Cognitive Symptoms Of Dementia Research Articles

Risk factors of dementia cognitive symptoms among older patients in Vietnam: A cross-sectional study

Background. Dementia has emerged as a significant contributor to declining quality of life and stands as a prominent factor in the increase of disability and dependency among elderly populations globally. This study aimed to explore the relationship between cognitive symptoms of dementia and their risk factors in individuals aged 60 years and older among Vietnamese outpatients who visited Geriatrics Clinic at University Medical Center of Ho Chi Minh city, Vietnam. Methods. 387 participants who were aged ≥ 60 years old were included in the cross-sectional study. Cognitive impairment was assessed by using the Mini Mental State Evaluation (MMSE) questionnaire. The functional limitations in activities of daily living (ADL) and Instrumental Activities of Daily Living (IADL), multimorbidity, and polypharmacy were also evaluated. Frailty was determined by The Canadian Study of Health and Aging Clinical Frailty Scale. Suffering dementia was determined when MMSE score was below 24 and IADL score less than 8. Results. People with dementia cognitive symptoms accounted for 22.74 % of the cohort. The percentage increased with age, and was higher in women than in men. Factors that increased the odds of having dementia symptoms were of older age, female, multimorbidity, Frailty Scale > Grade 4 and ADL dependency. Conclusions. Age, female gender, multimorbidity, frailty and ADL dependency were considered as risk factors of dementia cognitive symptoms among the Vietnamese people aged 60 years and older.

PATIENT PORTAL MESSAGING IN THE CONTEXT OF DEMENTIA: A FIRST LOOK

Abstract Primary care providers (PCPs) play an integral role in diagnosis and early management of dementia. Secure messaging through the patient portal is increasingly being used by patients to communicate with PCPs. Little is known about the nature of concerns raised by patients with dementia and their care partners when messaging PCPs following dementia diagnosis. We conducted a content analysis of 100 message threads initiated by patients and care partners with PCPs at an academic integrated health system during the twelve months following diagnosis of dementia. Message threads ranged in length from two to eleven messages and included 337 unique messages from 79 distinct accounts, sent between 01/03/2020 and 01/20/2022. Of 100 message threads, 89 were sent by care partners and 11 were sent by patients. Threads often focused on medications. Of 36 threads mentioning medications, 12 discussed dementia-specific medications. Other common dementia-specific topics included behavioral and/or cognitive symptoms of dementia (22/100) and sleep disturbance (8/100). Safety concerns related to falls, wandering, or driving were also common (15/100). Care partners raised issues related to their own needs or wellbeing (e.g., caregiving stress, need for caregiver education) (15/100 threads) and messaged to coordinate care between the PCP and other providers (26/100). Findings demonstrate care partners commonly message on behalf of persons with dementia and use the portal to address dementia-related care needs. Identifying issues raised via messaging offers insight into resources and strategies for PCPs to effectively and efficiently address common concerns after dementia diagnosis, including strategies that leverage the patient portal.

Medicines use before and after comprehensive medicines review among residents of long-term care facilities: a retrospective cohort study.

BackgroundResidential Medication Management Review (RMMR) is a subsidized comprehensive medicines review program for individuals in Australian residential aged care facilities (RACFs). This study examined weekly trends in medicines use in the four months before and after an RMMR and among a comparison group of residents who did not receive an RMMR.MethodsThis retrospective cohort study included individuals aged 65 to 105 years who first entered permanent care between 1/1/2012 and 31/12/2016 in South Australia, Victoria, or New South Wales, and were taking at least one medicine. Individuals with an RMMR within 12 months of RACF entry were classified into one of three groups: (i) RMMR within 0 to 3 months, (ii) 3 to 6 months, or (iii) within 6 to 12 months of RACF entry. Individuals without RMMRs were included in the comparison group. Weekly trends in the number of defined daily doses per 1000 days were determined in the four months before and after the RMMR (or assigned index date in the comparison group) for 14 medicine classes.Results113909 individuals from 1979 RACFs were included, of whom 55021 received an RMMR. Across all three periods examined, decreased use of statins and proton pump inhibitors was observed post-RMMR in comparison to those without RMMRs. Decreases in calcium channel blockers, benzodiazepines/zopiclone, and antidepressants were observed following RMMR provision in the 3–6 and 6–12 months after RACF entry. Negligible changes in antipsychotic use were also observed following an RMMR in the 6–12 months after RACF entry by comparison to those without RMMRs. No changes in use of opioids, ACE inhibitors/sartans, beta blockers, loop diuretics, oral anticoagulants, or medicines for osteoporosis, diabetes or the cognitive symptoms of dementia were observed post-RMMR.ConclusionsFor six of the 14 medicine classes investigated, modest changes in weekly trends in use were observed after the provision of an RMMR in the 6–12 months after RACF entry compared to those without RMMRs. Findings suggest that activities such as medicines reconciliation may be prioritized when an RMMR is provided on RACF entry, with deprescribing more likely after an RMMR the longer a resident has been in the RACF.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12877-022-03187-0.

Default mode network connectivity and treatment response in geriatric depression

<h3>Introduction</h3> Depression is associated with decreased default mode network (DMN) connectivity. Memantine is a non-competitive N-methyl-D-aspartate receptor antagonist that is currently FDA-approved for the treatment of cognitive symptoms in dementia. We evaluated the relationship between changes in DMN connectivity and improvement in depression in a subsample of our parent clinical trial comparing escitalopram/memantine (ESC/MEM) to escitalopram/placebo (ESC/PBO) in older depressed adults (NCT01902004). <h3>Methods</h3> Twenty-six participants with major depression (age >60 years) and subjective memory complaints underwent treatment with ESC/MEM (n=13) or ESC/PBO (n=13), and completed baseline and 3-month follow-up resting state magnetic resonance imaging scans. DMN maps were estimated using group independent analysis and dual regression; a single DMN component, comprising both anterior and posterior DMN key nodes (precuneus and medial prefrontal cortices), was identified. The 3-month change in DMN connectivity was calculated by subtracting the baseline DMN map from the 3-month DMN map. Multi-block partial least squares correlation analysis was used to evaluate the impact of treatment on DMN connectivity changes and their relationship with symptom improvement (as assessed by the MADRAS) at 3 months (controlling for age and sex). <h3>Results</h3> A significant latent variable was identified, reflecting DMN connectivity related to symptom improvement (p=0.01). Although there were no significant overall group differences in DMN connectivity changes, greater improvement in depressive symptoms was more strongly correlated with DMN connectivity increases in posterior and lateral DMN regions, as well as both increases and decreases in portions of the anterior DMN, in the ESC/MEM group (r=0.97, 95% confidence interval: 0.85-0.98) than in the ESC/PBO group (r=0.36, 95% confidence interval: 0.14-0.71). Figure 1 shows the DMN connectivity changes associated with symptom improvement (Red areas: increased DMN connectivity following treatment was more positively associated with symptom improvement in the ESC/MEM group than in the ESC/PBO group. Blue areas: decreased DMN connectivity following treatment was more positively associated with symptom improvement in the ESC/MEM group than in the ESC/PBO group). <h3>Conclusions</h3> Increased DMN connectivity in posterior and lateral nodes of the DMN following 3 months of treatment with ESC was associated with greater improvement in depression severity as assessed by the MADRS; however, this relationship was further enhanced with the addition of MEM than with placebo. This stronger relationship at 3 months from treatment initiation may be related to greater longer-term clinical and cognitive outcomes with ESC/MEM than with ESC/PBO. The present study adds to the limited literature on the role of the DMN in treatment-related effects in geriatric depression, and supports an improved engagement of brain circuitry beneficial to the amelioration of depressive symptoms with combined ESC/MEM treatment in older adults with depression and subjective memory complaints. <h3>Funding</h3> Sponsored by NIH grants R01MH097892 and AT009198, and National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number UL1TR001881.

324 Effect of Regular Multidisciplinary Psychotropic Review Meetings on Anti-psychotic Prescribing Practices in a Community Nursing Unit

Abstract Background The management of non cognitive symptoms of dementia can be challenging for people living with dementia and their carers. The risks and limited benefit of antipsychotics in this setting is well documented however despite this they still are often prescribed. A previous study at our facility in 2016 highlighted a high prevalence of antipsychotic prescribing at 35% (Bambrick, et al. 2016). As a result of this, multidisciplinary psychotropic review meetings were established and are ongoing. Methods Two wards in our community nursing unit were selected. Inclusion criteria included residency &gt; 6 months. The case notes, medication lists (admission and current prescriptions), and psychotropic review meeting notes were reviewed. Results 43 residents were included in the study. 72% (n=31) were female. The average age was 85 years. 74% (n= 32) of residents had a documented dementia diagnosis. On admission, 7 residents were taking regular antipsychotics. 5 of these medications were subsequently either reduced or discontinued. At the time of the study, 16% (n=7) were prescribed regular antipsychotics. There was a definite indication for 3 of these (schizoaffective disorder, psychosis, paranoid depression). 1 resident had a traumatic brain injury with associated distressing symptoms with harm incidents. 3 had a dementia diagnosis with associated distressing symptoms. A further 14% (n= 6) were prescribed antipsychotics on a PRN basis. 5 had a documented diagnosis of dementia with associated distressing symptoms. None of these residents received these medications in the 4 weeks prior to the study. Conclusion Significant improvements are noted since 2016 with the overall prevalence of antipsychotic prescribing decreasing from 35% to 16%, with the majority of these prescriptions having a clear indication. It is reassuring that residents are not receiving prn medications frequently. We await the national clinical guidance on “Appropriate Prescribing of Psychotropic Medication in People with Dementia” to further guide our practice.

Dementia and associated factors among the elderly in Vietnam: a cross-sectional study

BackgroundDementia poses a serious threat to the wellbeing of the elderly. In the context of the rapidly ageing population of Vietnam however, little is known about the prevalence of symptoms and other related factors. This study aims to detect the prevalence of cognitive symptoms of dementia in the elderly in Vietnam as well as other associated factors.MethodsA cross-sectional study was conducted over a period of six communes at the Northern, Central and Southern region of Vietnam. Prevalence of cognitive symptoms of dementia was the outcome of interest and assessed by Mini Mental State Evaluation (MMSE) questionnaire and was standardized according to the age structure of Vietnam. A total of 3308 adults aged 60 and above were included. Association between having cognitive symptoms of dementia and other factors was assessed with logistic regression.FindingsCognitive symptoms of dementia were perceived in 46.4% of the sample group. The symptoms were more common among participants who were older, female, had a lower educational level, were not physically active or have previously had stroke.ConclusionsPrevalence of cognitive symptoms of dementia in adults aged 60 and above was relatively high in Vietnam. Other modifiable associated factors including physical inactivity and social connectedness should also be considered in designing intervention program to prevent dementia in the future.

Primary headaches and cognitive disorders — pathophysiologically associated and comorbidity conditions.

Primary headaches (migraine, tension-type headache and other primary headaches) cause 3% of all disability cases in adult population, fully decrease possibilities of social functioning. Te phenomenon of the central sensitization is one of the fundamental pathophysiological units of primary headaches. NMDA receptors are involved both in initiation and in maintaining of mechanisms of a long-term central sensitization. NMDA activation by glutamate play important role in the initiation of primary headaches. Cognitive impairment development also conducted with NMDA-excitotoxicity due to hyper excitability of NMDA receptors. Tus, it is evident that mechanisms of antinociceptive changes in primary headaches and development of a glutamate excitotoxicity are strongly interdependent. Relationship between somatic symptoms, such as headache in dementia and cognitive symptoms now is represented more widely than just a comorbidity. Te gravity of migraine, tension-type headache and severity of cognitive impairment are strongly connected. Tus, the reliable interrelation between development of primary headache and cognitive decrease is traced, considering a community of pathophysiological mechanisms that has important practical value due to possible correction by NMDA-antagonists. Memantine not only slows the progression of cognitive symptoms in dementia, but also signifcantly influences the frequency and expressiveness of primary headache.

“Music First”

Abstract. Existing research has primarily evaluated music therapy (MT) as a means of reducing the negative affect, behavioral, and/or cognitive symptoms of dementia. Music listening (ML), on the other hand, offers a less-explored, potentially equivalent alternative to MT and may further reduce exposure to potentially harmful psychotropic medications traditionally used to manage negative behavioral and psychological symptoms of dementia (BPSD). This 5-month prospective, naturalistic, interprofessional, single-center extended care facility study compared usual care (45 residents) and usual care combined with at least thrice weekly personalized ML sessions (47 residents) to determine the influence of ML. Agitation decreased for all participants (p &lt; .001), and the ML residents receiving antipsychotic medications at baseline experienced agitation levels similar to both the usual care group and the ML patients who were not prescribed antipsychotics (p &lt; .05 for medication × ML interaction). No significant changes in psychotropic medication exposure occurred. This experimental study supports ML as an adjunct to pharmacological approaches to treating agitation in older adults with dementia living in long-term care facilities. It also highlights the need for additional research focused on how individualized music programs affect doses and frequencies of antipsychotic medications and their associated risk of death and cerebrovascular events in this population.

Rethinking Psychosis in Dementia: An Analysis of Antecedents and Explanations.

An in-depth analysis of qualitative data regarding antecedents, consequences, and descriptions of delusions of persons with dementia (PwD) provided by family caregivers is presented. Three broad classifications of reasons given behind types of delusions are included, namely environmental factors, personal factors, and dementia, with dementia being the most prominent factor. We observed an overlap between known cognitive symptoms of dementia and the characteristics of the reported "delusions" in dementia. It therefore appears that what is often classified as a delusion of a seemingly psychotic nature is in fact the PwD's disorientation combined with an attempt to fill in gaps caused by cognitive deficiencies.

Primary headache - risk factor or comorbid pathology in cognitive impairment

Currently, the relationship between headache and dementia is considered more widely than just a comorbidity. The severity of migraine and tension-type headache and the severity of cognitive impairment are strongly correlated. Common pathophysiological mechanisms underlie the relationship between primary headache and cognitive impairment. Antinociceptive changes in primary headaches and in glutamate excitotoxicity in dementia developed due to hyper excitability of NMDA receptors are strongly interdependent. It is important in the aspect of possible correction of this pathology by NMDA-antagonists. Memantine not only slows the progression of cognitive symptoms in dementia, but also significantly influences the frequency and severity of primary headache.

Guideline Watch (October 2014): Practice Guideline for the Treatment of Patients With Alzheimer's Disease and Other Dementias.

(Reprinted with permission from American Psychiatric Association, http://psychiatryonline.org/guidelines).

Visual Hallucinations Due to Rivastigmine Transdermal Patch Application in Alzheimer's Disease; The First Case Report

Summary Rivastigmine is a well-known dual acting acetylcholinesterase and butyrylcholinesterase inhibitor, which is effective on behavioral and psychiatric symptoms including hallucinations, as well as cognitive symptoms of dementia. The most common adverse effects of rivastigmine related to cholinergic stimulation in brain and peripheral tissues are gastrointestinal, cardiorespiratory, extrapyramidal, genitourinary, musculoskeletal symptoms, sleep disturbances, and skin irritations with the transdermal patch form in particular. Despite to the previous reports revealing the improving effects of the drug on hallucinations, we presented a-80 year old women with Alzheimer's disease suffering from visual hallucinations whose complaints began with rivastigmine treatment. Since the patient had recent memory disturbance without any behavioral and/or psychiatric symptoms before rivastigmine administration, and visual hallucinations disappeared with the discontinuation of the drug, visual hallucinations were attributed to rivastigmine.

Personality, Alzheimer's disease and behavioural and cognitive symptoms of dementia: the PACO prospective cohort study protocol.

BackgroundAlzheimer’s disease is characterised by a loss of cognitive function and behavioural problems as set out in the term “Behavioural and Psychological Symptoms of Dementia”. These behavioural symptoms have heavy consequences for the patients and their families.A greater understanding of behavioural symptoms risk factors would allow better detection of those patients, a better understanding of crisis situations and better management of these patients. Some retrospective studies or simple observations suggested that personality could play a role in the occurrence of behavioural symptoms. Finally, performance in social cognition like facial recognition and perspective taking could be linked to certain personality traits and the subsequent risks of behavioural symptoms.We propose to clarify this through a prospective, multicentre, multidisciplinary study.Main Objective:- To assess the effect of personality and life events on the risk of developing behavioural symptoms.Secondary Objectives:- To evaluate, at the time of inclusion, the connection between personality and performance in social cognition tests;- To evaluate the correlation between performance in social cognition at inclusion and the risks of occurrence of behavioural symptoms;- To evaluate the correlation between regional cerebral atrophy, using brain Magnetic Resonance Imaging at baseline, and the risk of behavioural symptoms.Methods/DesignStudy type and Population: Prospective multicentre cohort study with 252 patients with Alzheimer’s disease at prodromal or mild dementia stage.The inclusion period will be of 18 months and the patients will be followed during 18 months. The initial evaluation will include: a clinical and neuropsychological examination, collection of behavioural symptoms data (Neuropsychiatric-Inventory scale) and their risk factors, a personality study using both a dimensional (personality traits) and categorical approach, an inventory of life events, social cognition tests and an Magnetic Resonance Imaging. Patients will be followed every 6 months (clinical examination and collection of behavioural symptoms data and risk factors) during 18 months.DiscussionThis study aims at better identifying the patients with Alzheimer’s disease at high risk of developing behavioural symptoms, to anticipate, detect and quickly treat these disorders and so, prevent serious consequences for the patient and his caregivers.Trial registrationClincalTrials.gov: NCT01297140

Editorial (Thematic Issue: Psychogeriatrics: An Interdisciplinary Approach)

In the past four decades there have been numerous advances in various branches of science in general and medicine in particular that had led to increasing elderly population. Depression, cognitive impairment and dementia are among the most important mental health problems in elderly people. Both conditions have severe consequences for the patients, including diminished quality of life, functional decline, increased use of services, and high mortality. Furthermore, these diseases impact health of caregivers. The World Health Organization considers the care of these pathologies a risk factor for the development of mental disorders and burden. The aim of this thematic issue is to describe different pathologies present in elderly patients and develop these topics with an interdisciplinary approach. This thematic issue focuses on different aspects of psychogeriatrics such as onset age and clinical heterogeneity of dementias. Frontotemporal dementia (FTD) is the main differential diagnosis with early stages of Alzheimer’s disease (AD). Usually, differential diagnosis between a first depressive episode and the beginning of an early degenerative dementia with mood disorders, either AD or FTD, can be difficult. This topic is addressed in the research article of Serrano and colleagues [1], were they conclude that onset age of cognitive and/or behavioral impairment may be one of the variables influencing the clinical heterogeneity of dementias. Many of the young-onset dementias may be potentially reversible so its early identification and pathophysiology understand increase pharmacological intervention opportunities of halting the cascade of events that lead inexorably to dementia. Moreover, cognitive impairment underpins some of the clinical spectrum of the cerebrovascular disease (CVD), as well as contributes to the patient´s impaired social and behavioral functioning, and the higher mortality. Despite a general emphasis in the international literature on the primary and secondary prevention of CVD to avoid vascular dementia or their combination with Alzheimer’s disease, the controversy concerning their diagnostic criteria and optimal treatment is still open. Given its growing burden, the prevention and treatment of CVD and the spectrum of VCI are critical priorities for clinical care and research. Russo and Allegri [2] performed a selective review about the current status of vascular dementia, mild cognitive impairment due to CVD, and mixed dementia, with special emphasis on available evidence of pharmacological strategies for treatment and prevention from controlled clinical trials. Late life depression is a prevalent disorder that affects elderly population and it is frequently associated to cognitive impairment. This disease is sub diagnosed due to great variability in the sample involved, the definition of depression, the methodology used, and the experience of the evaluator. Dillon, Rodriguez and Taragano, in their review [3], analyze the different subtypes of late life depression, the diagnostic methods that can be performed and the pharmacological treatment of this disease. Elderly patients who suffer degenerative diseases generally need caregiving. Considering that the task of caregiving, this is generally carried out by a family member who becomes an easy target for diseases, especially for being subjected to a stressing process. Tartaglini and colleagues [4] studied whether the older caregivers’ health suffers affections if compared with the health conditions of those who do not take care of family members. Environmental complexity states that those individuals involved in activities that require greater cognitive demands keep their cognitive abilities undamaged despite the passing of time. Feldberg, Stefani and Allegri [5] will demonstrate how environmental complexity and the importance of engaging in recreational activities influence individuals’ lives and their cognitive healthy aging. Finally, in relation to pharmacological treatment in dementia, in the last decade, various medications have been used for the treatment of cognitive symptoms in Dementia. Many of them have few scientific evidence of their effectiveness. Pérez Leguizamón and colleagues [6] review and update the current status of the pharmacological treatment of cognitive symptoms in Alzheimer´s Disease, one of the most prevalent and disabling diseases in the elderly.

FDG PET and cognitive symptoms of dementia

The fundamentals of FDG PET are well established, and are based on extensively explored molecular mechanisms. The existing methods for semi-quantitative assessment of brain functional changes provide topographical maps of molecular alterations both for group and single-subject comparisons. This functional brain-based approach to derangement of high-order cognition has provided and will continue to provide high-quality findings that will help further understanding of brain cognitive activity and of the brain-cognition correlates and their importance in the diagnosis of the underlying pathology. This article examines the relationship between changes in brain metabolic activity and the resulting impairment of high-order cognition in dementia conditions. FDG PET imaging in subjects with underlying neurodegenerative pathology has emerged as a crucial tool available to the fields of cognitive neurology and neuroscience for both diagnosis and evaluation of the involved neural systems, extending the neuropsychology-based understanding of the brain/cognition relationship. As an effect of the multiple underlying pathologies, the cognitive deficits encountered encompass different aspects of neuropsychology: language, memory, performance monitoring, decision making, reasoning, and even “personality.” It is to be noted that FDG PET studies of brain cognitive reserve have so far supported the existence of functional reserve phenomena in neurodegenerative dementia, and specifically in AD. The newly integrated PET/MRI techniques will likely become crucial clinical and research tools in neurology, nuclear medicine and in the neuroscience field generally. Hybrid PET/MRI will allow integration of the molecular information provided by PET with the various morphological and functional parameters measured by MRI, in the same subject and in a single study session. Future progress depends on exploration of these relationships to pave the way for new insights into neuroscience and neurology.

Investigating the Influence of Cognitive Decline on the Quality of Financial Decision-Making in Older Adults: The Case of Self-Managed Superannuation Funds

As populations age, increasing numbers of older people are controlling significant financial assets at the same time as the level of choice in retirement funding arrangements also increases. The population faced with these investment decisions are the same population susceptible to cognitive decline with advancing age and particularly by way of dementia and Alzheimer’s. This study explores the relationship between cognitive ability, retirement self-efficacy, financial literacy and financial decision-making in a group of 103 SMSFs Managers aged 51 and over. Demographic variables (age, gender, education, value of superannuation), psychosocial variables (risk aversion, mastery), cognitive ability as determined by the Wonderlic, and self-reported dementia symptoms according to the HABC scales were explored as predictors of financial literacy, decision-making and retirement self-efficacy. Males tended to report higher levels of mastery than women, although this did not predict financial literacy. Women tended to involve family and friends more in financial decision-making, while men and women consulted with financial advisers equally. Cognitive ability ( ), Behavioural dementia symptoms (-) and total assets ( ) predicted financial literacy while retirement self-efficacy was best predicted by age ( ), cognitive ability ( ), financial literacy ( ), sense of mastery ( ) and self-rated behavioural dementia symptoms (-). Those with self-reported cognitive dementia symptoms appear more vulnerable to making poor financial judgments. Findings have important implications for financial decision making and the monitoring of on-going cognitive decline.

The problem with “problem behaviors”: a systematic review of the association between individual patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient–caregiver dyad

Behavioral and psychological symptoms of dementia (BPSDs) are routinely cited as important predictors of caregiver burden and depression. Although BPSDs include a wide variety of patient behaviors, they are routinely grouped together as one construct to differentiate them from cognitive symptoms of dementia. Determining the specific BPSDs that result in increased depression and burden for caregivers may elucidate the stress process for caregivers and facilitate the development of effective interventions for caregivers. We conducted a systematic review of English-language articles published from 1990 to 2010 to determine whether there are known symptoms or symptom clusters which exert undue negative impact on caregiver depression and burden. Additionally, we review systems used for classifying BSPD symptom clusters and determine whether there have been any mechanisms studied by which individual BPSD symptoms negatively affect caregivers. Finally, we examine how the role of timing of symptoms has been examined within the literature. Thirty-five original research articles examined the impact of an individual behavior symptom on caregiver burden or depression/depressive symptoms. The studies had no consistent system for categorizing symptoms. Although depression, aggression, and sleep disturbances were the most frequently identified patient symptoms to impact negatively on caregivers, a wide range of symptoms was associated with caregiver burden and depression. The evidence is not conclusive as to whether some symptoms are more important than others. The studies reviewed were largely exploratory relative to the differential impact of individual BPSDs and did not focus on testing causal mechanisms by which specific symptoms exert more impact on caregiver mental health than others. Future research may benefit from the re-conceptualization of BPSDs from the perspective of their impact on the caregiver to examine hypothesis-driven differences among BPSD symptom clusters.

Lack of awareness of symptoms in people with dementia: the structural and functional basis

To review studies investigating the brain correlates of unawareness of cognitive and behavioural symptoms in people with dementia. A detailed search of the literature was conducted to include all the peer-reviewed studies published in English aimed at identifying the structural or functional brain correspondents of unawareness in dementia patients. Their results were interpreted in relation to the methodological differences in terms of type of dementia studied, the protocol adopted to measure lack of awareness, the imaging techniques employed, the experimental designs and statistical analyses performed. Eighteen studies undertaken to explore the functional and structural correlates of unawareness of cognitive symptoms in dementia were identified. Although their results showed a disparate range of brain correlates, they were mainly localized in frontal and temporo-parietal regions. Although the anatomical correlates of unawareness of disease in dementia have not yet been exhaustively explored, understanding the correlates of unawareness may also contribute to understand the brain correlates of self-awareness and self-reflection. We discuss the current knowledge base and consider potential future directions for research.

Use of Psychostimulants in Patients with Dementia

To review the efficacy and safety of psychostimulants for negative behavioral symptoms (ie, apathy, excessive daytime sedation) and cognition in patients with dementia. Literature was accessed through PubMed and MEDLINE (1966-June 2010), using the terms stimulant, psychostimulant, methylphenidate, dexmethylphenidate, amphetamine, dextroamphetamine, lisdexamfetamine, atomoxetine, modafinil, armodafinil, dementia, Alzheimer disease, vascular dementia, Lewy body dementia, mixed dementia, frontotemporal dementia, therapy, treatment, and therapeutic. Additional references identified from the initial search were reviewed. All relevant clinical trials published in English and involving primarily older adults with dementia were included. Case reports, review articles, and other preclinical literature were included as appropriate. Psychostimulants have been employed as a treatment for cognitive and behavioral symptoms in dementia for decades, but the literature has lagged behind this practice. Eight reports on use of psychostimulants as a treatment of apathy in dementia were reviewed. Methylphenidate was the most frequently studied medication and improvements in apathy were consistently noted; however, the magnitude and duration of effect remain unclear. Six studies examining the cognitive effects of a variety of psychostimulants in patients with dementia were reviewed; psychostimulants had little to no effect on cognition. A lack of studies exists to draw conclusions about the use of psychostimulants for the treatment of excessive daytime sedation in dementia. The possibility of psychostimulants to increase blood pressure; elevate heart rate; and lead to irritability, agitation, and psychosis makes careful patient selection critical, especially in older adults with severe cardiovascular disease or other underlying cardiac abnormalities. Based on limited studies, methylphenidate is a possible treatment for apathy in patients with dementia. Psychostimulants, as a group, do not appear to be broadly effective treatments for behavioral or cognitive symptoms of dementia. The potential utility of psychostimulants must be balanced with careful patient selection.

Effectiveness of StandardizedGinkgo bilobaExtract on Cognitive Symptoms of Dementia with a Six-Month Treatment: A Bivariate Random Effect Meta-Analysis

The objective of this study is to take into consideration the influence of baseline risk on the treatment effect and evaluate the effectiveness of standardized GINKGO BILOBA extract (GbE) on cognitive symptoms of dementia with the treatment period of approximately 6 months. We systematically searched the literature to identify all randomized placebo-controlled clinical trials (English language) of GbE in the treatment of dementia. Data were extracted from selected trials and combined with standard meta-analysis methods. A bivariate meta-analysis was carried out to further estimate the effect size of GbE. The random effect estimate of standard mean difference (SMD) between GbE and placebo groups of 6 selected trials was -0.89 (95% CI -1.82 to 0.04) in the assessment of cognitive function. Bivariate random effect estimate of difference of change in ADAS-cog scores was -2.65 (95% CI --4.53 to -0.76), which showed a significant difference in favor of GbE. Considering baseline risk in the assessment of treatment effect, GbE was found to be effective for cognitive functions in dementia with the treatment of 6 months.