Archives for July 2013

Common Blood Pressure Drugs May Slow Dementia

BMJ Open 2013;3:e002881 doi:10.1136/bmjopen-2013-002881

Effects of centrally acting ACE inhibitors on the rate of cognitive decline in dementia

Yang Gao1,2, Rónán O’Caoimh1, Liam Healy1, David M Kerins3,4, Joseph Eustace5,Gordon Guyatt6, David Sammon2, D William Molloy1,7

Abstract

Objectives

There is growing evidence that antihypertensive agents, particularly centrally acting ACE inhibitors (CACE-Is), which cross the blood–brain barrier, are associated with a reduced rate of cognitive decline. Given this, we compared the rates of cognitive decline in clinic patients with dementia receiving CACE-Is (CACE-I) with those not currently treated with CACE-Is (NoCACE-I), and with those who started CACE-Is, during their first 6 months of treatment (NewCACE-I).

Design

Observational case–control study.

Setting

2 university hospital memory clinics.

Participants

817 patients diagnosed with Alzheimer’s disease, vascular or mixed dementia. Of these, 361 with valid cognitive scores were included for analysis, 85 CACE-I and 276 NoCACE-I.

Measurements

Patients were included if the baseline and end-point (standardised at 6 months apart) Standardised Mini-Mental State Examination (SMMSE) or Quick Mild Cognitive Impairment (Qmci) scores were available. Patients with comorbid depression or other dementia subtypes were excluded. The average 6-month rates of change in scores were compared between CACE-I, NoCACE-I and NewCACE-I patients.

Results

When the rate of decline was compared between groups, there was a significant difference in the median, 6-month rate of decline in Qmci scores between CACE-I (1.8 points) and NoCACE-I (2.1 points) patients (p=0.049), with similar, non-significant changes in SMMSE. Median SMMSE scores improved by 1.2 points in the first 6 months of CACE treatment (NewCACE-I), compared to a 0.8 point decline for the CACE-I (p=0.003) group and a 1 point decline for the NoCACE-I (p=0.001) group over the same period. Multivariate analysis, controlling for baseline characteristics, showed significant differences in the rates of decline, in SMMSE, between the three groups, p=0.002.

Conclusions

Cognitive scores may improve in the first 6 months after CACE-I treatment and use of CACE-Is is associated with a reduced rate of cognitive decline in patients with dementia.

Citation

http://bmjopen.bmj.com/content/3/7/e002881.short?rss=1

Copyright © 2013 by the BMJ Publishing Group Ltd.

 

Finding the Right Place for the Person with AD

(NIH) Sometimes you can no longer care for the person with AD at home. The person may need around-the-clock care. Or, he or she may be incontinent, aggressive, or wander a lot. It may not be possible for you to meet all of his or her needs at home anymore.

When that happens, you may want to look for another place for the person with AD to live. You may feel guilty or upset about this decision, but remember that many caregivers reach this point as the disease worsens. Moving the person to a care facility may give you greater peace of mind. You will know that the person with AD is safe and getting good care.

“We knew it was time to find another home for dad. But where? We had so many questions. And, more than anything, we wanted him to be safe and well cared for.

Choosing the right place is a big decision. It’s hard to know where to start.

Below we list steps you can take to find the right place:

1. Gather information

  • Talk with your support group members, social worker, doctor, family members, and friends about facilities in your area.
  • Make a list of questions to ask about the facility.
  • Call to set up a time to visit.

Check these resources:

  • Centers for Medicare and Medicaid Services (CMS)
    7500 Security Boulevard
    Baltimore, MD 21244-1850
    1-800-MEDICARE (1-800-633-4227)
    TTY: 1-877-486-2048
    www.medicare.gov

CMS has a guide to help older people and their caregivers choose a good nursing home. It describes types of long-term care, questions to ask the nursing home staff, and ways to pay for nursing home care. CMS also offers a service called Nursing Home Compare on its website. This service has information on nursing homes that are Medicare or Medicaid certified. These nursing homes provide skilled nursing care. Please note that there are many other places that provide different levels of health care and help with daily living. Many of these facilities are licensed only at the State level. CMS also has information about the rights of nursing home residents and their caregivers.

The Joint Commission evaluates nursing homes, home health care providers, hospitals, and assisted living facilities to determine whether or not they meet professional standards of care. Consumers can learn more about the quality of health care facilities through their online service at www.qualitycheck.org.

Other resources include:

  • Assisted Living Federation of America
    1650 King Street, Suite 602
    Alexandria, VA 22314
    1-703-894-1805
    www.alfa.org
  • National Center for Assisted Living
    1201 L Street, NW
    Washington, DC 20005
    1-202-842-4444
    www.ncal.org
  • National Clearinghouse for Long Term Care Information
    Administration for Community Living
    Washington, DC 20201
    1-202-619-0724
    www.longtermcare.gov

2. Visit assisted living facilities and nursing homes.

Make several visits at different times of the day and evening.

Ask yourself:

  • How does the staff care for the residents?
  • Is the staff friendly?
  • Does the place feel comfortable?
  • How do the people who live there look?
  • Do they look clean and well cared for?
  • Are mealtimes comfortable?
  • Is the facility clean and well maintained?
  • Does it smell bad?

Ask the staff:

  • What activities are planned for residents?
  • How many staff members are at the facility? How many of them are trained to provide medical care if needed?
  • How many people in the facility have AD?
  • Does the facility have a special unit for people with AD? If so, what kinds of services does it provide?
  • Is there a doctor who checks on residents on a regular basis? How often?

You also may want to ask staff:

  • What is a typical day like for the person with AD?
  • Is there a safe place for the person to go outside?
  • How do staff members speak to residents—with respect?
  • What is included in the fee?
  • How does my loved one get to medical appointments?

Talk with other caregivers who have a loved one at the facility. Find out what they think about the place.

Find out about total costs of care. Each facility is different. You want to find out if long-term care insurance, Medicaid, or Medicare will pay for any of the costs. Remember that Medicare only covers nursing home costs for a short time after the person with AD has been in the hospital for a certain amount of time.

If you’re asked to sign a contract, make sure you understand what you are agreeing to.

Assisted living facilities

Assisted living facilities have rooms or apartments. They’re for people who can mostly take care of themselves, but may need some help. Some assisted living facilities have special AD units. These units have staff who check on and care for people with AD. You will need to pay for the cost of the room or apartment, and you may need to pay extra for any special care. Some assisted living facilities are part of a larger organization that also offers other levels of care. For example, continuing care retirement communities also offer independent living and skilled nursing care.

Group homes

A group home is a home for people who can no longer take care of themselves. Four to 10 people who can’t care for themselves and two or more staff members live in the home. The staff takes care of the people living there: making meals, helping with grooming and medication, and providing other care. You will need to pay the costs of the person with AD living in this kind of home. Remember that these homes may not be inspected or regulated, but may still provide good care.

Check out the home and the staff. Visit at different times of the day and evening to see how the staff takes care of the residents. Also check to see how clean and comfortable the home is. You’ll want to look at how the residents get along with one another and with the staff.

Nursing homes

Nursing homes are for people who can’t care for themselves anymore. Some nursing homes have special AD care units. These units are often in separate sections of the building where staff members have special training to care for people with AD. Some units try to make the person feel more like he or she is at home. They provide special activities, meals, and medical care. In most cases, you will have to pay for nursing home care. Some nursing homes accept Medicaid as payment. Also, long-term care insurance may cover some of the nursing home costs. Nursing homes are inspected and regulated by State governments.

How to make moving day easier

Moving is very stressful. Moving the person with AD to an assisted living facility, group home, or nursing home is a big change for both the person and the caregiver. You may feel many emotions, from a sense of loss to guilt and sadness. You also may feel relieved. It is okay to have all these feelings. A social worker may be able to help you plan for and adjust to moving day. It’s important to have support during this difficult step.

Here are some things that may help:

  • Know that the day can be very stressful.
  • Talk to a social worker about your feelings about moving the person into a new place. Find out how to help the person with AD adjust.
  • Get to know the staff before the person moves into a facility
  • Talk with the staff about ways to make the change to the assisted living facility or nursing home go better.
  • Don’t argue with the person with AD about why he or she needs to be there

Be an advocate

Once the person has moved to his or her new home, check and see how the person is doing. As the caregiver, you probably know the person best. Look for signs that the person may need more attention, is taking too much medication, or may not be getting the care they need. Build a relationship with staff so that you work together as partners.

Citation

http://www.nia.nih.gov/alzheimers/publication/when-you-need-help/finding-right-place-person-ad

National Institutes of Health

 

Relationships between Alzheimer Disease Progression and Psychosis, Depressed Mood, and Agitation/Aggression

Am J Geriatr Psychiatry. 2013 Jul 17. pii: S1064-7481(13)00201-7. doi: 10.1016/j.jagp.2013.03.014. [Epub ahead of print]

Longitudinal Relationships Between Alzheimer Disease Progression and Psychosis, Depressed Mood, and Agitation/Aggression.

Zahodne LBOrnstein KCosentino SDevanand DPStern Y.

Cognitive Neuroscience Division, Department of Neurology and the Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, NY.

Abstract

Objectives

Behavioral and psychological symptoms of dementia (BPSD) are prevalent in Alzheimer disease (AD) and are related to poor outcomes such as nursing home placement. No study has examined the impact of individual BPSD on dependence, a clinically important feature that reflects changing patient needs and their effect on caregivers.

The current study characterized independent cross-sectional and longitudinal relationships between three BPSD (psychosis, depressed mood, and agitation/aggression), cognition, and dependence to better understand the interplay between these symptoms over time.

Design

The Predictors Study measured changes in BPSD, cognition, and dependence every 6 months in patients with AD. Cross-sectional and longitudinal relationships between individual BPSD, cognition, and dependence over 6 years were characterized by using multivariate latent growth curve modeling. This approach characterizes independent changes in multiple outcome measures over time.

Setting

Four memory clinics in the United States and Europe.

Participants

A total of 517 patients with probable AD.

Measurements

Columbia University Scale for Psychopathology, modified Mini-Mental State Examination, and Dependence Scale.

Results

Both psychosis and depressed mood at study entry were associated with worse subsequent cognitive decline. Independent of cognitive decline, initial psychosis was associated with worse subsequent increases in dependence. Rates of increase in agitation/aggression separately correlated with rates of declines in both cognition and independence.

Conclusions

Although purely observational, our findings support the poor prognosis associated with psychosis and depression in AD. Results also show that agitation/aggression tracks declines in cognition and independence independently over time. Targeted intervention for individual BPSD, particularly psychosis, could have broad effects not only on patient well-being but also on care costs and family burden.

 

Effects of Yoga on Cognitive Function

Journal of Physical Activity

JPAH Volume 10, Issue 4, May

The Acute Effects of Yoga on Executive Function

Neha Gothe, Matthew B. Pontifex, Charles Hillman, Edward McAuley

Abstract

Background

Despite an increase in the prevalence of yoga exercise, research focusing on the relationship between yoga exercise and cognition is limited. The purpose of this study was to examine the effects of an acute yoga exercise session, relative to aerobic exercise, on cognitive performance.

Methods

A repeated measures design was employed where 30 female college-aged participants (Mean age = 20.07, SD = 1.95) completed 3 counterbalanced testing sessions: a yoga exercise session, an aerobic exercise session, and a baseline assessment. The flanker and n-back tasks were used to measure cognitive performance.

Results

Results showed that cognitive performance after the yoga exercise bout was significantly superior (ie, shorter reaction times, increased accuracy) as compared with the aerobic and baseline conditions for both inhibition and working memory tasks. The aerobic and baseline performance was not significantly different, contradicting some of the previous findings in the acute aerobic exercise and cognition literature.

Conclusion

These findings are discussed relative to the need to explore the effects of other nontraditional modes of exercise such as yoga on cognition and the importance of time elapsed between the cessation of the exercise bout and the initiation of cognitive assessments in improving task performance.

Citation

http://journals.humankinetics.com/jpah-current-issue/jpah-volume-10-issue-4-may/the-acute-effects-of-yoga-on-executive-function

2013 Human Kinetics, Inc.

 

Three Questions to Ask Your Doctor About Exercise

(NIH) Are you considering adding exercise to your daily routine? Or do you want to increase your exercise level significantly?

There’s a safe way for almost everyone to be more active. Even if you have a health condition, there are exercises you can do that offer great health benefits. One way to get started is to talk with your doctor about the exercises and physical activities that are best for you. If you have a specific health issue that you are concerned about, ask your doctor for some tips to help you exercise safely. Here are some questions to consider:

1. Are there any exercises or activities I should avoid?

Your doctor can make recommendations based on your health history, keeping in mind any recent surgeries or ongoing health conditions such as arthritis, diabetes, or heart disease. This would be a great time to check with your doctor about any unexplained symptoms you’ve been experiencing, such as chest pain or pressure, joint pain, dizziness, or shortness of breath. Your doctor may recommend postponing exercise until the problem is diagnosed and treated.

2. Is my preventive care up to date?

Your doctor can tell you if there are any tests you might need. For example, women over age 65 should be checked regularly for osteoporosis.

3. How does my health condition affect my ability to exercise?

Some health conditions can affect your exercise routine. For example, people with arthritis may need to avoid some types of activity, especially when joints are swollen or inflamed. Those with diabetes may need to adjust their daily schedule, meal plan, or medications when planning their activities. Your doctor can talk to you about any adjustments you need to make to ensure that you get the most out of your new exercise routine.

Citation

http://go4life.nia.nih.gov/sites/default/files/DoctorQuestions.pdf

National Institute on Aging National Institutes of Health

U.S. Department of Health & Human Services

Go4Life is a registered trademark of the U.S. Department of Health and Human Services

 

Antioxidants for Alzheimer Disease

Arch Neurol. Author manuscript; available in PMC 2013 May 22.

Published in final edited form as: Arch Neurol. 2012 July; 69(7): 836–841.

Antioxidants for Alzheimer Disease: A Randomized Clinical Trial With Cerebrospinal Fluid Biomarker Measures

Dr Douglas R. Galasko, MD, Dr Elaine Peskind, MD, Dr Christopher M. Clark, MD, Dr Joseph F. Quinn, MD, Dr John M. Ringman, MD, Dr Gregory A. Jicha, MD, PhD, Dr Carl Cotman, PhD, Ms Barbara Cottrell, BS, Dr Thomas J. Montine, MD, PhD, Dr Ronald G. Thomas, PhD, and Dr Paul Aisen, MD

Abstract

Objective

To evaluate whether antioxidant supplements presumed to target specific cellular compartments affected cerebrospinal fluid (CSF) biomarkers.

Design

Double-blind, placebo-controlled clinical trial.

Setting

Academic medical centers.

Participants

Subjects with mild to moderate Alzheimer disease.

Intervention

Random assignment to treatment for 16 weeks with 800 IU/d of vitamin E (α-tocopherol) plus 500 mg/d of vitamin C plus 900 mg/d of α-lipoic acid (E/C/ALA); 400 mg of coenzyme Q 3 times/d; or placebo.

Main Outcome Measures

Changes from baseline to 16 weeks in CSF biomarkers related to Alzheimer disease and oxidative stress, cognition (Mini-Mental State Examination), and function (Alzheimer’s Disease Cooperative Study Activities of Daily Living Scale).

Results

Seventy-eight subjects were randomized; 66 provided serial CSF specimens adequate for biochemical analyses. Study drugs were well tolerated, but accelerated decline in Mini-Mental State Examination scores occurred in the E/C/ALA group, a potential safety concern. Changes in CSF Aβ42, tau, and P-tau181 levels did not differ between the 3 groups. Cerebrospinal fluid F2-isoprostane levels, an oxidative stress biomarker, decreased on average by 19% from baseline to week 16 in the E/C/ALA group but were unchanged in the other groups.

Conclusions

Antioxidants did not influence CSF biomarkers related to amyloid or tau pathology. Lowering of CSF F2-isoprostane levels in the E/C/ALA group suggests reduction of oxidative stress in the brain. However, this treatment raised the caution of faster cognitive decline, which would need careful assessment if longer-term clinical trials are conducted.

Citation

clinicaltrials.gov Identifier: NCT00117403
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3661272/

PMCID: PMC3661272 NIHMSID: NIHMS446574

National Center for Biotechnology Information, U.S. National Library of Medicine

 

Alzheimer’s Progression, Step by Step

(HealthDay) New research seeks to delineate just how Alzheimer’s disease unfolds in the human brain.

Biological changes may happen earlier than scientists had previously thought, according to a new disease model. This suggests that early signs of risk could potentially become treatment targets long before symptoms of Alzheimer’s begin to appear, the researchers said.

“We’re getting a better idea of what is happening during the asymptomatic [symptomless] phases of the disease,” said Dean Hartley, director of science initiatives at the Alzheimer’s Association, who was not involved with the new research.

The scientists behind the new research identified distinct but overlapping phases in the course of Alzheimer’s disease, each detectable by biological “markers” showing physical changes in the brain. They also have refined their model to distinguish between these “biomarkers” of Alzheimer’s disease and those of normal aging.

In the first phase of Alzheimer’s, brain markers signaling changes in beta-amyloid protein show up first, the model suggests. Beta-amyloid plaques are protein pieces from the fatty membrane surrounding nerve cells that clump together, contributing to nerve dysfunction.

In the second phase of the disease, signs of degeneration and death of brain cells occur.

Symptoms of dementia are seen in the third phase of Alzheimer’s disease, according to the new model.

The refined model should help researchers design better research, guide the selection of study participants, suggest the ideal time to begin treatment and help measure the impact of treatment, said Dr. Clifford Jack Jr.

Jack is lead author of one of three related studies to be presented Tuesday at the Alzheimer’s Association International Conference, in Boston. He said his research has been accepted for publication in the journal Neurology.

In addition to beta-amyloid proteins, “tau” — another protein — also plays a role in Alzheimer’s, creating what are called “neurofibrillary tangles.” Jack said the changes in the brain created by tau seem to occur first, but amyloid aggregation, or clumping, accelerates the changes in tau and causes it to spread.

The central message is that tau and beta-amyloid plaque interact with each other in a synergistic way, said Jack, a professor of radiology and a neuroradiologist at the Mayo Clinic College of Medicine, in Rochester, Minn.

Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills. Symptoms typically appear after age 60, and about 5 million Americans may have the disease, according to the U.S. National Institute on Aging.

Jack and his team published a hypothetical model of the major Alzheimer’s disease biomarkers in Neurology in 2010, describing how the biomarkers changed over time and were related to the beginning and progression of symptoms. For this study, the team reviewed studies that tested and evaluated that model, spurring them to further refine it.

How could the model spark new ideas for treating Alzheimer’s disease? “What really makes sense probably is a combined therapeutic approach where you target a point or points in tau and in the amyloid pathways simultaneously,” Jack explained.

Just as people often take statins — drugs that lower cholesterol — to reduce their risk of heart disease, it could someday be possible that those at risk for Alzheimer’s could take medication to help prevent it, Jack said. He envisions a “cocktail” or combination of drugs that could target different points in the molecular pathways of the disease, administered at an early age, depending on a person’s risk for Alzheimer’s disease.

The Alzheimer’s Association’s Hartley said he’s excited about the revised model. “It suggests that some of the treatments we’re using may be too late in the progression of the disease.”

Two related studies were also scheduled for presentation at the meeting. Dr. Victor Villemagne at the University of Melbourne, in Australia, and colleagues followed about 200 people with and without signs of Alzheimer’s disease over four years to estimate when beta-amyloid levels tend to become abnormal. The scientists concluded that Alzheimer’s disease is a slow process, likely extending for more than 20 years.

The other study, led by Daniela Bertens at VU University Medical Center, in Amsterdam, Holland, provided more evidence that abnormal beta-amyloid is what triggers the development of Alzheimer’s disease. The research included about 300 people with abnormal beta-amyloid, and followed them over four years, testing their cerebrospinal fluid for diagnostic signs of the disease.

Because these studies were presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

Citation

By Barbara Bronson Gray, HealthDay Reporter

http://www.webmd.com/alzheimers/news/20130716/scientists-detail-alzheimers-progression-step-by-step?page=1

SOURCES: Clifford Jack Jr. M.D., professor, radiology, neuroradiologist and the Alexander Family Professor of Alzheimer’s Disease Research, Mayo Clinic College of Medicine, Rochester, Minn.; Dean Hartley, Ph.D., director of science initiatives, Alzheimer’s Association, Chicago; Victor Villegmagne, M.D., department of nuclear medicine and centre for PET, Austin Health, Melbourne, Australia; Daniela Bertens, department of neurology, VU University Medical Center, Amsterdam; July 16, 2013, presentations, Alzheimer’s Association International Conference, Boston

Copyright © 2013 HealthDay.

 

Tailored Interventions May Help Caregivers of Those With Dementia

(MedicalNewsToday) Rhode Island Hospital researchers have found that multiple factors contribute to the burden felt by caregivers of people living with Alzheimer’s and other forms of dementia. These factors include the direct impact of providing care upon the caregivers’ lives, guilt, and frustration or embarrassment. The study is published online in advance of print inAmerican Journal of Geriatric Psychiatry.

The study, conducted by Beth A. Springate, Ph.D, and Geoffrey Tremont, Ph.D, of the division of neuropsychology in the department of psychiatry at Rhode Island Hospital, found that caregivers may benefit from interventions tailored to their specific type of burden.

“Caregivers are often physically and emotionally exhausted when caring for a spouse or parent who is suffering from some form of dementia, including Alzheimer’s,” Springate said.

“There are so many factors that contribute to the burden felt by the caregiver, such as the relationship between the caregiver and patient, the severity of the dementia and the age of the caregiver. There is simply no one-size-fits-all response to their burden, and they would greatly benefit from interventions specific to their situation.”

These burdens can have detrimental effects on the caregiver, including poorer physical health, increased rates of emotional distress and depression.

According to the Alzheimer’s Association, there are 5 million people in the U.S. with Alzheimer’s, and it is the country’s sixth leading cause of death. More than 15 million family and friends provide care for those with Alzheimer’s and other forms of dementia, resulting in 17.5 billion hours of unpaid care each year.

“It’s taxing to say the least,” said Tremont, the study’s senior author.

“Their lives are essentially put on hold while they care for their loved ones, and their own health can suffer as a result. It’s hard to worry about taking care of yourself when you feel responsible to take care of someone else, someone who has needs that seem much greater than your own.”

The study observed both spousal caregivers and adult children caregivers, with a total of 206 participants. The results of these participants demonstrated that about 84 percent of caregivers reported a clinically significant burden. Within the three factors that were discovered to be significant contributors to burden, frustration or embarrassment showed a direct correlation to the impact on the caregiver’s life. The last factor, feelings of guilt, did not show a correlation to the other factors, however, it did show a direct relation to depressive symptoms, as did frustration and embarrassment.

“Guilt, frustration and embarrassment are all very normal feelings when providing care for someone with dementia,” Tremont said.

“It’s important that caregivers know this, and know that they aren’t alone.”

The researchers noted that limitations do exist to this study because of the predominantly Caucasian female caregiver population caring mostly for patients with Alzheimer’s disease, compared to other types of dementia. Due to this and other factors, further research should be conducted.

Citation

The study was funded in part by a grant from the National Institute of Nursing Research (NR010559) awarded to Geoffrey Tremont, Ph.D. Both Tremont and Beth A. Springate’s principal affiliation is Rhode Island Hospital, a member hospital of the Lifespan health system in Rhode Island. Both also have academic appointments at The Warren Alpert Medical School of Brown University. Lifespan

Lifespan. (2013, July 23). “Tailored interventions may help caregivers of those with dementia.”Medical News Today. Retrieved from http://www.medicalnewstoday.com/releases/263692.php.

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