The Cross-Cultural Dementia Screening (CCD):A new neuropsychological screening instrument for dementia in elderly immigrants

Objective: Currently, approximately 3.9% of the European population are non-EU citizens, and a large part of these people are from "non-Western" societies, such as Turkey and Morocco. For various reasons, the incidence of dementia in this group is expected to increase. However, cognitive testing is challenging due to language barriers and low education and/or illiteracy. The newly developed Cross-Cultural Dementia Screening (CCD) can be administered without an interpreter. It contains three subtests that assess memory, mental speed, and executive function. We hypothesized the CCD to be a culture-fair test that could discriminate between demented patients and cognitively healthy controls. Method: To test this hypothesis, 54 patients who had probable dementia were recruited via memory clinics. Controls (N = 1625) were recruited via their general practitioners. All patients and controls were aged 55 years and older and of six different self-defined ethnicities (Dutch, Turkish, Moroccan-Arabic, Moroccan-Berber, Surinamese-Creole, and Surinamese-Hindustani). Exclusion criteria included current or previous conditions that affect cognitive functioning. Results: There were performance differences between the ethnic groups, but these disappeared after correcting for age and education differences between the groups, which supports our central hypothesis that the CCD is a culture-fair test. Receiver-operating characteristic (ROC) and logistic regression analyses showed that the CCD has high predictive validity for dementia (sensitivity: 85%; specificity: 89%). Discussion: The CCD is a sensitive and culture-fair neuropsychological instrument for dementia screening in low-educated immigrant populations.</p

Anticholinergic and Sedative Medications and Dynamic Gait Parameters in Older Patients

BACKGROUND: Anticholinergic and sedative medications are associated with poorer physical function in older age. Gait and physical function have traditionally been assessed with the time needed to execute objective function tests. Accelerometer-based gait parameters provide a precise capturing of gait dynamics and patterns and as such have added value. OBJECTIVES: This study examined the associations between cumulative exposure to anticholinergic and sedative medications and gait dimensions as assessed with accelerometer-based dynamic gait parameters. METHODS: Data were collected from outpatients of a diagnostic geriatric day clinic who underwent a comprehensive geriatric assessment (CGA). Cumulative exposure to anticholinergic and sedative medications was quantified with the Drug Burden Index (DBI), a linear additive pharmacological dose-response model. From a total of 22 dynamic gait parameters, the gait dimensions 'Regularity', 'Complexity', 'Stability', 'Pace', and 'Postural Control' were derived using factor analysis (and standardized total scores for these dimensions were calculated accordingly). Data were analyzed with multivariable linear regression analysis, in which adjustment was made for the covariates age, gender, body mass index (BMI), Mini Mental State Examination (MMSE) score, Charlson Comorbidity Index (CCI) including dementia, and number of medications not included in the DBI. RESULTS: A total of 184 patients participated, whose mean age was 79.8 years (± SD 5.8), of whom 110 (60%) were women and of whom 88 (48%) had polypharmacy (i.e., received treatment with ≥5 medications). Of the 893 medications that were prescribed in total, 157 medications (17.6%) had anticholinergic and/or sedative properties. Of the patients, 100 (54%) had no exposure (DBI = 0), 42 (23%) had moderate exposure (0 > DBI ≤ 1), while another 42 (23%) had high exposure (DBI >1) to anticholinergic and sedative medications. Findings showed that high cumulative exposure to anticholinergic and sedative medications was related with poorer function on the Regularity and Pace dimensions. Furthermore, moderate and high exposure were associated with poorer function on the Complexity dimension. CONCLUSIONS: These findings show that in older patients with comorbidities, cumulative anticholinergic and sedative exposure is associated with poorer function on multiple gait dimensions

Gait characteristics and their discriminative power in geriatric patients with and without cognitive impairment

Abstract Background A detailed gait analysis (e.g., measures related to speed, self-affinity, stability, and variability) can help to unravel the underlying causes of gait dysfunction, and identify cognitive impairment. However, because geriatric patients present with multiple conditions that also affect gait, results from healthy old adults cannot easily be extrapolated to geriatric patients. Hence, we (1) quantified gait outcomes based on dynamical systems theory, and (2) determined their discriminative power in three groups: healthy old adults, geriatric patients with- and geriatric patients without cognitive impairment. Methods For the present cross-sectional study, 25 healthy old adults recruited from community (65 ± 5.5 years), and 70 geriatric patients with (n = 39) and without (n = 31) cognitive impairment from the geriatric dayclinic of the MC Slotervaart hospital in Amsterdam (80 ± 6.6 years) were included. Participants walked for 3 min during single- and dual-tasking at self-selected speed while 3D trunk accelerations were registered with an IPod touch G4. We quantified 23 gait outcomes that reflect multiple gait aspects. A multivariate model was built using Partial Least Square- Discriminant Analysis (PLS-DA) that best modelled participant group from gait outcomes. Results For single-task walking, the PLS-DA model consisted of 4 Latent Variables that explained 63 and 41% of the variance in gait outcomes and group, respectively. Outcomes related to speed, regularity, predictability, and stability of trunk accelerations revealed with the highest discriminative power (VIP > 1). A high proportion of healthy old adults (96 and 93% for single- and dual-task, respectively) was correctly classified based on the gait outcomes. The discrimination of geriatric patients with and without cognitive impairment was poor, with 57% (single-task) and 64% (dual-task) of the patients misclassified. Conclusions While geriatric patients vs. healthy old adults walked slower, and less regular, predictable, and stable, we found no differences in gait between geriatric patients with and without cognitive impairment. The effects of multiple comorbidities on geriatric patients’ gait possibly causes a ‘floor-effect’, with no room for further deterioration when patients develop cognitive impairment. An accurate identification of cognitive status thus necessitates a multifactorial approach

Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults:a prospective cohort study

Background: Vertebral fractures, an increased thoracic kyphosis and a flexed posture are associated with falls. However, this was not confirmed in prospective studies. We performed a prospective cohort study to investigate the association between vertebral fractures, increased thoracic kyphosis and/or flexed posture with future fall incidents in older adults within the next year. Methods: Patients were recruited at a geriatric outpatient clinic. Vertebral fractures were evaluated on lateral radiographs of the spine with the semi-quantitative method of Genant; the degree of thoracic kyphosis was assessed with the Cobb angle. The occiput-to-wall distance was used to determine a flexed posture. Self-reported falls were prospectively registered by monthly phone contact for the duration of 12 months. Results: Fifty-one older adults were included; mean age was 79 years (SD = 4.8). An increased thoracic kyphosis was independently associated with future falls (OR 2.13; 95% CI 1.10-4.51). Prevalent vertebral fractures had a trend towards significancy (OR 3.67; 95% CI 0.85-15.9). A flexed posture was not significantly associated with future falls. Conclusion: Older adults with an increased thoracic kyphosis are more likely to fall within the next year. We suggest clinical attention for underlying causes. Because patients with increased thoracic curvature of the spine might have underlying osteoporotic vertebral fractures, clinicians should be aware of the risk of a new fracture

Long-term exposure to anticholinergic and sedative medications and cognitive and physical function in later life

Background: Anticholinergic and sedative medications are frequently prescribed to older individuals. These medications are associated with short-term cognitive and physical impairment, but less is known about long-term associations. We therefore examined over twenty years whether cumulative exposure to these medications was related to poorer cognitive and physical functioning. Methods: Older adult participants of the Longitudinal Aging Study Amsterdam (LASA) were followed from 1992-2012. On 7 measurement occasions, cumulative exposure to anticholinergic and sedative medications was quantified with the Drug Burden Index (DBI), a linear additive pharmacological dose-response model. Cognitive functioning was assessed with the Mini Mental State Examination (MMSE), Alphabet Coding Task (ACT, 3 trials), Auditory Verbal Learning Test (AVLT, learning and retention condition), and Raven Colored Progressive Matrices (RCPM, 2 trials). Physical functioning was assessed with the Walking Test (WT), Cardigan Test (CT), Chair Stands Test (CST), Balance Test (BT), and self-reported Functional Independence (FI). Data were analyzed with linear mixed models adjusted for age, education, sex, living with a partner, BMI, depressive symptoms, co-morbidities (cardiovascular disease, diabetes, cancer, COPD, osteoarthritis, CNS diseases), and prescribed medications. Results: Longitudinal associations were found of the DBI with poorer cognitive functioning (less items correct on the 3 ACT trials, AVLT learning condition, and the 2 RCPM trials) and with poorer physical functioning (longer completion time on the CT, CST, and lower self-reported FI). Conclusions: This longitudinal analysis of data collected over 20 years, showed that higher long-term cumulative exposure to anticholinergic and sedative medications was associated with poorer cognitive and physical functioning

Application of a theoretical model to evaluate COPD disease management

Background: Disease management programmes are heterogeneous in nature and often lack a theoretical basis. An evaluation model has been developed in which theoretically driven inquiries link disease management interventions to outcomes. The aim of this study is to methodically evaluate the impact of a disease management programme for patients with chronic obstructive pulmonary disease (COPD) on process, intermediate and final outcomes of care in a general practice setting. Methods. A quasi-experimental research was performed with 12-months follow-up of 189 COPD patients in primary care in the Netherlands. The programme included patient education, protocolised a

Gait stability and variability measures show effects of impaired cognition and dual tasking in frail people

<p>Abstract</p> <p>Background</p> <p>Falls in frail elderly are a common problem with a rising incidence. Gait and postural instability are major risk factors for falling, particularly in geriatric patients. As walking requires attention, cognitive impairments are likely to contribute to an increased fall risk. An objective quantification of gait and balance ability is required to identify persons with a high tendency to fall. Recent studies have shown that stride variability is increased in elderly and under dual task condition and might be more sensitive to detect fall risk than walking speed. In the present study we complemented stride related measures with measures that quantify trunk movement patterns as indicators of dynamic balance ability during walking. The aim of the study was to quantify the effect of impaired cognition and dual tasking on gait variability and stability in geriatric patients.</p> <p>Methods</p> <p>Thirteen elderly with dementia (mean age: 82.6 ± 4.3 years) and thirteen without dementia (79.4 ± 5.55) recruited from a geriatric day clinic, walked at self-selected speed with and without performing a verbal dual task. The Mini Mental State Examination and the Seven Minute Screen were administered. Trunk accelerations were measured with an accelerometer. In addition to walking speed, mean, and variability of stride times, gait stability was quantified using stochastic dynamical measures, namely regularity (sample entropy, long range correlations) and local stability exponents of trunk accelerations.</p> <p>Results</p> <p>Dual tasking significantly (p < 0.05) decreased walking speed, while stride time variability increased, and stability and regularity of lateral trunk accelerations decreased. Cognitively impaired elderly showed significantly (p < 0.05) more changes in gait variability than cognitive intact elderly. Differences in dynamic parameters between groups were more discerned under dual task conditions.</p> <p>Conclusions</p> <p>The observed trunk adaptations were a consistent instability factor. These results support the concept that changes in cognitive functions contribute to changes in the variability and stability of the gait pattern. Walking under dual task conditions and quantifying gait using dynamical parameters can improve detecting walking disorders and might help to identify those elderly who are able to adapt walking ability and those who are not and thus are at greater risk for falling.</p