Faculty Bibliography

Background: Approximately 5.2 million Americans are affected by Alzheimer's disease (AD), with another 1.3 million individuals affected by Lewy Body Dementia (LBD), the second most common cause. Nearly 60% of dementia caregivers rate emotional stress of caregiving as high or very high, and this will only increase as more resources are required with dementia progression. As such, the grieving process for caregivers likely begins early, as adult children and spouses often take on a multitude of new responsibilities previously managed by the patient, often prior to the formal diagnosis. Adverse outcomes for the caregiver (e.g., stress, depression and poor health) directly lead to declines in quality of life for both the patient and the caregiver. Improved understanding of caregiver grief will provide important information to develop interventions for the early identification of caregiver grief. We examine the sensitivity of the underlying constructs measured by the Marwit-Meuser Caregiver Grief Inventory Short Form (MMCGI-SF), a common self-reported measure of caregiver grief. Methods: An online survey of dementia caregivers [AD (n=64), LBD (n=350)] was completed including the MMCGI-SF. The MMCGI-SF contains three constructs: Personal Sacrifice Burden, Heartfelt Sadness, and Worry and Felt Isolation. We conducted confirmatory factor analyses to determine goodness of fit testing whether this model of grief holds for spouse and child primary caregivers for patients with AD and LBD. Results: Caregiver ages were equivalent (M=62.0(610.5) as were patient dementia stage (CDR Box Scores; M=10.4(64.4). Confirmatory factor analysis rejected the current MMCGI-SF model for both groups. The model was improved by separating the construct of "Worry and Felt Isolation" into separate categories in both AD: CFI = .88, NFI = .89, RMSEA = .091 (.062-.117) and LBD: CFI = .93, NFI = .92, RMSEA = .072 (.063-.080). Conclusions: Isolation was shown to be an important component of grief state for spouse and adult child caregivers, particularly caregivers of LBD. This may be due to constellation of cognitive, motor, behavioral, and autonomic features that distinguish LBD from AD. We believe that changes in healthcare and the extended lifespan of patients have led to the need for caregiver interventions that specifically targeting isolation

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