Quality of life evidence for patients with Alzheimer’s disease: use of existing quality of life evidence from the ADENA trials to estimate the utility impact of Exelon®

This paper utilises the Mini-Mental State Examination (MMSE) score of patients with Alzheimer’s disease to establish a relationship between disease progression and quality of life measures, and the author also compares his results to findings from the literature review about Alzheimer’s patient utility.Alzheimer's disease; quality of life

An evaluation of in-patient respite care at St. Vincent de Paul Residence

Aim: To identify the multi-dimensional characteristics and need for inter-disciplinary input associated with in-patient respite care. Methods: During the period January-December 2007, 91 in-patient respite users, aged ≥60 years, were assessed on admission for respite care at St. Vincent de Paule Residence. Assessment instruments used included the Barthel Index, the Mini-Mental State Examination, a Caregiver Strain Index, the Functional Oral Intake Scale and the Communicative Effectiveness Index. Findings: Of the study group (n=91), 65% of respite users were found to be suffering from moderate to severe dementia (Mini-Mental State Examination score 0-20). High dependency on the Barthel Index (0-7/20) was found in 52% of cases whilst 45% had low dependency (13-20/20). Carer strain was reported in 60% of care-givers (carers). Interdisciplinary input requirements in the group studied included nursing in 85%, dental (83%), speech language pathology (70%), physiotherapy (39%), occupational therapy (38%), medical (33%) and social worker assistance (24%). Conclusion: Elderly respite users are a mixed group with multiple and diverse needs. In their own homes, these care needs are principally met by informal helpers who are frequently under stress. The expansion of in-patient respite services will reinforce the informal community care network and will help avoid or postpone long-term institutionalisation.peer-reviewedpeer-reviewe

Combining Cognitive Screening Tests for the Evaluation of Mild Cognitive Impairment in the Elderly

OBJECTIVE: To determine the accuracy of the Mini-Mental State Examination combined with the Verbal Fluency Test and Clock Drawing Test for the identification of patients with mild cognitive impairment and Alzheimer's disease (AD). METHOD: These tests were used to evaluate cognitive function in 247 older adults. Subjects were divided into three groups according to their cognitive state: mild cognitive impairment (n=83), AD (n=81), cognitively unimpaired controls (n=83), based on clinical and neuropsychological data. The diagnostic accuracy of each test for discriminating between these diagnostic groups (mild cognitive impairment or AD vs. controls) was examined with the aid of Receiver Operating Characteristic (ROC) curves. Additionally, we evaluated the benefit of the combination of tests on diagnostic accuracy. RESULTS: Although they were accurate enough for the identification of Alzheimer's disease, neither test alone proved adequate for the correct separation of patients with mild cognitive impairment from healthy subjects. Combining these tests did not improve diagnostic accuracy, as compared to the Mini-Mental State Examination alone, in the identification of patients with mild cognitive impairment or Alzheimer's disease. CONCLUSIONS: The present data do not warrant the combined use of the Mini-Mental State Examination, the Verbal Fluency Test and the Clock Drawing Test as a sufficient diagnostic schedule in screening for mild cognitive impairment. The present data do not support the notion that the combination of test scores is better that the use of Mini-Mental State Examination scores alone in the screening for Alzheimer's disease

Feasibility of a multiple-choice mini mental state examination for chronically critically ill patients:

Objectives: Following treatment in an ICU, up to 70% of chronically critically ill patients present neurocognitive impairment that can have negative effects on their quality of life, daily activities, and return to work. The Mini Mental State Examination is a simple, widely used tool for neurocognitive assessment. Although of interest when evaluating ICU patients, the current version is restricted to patients who are able to speak. This study aimed to evaluate the feasibility of a visual, multiple-choice Mini Mental State Examination for ICU patients who are unable to speak.Design: The multiple-choice Mini Mental State Examination and the standard Mini Mental State Examination were compared across three different speaking populations. The interrater and intrarater reliabilities of the multiple-choice Mini Mental State Examination were tested on both intubated and tracheostomized ICU patients.Setting: Mixed 36-bed ICU and neuropsychology department in a university hospital.Subjects: Twenty-six healthy volunteers, 20 neurological patients, 46 ICU patients able to speak, and 30 intubated or tracheostomized ICU patients.Interventions: None.Measurements and Main Results: Multiple-choice Mini Mental State Examination results correlated satisfactorily with standard Mini Mental State Examination results in all three speaking groups: healthy volunteers: intraclass correlation coefficient = 0.43 (95% CI, –0.18 to 0.62); neurology patients: 0.90 (95% CI, 0.82–0.95); and ICU patients able to speak: 0.86 (95% CI, 0.70–0.92). The interrater and intrarater reliabilities were good (0.95 [0.87–0.98] and 0.94 [0.31–0.99], respectively). In all populations, a Bland-Altman analysis showed systematically higher scores using the multiple-choice Mini Mental State Examination.Conclusions: Administration of the multiple-choice Mini Mental State Examination to ICU patients was straightforward and produced exploitable results comparable to those of the standard Mini Mental State Examination. It should be of interest for the assessment and monitoring of the neurocognitive performance of chronically critically ill patients during and after their ICU stay. The multiple-choice Mini Mental State Examination tool’s role in neurorehabilitation and its utility in monitoring neurocognitive functions in ICU should be assessed in future studies

Minocycline 200 mg or 400 mg versus placebo for mild Alzheimer's disease: the MADE Phase II, three-arm RCT

Background: Minocycline is an anti-inflammatory drug and protects against the toxic effects of β-amyloid in vitro and in animal models of Alzheimer’s disease. To the best of our knowledge, no randomised placebo-controlled clinical trials in patients with Alzheimer’s disease looking at the efficacy and tolerability of minocycline have been carried out. Objectives: The trial investigated whether or not minocycline was superior to placebo in slowing down the rate of decline in cognitive and functional ability over 2 years. The safety and tolerability of minocycline were also assessed. Design: A Phase II, three-arm, randomised, double-blind, multicentre trial with a semifactorial design. Participants continued on trial treatment for up to 24 months. Setting: Patients were identified from memory services, both within the 32 participating NHS trusts and within the network of memory services supported by the Dementias and Neurodegenerative Diseases Research Network (also known as DeNDRoN). Participants: Patients with standardised Mini Mental State Examination scores of > 23 points and with Alzheimer’s disease assessed by the National Institute on Aging–Alzheimer’s Association’s criteria were identified from memory services. Intervention: Patients with mild Alzheimer’s disease were randomly allocated 1 : 1 : 1 to receive one of three treatments: arm 1 – 400 mg per day of minocycline; arm 2 – 200 mg per day of minocycline; or arm 3 – placebo. Patients continued treatment for 24 months. Participants, investigators and outcome assessors were blind to treatment allocation. Main outcome measures: Primary outcome measures were decline in standardised Mini Mental State Examination and Bristol Activities of Daily Living Scale scores of combined minocycline treatment arms versus placebo, as analysed by intention-to-treat repeated measures regression. Results: Between 23 May 2014 and 14 April 2016, 554 participants were randomised. Of the 544 eligible participants, the mean age was 74.3 years and the average standardised Mini Mental State Examination score was 26.4 points. A total of 252 serious adverse events were reported, with the most common categories being neuropsychiatric and cardiocirculatory. Significantly fewer participants completed treatment with 400 mg of minocycline [29% (53/184)] than 200 mg [62% (112/181)] or placebo [64% (114/179)] (p < 0.0001), mainly because of gastrointestinal symptoms (p = 0.0008), dermatological side effects (p = 0.02) and dizziness (p = 0.01). Assessment rates were also lower in the 400-mg treatment arm: 68% (119 of 174 expected) for standardised Mini Mental State Examination scores at 24 months, compared with 82% (144/176) for the 200-mg treatment arm and 84% (140/167) for the placebo arm. Decline in standardised Mini Mental State Examination scores over the 24-month study period in the combined minocycline arms was similar to that in the placebo arm (4.1- vs. 4.3-point reduction; p = 0.9), as was the decline in the 400- and 200-mg treatment arms (3.3 vs. 4.7 points; p = 0.08). Likewise, worsening of Bristol Activities of Daily Living Scale scores over 24 months was similar in all trial arms (5.7, 6.6 and 6.2 points in the 400-mg treatment arm, 200-mg treatment arm and placebo arm, respectively; a p-value of 0.57 for minocycline vs. placebo and a p-value of 0.77 for 400 vs. 200 mg of minocycline). Results were similar in different patient subgroups and in sensitivity analyses adjusting for missing data. Limitations: Potential limitations of the study include that biomarkers were not used to confirm the diagnosis of Alzheimer’s disease, as these and apolipoprotein E (APOE) genotyping are not routinely available within the NHS. Compliance was also worse than expected and differential follow-up rates were observed, with fewer assessments obtained for the 400-mg treatment arm than for the 200-mg treatment and placebo arms. Conclusions: Minocycline does not delay the progress of cognitive or functional impairment in people with mild Alzheimer’s disease over a 2-year period. Minocycline at a dose of 400 mg is poorly tolerated in this population. Future work: The Minocycline in mild Alzheimer’s DiseasE (MADE) study provides a framework for a streamlined trial design that can be usefully applied to test other disease-modifying therapies

Social support in the context of poverty: a study of the elderly with cognitive impairments and their family caregivers

Objective: To describe the structure and function of social support networks of elderly people with cognitive impairments who reside in the context of high social vulnerability, and their family caregivers. Method: The subjects were 33 elderly enrolled in Family Health Units that showed performance on the Mini Mental State Examination below the cutoff score in a previous study, and their 33 caregivers. We applied the Mini-Mental State Examination and Diagram Escort. All ethical guidelines were followed. Results: Both the elderly and caregivers relate social networks with similar characteristics. Caregivers, however, provide more support than the elderly. In both cases networks are numerous, however, few members providing or receiving support. Conclusion: The use of social networks as a therapeutic resource must be designed to establish the plan of care to the elderly