Advance directives for future dementia can be modified by a brief video presentation on dementia care: An experimental study

<div><p>Objectives</p><p>To investigate whether life-sustaining measures in medical emergency situations are less accepted for an anticipated own future of living with dementia, and to test whether a resource-oriented, in contrast to a deficit-oriented video about the same demented person, would increase the acceptance of such life-saving measures.</p><p>Design</p><p>Experimental study conducted between September 2012 and February 2013.</p><p>Setting</p><p>Community dwelling female volunteers living in the region of Bonn, Germany.</p><p>Participants</p><p>278 women aged 19 to 89 (mean age 53.4 years).</p><p>Intervention</p><p>Presentation of a video on dementia care focusing either on the deficits of a demented woman (negative framing), or focusing on the remaining resources (positive framing) of the same patient.</p><p>Main outcome measures</p><p>Approval of life-sustaining treatments in five critical medical scenarios under the assumption of having comorbid dementia, before and after the presentation of the brief videos on care.</p><p>Results</p><p>At baseline, the acceptance of life-sustaining measures in critical medical situations was significantly lower in subjects anticipating their own future life with dementia. Participants watching the resource-oriented film on living with dementia had significantly higher post-film acceptance rates compared to those watching the deficit-oriented negatively framed film. This effect particularly emerges if brief and efficient life-saving interventions with a high likelihood of physical recovery are available (eg, antibiotic treatment for pneumonia).</p><p>Conclusions</p><p>Anticipated decisions regarding life-sustaining measures are negatively influenced by the subjective imagination of living with dementia, which might be shaped by common, unquestioned stereotypes. This bias can be reduced by providing audio-visual information on living with dementia which is not only centred around cognitive and functional losses but also focuses on remaining resources and the apparent quality of life. This is particularly true if the medical threat can be treated efficiently. These findings have implications for the practice of formulating, revising, and supporting advance directives.</p></div

Difference in the acceptance of life- extending measures overall and according to each scenario at baseline.

<p>Labels on the X-Axis are paraphrases of the original Likert-Scale response categories. DCV: Dementia Case Vignette, CCV: Control Case Vignette. * Significant difference between groups (p<0.05).</p

Description of demographical data of the study sample (n = 278).

<p>Description of demographical data of the study sample (n = 278).</p

Two-step experimental design.

<p>DCV: Dementia Case Vignette; CCV: Control Case Vignette; DCV+: Dementia Case Vignette after seing a resource-oriented film on living with dementia ("positive film"); DCV-: Dementia Case Vignette after seeing a deficit-oriented film on living with dementia ("negative film").</p

The impact of memory concerns on the risk of future Alzheimer's Dementia is moderated by objective memory performance at baseline.

<p><i>Note</i>. The impact of memory concerns on the risk of future Alzheimer's Dementia, expressed in terms of the Hazard Ratio (HR) for the predictor “memory concerns”, is plotted as a function of objective memory performance at baseline, i.e. the interaction effect between memory concerns and objective memory performance is depicted. Values are derived from the multivariate Cox-proportional Hazard Regression analysis (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0100812#pone-0100812-t001" target="_blank">Table 2</a>, model step 3: HR of the interaction-term  = 1.51, 95% Confidence Interval: 1.01–2.25). The black solid line corresponds to the estimated HR-value  = 1.51 of the interaction effect. The two dotted lines represent the functional curves that result when the boundary HR-values of the lower 95% Confidence Interval ( = 1.01) or upper 95% Confidence Interval ( = 2.25) respectively, are inserted as numbers to plot the interaction effect. CERAD-DR  =  Delayed Recall of the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Assessment Battery.</p

Risk of incident Alzheimer's Dementia: Results from hierarchically formulated multivariate Cox proportional hazard regression models.

<p><i>Note</i>. M2LL of the Intercept model  = 830.6. Details of the modeling process are given in the methods section. The HR for the CERAD-DR is below one as it represents the HR for a one unit increase in CERAD-DR scores (i.e. for better memory performance). Lower CERAD-DR scores are therefore associated with a higher risk of developing incident AD. B  =  Beta-Coefficient of the predictor, CI  =  Confidence Interval, CERAD-DR  =  Delayed Recall of the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Assessment Battery, HR  =  Hazard Ratio, M2LL  =  Minus-Two-Log-Likelihood, MC  =  Memory Concerns, SE  =  Standard Error for B.</p

Data_Sheet_1_Midlife occupational cognitive requirements protect cognitive function in old age by increasing cognitive reserve.pdf

IntroductionSeveral lifestyle factors promote protection against Alzheimer's disease (AD) throughout a person's lifespan. Although such protective effects have been described for occupational cognitive requirements (OCR) in midlife, it is currently unknown whether they are conveyed by brain maintenance (BM), brain reserve (BR), or cognitive reserve (CR) or a combination of them.MethodsWe systematically derived hypotheses for these resilience concepts and tested them in the population-based AgeCoDe cohort and memory clinic-based AD high-risk DELCODE study. The OCR score (OCRS) was measured using job activities based on the O*NET occupational classification system. Four sets of analyses were conducted: (1) the interaction of OCR and APOE-ε4 with regard to cognitive decline (N = 2,369, AgeCoDe), (2) association with differentially shaped retrospective trajectories before the onset of dementia of the Alzheimer's type (DAT; N = 474, AgeCoDe), (3) cross-sectional interaction of the OCR and cerebrospinal fluid (CSF) AD biomarkers and brain structural measures regarding memory function (N = 873, DELCODE), and (4) cross-sectional and longitudinal association of OCR with CSF AD biomarkers and brain structural measures (N = 873, DELCODE).ResultsRegarding (1), higher OCRS was associated with a reduced association of APOE-ε4 with cognitive decline (mean follow-up = 6.03 years), consistent with CR and BR. Regarding (2), high OCRS was associated with a later onset but subsequently stronger cognitive decline in individuals converting to DAT, consistent with CR. Regarding (3), higher OCRS was associated with a weaker association of the CSF Aβ42/40 ratio and hippocampal volume with memory function, consistent with CR. Regarding (4), OCR was not associated with the levels or changes in CSF AD biomarkers (mean follow-up = 2.61 years). We found a cross-sectional, age-independent association of OCRS with some MRI markers, but no association with 1-year-change. OCR was not associated with the intracranial volume. These results are not completely consistent with those of BR or BM.DiscussionOur results support the link between OCR and CR. Promoting and seeking complex and stimulating work conditions in midlife could therefore contribute to increased resistance to pathologies in old age and might complement prevention measures aimed at reducing pathology.</p