Faculty Bibliography

INTRODUCTION: Test the validity and reliability of the Quick Dementia Rating System (QDRS), a rapid dementia staging tool. METHODS: The QDRS was tested in 267 patient-caregiver dyads compared with Clinical Dementia Ratings (CDR), neuropsychological testing, and gold standard measures of function, mood, and behavior. Psychometric properties including, item variability, floor and ceiling effects, concurrent and construct validity, and internal consistency were determined. The QDRS was used to derive an independent CDR and sum of boxes. Interscale reliability between QDRS and CDR was tested using intraclass correlation coefficients (ICC). Area under the receiver operator characteristic curves (AUC) tested discrimination properties of QDRS across CDR stages. RESULTS: QDRS scores increased with higher CDR staging and poorer neuropsychological performance (p's <.001). The QDRS demonstrated low floor and ceiling effects; excellent known-groups validity across CDR stages (p's<.001); construct validity against cognitive, behavioral, and functional measures (p-value's:0.004 to <0.001); and reliability (Cronbach alpha: 0.86-0.93). The QDRS demonstrated differential scores across different dementia etiologies. The AUC for the QDRS was 0.911 (95%CI 0.86-0.96) and for the CDR-SB was 0.996 (95% CI: 0.99-1.0) demonstrating comparable ability to discriminate normal controls from dementia. The QDRS-generated CDR demonstrated excellent correspondence with the CDR (ICC=0.90) and sum-of-boxes (ICC=0.92). DISCUSSION: The QDRS validly and reliably differentiates individuals with and without dementia and accurately stages dementia without extensive training or clinician input, and is highly correlated with our gold standard measures. The QDRS provides a rapid method to determine study eligibility; stage patients in clinical practice; and improve case ascertainment in population studies.

BACKGROUND: Baseline health and functional vulnerabilities increase the risk for complications in persons with dementia and predispose family caregivers (FCGs) to increased stress. METHODS: This secondary analysis used a combined quantitative and qualitative approach. Regression analyses examined the contribution of patient and FCG characteristics to FCG anxiety. Interviews with FCGs explored the experiences and responses of FCGs during hospitalization of their family member with dementia. RESULTS: Lower patient physical function and higher caregiver strain were associated with higher FCG anxiety. FCGs described the following themes related to the hospitalization: (1) added strain, (2) care-related worries, (3) keeping vigil, (4) need to be heard, and (5) enablers of FCGs. CONCLUSIONS: Routine evaluation of caregiver strain and baseline patient function is integral to informing the transitional planning for persons with dementia. The FCG responses suggest that a multifactorial approach (family-centered policies of partnership in care, staff education addressing the specialized needs of patients and family members, and attention to promoting functional recovery) may benefit both hospitalized patients with dementia as well as FCGs and warrants future research.

BACKGROUND AND OBJECTIVES: Rivastigmine patch is approved for the treatment of all stages of Alzheimer's disease (AD). Application site reactions may be a concern to clinicians and we used two large clinical trial databases to investigate the incidence of skin reactions in patients receiving rivastigmine patch. METHODS: Data from a 24-week, randomised, double-blind (DB) evaluation of 13.3 vs. 4.6 mg/24 h rivastigmine patch in severe AD (ACTION) and a 72- to 96-week study comprising an initial open-label (IOL) phase followed by a 48-week randomised, DB phase (13.3 vs. 9.5 mg/24 h rivastigmine patch) in declining patients with mild-to-moderate AD (OPTIMA) were analyzed. The incidence, frequency, severity, management and predictors of application site reactions were assessed. RESULTS: Application site reactions were mostly mild or moderate in severity and reported by similar proportions in each treatment group ( ACTION: 13.3 mg/24 h, 24.5% and 4.6 mg/24 h, 24.2%; OPTIMA: IOL 9.5 mg/24 h, 22.9%; DB 13.3 mg/24 h, 11.4% and 9.5 mg/24 h, 12.0%); none were rated serious. In both studies, < 9% of patients required treatment for application site reactions. Application site reactions led to discontinuation of 1.7% and 2.5% of the 13.3 mg/24 h and 4.6 mg/24 h groups, respectively, in ACTION, 8.7% in OPTIMA IOL and 1.8% and 3.5% of the 13.3 mg/24 h and 9.5 mg/24 h groups, respectively, in OPTIMA DB. CONCLUSIONS: Application site reactions were experienced by < 25% of patients in both studies, with no notable effect of dose. No reactions qualified as serious and skin reactions were uncommon as a reason for study discontinuation.

Background: We aimed to develop a clinically practical, multi-domain tool for measuring and monitoring self-reported and caregiver-reported symptoms of older patients. Most existing tools are disease specific, single-domain, or too lengthy for clinical practice. SymTrak was developed to be brief, clinically actionable, sensitive to change, broadly applicable to multiple chronic conditions, culturally sensitive, and easily understood. Methods: SymTrak was developed from multidisciplinary expert panels, existing data, extant instruments, and focus groups. Results: Items tapped psychological, functional, cognitive, pain, sleep, fatigue, and other physical symptoms. Focus groups preferred 3 to 5 item response options, but were neutral regarding frequency versus severity format. Four frequency options (never, sometimes, often, always) were chosen for all items to balance clinical brevity with sensitivity to change. Physician and nurse practitioner focus groups highly valued instrument performance: administrable within 5 minutes; easily retrievable visual graphics from medical records; viewable at item, domain and total-score levels. SymTrak was perceived as more useful for tracking than screening. Clinicians preferred a single brief physical symptom domain instead of multi-item pain, sleep, and fatigue domains. Patient and caregiver focus groups valued item wording: simple language; and applicability regardless of roles. They provided numerous helpful item revisions during "think aloud" interviewing, held subsequent to focus group sessions. They also rated SymTrak highly useful on an 8-item usability scale and were enthusiastic about its use as a communication aid with providers. Version 1.0 (25 items) was finalized and is currently being psychometrically tested. Conclusions: Focus groups of clinicians, patients, and caregivers were helpful in developing Version 1.0 of SymTrak and evaluated it to be useful for tracking symptoms in primary care

The Lewy Body Composite Risk Score (LBCRS) was developed as an useful tool to enhance the accuracy of the cognitive diagnosis for patients affected by Lewy Bodies' pathological conditions. This study aimed to assess the diagnostic accuracy of the Korean version of the LBCRS (K-LBCRS) among Korean population with Alzheimer's dementia (AD) and Dementia with Lewy bodies (DLB). The 49 subjects who participated in this study have (32 with AD, 17 with DLB) visited the neurology outpatient clinic of KUMC. The subjects' demographic data and administered K-MMSE, Clinical Dementia Rating sum of boxes (CDR-SB), K-LBCRS, NPI, Mayo Fluctuation Scale (MFS), Mayo Sleep Questionnaire (MSQ), Epworth Sleepiness Scale (ESS), and mini Physical Performance Test (PPT) were collected. The K-LBCRS was created through translation and back-translation of the LBCRS. The sensitivity, the specificity, and the area under the curve were evaluated by receiver operator characteristics (ROC) analysis. An ROC curve was used to determine the optimal cut-off values for discrimination of DLB against AD. The ROC analysis showed that the optimal cut-off point of the K-LBCRS for identification of DLB was 2/3, which gave the balance between sensitivity (94%) and specificity (75%). The K-LBCRS was significantly correlated with CDR-SB (r=0.40), MFQ (r=0.75) in AD group, whereas ESS (r=0.71), MFQ (r=0.82) was significant in DLB group. The K-LBCRS has important clinical characteristics of DLB that may differentiate it from AD, and as a result may enable the K-LBCRS as a clinically useful screening tool to discriminate the two groups

INTRODUCTION: OPtimizing Transdermal Exelon In Mild-to-moderate Alzheimer's disease (OPTIMA) was a randomized, double-blind comparison of 13.3 mg/24 h versus 9.5 mg/24 h rivastigmine patch in patients with mild-to-moderate Alzheimer's disease who declined despite open-label treatment with 9.5 mg/24 h patch. Over 48 weeks of double-blind treatment, high-dose patch produced greater functional and cognitive benefits compared with 9.5 mg/24 h patch. METHODS: Using OPTIMA data, a post-hoc responder analysis was performed to firstly, compare the proportion of patients demonstrating improvement or absence of decline with 13.3 mg/24 h versus 9.5 mg/24 h patch; and secondly, identify predictors of improvement or absence of decline. 'Improvers' were patients who improved on the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) by >/=4 points from baseline, and did not decline on the instrumental domain of the Alzheimer's Disease Cooperative Study-Activities of Daily Living scale (ADCS-IADL). 'Non-decliners' were patients who did not decline on either scale. RESULTS: Overall, 265 patients randomized to 13.3 mg/24 h and 271 to 9.5 mg/24 h patch met the criteria for inclusion in the intention-to-treat population and were included in the analyses. Significantly more patients were 'improvers' with 13.3 mg/24 h compared with 9.5 mg/24 h patch at Weeks 24 (44 (16.6%) versus 19 (7.0%); P < 0.001) and 48 (21 (7.9%) versus 10 (3.7%); P = 0.023). A significantly greater proportion of patients were 'non-decliners' with 13.3 mg/24 h compared with 9.5 mg/24 h patch at Week 24 (71 (26.8%) versus 44 (16.2%); P = 0.002). At Week 48, there was a trend in favor of 13.3 mg/24 h patch. Functional and cognitive assessment scores at double-blind baseline did not consistently predict effects at Weeks 24 or 48. CONCLUSION: More patients with mild-to-moderate Alzheimer's disease who are titrated to 13.3 mg/24 h rivastigmine patch at time of decline are 'improvers' or 'non-decliners' i.e. show responses on cognition and activities of daily living compared with patients remaining on 9.5 mg/24 h patch. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00506415; registered July 20, 2007.

BACKGROUND: Whether older adults with sarcopenia who underperform controls on tests of physical performance and cognition also have a higher likelihood of combined cognitive-physical impairment is not clear. We assessed the impact of sarcopenia on impairment in both aspects of functionality and the relative contribution of its components, muscle mass and strength. METHODS: Two hundred and twenty-three community-dwelling adults aged 40 years and older (mean age =68.1+/-10.6 years; 65% female) were recruited and underwent physical functionality, anthropometry, and cognitive testing. Participants with low muscle mass were categorized as pre-sarcopenic; those with low muscle mass and muscle strength as sarcopenic; those with higher muscle mass and low muscle strength only were categorized as non-sarcopenic and were compared on risk of cognitive impairment (Montreal Cognitive Assessment <26; Ascertaining Dementia 8 >/=2), physical impairment (Mini Physical Performance Test <12), both, or neither by ordinal logistic regression. RESULTS: Compared to controls, those with sarcopenia were six times more likely to have combined cognitive impairment/physical impairment with a fully adjusted model showing a three-fold increased odds ratio. The results were consistent across different measures of global cognition (odds ratio =3.46, 95% confidence interval =1.07-11.45 for the Montreal Cognitive Assessment; odds ratio =3.61, 95% confidence interval =1.11-11.72 for Ascertaining Dementia 8). Pre-sarcopenic participants were not different from controls. The effect of sarcopenia on cognition is related to low muscle strength rather than low muscle mass. CONCLUSION: Individuals with sarcopenia are not only more likely to have single but also to have dual impairment in cognitive and physical function. Interventions designed to prevent sarcopenia and improve muscle strength may help reduce the burden of cognitive and physical impairments of functionality in community-dwelling seniors.