Faculty Bibliography

INTRODUCTION: The AD8 is a brief informant-based questionnaire that may also be self-administered, and which aids in identifying cognitive impairment (CI). Our goal is to assess the diagnostic accuracy (DA) of a Spanish version of that questionnaire. MATERIAL AND METHODS: Cross-sectional study of a clinical sample of patient/informant dyads including 330 subjects with suspected CI or dementia (DEM) and 71 controls. We evaluated internal consistency (Cronbach's alpha) and validity (partial correlations with GDS stage, Fototest results and functional index measure [FIM]). We assessed DA for CI vs no CI (GDS stage 3-4) using the area under the ROC curve (AUC), and the cut-off with the highest Youden index was determined to be optimal. RESULTS: In the sample, 105 subjects had no CI, 99 had CI without DEM and 203 had DEM. Internal consistency was high (alpha 0.90, 95% confidence interval: 0.89-0.92), as were correlations with the GDS score (r=0.72, P<.001), Fototest results (r=-0.61, P<.001) and FIM (r=0.59, P<.001). The AUC for AD8 was 0.90 (95% confidence interval: 0.86-0.93), which was not significantly different from that of the Fototest (AUC 0.93, 95% confidence interval: 0.89-0.96). The optimal cut-off point was 3/4 with a sensitivity of 0.93 (95% confidence interval: 0.88-0.96) and a specificity of 0.81 (95% confidence interval: 0.72-0.88); 88.8% of the classifications were correct. Combined use of AD8 and the Fototest significantly improved the DA of both (AUC 0.96, 95% confidence interval: 0.93-0.98, P<.05). CONCLUSIONS: The Spanish version of the AD8 questionnaire preserves the psychometric qualities and DA of the original. Using this test in combination with the Fototest significantly increases the DA of both tests.

The number of individuals with dementia is expected to increase dramatically over the next 20 years. Given the complicated clinical, sociobehavioral, and caregiving skills that are needed to comprehensively assess and manage individuals with dementia, the gold standard of care requires involvement of interprofessional teams. This systematic review examined 4,023 abstracts, finding 18 articles from 16 studies where an interprofessional dissemination program was performed. Most studies found some improvement in clinician knowledge or confidence, or patient outcomes, though methods and patient and clinician populations were disparate. Although a significant evidence base for assessing and managing individuals with dementia has been developed, few studies have examined how to disseminate this research, and even fewer in an interprofessional manner. These findings suggest that greater emphasis needs to be placed on disseminating existing evidence-based care and ensuring that programs are interprofessional in nature so that excellent, patient-centered care is provided.

OBJECTIVES: To determine the circumstances under which persons with dementia become lost while driving, how missing drivers are found, and how Silver Alert notifications are instrumental in those discoveries. DESIGN: A retrospective, descriptive study. SETTING: Retrospective record review. PARTICIPANTS: Conducted using 156 records from the Florida Silver Alert program for October 2008 through May 2010. These alerts were issued in Florida for missing drivers with dementia. MEASUREMENTS: Information derived from the reports on characteristics of the missing driver, antecedents to missing event, and discovery of a missing driver. RESULTS: The majority of missing drivers were men aged 58 to 94 who were being cared for by a spouse. Most drivers became lost on routine, caregiver-sanctioned trips to usual locations. Only 15% were driving when found, with most being found in or near a parked car. Law enforcement officers found the large majority. Only 40% were found in the county where they went missing, and 10% were found in a different state. CONCLUSION: Silver Alert notifications were most effective for law enforcement; citizen alerts resulted in a few discoveries. There was 5% mortality in the study population, with those living alone more likely to be found dead than alive. An additional 15% were found in dangerous situations such as stopped on railroad tracks. Thirty-two percent had documented driving or other dangerous errors, such as driving the wrong way or into secluded areas or walking in or near roadways.

Alzheimer's disease (AD) is characterized by progressive declines in cognitive function and ability to carry out activities of daily living; and the emergence and worsening of behavioral/neuropsychiatric symptoms. While there is no cure for AD, non-pharmacologic interventions and medications that modulate neurotransmission can slow symptomatic progression. Medical foods may also be useful as adjuncts to pharmacologic agents in AD. Medium chain triglycerides aimed at improving cerebral metabolism significantly improve Alzheimer's Disease Assessment Scale-Cognitive scores when added to ongoing pharmacotherapy in patients with mild-to-moderate AD. Combination of interventions, such as non-pharmacologic treatments, pharmacotherapy, and medical foods, with complementary mechanisms of action may provide a rational approach that may result in maximum preservation of cognitive function in patients with AD.

To date, user-friendly, practical guidelines for dementia have not been available for busy family physicians. However, the growing number of patients with dementia means that primary care physicians will have an increasingly important role in the diagnosis and subsequent management of dementia. This article provides practical guidance for the recognition and diagnosis of dementia and is aimed at family physicians, who are usually the first clinicians to whom patients present with dementia symptoms. Because Alzheimer disease (AD) is the most common form of dementia, this condition is the main focus of this article. We review the pathophysiology of AD and discuss recommended diagnostic protocols and the importance of early diagnosis. An AD diagnostic algorithm is provided, with clearly defined steps for screening and diagnosing AD and assessing daily functioning, behavioral symptoms, and caregiver status.

Family physicians play a crucial role in the management and ongoing care of patients with Alzheimer disease (AD). This article reviews the effects of nonpharmacologic and pharmacologic interventions on the functional abilities and behavior of patients with dementia and how these can be implemented into clinical practice. Nonpharmacologic interventions are recommended as the initial strategy for managing problematic behaviors. Strategies for improving behavior include ensuring that the patient's environment is safe, calm, and predictable; removing environmental stressors; and identifying and avoiding situations that agitate or frighten the patient. Simple interventions include redirecting and refocusing the patient, increasing social interaction, establishing regular sleep habits, eliminating sources of conflict and frustration, and establishing rewards for successes. The effectiveness of long-term behavioral management is largely dependent on the caregiver; as such, it is important to assess the role and needs of the caregiver. Because currently available therapies cannot reverse the pathologic processes of AD, the primary objective of pharmacotherapy is to preserve cognitive and functional ability, minimize behavioral disturbances, and slow disease progression. Cholinesterase inhibitors represent first-line therapy for patients with mild to moderate AD, whereas a glutamate N-methyl D-aspartate antagonist is used in the treatment of moderate to severe AD. Looking forward, there are a number of therapies in development aimed at modifying the disease course; these include amyloid-lowering drugs, tau-based and neuroprotective approaches, acetylcholine agonists, and mitochondrial inhibitors.

BACKGROUND: Primary care providers routinely evaluate older adults and are thus in a position to first detect symptoms and signs of Alzheimer disease. In urban areas, diagnostic or management difficulties may be referred to specialists; however, in rural areas, specialists may not be available. The Clinician Partners Program (CPP) was initiated to enhance rural health providers' ability in the diagnosis of dementia and care, and to increase research recruitment into dementia research studies of participants from rural communities. METHODS: The CPP is a 3-day 'miniresidency' of didactic, observational, and skill-based teaching techniques. Participants completed pretests and posttests evaluating dementia knowledge, confidence in providing care, and practice behaviors. RESULTS: Between 2000 and 2009, 146 health care professionals with a mean age of 45.7+/-10.8 years attended the CPP; 79.2% were white, 58.2% were women, and 58% of participants had been in practice for more than 10 years. Posttests showed an improvement in knowledge and confidence for diagnosis and treatment and increased the use of dementia screening tools. Rural research participation in an urban Alzheimer Disease Research Center increased 52% over the pre-CPP period. CONCLUSIONS: The following primary goals were accomplished: increased knowledge and confidence, changed practice habits, and enhanced research recruitment. Educational programs such as the CPP may be beneficial for increasing access to accurate diagnoses and appropriate treatment for Alzheimer disease while also enhancing research participation