Caregiving award recognizes two NIA-supported programs
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Jennifer Martindale-Adams, Ed.D., Memphis VA Medical Center; Former First Lady Rosalynn Carter; Linda Nichols, Ph.D., Health Services Researcher, Memphis VA Medical Center |
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The Rosalyn Carter Leadership in Caregiving Award is among the most prestigious awards in the caregiving field. This award, presented annually by the Rosalyn Carter Institute of Caregiving, recognizes programs that develop and implement innovative approaches to promote collaborations between community agencies and caregiving researchers that bridge the gap between science and practice.
One of two 2008 awards recognizes the REACH VA program, implemented by the Veterans Health Administration (VHA) Geriatrics and Extended Care Unit in partnership with the Memphis VA Medical Center. REACH VA focuses on "education, safety for the patient, support for the caregiver, and skills building to help caregivers manage difficult patient behaviors and decrease their own stress." The goal of REACH VA is "to implement an effective intervention to decrease caregiver stress and improve the management of patient behaviors throughout the VHA system."
REACH VA is the first national clinical translation of a proven dementia behavioral intervention, REACH II (Resources for Advancing Alzheimer's Caregiver Health). REACH II is a social and behavioral research effort funded by NIA and the National Institute of Nursing Research. The goal of REACH II is to translate the results of research in caregiver support into evidence-based community practices. REACH VA has made it possible to broadly implement the findings from the REACH II research project. Clinical staffs from VA Home-Based Primary Care programs in 36 cities and 19 states have volunteered to learn and deliver the intervention to caregivers of dementia patients.
The second winner of the 2008 award is Minnesota's NYU Caregiver Intervention Project, designed and implemented by the Minnesota Board on Aging and the Alzheimer's Association Minnesota/North Dakota Chapter, in partnership with New York University's Dr. Mary Mittelman and Cynthia Epstein. The goals of the project are to develop and improve appropriate supportive services for people with Alzheimer's disease and to integrate these services into long-term care-, home-, and community-based systems. The project uses the care model developed by Dr. Mittelman and funded in part by NIA. In the journal Neurology, Dr. Mittelman and colleagues report that nursing home placement for patients with AD who received their care intervention was delayed a median of 557 days, due in large part to improvements in caregiver social support, learned responses to patient behavior problems, and symptoms of depression.
Research summaries
Combination scanning yields better diagnosis of mild cognitive impairment
A combination of magnetic resonance imaging (MRI) and positron emission tomography (PET) can more accurately detect mild cognitive impairment (MCI) brain abnormalities in the early stages of their development than can either method used alone, a recent study finds. Early diagnosis of amnestic MCI is important because the condition is often a precursor to Alzheimer's disease (AD).
The researchers, from the National Institute on Aging (NIA) and the University of Pennsylvania, examined MRI and PET images from 30 elderly participants in NIA's Baltimore Longitudinal Study of Aging to distinguish people with aMCI from people who were aging normally. They looked at spatial patterns of brain atrophy and reduced blood flow in dozens of regions of the brain.
MRI data alone produced an 87 percent accuracy rate for aMCI diagnosis, and PET data alone produced a 50 percent accuracy rate. However, when the two were combined, researchers obtained a 90 to 100 percent accuracy rate—"an excellent diagnostic value" for this method.
Fan Y., et al. Structural and functional biomarkers of prodromal Alzheimer's disease: a high-dimensional pattern classification study. Neuroimage. 2008. 41:277-85.
Dementia diagnosis does not increase depression or anxiety
Receiving a diagnosis of dementia does not prompt a strong negative reaction in most people and may even provide relief because it explains symptoms and makes patients feel less helpless, concludes a recent study.
To gauge psychological reactions to a dementia diagnosis, researchers from Washington University in St. Louis conducted telephone interviews with patients a few days after they received a dementia diagnosis. Two tests were used: the Geriatric Depression Scale and the "State" version of the State-Trait Anxiety Inventory. Both patients and their companions took the tests. Baseline scores were obtained through comprehensive physical and neurological examinations. Of 90 study participants, 41 were diagnosed with very mild dementia, 21 with mild dementia, and 28 with no dementia.
The researchers found no significant increase in depression in individuals or their companions, regardless of diagnostic outcome or dementia severity. The level of anxiety also did not increase—and decreased significantly in some cases.
Carpenter, B.D., et al. Reaction to a dementia diagnosis in individuals with Alzheimer's disease and mild cognitive impairment. J Am Geriatr Soc. 2008. 56:405-12.
More information for health care professionals about communicating with older patients is provided in the NIA publication Talking With Your Older Patient: A Clinician's Handbook.
Familial Alzheimer's disease may provide biomarker model
Examination of people at risk for the rare familial form of AD may provide clues to how the disease develops in others—years before clinical symptoms appear, according to a recent study. The clues are levels of certain proteins found in plasma and cerebrospinal fluid (CSF), biomarkers that might be used to diagnose AD in its earliest preclinical stage.
The research team, led by scientists at the University of California, Los Angeles, examined blood and CSF samples from 21 adults under age 50, most of whom had no symptoms of AD but were related to people with familial AD, a genetically inherited form of the disease. One of their biomarkers, elevated levels of plasma Aß42 (a type of beta-amyloid protein), also has been found in people with late-onset AD.
The results confirmed and amplified what previous studies have shown: Pre-symptomatic people with the familial-AD mutation had higher levels of plasma Aß42, which declined as the disease progressed, as well as higher plasma Aß42/Aß40 ratios, than those in people without the mutation. People with the mutation had lower CSF Aß42/Aß40 ratios and higher levels of CSF tau and p-tau181 than people who did not carry the mutation. There was no significant difference between the two groups in plasma F2-isoprostane levels.
Ringman, J.M., et al. Biochemical markers in persons with preclinical familial Alzheimer disease. Neurology. 2008 July. 71:85-92.
Frailty in older adults linked to Alzheimer's disease pathology
Previous studies have suggested that frailty, a common but poorly understood condition in older people, may predict the development of dementia. In this study, Rush University researchers examined 165 physically frail older adults before and after their deaths to investigate this connection. First, participants' frailty was evaluated by measuring their grip strength, timed walk, body composition, and fatigue. After death (at a mean age of 88.1 years), their brains were autopsied for evidence of AD, cerebral infarcts, and Lewy body disease.
Regression analyses controlling for age, chronic diseases, medications, and other factors showed an association between levels of frailty and of AD pathology but no association between frailty and cerebral infarcts or Lewy body disease. A higher level of AD pathology was associated with a higher level of frailty. The link was similar in people with and without dementia.
The researchers speculate that AD pathology may contribute to frailty by affecting parts of the brain that control movement. Or, AD and frailty may share a common cause. "These different mechanisms are not mutually exclusive and underscore the need for further studies of the relationship between AD and frailty," they conclude.
Buchman, A.S., et al. Physical frailty in older persons is associated with Alzheimer disease pathology. Neurology. 2008. 71:499-504.
More tau protein in cerebrospinal fluid associated with earlier onset of Alzheimer's
People with increased levels of tau protein in their CSF develop late-onset AD at earlier ages than do others with the disease, according to a study by researchers at the Washington University School of Medicine in St. Louis. The levels of this protein in CSF may provide a potential biomarker to identify people who may develop AD sooner than others do. The levels of both beta-amyloid and tau—two proteins whose abnormalities characterize AD—in CSF vary widely in individuals with the disease.
The investigators used genotyping to pinpoint the association between MAPT, the gene that encodes tau, and AD. They found four genetic variants of MAPT that were associated with higher levels of tau, but the higher tau levels were found only in the presence of beta-amyloid deposits. The researchers also confirmed that the genetic variants of MAPT influenced the age at onset of AD clinical symptoms but had no effect on the overall risk of developing AD.
The results indicate that beta-amyloid deposition leads to MAPT gene expression, which in turn raises tau levels and increases early neurodegeneration in late-onset AD.
Kauwe, J.S., et al. Variation of MAPT is associated with cerebrospinal fluid tau levels in the presence of amyloid-beta deposition. Proc Natl Acad Sci USA. 2008 Jun 10. 105(23):8050-54.
New scoring on dementia screening recommended for more highly educated people
A recent study by researchers from the Texas Tech University Health Science Center and the Mayo Clinic Department of Medicine shows that raising the Mini-Mental State Examination (MMSE, a standard screening tool for dementia) "cut score" for more highly educated people increases the early accuracy of results for this group. Earlier identification of cognitive decline could aid in their treatment.
Scores on the MMSE decrease with advanced age and less education. The standard MMSE cut score is 24, meaning that a score of 23 or below indicates possible dementia. However, a review of data for 4,248 people, including 1,141 with 16 or more years of education, suggests that a more appropriate cut score for college-educated individuals is 27. Raising the MMSE cut score for this group to 27 increased the accuracy of the classification rate from 89 to 90 percent and provided an "optimal balance" of sensitivity and specificity, the study results reveal. A cut score of 27 identified 70 of the 104 college-educated patients with dementia who were missed when a cut score of 24 was used.
The researchers conclude that older, more highly educated patients who complain of cognitive decline and score below 27 on the MMSE should be referred for a comprehensive dementia evaluation.
O'Bryant, S.E., et al. Detecting dementia with the mini-mental state examination in highly educated individuals. Arch Neurol. 2008 July. 65(7):963-67.