Faculty Bibliography

OBJECTIVE: Investigate efficacy of 13.3 mg/24 h rivastigmine patch in patients with severe Alzheimer's disease on Alzheimer's Disease Cooperative Study-Activities of Daily Living Scale-Severe Impairment Version items and domains. METHODS: Retrospective analysis of the 24-week, randomized, double-blind ACTivities of daily living and cognitION (ACTION) study, using factor analysis to establish "best fit" for Alzheimer's Disease Cooperative Study-Activities of Daily Living Scale-Severe Impairment Version items into domains. Treatment differences (13.3 vs 4.6 mg/24 h patch) on items and domains were assessed. RESULTS: Overall, 632 patients provided Alzheimer's Disease Cooperative Study-Activities of Daily Living Scale-Severe Impairment Version data. Factor analysis yielded four domains. The 13.3 versus 4.6 mg/24 h patch demonstrated significantly greater efficacy on "Daily function" (p = 0.038), supported by greatest effect sizes on items within this domain, and trend toward greater efficacy on "Communication" (p = 0.052). No significant between-group differences were observed on "Independence" (p = 0.600) or "Environment" (p = 0.261). CONCLUSION: The 13.3 mg/24 h patch was superior to 4.6 mg/24 h patch on "Daily function" in severe Alzheimer's disease.

Nurses Improving Care of Healthsystem Elders (NICHE) provides hospitals with tools and resources to implement an initiative to improve health outcomes in older adults and their families. Beginning in 2011, members have engaged in a process of program self-evaluation, designed to evaluate internal progress toward developing, sustaining, and disseminating NICHE. This manuscript describes the NICHE Site Self-evaluation and reports the inaugural self-evaluation data in 180 North American hospitals. NICHE members evaluate their program utilizing the following dimensions of a geriatric acute care program: guiding principles, organizational structures, leadership, geriatric staff competence, interdisciplinary resources and processes, patient- and family-centered approaches, environment of care, and quality metrics. The majority of NICHE sites were at the progressive implementation level (n = 100, 55.6%), having implemented interdisciplinary geriatric education and the geriatric resource nurse (GRN) model on at least one unit; 29% have implemented the GRN model on multiple units, including specialty areas. Bed size, teaching status, and Magnet status were not associated with level of implementation, suggesting that NICHE implementation can be successful in a variety of settings and communities.

Dementia with Lewy bodies (DLB) is the second most common form of dementia after Alzheimer disease (AD). DLB is characterized pathologically by Lewy body and Lewy neuritic pathology, often with variable levels of Alzheimer-type pathology. Core clinical features include fluctuating cognition, visual hallucinations, and parkinsonism resulting in greater impairments of quality of life, more caregiver burden, and higher health-related costs compared with AD. These issues, together with a high sensitivity to adverse events with treatment with antipsychotic agents, make the need for an early and accurate diagnosis of DLB essential. Unfortunately, current consensus criteria are highly specific but lack sufficient sensitivity. Use of composite risk scores may improve accuracy of clinical diagnosis. Imaging findings, particularly targeting dopaminergic systems have shown promise as potential markers to differentiate DLB from AD. A combination of non-pharmacologic treatments and pharmacotherapy interventions may maximize cognitive function and overall quality of life in DLB patients.

After Alzheimer's disease, Lewy body dementia (LBD) is the most prevalent progressive dementia of the many cognitive disorders wreaking unspeakable havoc on millions of lives. LBD is characterized by the presence of Lewy bodies, which are abnormal aggregates of a protein called alpha-synuclein, and are found in regions of the brain that regulate behavior, memory, movement, and personality. Many of the symptoms of Alzheimer's, Parkinson's, and LBD overlap, but LBD is more difficult to diagnose. Underdiagnosis is just part of the reason why LBD is unknown to the public and many health-care providers, and why funding for research lags far behind that for almost every other cognitive disorder.

OBJECTIVES: To determine whether mildly impaired physical function (based on performance-based assessment) is associated with development of dementia of the Alzheimer's type (DAT) in cognitively normal older adults. DESIGN: Longitudinal, observational study with yearly assessments of physical and cognitive function. Mean follow-up was 5 years. SETTING: Knight Alzheimer's Disease Research Center at Washington University, St. Louis, Missouri. PARTICIPANTS: Four hundred thirty-five cognitively normal adults aged 60 and older participating in longitudinal studies of aging. MEASUREMENTS: Survival analyses were used to examine whether scores on the 9-item Physical Performance Test (PPT) predicted time to DAT diagnosis. Cox proportional hazards models were used to examine associations between PPT total scores and time to cognitive impairment and DAT; as well as the association between time and these events, adjusting for and simultaneously testing the effects of age, sex, education, and presence of one or more apolipoprotein (APOE) epsilon4 alleles. RESULTS: During the follow-up period, 81 participants developed DAT. Participants diagnosed with DAT were older (81.0 vs 74.2, P = .001) and had worse performance on the PPT (25.5 vs 28.1, P = .009) than those who remained cognitively normal. Time to DAT diagnosis was associated with PPT total score (hazard ratio (HR) = 0.89, 95% confidence interval (CI) = 0.86-0.93, P < .001) such that time to DAT diagnosis was longer for participants with higher physical performance scores. In the adjusted analysis, PPT score significantly predicted time to DAT diagnosis (HR = 0.94, 95% CI = 0.89-0.99, P = .02). CONCLUSION: Mild physical impairment in cognitively normal older adults is associated with subsequent development of DAT. Although the physical impairment may be sufficiently mild that it is recognized only using performance-based assessments, its presence may predate clinically detectable cognitive decline.

Background: The HABC Monitor was developed to provide dementia care providers with a clinical tool for managing dementia symptoms similar to the blood pressure cuff used by clinicians and patients for managing hypertension. The HABC Monitor is an inexpensive, simple, user-friendly, easily standardized, sensitive-to-change, and widely available multi-domain instrument for clinical providers and informal caregivers to measure and monitor the severity of dementia symptoms. Two parallel versions of the tool were developed - the Caregiver Version (CG Version) that measures and monitors the severity of dementia symptoms through caregiver reports and the Self Report Version (SR Version) that relies on patient report. We have found in our memory care clinic that patients with less than severe cognitive impairment are able to complete the HABC Monitor and to provide valuable information that can be used in conjunction with reports from their corresponding caregiver. In our previous work, we found strong psychometric evidence for the reliability and validity of the CG Version as a clinically practical tool for measuring and monitoring the severity of dementia symptoms through caregiver report. The purpose of this study was to assess the reliability and validity of the SRVersion. Methods: The HABC-Monitor has three patient symptom domains (cognitive, functional, and behavioral/psychological) with parallel items for both the CG Version and the SRVersion. The Caregiver Quality of Life domain is included on the CG Version but not the SRVersion. Patients (n = 291) were consecutively approached and consented during a patient's routine visit to their primary care provider. The SR Version was administered to each patient during a subsequent phone interview. Results: The HABC-Monitor demonstrated excellent fit for the confirmatory factor analysis model (RMSEA = 0.020, CFI = 0.974, WRMR = 0.837); good internal consistency (0.78-0.92); and adequate knowngroups validity, indicated by significant separation of TICSm !

PURPOSE: The purpose of the study was to describe nurses' views of the issues to be addressed to improve care of the older adult in the emergency department (ED). DESIGN AND METHODS: An exploratory content analysis examined the qualitative responses of 527 registered nurses from 49U.S. hospitals who completed the Geriatric Institutional Profile. RESULTS: 5 central themes emerged from the analysis, representing a lack of older personhospital environment fit in the ED: (a) respect for the older adult and carers, (b) correct and best procedures and treatment, (c) time and staff to do things right, (d) transitions, and (e) a safe and enabling environment. The nurses offered solutions to address lack of fit, including modifications to the social climate, policies and procedures, care systems and processes, and physical design. IMPLICATIONS: The nurses' descriptions of the pressing issues surrounding care of older adults in the ED provide useful information to consider when developing a senior-friendly ED. Results also illuminate solutions that can be taken to address issues. These solutions give direction for future intervention research.

ABSTRACT Background: Capgras syndrome is characterized by the recurrent, transient belief that a person has been replaced by an identical imposter. We reviewed clinical characteristics of Dementia with Lewy Bodies (DLB) patients with Capgras syndrome compared to those without Capgras. Methods: We identified 55 consecutive DLB patients (11 cases with Capgras syndrome (DLB-C) and 44 cases without evidence of Capgras (DLB). Semi-structured interviews with the patient and an informant, neurological exams, and neuropsychological testing were performed. Caregivers were assessed for caregiver burden and depression. Primary comparisons were made between DLB-C and DLB. Exploratory analyses using stepwise logistic regression and bootstrap analyses were performed to determine clinical features associated with Capgras. Results: DLB-C patients experienced more visual hallucinations and self-reported anxiety, had higher scores on the Neuropsychiatric Inventory, and were less likely to be treated with cholinesterase inhibitors at time of initial evaluation. Extrapyramidal symptoms and depression were not associated with Capgras. Caregivers of DLB-C patients had higher caregiver burden. DLB-C was associated with self-reported anxiety (OR = 10.9; 95% CI = 2.6-47.6). In a bootstrap analysis, clinical findings that were predictors of Capgras included visual hallucinations (log(OR) = 18.3; 95% CI = 17.9-19.3) and anxiety (log(OR) = 2.9; 95% CI = 0.31-20.2). Conclusions: Our study suggests that Capgras syndrome is common in DLB and usually occurs in the presence of anxiety and visual hallucinations, suggesting related etiopathogenesis. Early appreciation of Capgras syndrome may afford the opportunity to alleviate caregiver burden and improve patient and caregiver outcomes.