Functional Assessment Staging Research Articles

Feasibility of Oral Function Evaluation According to Dementia Severity in Older Adults with Alzheimer's Disease.

Oral function evaluation in older adults with dementia is important for determining appropriate and practical dietary support plans; however, it can be challenging due to their difficulties in comprehending instructions and cooperating during assessments. The feasibility of oral function evaluation has not been well studied. This cross-sectional study aimed to determine the feasibility of oral function evaluation in older adults with Alzheimer's disease (AD) according to Functional Assessment Staging of Alzheimer's Disease (FAST) stages. In total, 428 older adults with AD (45 men and 383 women; mean age: 87.2 ± 6.2 years) were included. Multilevel logistic regression models were used to examine the prevalence of participants who were unable to perform oral function evaluations, including oral diadochokinesis (ODK), repeated saliva swallow test (RSST), and modified water swallow test (MWST). In comparison to the reference category (combined FAST stage 1-3), FAST stage 7 was associated with the infeasibility of ODK (adjusted odds ratio, 95% confidence interval = 26.7, 4.2-168.6), RSST (5.9, 2.2-16.1), and MWST (8.7, 1.6-48.5, respectively). Oral function evaluation is difficult in older adults with severe AD. Simpler and more practical swallowing function assessments and indicators that can be routinely observed are required.

PRESENCE OF DYSPHAGIA IN A COHORT OF PERSONS LIVING WITH DEMENTIA: OUTCOMES FROM A MULTIDISCIPLINARY CLINIC

Abstract The Cognitive Care Clinic (CCC) provides evaluation for Veterans living with dementia. Speech-language pathology (SLP) is incorporated to facilitate early identification and proactive management of dysphagia. This project sought to describe dysphagia frequency in persons living with dementia (PWD) in CCC. Multidisciplinary assessments led to consensus diagnosis of dementia subtype. Stage was determined using the Functional Assessment Staging Tool (FAST). Validated dysphagia screening tools included Eating Assessment Tool (EAT-10), water swallow test (WST), and Test of Mastication and Swallowing Solids (TOMASS). Penetration-Aspiration Scale (PAS) scores were determined following videofluoroscopic swallow studies (VFSS); scores were classified as “safe” (PAS< 3) or “unsafe” (PAS>=3). Descriptive statistics were calculated for dementia subtype, stage, and dysphagia measures. 78 Veterans were diagnosed with dementia between 2017 and 2023 (mean age=77 years; 5% female) and completed dysphagia screening. The majority had Alzheimer’s disease (43%) and were in the mild disease stage (61%). 37% failed the WST, suggesting impaired safety. 49% failed the TOMASS, indicating masticatory inefficiency. 26% scored 3 or higher on EAT-10, indicating increased dysphagia risk. 22 patients completed VFSS; 55% exhibited unsafe swallows. No significant differences in EAT-10 total scores were observed between those with safe and unsafe PAS scores. Nearly half of this cohort demonstrated signs of swallowing impairment based on clinical testing and/or VFSS. Additionally, EAT-10 scores were low overall with no differences based on dysphagia status on VFSS, which suggests underreporting of dysphagia. These findings highlight the necessity of SLPs in dementia care teams to support early identification and management of dysphagia.

Exploring language performance in people with mild cognitive impairment and Alzheimer's disease: a prospective longitudinal study

Background/Aims Language changes are the earliest signs and symptoms of mild cognitive impairment and Alzheimer's disease. The aim of this study was to explore the language difference performance between people with mild cognitive impairment, people with Alzheimer's disease and healthy individuals as a control group. To accomplish this aim, the language profile of both mild cognitive impairment and Alzheimer's disease needs to be characterised to determine which feature is more affected by both mild cognitive impairment and Alzheimer's disease among expressive language, receptive language, executive function and memory performance. Methods This case-control prospective study involved 90 participants. The Mini-Mental Status Examination and the Functional Assessment Staging Tool were used to classify the participants into three groups: people with mild cognitive impairment, people with Alzheimer's disease and healthy individuals as a control group. Then, the language performance of patients in the mild cognitive impairment and Alzheimer's disease groups was investigated and compared with those of the control group by using the Barnes Language Assessment. The groups were reassessed 6 months later to see if there was any change in language ability. Results The results showed that the mild cognitive impairment group and Alzheimer's disease group had significant decreases in expressive language (P>0.01), executive function (P>0.01), receptive language (P>0.01) and memory skills (P>0.01) from baseline to the reassessment at 6 months. Conclusions Language deficits, especially expressive language deficits, could appear before impairment in executive function, receptive language and verbal episodic memory in participants with mild cognitive impairment or Alzheimer's disease. Speech and language therapists can use the findings of this study to design and implement treatment programmes.

Heuristic evaluation and usability testing of a functional dementia stages app for Hispanic family caregivers

AbstractBackgroundHispanic family caregivers of persons with Alzheimer’s disease and other dementias are not getting the anticipatory guidance they need about how functional abilities will change as dementia progresses. Existing informational resources are overwhelming to navigate and written at a high reading level. Furthermore, professional assessment of functional abilities is not universally available. Innovative, tailored approaches are needed. Our aim was to develop and test a mobile application, the Interactive Functional Assessment Staging Navigator (I‐FASTN), to support Hispanic family caregivers’ assessment of care recipients’ functional stage of dementia in either English or Spanish.MethodWe conducted heuristic evaluation with informatics experts (N = 5, English only) and usability testing with caregivers (n = 10 English, n = 10 Spanish). Participants attempted a series of tasks with the app using a think‐aloud protocol and then rate the usability of the app using mobile app heuristics (experts) and two usability instruments (caregivers). Sessions were recorded and transcribed. For heuristic evaluation, we tabulated the number of usability problems by category: cosmetic, minor, major, and catastrophic. For usability testing, recordings, notes, and transcripts were content analyzed to extract usability problems, suggestions for improvement, desired app features, and other feedback.ResultRefinements to the app were made after each of the five evaluations to address the problems encountered. Caregivers’ mean usability scores were high (4.6 and 4.7 out of 5.0), reflecting good usability overall. Chief usability problems were a confusing tutorial and difficulty finding the app’s side menu. These will be addressed by creating a video tutorial and moving all menu items to the home screen. The app was very well received by caregivers, who indicated that the concise, illustrated content met their informational needs. However, analog alternatives are still needed by caregivers unaccustomed to using apps as they had difficulty moving on from even the simplest screens (see Figure 1a).ConclusionCaregivers are not receiving informational support in a way that meets their needs. The focus should be on providing concise information that addresses the practical aspects of caregiving, tailored to the care recipient’s functional stage.

Feasibility of Using Wearable Actigraphy for Behavioural Monitoring in Care Home Residents Living with Moderate to Severe Alzheimer’s Disease and Agitation

AbstractBackgroundMeasuring and monitoring behaviour is difficult in people living with later stage Alzheimer’s disease and specific behavioural symptoms such as agitation and aggression (AA). Currently, subjective information given by these patients is highly susceptible to inaccurate recall, clinicians rely on answers provided by care givers, which can be biased and lack fine‐grain temporal detail. Although actigraphy watches have been useful tools for research, little is known about the feasibility of their use in agitated dementia participants and on the factors influencing watch compliance.MethodPeople diagnosed with Alzheimer’s disease and significant AA symptoms living in care homes were asked to wear an actigraphy watch (GENEactiv Original) for 4 consecutive weeks. Demographic data, Functional Assessment Staging Tool (FAST) score, behavioural symptom pattern and severity were recorded using the Neuropsychiatric Inventory Nursing Home Version (NPI‐NH). Watch‐recorded wearing time and activity data were used to evaluate adherence. Care home staff were interviewed to explore factors influencing watch wearing by participants and to develop solutions to improve compliance.ResultWe recruited 28 participants (14 female) and found wearing the watch feasible overall. No statistical compliance difference was found between different groups based on age, FAST score, agitation pattern or severity; however, a significant gender difference was found with male participants being more adherent (Table). Participants were more compliant in weeks 3‐4, and first week adherence predicted overall adherence (Figure). Factors influencing compliance include the design and appearance of the watch, previous watch wearing habit, and the perceived purpose of the study. Using documents easily readable to participants and care givers to facilitate understanding of the study and to communicate challenging clinical scenarios appeared to enhance adherence.ConclusionWearing an actigraphy watch for behavioural monitoring was feasible for moderate to severe Alzheimer’s disease patients with AA symptoms in care home settings. Gender‐specific design and appearance should be considered when selecting the actigraphy watch. For dementia studies planning to use an actigraphy watch, compliance can be improved by incorporating a short lead‐in phase to establish a watch wearing routine and by providing reader‐friendly documents about the watch purpose to communicate with participants and care givers.

Claims-Based Frailty Index as a Measure of Dementia Severity in Medicare Claims Data.

Dementia severity is unavailable in administrative claims data. We examined whether a claims-based frailty index (CFI) can measure dementia severity in Medicare claims. This cross-sectional study included the National Health and Aging Trends Study Round 5 participants with possible or probable dementia whose Medicare claims were available. We estimated the Functional Assessment Staging Test (FAST) scale (range: 3 [mild cognitive impairment] to 7 [severe dementia]) using information from the survey. We calculated CFI (range: 0-1, higher scores indicating greater frailty) using Medicare claims 12 months prior to the participants' interview date. We examined C-statistics to evaluate the ability of the CFI in identifying moderate-to-severe dementia (FAST stage 5-7) and determined the optimal CFI cut-point that maximized both sensitivity and specificity. Of the 814 participants with possible or probable dementia and measurable CFI, 686 (72.2%) patients were ≥75 years old, 448 (50.8%) were female, and 244 (25.9%) had FAST stage 5-7. The C-statistic of CFI to identify FAST stage 5-7 was 0.78 (95% confidence interval: 0.72-0.83), with a CFI cut-point of 0.280, achieving the maximum sensitivity of 76.9% and specificity of 62.8%. Participants with CFI ≥0.280 had a higher prevalence of disability (19.4% vs 58.3%) and dementia medication use (6.0% vs 22.8%) and higher risk of mortality (10.7% vs 26.3%) and nursing home admission (4.5% vs 10.6%) over 2 years than those with CFI <0.280. Our study suggests that CFI can be useful in identifying moderate-to-severe dementia from administrative claims among older adults with dementia.

Functional Dementia Stages App for Hispanic Family Caregivers: Heuristic Evaluation and Usability Testing.

Hispanic family caregivers of persons with dementia are not getting the anticipatory guidance they need about how functional abilities will change as dementia progresses. Existing informational resources are overwhelming to navigate and written at a high reading level. Furthermore, professional assessment of functional abilities is not universally available. Innovative, tailored approaches are needed. Our aim was to develop and test a mobile application (app), the Interactive Functional Assessment Staging Navigator (I-FASTN), to support Hispanic family caregivers' assessment of care recipients' functional stage of dementia in either English or Spanish. We conducted heuristic evaluation with experts (N = 5) and usability testing with caregivers (N = 20). Chief usability problems were a confusing tutorial and difficulty finding the app's side menu. The app was well-received by caregivers, who indicated that the concise, illustrated content met their informational needs. However, analog alternatives are still needed by caregivers unaccustomed to using apps. [Journal of Gerontological Nursing, 49(7), 9-15.].

Families of patients with Alzheimer's disease dementia notice progression from symptoms of disorientation and visual memory disturbance.

Alzheimer's disease dementia (ADD) is the most common cognitive disease, but patients' families may notice some symptoms yet not recognise that they indicate ADD. This study investigated the symptoms that families notice as ADD as the disease progresses. New outpatients diagnosed with ADD (n = 315) at five memory clinics completed two cognitive assessments, the Revised Hasegawa Dementia Scale (HDS-R) and Mini-Mental State Examination (MMSE). During an interview, family members completed the Functional Assessment Staging Test (FAST), an observational assessment tool that classifies ADD progression into seven stages. We then examined the relationship of the family-assessed FAST score with clinician-assessed HDS-R and MMSE domain scores by comparing between patients with FAST 1-3 and FAST 4-7. Next, we divided the FAST 4-7 group into the FAST 4-5 and FAST 6-7 subgroups and divided the FAST 1-3 group into the FAST 1-2 and FAST 3 subgroups. Surprisingly, half of the families did not recognise that the symptoms indicated ADD. Scores for orientation of time and place on the HDS-R and MMSE and for visual memory on the HDS-R were significantly related to family-assessed FAST score. Moreover, the orientation of time and place score on both scales and visual memory on the HDS-R were significantly worse in the FAST 4-7 group than in FAST 1-3 group. In the FAST 4-7 group, scores for age on the HDS-R and for reading and drawing on the MMSE were significantly worse in the FAST 6-7 subgroup. In the analysis of the FAST 1-3 group, there was no significant difference among the HDS-R and MMSE domains between the FAST 1-2 and FAST 3 subgroups. Family members of patients with ADD tend to notice the progression of ADD from the symptoms of disorientation and visual memory.

Investigating ADHD and ASD features in dementia patients referred to a memory clinic in Iran

AbstractBackgroundDementia is a clinical syndrome characterized by a progressive cognitive decline interfering with the function of activity of daily living in patients (1). Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) are two prevalent neurodevelopmental disorders affecting different brain functions manifesting mostly with impaired communication and behavior (3). These disorders initiate in childhood but usually persist into adulthood (3, 4). These disorders might overlap with dementia symptoms, as they might share common genetic and environmental backgrounds (5‐7). ASD and ADHD in dementia patients may complicate the timely diagnosis of each disorder leading to more pronounced dysfunction. Hence, this study aimed to evaluate ASD and ADHD symptoms in dementia patients referred to a memory clinic in Iran.MethodWe recruited 65 dementia patients in this study. Firstly, a cognitive neurologist diagnosed dementia’s subtypes by a precise clinical examination, cognitive assessment by applying the Montreal cognitive Assessment (MoCA). The severity of dementia was determined using the Functional Assessment Staging Tool (FAST). Consequently, we instructed the participants to fill out the autism quotient (AQ) and the Conners' Adult ADHD Rating Scales (CAARS) questionnaires for investigating their ASD and ADHD symptoms.ResultConsidering the cut‐off points of AQ and CAARS questionnaires, 18.5% of participants were diagnosed with ASD, and 35.4% were diagnosed with ADHD. Besides, we found a significant positive relationship between all subscales of CAARS and the FAST score (P &lt; 0.05). In other words, patients with more severe dementia were more likely to have increased ADHD symptoms.ConclusionThe results indicated that ADHD and ASD symptoms might be common manifestations in patients with dementia. This finding was in line with the previous research findings regarding the high co‐occurrence of ADHD and dementia (8). This comorbidity can further prohibit function and further worsen the prognosis. Given that there is scarce evidence on the association between ADHD and dementia in Iran, the findings of this study can pave the way for future research to elaborate more precisely on the etiological backgrounds of this association.

Effect of agitation and aggression on quality of life in patients with dementia

AbstractBackgroundBehavioral and psychological symptoms of dementia (BPSD) are highly prevalent in patients with dementia during the course of the disease. Among BPSD symptoms, agitation and aggression are a source of distress for both the patients and their caregivers. In this study, we investigated the impact of agitation and aggression on Quality of Life (QoL) of patients with dementia living in long‐term care homes or admitted to psychiatric inpatient units.MethodData were obtained from the Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study, a multisite trial conducted in Canada. Agitation and aggression were assessed with the Cohen‐Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory Clinician rating scale (NPI‐C); QoL with the informant‐rated Alzheimer’s Disease Related Quality of Life (ADRQL) tool; stage of dementia with the Functional Assessment Staging Tool (FAST); and burden of physical illness with the Cumulative Illness Rating Scale‐Geriatric (CIRS‐G). Regressions were performed to investigate the associations between agitation or aggression and QoL controlling for demographic factors, FAST score, and CIRS‐G score.Result179 participants were included (52.5% female; mean (SD) age = 80.79 (9.45) years. The ADRQL score was correlated with: (1) CMAI total frequency score (Pearson’s r = ‐.333, p&lt;.001); (2) NPI‐C agitation score (Pearson’s r = ‐.209, p = .005); and (3) NPI‐C aggression score (Pearson’s r = ‐.300, p&lt;.001). The associations remained significant for the CMAI total frequency score (β = ‐.235, SE B = 0.054, p&lt;.001), and NPI‐C agitation and aggression composite score (β = ‐.288, SE B = 1.254, p&lt;.001) after controlling for age, sex, current residence, FAST score and CIRS‐G score.ConclusionQoL is related to agitation and aggression in patients with dementia. The relationship is independent of demographic factors, stage of dementia, and burden of comorbid physical illness. This suggests that better management of agitation and aggression may be an important factor in improving QoL in patients with dementia.

Association between Dementia Severity and Oral Hygiene Management Issues in Older Adults with Alzheimer’s Disease: A Cross-Sectional Study

Oral hygiene management issues vary across types and clinical stages of dementia. We aimed to clarify the issues related to oral hygiene management in older adults with Alzheimer's disease (AD) according to stages defined by the Functional Assessment Staging of Alzheimer's Disease (FAST). In all, 397 records (45 men and 352 women; average age, 86.8 years; age range, 65-106) from older adults with AD were used for the cross-sectional study. We used data from a cohort of older adults (≥65 years old) who required long-term care and lived in the Omorimachi area of Yokote City, Akita Prefecture, Japan. Multilevel logistic regression analysis was conducted to examine the associations of the FAST stage, set as the exposure variable, with oral hygiene management parameters set as outcome variables. Compared to the reference category (combined FAST stage 1-3), FAST stages 6 and 7 had significantly higher odds ratios for refusal of oral health care, dependence in performing oral health care, and rinsing and gargling disability. FAST stages 4 and 7 were associated with dental plaque accumulation. Oral health care for older adults with AD should be planned appropriately according to dementia severity.

Validation study of the Persian version of behavioral pathology in Alzheimer’s Disease Rating scale (BEHAVE-AD) and the empirical BHAVE-AD (E-BEHAVE-AD)

Introduction Behavioral and psychological symptoms of dementia (BPSD) are observed in more than 90% of patients with Alzheimer’s disease (AD). BPSDs are remediable if detected early and managed appropriately. Behavioral Pathology in Alzheimer’s disease Rating Scale (BEHAVE-AD) and Empirical BEHAVE-AD (E-BEHAVE-AD) were designed to identify BPSD. The aim of this study is to validate and prepare BEHAVE-AD and E-BEHAVE-AD in Persian language for clinical and research applications. Method 120 patients were selected through a combination of intentional and convenience sampling. All participants should fulfill the NINCDS-ADRDA Work Group criteria for a clinical diagnosis of Alzheimer’s disease. Functional Assessment Staging Tool (FAST) was used to determine the rate of AD progression. All patients were evaluated using the BEHAVE-AD and E-BEHAVE-AD questionnaires, as well as the Persian version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Mini-Mental State Examination (MMSE). The Content Validity Index (CVI) is determined based on the compatibility of the Persian and the original version of the two scales according to the opinion of expert panels. Correlation of MMSE with BEHAVE-AD and E-BEHAVE-AD as well as the BPSD pattern on AD progression continuum by FAST were considered as indices of construct validity. Concurrent validity was estimated by correlating NPI-Q scores with BEHAVE-AD and E-BEHAVE-AD scores. For both scales, interrater reliability was extracted as a reliability index. Results Pearson correlation coefficients for the BEHAVE-AD scale were as follows: with NPI-Q (r = 0.77, p-value <0.01), with MMSE (r = −0.34, p-value <0.01), indicating concurrent and construct validity, respectively. The result for E-BEHAVE-AD was as follows: with NPI-Q-total (r = 0.59, p-value <0.01), and with MMSE (r = 0.31, p-value <0. 01). BEHAVE-AD and E-BEHAVE-AD scores increased in parallel with AD severity according to FAST, but not on the most severe AD stage. The area under the curve was estimated to be 0.84 (p-value <0.001) for BEHAVE-AD and 0.78 (p-value <0.001) for E-BEHAVE-AD. Correlation between BEHAVE-AD and E-BEHAVE-AD scores ranged from 0.45 to 0.63. The inter-rater reliability index ranged from 0.88 to 0.99 for BEHAVE-AD and from 0.74 to 0.95 for E-BEHAVE-AD. Conclusions The Persian version of BEHAVE-AD and E-BEHAVE-AD is valid and reliable for the assessment of BPSD in patients with AD.

PROGNOSTIC SIGNIFICANCE OF OROPHARYNGEAL DYSPHAGIA IN DEMENTIA PATIENTS WITH EATING DISORDERS

SUMMARY Purpose: The purpose of the study was to study the prognostic value of OD in patients with ongoing dementia with eating disorders. Materials and methods: 46 patients with dementia were selected for the study, 35 of whom had eating disorders. The research contingent was divided into three groups: Group 1 (n=22) - patients with eating disorders with dysphagia, Group 2 (n=13) - patients with eating disorders without dysphagia, Group 3 (n=11) - patients without eating disorders. A minimental scale was used to assess mental status, Mental State Examination – MMSE), To evaluate the severity of the disease - clinical scale of dementia, (Clinical Dementia Rating – СDR); For assessment of the functional state – we use the test of assessment staging test - (Functional Assessment Staging Test - FAST). The obtained results were statistically processed with computer program SPSS 24.0. Quantitative parameters were analyzed by Student's t-test, and categorical parameters by Chi2-test. p&lt;0.05 was used as a reliability criterion. Results: The results of the study showed that patients with dementia and eating disorders with dysphagia had statistically significantly lower MMSE scores compared to groups 2 and 3. It should also be noted that the MMSE indicators of groups 2 and 3 did not reliably differ from each other. The same trend was observed in CDR indicators. Patients with dementia and eating disorders with dysphagia had a statistically significantly higher percentage of CDR=3 compared to groups 2 and 3. It should also be noted that the indicators of CDR=3 of the 2nd and 3rd groups did not reliably differ from each other. According to the FAST indicators, there was no reliable difference in the distribution of responses between the groups. Conclusion: OD is a common condition in patients with advanced dementia and is associated with severe complications, poor prognosis, and poor compliance with fluid and texture adaptations. Supported by the study results, we believe that new nutrition-related strategies should be developed to increase the therapeutic effect in the clinical management of patients with dementia, and new evidence should be provided for these promising interventions.

Comparing the Diagnostic Value of Four Dementia Tests in the Amnestic and Healthy Elderly.

This study aimed to compare the diagnostic value of four questionnaires for the diagnosis of neurocognitive disorders (NCDs) in the elderly. In this project, people older than 60 years who lived in Tehran were investigated. A total of 99 literate cases were enrolled in the study, and four questionnaires, including functional assessment staging tool (FAST), abbreviated mental test score (AMTS), mini-mental state examination (MMSE), and modified Persian test of elderly for assessment of cognition and executive function (PEACE) were completed for them. They were then referred to a neuropsychiatrist, and the status of their cognition and neurobehavior was determined. The specialists were blinded to the results of the tests. Of the 99 participants studied, 39 cases were healthy, eight cases had mild Alzheimer's disease, 38 had amnesic MCI, five cases had secondary dementia, and nine cases had mixed vascular dementia and Alzheimer's disease. The area under the ROC curve for distinguishing the healthy group from the rest of the population was 0.692, 0.629, 0.734, and 0.751 for the FAST, AMTS, MMSE, and NBCSS questionnaires, respectively. MMSE and NBCSS tests had better diagnostic power than the other two tests to distinguish the healthy group from the rest of the population.

Total pain in advanced dementia: a quick literature review.

Objective: This quick literature review aimed to organize information on the detailed components of total pain in older people with advanced dementia in a holistic manner. Materials and Methods: The authors analyzed qualitative data from relevant clinical guidelines or textbooks, focusing on certain types of pain and distress in older people with advanced dementia, followed by an expert panel review by research team members. In the search, the authors defined a person with advanced dementia as having a functional assessment staging tool scale score greater than or equal to six. Results: The model covered a wide variety of pain, from physical pain to dementia-related psychological and spiritual aspects of total pain, including living environment change, stigma, discrimination, lack of communication and understanding, loss of sense of control and dignity, and cultural distress. It also identified physical appearance as an important factor in dying with dignity, as established by existing research on individuals with incurable cancers. Conclusion: The conceptual model of total pain in people with advanced dementia is expected to help turn healthcare professionals' attention to physical, psychological, social, and spiritual contributors to total pain in advanced dementia.

CLAIMS-BASED FRAILTY INDEX (CFI) AS A MEASURE OF DEMENTIA SEVERITY IN MEDICARE BENEFICIARIES WITH ADRD

Abstract Lack of a dementia severity measure in administrative claims data is a major barrier in Alzheimer’s Disease and Related Dementias (ADRD) research using such data sources. A claims-based frailty index (CFI; range 0 to 1, higher scores indicating greater frailty) is a validated measure of frailty that can be calculated from administrative claims data and is correlated with functional status. We conducted a cross-sectional study to examine whether CFI can be a claims-based measure to differentiate dementia severity in 814 participants with ADRD with linked to Medicare claims in the National Health and Aging Trends Study (NHATS). We estimated the Functional Assessment Staging Test (FAST) scale (3: mild cognitive impairment; 4: mild dementia; 5: moderate dementia; 6–7 moderate-to-severe dementia) using NHATS variables and calculated CFI from Medicare claims in the prior 12 months. The prevalence of FAST stage 5 or higher was 244 (weighted percentage, 25.9%). The C-statistic of CFI to identify FAST stage 5 or higher was 0.78 [95% CI:0.73–0.82], with a CFI cut-point of 0.3 achieving the maximum sensitivity 72.5% and specificity 67.5%. The equipercentile linking procedure showed that CFI scores of 0.30, 0.35, and 0.40 corresponded to FAST stages 4, 5, and 6, respectively. Our results support the utility of a CFI as a proxy of dementia severity in administrative claims data.

Functional Outcomes of a Comprehensive, Individualized, Person‐Centered Management Program in Advanced Alzheimer’s Disease(AD): Results from a 52‐Week Randomized Controlled Trial

AbstractBackgroundWe conducted a 28‐week, single‐blind, randomized, controlled trial of the efficacy of Comprehensive, Individualized, Person‐Centered Management (CI‐PCM) and memantine treatment (Reisberg et al., Dement Geriatr Cogn Disord, 2017) in advanced AD persons. CI‐PCM and memantine was approximately 7.5 times more beneficial to AD persons on the Functional Assessment Staging Tool (FAST) (Kenowsky et. al., Alzheimer’s and Dementia, 2017) than to AD persons who received memantine alone in the memantine FDA approval pivotal trial conducted by Reisberg et. al., (NEJM 2003). We also conducted a 24‐week extension study. Herein, we report the difference in functional outcomes between the CI‐PCM and Usual Community Care (UCC+FC) groups at 52‐weeks on the FAST and the ADCS‐ADLSev‐Abv. See Figures 1 and 2.MethodAfter screening, 20 eligible subject‐carepartner dyads were randomized equally to the CI‐PCM and UCC+FC groups. All 20 dyads completed the 28‐week study and entered the 24‐week extension study. One subject in the UCC+FC group died during the extension study. The FAST and ADCS‐ADLsev‐abv were conducted at baseline, and weeks 4, 12, 28, and 52. P values were calculated using the Wilcoxon Mann Whitney test.ResultThe mean FAST total score from baseline (6.6±0.1SE) to week 52 (6.5±0.01SE) showed an improvement of functional limitations in the CI‐PCM group. The mean FAST total score for the UCC+FC group showed a functional decline from baseline (6.6±0.1SE) to week 52 (6.8±0.1SE), displaying a robustly significant difference between the two groups (p&lt;0.0014). The mean ADCS‐ADL‐sev‐abv total score for the CI‐PCM group demonstrated a 20.9% improvement in functioning from baseline (15.3±2.0SE) to week 52 (18.5±2.5SE). The mean ADCS‐ADL‐sev‐abv total score for the UCC+FC group showed a decline of 48.6% from baseline (14.8±2.1SE) to week 52 (7.6±2.3SE), indicating a significant difference between the two groups (p&lt;0.009).ConclusionThe CI‐PCM program is the only evidenced‐based treatment to date that can significantly improve and reverse functional deterioration in advanced AD persons. The functional success of the CI‐PCM program may primarily be attributed to care partners learning to memory coach AD persons to perform daily activities such as bathing, dressing, feeding and toileting themselves, and to become/maintain urinary and fecal continence.

Frequent Cognitive Tests Increase Power for Alzheimer’s Disease Clinical Trials

AbstractBackgroundMany clinical trials use performance‐based cognitive or functional test results as primary outcome measures. As few as two measurements, typically pre‐ and post‐intervention, can be used to define a cognitive trajectory. Increasing the number and frequency of assessments can increase power to test the primary hypothesis. However, increased assessment frequency may be expensive and burdensome to participants and staff. Frequent neuropsychological testing may also introduce a practice effect or learning effect. Trials should be designed with attention to the costs and benefits of more frequent assessments.MethodWe conducted two clinical trials and performed Monte Carlo simulations. The Montreal Cognitive Assessment (MoCA) and the MCI Screen (MCIS) were used to assess cognition; the Functional Assessment Staging Tool (FAST) was used to assess function. In addition to simulated data, we employed data from the Coaching for Cognition in Alzheimer’s (COCOA) and Precision Recommendations for Environmental Variables, Exercise, Nutrition and Training Interventions to Optimize Neurocognition (PREVENTION) Trials.ResultEffect sizes and measurement variability were similar between the two cognitive screens. More frequent assessments increased power to reject a null hypothesis The major factor driving this improved power was the influence of data from individuals withdrawing from or dropping out of the trial prior to trial end. More frequent testing captured more of the effect of the intervention over time in those individuals, and therefore, increased power for the entire study. The design of the MCIS with rotating word lists facilitated frequent testing without a learning effect. Hypothetically, a more frequently administered assessment might have less precision than a different assessment administered less frequently, and the unit costs of these assessments might differ. Under a wide range of parameters modeled in simulations, the advantages of more frequent testing outweighed decreases in the precision of individual assessments.ConclusionMore frequent testing should be preferred in clinical trials. Use of shorter and/or remote tests may facilitate such frequency, reduce costs, and increase safety during pandemics. In addition to gains in statistical power, dense measurements have other benefits. They may also reveal non‐linear trajectories and better enable longitudinal analyses such as time dependencies and dose‐response relationships.

Oral environment and cerebral blood flow in patients with neurodegenerative dementia: comparison of Alzheimer type dementia and dementia with Lewy bodies.

The number of patients with dementia is increasing worldwide. Modifying risk factors may significantly reduce the prevalence and cost of dementia. The number of remaining teeth, occlusal force, denture use, and periodontal disease status are associated with the risk of developing dementia. The oral environment may be a risk factor for dementia. This study aimed to investigate the association between the oral environment and cerebral blood flow in patients with mild cognitive impairment and dementia (either Alzheimer type dementia (ATD) or dementia with Lewy bodies (DLB)). We aimed to identify differences in the oral environment according to the underlying neurodegenerative disease. The participants were 25 patients with ATD and 25 patients with DLB who visited the Department of Dementia and Geriatric Medicine, Kanagawa Dental University Hospital. Patients were diagnosed with ATD and DLB by well-trained specialists certified by the Japanese Dementia Society and categorised as Level 3 or 4 by the Functional Assessment Staging of Alzheimer Disease scale. The correlation between oral environment (number of teeth, periodontal tissue, and oral function) and cerebral blood flow in each brain area calculated by single photon emission computed tomography was examined. The DLB group showed a significant correlation between masticatory performance and cerebral blood flow in some areas, while no such correlation was observed in the ATD group. Significant correlations were found between periodontal pocket depth and bleeding on probing and cerebral blood flow in some areas in both groups, although the correlation was considerable in the ATD group. The results of this study suggest that the association between changes in the oral environment and cerebral blood flow may differ among patients with ATD and DLB, depending on the underlying causative disease.

Electroconvulsive Therapy for Neuropsychiatric Symptoms due to Major Neurocognitive Disorder: A Prospective, Observational Study.

Neuropsychiatric symptoms (NPSs) in those with major neurocognitive disorder (MNCD) include the responsive behaviors of agitation and aggression. Electroconvulsive therapy (ECT) has shown some effectiveness based on retrospective studies and one open label prospective study. We hypothesized that ECT will reduce NPSs between baseline and after treatment in those with medication-refractory behaviors. This Canadian prospective multicenter study included MNCD patients admitted to geriatric psychiatry units for the management of refractory NPSs. All treatment-refractory participants suffered from advanced MNCD. We conducted the Neuropsychiatric Inventory-Clinician version and the Pittsburgh Agitation Scale at baseline, and during and after the ECT course. A bitemporal or bifrontal ECT series based on dose titration to 1.5 to 2.5 times seizure threshold was administered. Data were collected for 33 patients with a mean age of 73 and categorized with severe MNCD using the Functional Assessment Staging of Alzheimer's Disease scale (stages 6 and 7). The data showed a drop in mean Neuropsychiatric Inventory-Clinician version from 58.36 to 24.58 (P < 0.0001). Mean Neuropsychiatric Inventory agitation subscale dropped from 7.12 to 3.09 (P = 0.007). Mean Neuropsychiatric Inventory aggression subscale dropped from 6.94 to 0.97 (P < 0.0001). There was a concomitant significant decline in Pittsburgh Agitation Scale scores. No participants dropped out because of intolerance of ECT. One participant died from pneumonia, which did not appear related to ECT. In this naturalistic study, ECT was found to be a safe and effective treatment for certain NPSs in people with MNCD. This can translate into improving quality of life.