Dementia

The introduction of an additional meal in nursing homes may be associated with a positive impact on the BMI of residents with dementia.

Abstract

Background

Since 2010, many nursing homes in Norway have introduced an extra meal daily, with a hot lunch, and pushing dinner to later in the day. This initiative aims to reduce the long time interval between breakfast and supper.

Aim

This study examines how an extra meal affects the residents' body mass index (BMI) at nursing homes in Norway. Research questions include how an extra meal affects BMI among residents in the dementia unit.

Methods

We used a cross-sectional design to analyze data from residents over 65 years old in dementia care units. Both parametric and non-parametric statistical tests were used to evaluate changes in BMI.

Results

Our study identified a modest increase in BMI among residents in the dementia care unit after introducing an additional meal. The results imply that incorporating an extra meal to meet residents' needs could support the maintenance of a healthy BMI.

Discussion

Our study reveals that the introduction of an extra meal resulted in a slight increase in BMI among the residents with dementia, which does not correspond with previous studies indicating malnutrition among these residents. The dementia disease reduces functional abilities, and challenges related to mealtime behavior, restlessness, and depression can lead to weight loss. The fact that our results show a slight increase in BMI at the dementia units may be related to these residents often being troubled with restlessness and not finding the peace to consume a full meal. By introducing an extra meal, the total food intake increases since residents still eat a little at each meal, and focusing more on accommodating each resident might have influenced the increase in BMI values.

Conclusion

The study indicates that the introduction of an extra meal has a positive effect on the BMI value of residents with dementia in nursing homes.

Introduction

Physical and cognitive decline at an older age is preceded by changes that accumulate over time until they become clinically evident difficulties. These changes, frequently overlooked by patients and health professionals, may respond better than fully established conditions to strategies designed to prevent disabilities and dependence in later life. The objective of this study was twofold: to provide further support for the need to screen for early functional changes in older adults and to look for an early association between decline in mobility and cognition.

Methods

A cross-sectional cohort study was conducted on 95 active functionally independent community-dwelling older adults in Havana, Cuba. We measured their gait speed at the usual pace and their cognitive status using the MMSE. A value of 0.8 m/s was used as the cut-off point to decide whether they presented a decline in gait speed. A quantitative analysis of their EEG at rest was also performed to look for an associated subclinical decline in brain function.

Results

Results show that 70% of the sample had a gait speed deterioration (i.e., lower than 0.8 m/s), of which 80% also had an abnormal EEG frequency composition for their age. While there was no statistically significant difference in the MMSE score between participants with a gait speed above and below the selected cut-off, individuals with MMSE scores below 25 also had a gait speed < 0.8 m/s and an abnormal EEG frequency composition.

Conclusions

Our results provide further evidence of early decline in older adults – even if still independent and active - and point to the need for clinical pathways that incorporate screening and early intervention targeted at early deterioration to prolong the years of functional life in older age.

• Collaboration between a nursing home and an ambulatory geriatric-psychiatric team to patients with Behavioral and Psychological Symptoms of Dementia (BPSD)

Introduction

Healthcare professionals in nursing homes collaborate with specialized healthcare services to manage and support patients with BPSD. Geriatric- psychiatric ambulatory teams from the specialist health service provide professional assistance to healthcare professionals and family members for patients with geriatric psychiatric disorders and BPSD. This outreach- service is not very developed and could be further expanded. The study aimed to elucidate the collaboration between municipal health services and ambulatory geriatric-psychiatric teams within the specialist healthcare service.

Method

In this qualitative study we conducted individual interviews with six healthcare professionals representing four different nursing homes. The analysis is inspired by systematic text condensation. The research project has been submitted to the Norwegian Centre for Research Data.

Results

The informants expressed the importance of enhanced interaction with the specialist healthcare service in general and to patients with BPSD in spesific. When the informants receiving support from the team, the interaction is deemed more valuable and constructive. They find a shared meeting point with opportunity for sharing knowledge and engaging in dialogue.

Conclusion

The study indicates that health professionals see the importance of improved collaboration with specialized health services for patients with BPDS. When ambulatory teams engage actively, they experience collaboration characterized by closeness and shared understanding. The ambulatory-geriatric psychiatric team may become more well-known and the method of requesting professional help from the team can be made more transparent and clearer. It is also important that healthcare personnel proactively request professional assistance for patients with BPSD. With the increasing prevalence of patients with dementia, there is a need for further research to address the challenges in this area. Ambulatory geriatric-psychiatry teams are a service that should be explored further.

Abstract

Background: Cholinesterase inhibitors (ChEIs) are the primary medication for dementia treatment. Bradycardia is a possible adverse effect associated with ChEIs. However, the relationship between ChEIs and bradycardia has not been definitively established, particularly in the Asian population. We conducted a study investigating the association between ChEIs and heart rate.

Methods: We retrieved data from electronic medical records (EMR) of patients aged over 60 who were diagnosed with mild cognitive impairment or dementia at Ramathibodi Hospital between January 2009 and December 2022. These patients had outpatient records at 3, 6, and 12 months after the diagnosis. After filtering out by eligibility criterias, patients were categorised into ChEIs and non-ChEIs use, and then were 1:1 matched by baseline characteristics. We compared heart rate changes between the groups using Student’s t-tests or Mann Whitney U test depending on their distribution and Bayesian linear regression. Bradycardia was analysed using Kaplan-Meier Estimates and Cox proportional hazards model.

Results: 790 eligible patients were included, with 395 patients in each group. The median of difference of changes from baseline heart rate between group were -0.5 BPM (p = 0.06), -1.5 BPM (p = 0.12), and -1.5 BPM (p = 0.002) at 3, 6, and 12 months, respectively. The bradycardia incidence was higher in the ChEIs group (38.5%) compared with the non-ChEIs group (30.6%) at 12 months, but this difference was not statistically significant (p = 0.2). Among all regarded variables, baseline heart rate, age and beta-blocker usage associated with bradycardia, with adjusted hazard ratios (aHR) = 0.888 (95% CI 0.873–0.904, p<0.001), 1.019 (95% CI 1.001 –1.037, p=0.035) and 1.334 (95% CI 1.045-1.703, p=0.021).

Conclusions: The use of ChEIs was found to be associated with a decrease in heart rate. However, the changes were minimal and may not have had clinical implications for the patient.

INTRODUCTION Dementia in Parkinsons is common and under-recognised with a significant impact on person and their carer. Contrary to other services, Cardiff and Vale Parkinson's services run an integrated Parkinson's clinic where People with Parkinsons (PwP) developing dementia continue to be managed by the same clinical team.

METHODOLOGY An review of 425 patients diagnosed with dementia with a background of Parkinson's over last 10 years was undertaken. A random sample of 50 patients assessed for demographics, duration of Parkinson's, presentation of dementia and outcomes including place of residence and mortality data. RESULT Of 50 patients, the majority were male (28) with mean age of 75 years. The mean duration of Parkinson's prior to diagnosis of dementia was 6 years and from PD Dementia to death 3 years. The Median Clinical Frailty score on the diagnosis of dementia was 5. Pre-dementia diagnosis, there were no patients in care settings with 50% independently living at home, and the other half dependent on care support. Following dementia diagnosis, only 1 patient was living independently at home, with 19/50 (38%) in care facilities and 30/50 (60%) living at home with support. There was a trend towards increasing hospital admissions and increased need for support from the Parkinson's team following dementia diagnosis (pre-diagnosis 24 admissions, post-diagnosis 31 admissions) increased contact to Parkinson's team (323 versus 360).

CONCLUSION The onset of dementia appears to mark a significant shift in disease burden resulting in an increased rate of institutionalisation and care needs. The trend towards increasing hospital admissions in this cohort alongside increasing contact with the care team reflects increasing frailty, carer and disease burden. The onset of dementia should be a trigger for clinicians and service providers to proactively plan for future care provision. This needs further evaluation and we are analysing our wider sample currently.

INTRODUCTION: Guidance around optimal management of patients with cognitive impairment within a Parkinson’s disease (PD) multidisciplinary team (MDT) is lacking. This project aimed to improve the service pathway by integrating a Parkinson’s disease specialist psychiatrist (PDSP) within the MDT rather than referring patients to a separate mental health service.

METHODS: Data including mental health symptoms, time to review, diagnosis, treatment, and follow-up were collected over 12 months from the electronic clinical records of all patients referred to the PDSP with cognitive impairment. This data set was subject to descriptive analysis and economic evaluations.

RESULTS: 47 patients with Parkinson’s and cognitive impairment were referred to the PDSP - median waiting time to review was one month. Fourteen patients were diagnosed with mild cognitive impairment, 5 with dementia, and 28 with another condition or requiring further diagnostic assessment. Review with the PDSP prevented onward referral to another service in 29 cases, saving an estimated £1140 and reducing duplication of assessments.

CONCLUSIONS: Integration of a PDSP into a PD MDT avoided the need to refer the majority of patients to a separate mental health service, led to fewer health care professional contacts, reduced duplication, and cost savings. It is likely that the model led to earlier diagnoses and treatment. Evidence as to patient and carer experience is not yet available.

Introduction Many patients admitted with fragility femoral fractures have established cognitive impairment but no formal diagnosis of dementia. This lack of pre-existing diagnosis impacts care, counselling and discharge planning. This audit assessed how many people aged >65 admitted with a fragility fracture had information, at the time of admission, suggesting a likely but unconfirmed diagnosis of dementia and how their length of stay (LOS) and discharge destination compared to patients with confirmed dementia.

Methods 47 consecutive patients aged >65, admitted with a fragility femoral fracture had their electronic care records reviewed to identify information suggesting the presence of cognitive impairment/dementia. 30-day mortality, LOS and discharge destination was compared for three groups, 1) dementia, 2) informal dementia diagnosis and 3) no evidence of cognitive impairment.

Results Of 47 patients reviewed, 35(74%) were female, mean age 80.6 years (range, 68-94). Of these, 7/47(15%) had an established dementia diagnosis (mean age 82.4 years), 9/47 (19%) had unconfirmed cognitive impairment/dementia but without a formal diagnosis (mean age 82.2years) and 31/47 (66%) had no evidence of cognitive impairment(mean age 79.7 years). In cases of confirmed dementia diagnosis, the mean LOS was 54.7 days (range, 16-114). One patient died 1/7 (14.3%) and 3/7 (42.9%) were discharged home. For patients with an informal dementia diagnosis, the mean LOS was 35 days (range, 7-74). Two patients (2/9) died (22.2%), and 3/9 (33.3%) were discharged home. For those with no cognitive impairment, the mean LOS was 36 days (range, 7-92). Three patients 3/31 (9.7%) died, and 22/31 (71.0%) were discharged home.

Conclusion A significant minority of patients had likely undiagnosed dementia, with mortality and discharge destinations similar to patients with recognised dementia. Services need to consider how best to identify and diagnose cognitive impairment/dementia at the time of admission for fragility fractures.

“I would imagine it needed a review…” A qualitative study exploring the experiences of people with dementia and their informal carers of long-term condition reviews in primary care

Introduction

Multimorbidity is common for people with dementia (PWD) and is associated with increased healthcare utilisation and poorer outcomes. Part of the management of long-term conditions (LTCs) occurs through annual LTC reviews conducted in primary care. Little is known about the experiences or needs of people with dementia and informal carers in regard to LTC reviews.

Aim

To explore the experiences of PWD and their informal carers of the review and management of LTCs in primary care.

Method

Qualitative research study, protocol informed by discussion with people with lived experience as an informal carer. Institutional ethical approval (ref ETH2122-1035, University of East Anglia) was granted 25/3/2022. Semi-structured interviews were conducted with PWD and informal carers recruited through Join Dementia Research and local (to Norfolk, UK) charities. Thematic analysis was undertaken with reference to Braun and Clarke (2006).

Results

16 participants were interviewed: two PWD, 10 informal carers and two informal care/PWD dyads. Our findings fall into four main themes: 1) What matters to people; medication optimisation and holistic care 2) What is a review; the diversity of experiences 3) The importance of communication and 4) Preference for shared decision making.

Conclusion

Consideration should be given to ensuring patients and carers are aware when a LTC review will take place and providing an opportunity to be involved, thus allowing shared decision making and patient centred care. Further research into the clinician experience and their views on patients’ needs and how to meet them is required to inform how LTC reviews for people with dementia can be optimised.

Author names: M Mintun1; C Ritchie2; P Solomon3; JR Sims1; S Salloway4; O Hansson5; LG Apostolova6; JA Zimmer1; CD Evans1; M Lu1; P Ardayfio1; JD Sparks1; AM Wessels1; S Shcherbinin1; H Wang1; ESM Nery1; EC Collins1; EB Dennehy1; DA Brooks1; DM Skovronsky1; TRAILBLAZER-ALZ 2 Investigators; A Farquharson (Non-author presenter)1

Author provenances: 1. Eli Lilly and Company, USA; 2. Scottish Brain Sciences, UK; 3. Boston Center for Memory and Boston University Alzheimer's Disease Center, USA; 4. Departments of Neurology and Psychiatry, Alpert Medical School of Brown University, USA; Butler Hospital, USA; 5. Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Sweden; Memory Clinic, Skåne University Hospital, Sweden; 6. Department of Neurology, Indiana University School of Medicine, USA

Introduction: In TRAILBLAZER-ALZ donanemab (DONA) cleared brain amyloid plaques, significantly slowing disease progression in early symptomatic Alzheimer’s disease (ESAD).

Methods: TRAILBLAZER-ALZ2 enrolled participants with ESAD and amyloid and tau pathology by positron-emission tomography, randomizing (multicenter) those with low/medium-tau (n=1182) and high-tau (n=552) (missing tau n=2). Participants (randomized double-blind,1:1) received DONA (n=860)/placebo (n=876) IV every 4w for 72w. DONA participants meeting amyloid clearance treatment completion criteria at 24/52w had blinded switched to placebo. Primary outcomes: Integrated AD Rating Scale(iADRS) change from baseline at 76w in low/medium-tau or combined (low/medium- and high-tau) populations. Statistical testing allocated most power (80% α spend) to low/medium-tau population outcomes, with the remainder for combined population outcomes, including clinical and biomarker assessments.

Results: In the low/medium-tau population iADRS change at 76w: −6.02 (DONA) and −9.27 (placebo) (difference 3.25; 95%CI, 1.88-4.62; P<.001), 35.1% slowing of disease progression. change in clinical dementia rating scale (cdr)–sum boxes: 1.20 (dona) and 1.88 (placebo) (difference −0.67; 95% ci −0.95 to −0.40; p<0.001), 36.0% slowing. participants receiving dona experienced 38.6% less risk progressing next stage vs placebo over 76w (cdr-global score, hr="0.61;" p<0.001). amyloid clearance at 24 />52/76w: achieved in 34.2%/71.3%/80.1% DONA-treated participants. Significant, positive results were observed in the combined population. Serious AEs: 17.4% (DONA), and 15.8% (placebo), with 3 deaths among DONA patients who experienced serious amyloid-related imaging abnormalities (ARIA). AEs with DONA included ARIA-E (24.0%, 6.1% symptomatic); ARIA-H (31.4%); infusion-related reactions (8.7%).

Conclusion: DONA treatment significantly slowed clinical progression at 76w with a safety profile consistent with earlier studies.

Presented: AAIC2023.

Introduction

Community-based comprehensive geriatric assessment (CGA) reduces hospital admissions but the optimal way in which CGA can be delivered is not well understood. Digital and Remote Enhancements for the Assessment and Management of older people living with frailty (DREAM) is a programme of research seeking to develop an enhanced community CGA intervention.

We aimed to identify candidate cognitive assessment tools (CATs) that could be undertaken remotely and enhance CGA.

Methods

Searches were carried out on Medline, PsycINFO, CINAHL and Cochrane databases. Papers published since 2008 were included if they analysed the validity, reliability or acceptability of CATs that could be undertaken remotely in a domestic setting and were tested on older people.  

Results

Of 4286 papers identified, 56 were included. Four types of CAT were identified: computer/tablet/smartphone applications (23tools/27papers), telephone (16tools/23papers), video (2tools/2papers) and specialist equipment (4tools/4 papers). 14 tools demonstrated excellent accuracy for identifying mild cognitive impairment or dementia (specified as AUC >0.80 or sensitivity/specificity>80%). 42 papers presented concurrent/convergent validity, 14 reliability and 16 acceptability data. Time taken to perform tests ranged between 2-30 mins. Of the 23 computer/tablet/smartphone applications, 7 tools are currently available to download.

Key conclusions

Remote CATs could be used in CGA.  Computer/tablet/smartphone applications and some specialist equipment could enhance assessment by quickly and accurately identifying cognitive impairment, in some cases with greater accuracy than traditional tests. Tools that use ‘games’ may be more appealing than conventional pen and paper tools. ​However, many of the computer/tablet/smartphone applications tested are not available for clinical use.