interventions with ongoing support successfully demonstrated sustained implementation of new knowledge. Owing to methodological weaknesses and a lack of follow-up evaluations, little or no evidence existed for the efficacy or, particularly, the transfer of knowledge in simpler interventions when reinforcing and enabling factors were not present. Conclusion: On an international and, particularly, on a national level a lack of evaluated in-service training programs for caregivers in homes for people with dementia is apparent. Methodological weakness is common. This study highlights the need for well-defined methodologically improved studies, providing conclusive evidence of the effects of intervention types to help improve the quality of dementia care.

Prediction of dementia in primary care patients.

Background Current approaches for AD prediction are based on biomarkers, which are however of restricted availability in primary care. AD prediction tools for primary care are therefore needed. We present a prediction score based on information that can be obtained in the primary care setting. Methodology/Principal Findings We performed a longitudinal cohort study in 3.055 non-demented individuals above 75 years recruited via primary care chart registries (Study on Aging, Cognition and Dementia, AgeCoDe). After the baseline investigation we performed three follow-up investigations at 18 months intervals with incident dementia as the primary outcome. The best set of predictors was extracted from the baseline variables in one randomly selected half of the sample. This set included age, subjective memory impairment, performance on delayed verbal recall and verbal fluency, on the Mini-Mental-State-Examination, and on an instrumental activities of daily living scale. These variables were aggregated to a prediction score, which achieved a prediction accuracy of 0.84 for AD. The score was applied to the second half of the sample (test cohort). Here, the prediction accuracy was 0.79. With a cut-off of at least 80% sensitivity in the first cohort, 79.6% sensitivity, 66.4% specificity, 14.7% positive predictive value (PPV) and 97.8% negative predictive value of (NPV) for AD were achieved in the test cohort. At a cut-off for a high risk population (5% of individuals with the highest risk score in the first cohort) the PPV for AD was 39.1% (52% for any dementia) in the test cohort. Conclusions The prediction score has useful prediction accuracy. It can define individuals (1) sensitively for low cost-low risk interventions, or (2) more specific and with increased PPV for measures of prevention with greater costs or risks. As it is independent of technical aids, it may be used within large scale prevention programs.

Risk factors for incident mild cognitive impairment – results from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)

Luck T, Riedel‐Heller SG, Luppa M, Wiese B, Wollny A, Wagner M, Bickel H, Weyerer S, Pentzek M, Haller F, Moesch E, Werle J, Eisele M, Maier W, van den Bussche H, Kaduszkiewicz H for the AgeCoDe Study Group. Risk factors for incident mild cognitive impairment – results from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe).