Antipsychotics, avoidable hospitalizations two of many topics at Alzheimer's meeting

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Antipsychotics, avoidable hospitalizations two of many topics at Alzheimer's meeting
Antipsychotics, avoidable hospitalizations two of many topics at Alzheimer's meeting

Brain games, antipsychotics, avoidable hospitalizations, a checklist for mild behavioral impairment, and a dementia test that uses the sense of smell. Those were the topics of some of the major research studies discussed at last week's Alzheimer's Association International Conference in Toronto.

Speed-of-processing training shows success in reducing risk of cognitive decline

Speed-of-processing training may reduce the risk of developing cognitive decline or dementia over time, according to research funded by the National Institutes of Health.

The Advanced Cognitive Training for Independent and Vital Elderly, or ACTIVE, study examined the effect of particular types of cognitive training on healthy adults over 10 years. A total of 2,785 participants at six trial sites randomly were divided into four groups whose members underwent:

  1. memory training,
  2. reasoning training,
  3. computerized speed-of-processing training or
  4. no training (control group).

The speed-of-processing training group was the only one with members who experienced a statistically significant effect on cognitive decline. At 10 years, the researchers observed a 33% reduction in risk of developing dementia over the time of the study.

Participants in the speed-of-processing group were trained on a specific task designed to improve the speed and accuracy of visual attention. The user identified an object (for instance, a truck) at the center of his or her gaze while at the same time identifying a target in the periphery (for instance, a car). As the user got the answers correct, the speed of presentation became progressively briefer, whereas the targets became more similar. In the more difficult training tasks, the target in the periphery was obscured by distracting objects.

“We believe this is the first time a cognitive training intervention has been shown to protect against cognitive impairment or dementia in a large, randomized, controlled trial,” said University of South Florida Associate Professor Jerri Edwards, Ph.D., first author of the scientific abstract. “Next, we'd like to get a better grasp on what exactly is the right amount of cognitive training to get the optimal benefits.”

Minds in Motion program shows promise for physical, social health

The Minds in Motion physical activity and therapeutic recreation program developed in British Columbia, with a version launched in 2014 by the Alzheimer Society of Ontario, shows promise for the physical and social health of people with dementia and their care partners, according to researchers.

In the study discussed, the program was delivered once a week for eight weeks. Each session consisted of 50 minutes of exercise (cardiovascular, strength, balance, coordination and flexibility training), a short break and 50 minutes of therapeutic recreation (including social activities meant to invoke memory retrieval, imagination, word formation and group socialization).

Assessments were completed before and after the eight week program. Physical function was assessed with the Seniors' Fitness Test. Other outcomes were evaluated using questionnaires.

Key findings:

  • Most measures of physical function (endurance, upper/lower body strength, upper/lower body flexibility) improved similarly among people with dementia and their care partners.
  • People with dementia demonstrated improved agility, although their care partners did not.
  • Participants reported a significant increase in weekly frequency, duration and intensity of physical activity. Participants reported no change in physical activity self-efficacy, however, and only a small but significant decline in mood.

“Ninety-six percent of participants indicated that they enjoy the program, and 80% have returned to the program again,” said Kayla Regan of the University of Waterloo in Ontario. “Additionally, 53% of participants report that they have developed new relationships through MIM.”

She added: “Because there was a small but significant decline in mood among participants, we recommend further study to better understand whether this change is a result of the program or unrelated changes over time.”

Avoidable hospitalizations cost Medicare $2.6 billion

Management of co-existing diseases remains poor for many people with Alzheimer's or other dementias, reported researchers from Boston and New York.

More than 369,000 U.S. hospital admissions of people with Alzheimer's in 2013 were potentially avoidable, and these visits cost Medicare $2.6 billion.

At least 75% of older adults with Alzheimer's have multiple health problems, such as heart disease and diabetes, that require regular and specific medical management. Because of its effect on memory, thinking and behavior, Alzheimer's disease can significantly complicate management of other diseases, putting people with dementia at high risk for hospitalizations that may be preventable with proactive care. High-quality healthcare can potentially prevent the need for these expensive hospitalizations, the Alzheimer's Association said.

Findings of other studies related to economics that were presented at the conference:

  • Even without a treatment that changes the underlying course of the disease, ensuring that people with Alzheimer's receive the current standard of care for indicated medications has an economic benefit, according to the results of one study. Treated patients saved the health system money and resulted in lower mortality rates compared with untreated patients.
  • The Medicare Annual Wellness Visit offers an opportunity to establish a cognitive baseline, identify changes over time, and detect cognitive impairment. In 2013, however, only 11% of Medicare beneficiaries nationally used the AWV, and it was more likely to be skipped by those most vulnerable to dementia than healthier people. The AWV is being successfully implemented on a wide scale by Allina Health, a large Midwest health system.

Smell test may predict early stages of Alzheimer's disease

The University of Pennsylvania Smell Identification Test may offer a practical, low-cost alternative to other tests in predicting cognitive decline and detecting early-stage Alzheimer's disease, according to research presented by Columbia University Medical Center, New York State Psychiatric Institute and NewYork-Presbyterian.

Low scores on the test, which indicate a decreased ability to correctly identify odors, were found to predict cognitive decline. Current testing methods are only capable of clinically detecting Alzheimer's disease in the later stages of its development, when significant brain damage already has occurred.

“Although more research is needed, odor identification testing, which is much less expensive and easier to administer than positron emission tomography imaging or lumbar puncture, may prove to be a useful tool in helping physicians counsel patients who are concerned about their risk of memory loss,” said William Kreisl, M.D., the Boris and Rose Katz Assistant Professor of Neurology (in the Taub Institute) at CUMC and a neurologist at NewYork-Presbyterian/Columbia.

New condition / patient status introduced: Mild behavioral impairment

A new condition or patient status, known as mild behavioral impairment, or MBI, may be a forerunner of neurodegeneration and progression to mild cognitive impairment or dementia, according to researchers.

The researchers also proposed new MBI checklist (MBI-C), designed to be administered by physicians, that looks at five categories of behavioral symptoms: apathy/drive/motivation; mood/affect/anxiety; impulse control/agitation/reward; social appropriateness; and thoughts/perception.

The checklist eventually may help clinicians capture changes in behavior that signal the beginnings of neurodegeneration, they said. Once finalized, the proposed scale also may be made into a tool for caregivers of older adults with dementia to document the nature and extent of symptoms and measure changes over time.

“This proposed new checklist describes and helps identify a new clinical stage in the disease and has the potential to represent a paradigm shift in formal neurodegeneration testing — away from a sole focus on the memory to also encompass behavior,” said Maria C. Carrillo, Ph.D., chief science officer of the Alzheimer's Association. “By looking beyond memory-related issues to closely evaluate the behavioral issues included in the checklist, physicians could reach a more efficient and accurate diagnosis, sooner.”

Questions in the MBI-C rating were designed specifically to address a younger pre-dementia population and to emphasize that the emergence of neuropsychiatric symptoms (depression, anxiety, wandering, “sundowning,” resistance to daily care, physical aggression, repetitious questioning, sleep disturbance, rummaging/hoarding, social withdrawal from others and activities, disruptive vocalizations, demanding behavior/verbal aggression, refusing to eat/drink/take medication) was a significant change from previous behavior, present for at least 6 months.

Antipsychotics in dementia care can be reduced by training

The training of long-term care facility nurses in nonpharmacologic and person-centered approaches to managing the behavioral and psychological symptoms of dementia can result in successful “deprescribing” without the re-emergence of symptoms, according to researchers from Australia. Challenges remain regarding the sustainability and culture of prescribing in aged care, however, they said.

The Halting Antipsychotic use in Long Term care, or HALT, Project involved 140 residents at 23 care facilities; 132 began deprescribing, and antipsychotic medications were ceased in 121. Of these, 75% remain off the antipsychotic medication up to six months following initial reduction.

“Often there can be cultural and logistical barriers to moving away from antipsychotics in aged care settings,” said Henry Brodaty, M.D., D.Sc., of the Dementia Collaborative Research Center at the University of New South Wales, “but we hope the results of this project will serve as a positive example towards a more person-centered approach globally.”

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