Alzheimer Disease: Cooper C

Paradise M, Cooper C, Livingston G. · Department of Mental Health Sciences, University College London, UK. · Int Psychogeriatr. · Pubmed #19026089 No free full text.

Abstract: BACKGROUND: According to the cognitive reserve model, higher levels of education compensate for the neuropathology of Alzheimer's disease (AD), delaying its clinical manifestations. This model suggests that for any level of cognitive impairment, people with more education have worse neuropathology than those with less education and will therefore have shorter survival post-diagnosis. This is the first systematic review of the relationship between more education and decreased survival in people with AD. METHODS: We reviewed the literature systematically, searching electronic databases and reference lists of included studies. We used Centre for Evidence Based Medicine criteria for inclusion and rating of the validity of cohort studies that reported the relationship of education to survival in people with AD. RESULTS: 22 studies met inclusion criteria. We found Grade A evidence (highest evidence level) that more education was not associated with decreased survival post-diagnosis in AD. Only one of 11 studies rated 1b (highest level of quality) supported our hypothesis that more education predicted reduced survival after adjusting for age, gender and dementia severity; it comprised African-Caribbean participants, who had on average more severe cognitive impairment than other studies' participants. CONCLUSIONS: Education delays the onset of the dementia syndrome in AD, but does not lead to earlier death after diagnosis.

Cooper C, Katona C, Livingston G. · Department of Mental Health Sciences (Archway Campus), UCL, London, United Kingdom. · J Nerv Ment Dis. · Pubmed #19008735 No free full text.

Abstract: The Brief COPE is a self-completed questionnaire measuring coping strategies. It comprises 14 subscales for which psychometric properties are described. Three composite subscales measuring emotion-focused, problem-focused, and dysfunctional coping have proved useful in clinical research and have content validity. We report psychometric properties of these subscales for the first time. One hundred twenty-five family carers of people with Alzheimer's disease completed the Brief COPE at time 1, 92 (82.9% of eligible carers) a year later, and 74 (77.1%) 2 years later. Internal consistencies were good for emotion-focused, problem-focused, and dysfunctional subscales (alpha = 0.72, 0.84, 0.75). Test-retest reliability over a year was demonstrated for emotion-focused, problem-focused, and dysfunctional subscales among carers in whom burden scores did not change significantly (r = 0.58, r = 0.72, r = 0.68; p < 0.001). Change in burden score over 2 years correlated with change in problem-focused and dysfunctional (r = 0.33, r = 0.32; p < 0.01) subscales, indicating sensitivity to change, but not with change on the emotion-focused scale. Change in emotion-focused coping correlated with change in problem-focused and dysfunctional coping (r = 0.40, r = 0.26; p < 0.05). Regression analyses indicated convergent and concurrent validity: emotion-focused coping was predicted by secure attachment (beta = 0.23) and by problem-focused coping (beta = 0.68); dysfunctional coping by burden (beta = 0.36) and less secure attachment (beta = -0.25) and problem-focused coping (beta = 0.31;all p < 0.05). The model predicting problem-focused coping included avoidant attachment (beta = 0.22; p = 0.014), social support (beta = 0.10; p = 0.25), care recipient activities of daily living impairment (beta = 0.12; p = 0.14) and less secure attachment (beta = -0.25; p = 0.011) and emotion-focused (beta = 0.53; p < 0.001) and dysfunctional coping (beta = 0.25, p = 0.006). These subscales are potentially useful in clinical research as they reflect possible components of interventions to change coping, although more information about sensitivity to change of the emotion-focused subscale is needed.

Cooper C, Katona C, Orrell M, Livingston G. · Department of Mental Health Sciences, University College London, UK. · Int J Geriatr Psychiatry. · Pubmed #18383189 No free full text.

Abstract: OBJECTIVES: There have been few longitudinal studies investigating the impact of coping on psychological morbidity in caregivers of people with dementia. Findings have been inconsistent and little attention has been paid to anxiety in caregivers. We explored the hypothesis that the relationship between caregiver burden and anxiety and depression is mediated by coping style. METHODS: As part of the LASER-AD study, 93 (73.8%) people with Alzheimer's disease and their family caregivers recruited at baseline were re-interviewed 1 year later. Sampling aimed to ensure that the participants were representative of people living in the UK with Alzheimer's disease in terms of dementia severity, gender and care setting. We used the Hospital Anxiety and Depression Scale, the Zarit Burden scale and the Brief COPE to measure coping strategies. RESULTS: Using fewer emotion-focused strategies and more problem-focused strategies (but not dysfunctional strategies) mediated the relationship between caregiver burden and anxiety a year later, after controlling for potential confounders, in a well-fitting structural equation model (chi(2)=0.93, df=3, p=0.82; NFI=1.0, RFI=0.97, IFI=1.0, TLI=1.1, RMSEA=0.0). Using fewer emotion focused strategies also predicted higher psychological morbidity in general. The hypothesised relationship was not proved for depression. CONCLUSIONS: Using emotion-focussed coping strategies in response to caregiver burden seemed to protect caregivers from developing higher anxiety levels a year later; however using problem-focussed strategies did not. Our results suggest that a psychological intervention package to emphasise emotion-focused coping may be a rational approach to reduce anxiety in dementia caregivers. Studies are needed to test such interventions.

Cooper C, Owens C, Katona C, Livingston G. · Department of Mental Health Sciences, University College London, U.K. · Int Psychogeriatr. · Pubmed #18053290 No free full text.

Abstract: BACKGROUND: Preliminary evidence indicates that the quality of the carer-care recipient relationship predicts those carers most at risk from anxiety. Attachment style is related to higher carer burden, psychological morbidity and increased care recipient institutionalization. We tested, for the first time, the hypothesis that carer burden and the coping strategies used mediate a relationship between attachment style and anxiety. METHODS: We interviewed 83 people with Alzheimer's disease and their family carers, originally recruited for a larger community study. Carers filled in a validated measure about their attachment style, the Hospital Anxiety and Depression Scale, the COPE to measure coping strategies, and the Zarit-Burden interview. RESULTS: More avoidant attachment (beta = 0.28) and less secure attachment (beta = -0.32) predicted anxiety. After adding coping strategies to the equation, the relationship with avoidant attachment (beta = 0.15) was no longer significant, and that with less secure attachment was reduced (beta = -0.23). A well-fitting structural equation model supported our finding that dysfunctional coping mediated the relationship between attachment style and anxiety. CONCLUSION: Carers who were less secure or more avoidantly attached reported higher anxiety. Interventions that aim to modify coping strategies have shown promise in reducing carer anxiety. Our finding that coping strategies also appear partially to explain the excess of anxiety among less securely attached carers suggests they are likely to benefit from such interventions.

Livingston G, Cooper C, Woods J, Milne A, Katona C. · Department of Mental Health Sciences, University College London, Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW, UK. · J Neurol Neurosurg Psychiatry. · Pubmed #17898031 No free full text.

Abstract: BACKGROUND: Most models of successful ageing do not allow for the possibility of living "successfully," despite some degree of cognitive or physical impairment. We reviewed the successful ageing and related quality of life literature to identify their potential predictors. We then tested our hypotheses that wellbeing in adversity would be predicted by mental health (anxiety and depression) and social factors rather than physical health and that it would be stable over time. METHOD: We interviewed 224 people with Alzheimer's disease (AD) and their family carers, recruited to be representative of those living with AD in the community. We re-interviewed 122 (73.1% of eligible) participants 18 months later. Our main outcome measure was the perception of the person with AD on their life as a whole. RESULTS: Mean "wellbeing in adversity" scores did not change significantly over time (t = 0.23). Social relationships, subjective mental health, health perception, activities of daily living and baseline wellbeing in adversity were the significant correlates of wellbeing in adversity on univariate analysis. Only baseline wellbeing in adversity and mental health score were significant predictors in our regression analysis. In a well fitting structural equation model, less severe dementia and better health perception predicted fewer mental health problems and social relationships, but were not direct predictors of wellbeing in adversity at 18 months. CONCLUSION: Successful ageing was common among a cohort of people with dementia. The most important predictors of this were mental health and social relationships, which fully mediated the relationship we found between health perception and wellbeing 18 months later.

Cooper C, Manela M, Katona C, Livingston G. · Department of Mental Health Sciences, University College London, Archway Campus, London, UK. · Int J Geriatr Psychiatry. · Pubmed #17621366 No free full text.

Abstract: BACKGROUND: Several studies have investigated abusive behaviour by carers towards people with dementia, most using unvalidated scales; only two reported correlates of abuse after controlling for mediators and confounders, and these controlled for different factors. OBJECTIVE: To investigate the acceptability and validity of the Modified Conflict Tactics Scale (MCTS) and abuse correlates. METHODS: Eighty-six people with Alzheimer's disease and their family carers, originally recruited for a representative community study were interviewed. We asked carers about acceptability of the MCTS and investigated its validity by comparing scores to the Minimum Data Set (MDS) abuse screen (an objective measure) and testing hypotheses that MCTS score would correlate with the COPE dysfunctional coping scale but not carer education. RESULTS: Twenty-four (27.9%) were identified as abuse cases by interview. No care recipients (CRs) screened positive for abuse using the MDS screen. Seventy-two (83.7%) participants thought that the scale was acceptable, ten (11.6%) that it was neither acceptable nor unacceptable, and three (3.5%) that it was unacceptable. As hypothesised, MCTS scores correlated with dysfunctional coping scale score but not carer education. CONCLUSIONS: This is the most comprehensive study so far in this field. The MCTS was acceptable and had convergent and discriminant validity for measuring carer abuse. The MDS failed to identify cases of abuse. Carer male gender and burden, and greater CR irritability, cognitive impairment but less functional impairment predicted carer abusive behaviour. Our findings appear to refute UK government elder abuse reduction policy which assumes that few incidents of abuse arise from carer stress.

Katona C, Livingston G, Cooper C, Ames D, Brodaty H, Chiu E. · Old Age Taskforce, World Federation of Societies of Biological Psychiatry, Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, UK. · Int Psychogeriatr. · Pubmed #17386120 No free full text.

Abstract: Current symptomatic treatments for dementia have only modest efficacy. Assessing meaningful benefits in this variably progressive syndrome is complex and difficult. This consensus statement was generated by an international group representing caregivers, organizations and professionals with expertise in dementia. We recommend the statement of clear, pre-defined diagnostic and severity criteria and outcome measures, which include functional and executive capacity, in treatment trials. Outcomes can include effects on people with dementia (PWD) with regard to cognition, behavioral and psychological symptoms, quality of life, global assessments, and activities of daily living, and must be tailored to the education and culture of the participants. Outcomes can also appropriately encompass effects on caregivers. New instruments may be needed, as validation of many existing measures has been in relatively homogenous populations. Treatment goals can be to prevent dementia emerging, or in those with established dementia to slow deterioration, and to postpone, stabilize or improve symptoms. Comparisons between treatment groups should be on the basis of clinically relevant measures with both risk and benefit reported for all participants regardless of whether or not they continue to receive treatment throughout the trial. Characterization of any groups that respond well to treatment has been unsuccessful to date, but may be facilitated in the future by measurement of putative biomarkers. Despite considerable recent progress and several 'candidate' biomarkers, none is yet satisfactory for determining diagnosis, severity, progression or prediction of response. To provide meaningful data, economic analyses should use up-to-date, country-specific data. Health economic measures should be incorporated as secondary outcomes in all Phase 3 trials since health systems are concerned with cost-effectiveness as well as clinical outcome. Health utility measures are not, however, validated satisfactorily in dementia, thus calling into question previous health economic analyses. While current drugs appear to reduce the amount of family caregiver time required by PWD, these costs fall in the main on older individuals who often exert little political leverage, rather than on society at large. Traditionally, elderly people have been marginalized in the political process. The growth in the older population across the world, and their potential for increasing political empowerment may lead to a radical re-evaluation of the economics of treatment in dementia.

Livingston G, Walker AE, Katona CL, Cooper C. · Department of Mental Health Sciences, University College London, Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW, UK. · J Neurol Neurosurg Psychiatry. · Pubmed #16801350 No free full text.

Abstract: OBJECTIVE: To investigate in a longitudinal cohort of people with Alzheimer's disease whether taking antipsychotics is associated with more rapid cognitive deterioration. METHOD: From a sample of 224 people with Alzheimer's disease recruited as epidemiologically representative, those taking antipsychotic drugs for more than 6 months were compared with those who were not, in terms of change in three measures of cognition. The effects of potential mediators and confounders (demographic factors, neuropsychiatric symptoms, cognitive severity and cholinesterase inhibitors) were also examined. RESULTS: No significant difference was observed in cognitive decline between those taking antipsychotics (atypical or any) and others on any measure of cognition. The only predictor of more cognitive decline was greater baseline cognitive severity (B = 3.3, 95% confidence interval 0.6 to 6.1, t = 2.4, p<0.05). Although mortality was higher in those treated with antipsychotics, this reflected their greater age and severity of dementia. The results were the same when the whole cohort was included rather than the select group with potential to change who had been taking antipsychotics continuously. CONCLUSIONS: In this, the first cohort study investigating the effects of atypical antipsychotics on cognitive outcome in Alzheimer's disease, those taking antipsychotics were no more likely to decline cognitively over 6 months. Although clinicians should remain cautious when prescribing antipsychotic drugs to people with Alzheimer's disease, any increase in cognitive deterioration is not of the magnitude previously reported. There is a need for cohort studies that follow up patients from first prescription in clinical practice for a period of months rather than weeks to determine "real-life" risks and benefits.

Cooper C, Katona C, Orrell M, Livingston G. · Old Age Psychiatry, University College London, UK. · J Affect Disord. · Pubmed #16337688 No free full text.

Abstract: BACKGROUND: Caregivers of people with dementia (CGPD) frequently have anxiety symptoms but little is known about the relationship of anxiety with coping strategies. METHOD: 126 people with Alzheimer's disease (AD) and their family caregivers living in the community were recruited from local psychiatric services, the voluntary sector and care homes. Sampling was designed to ensure that the sample was epidemiologically representative in terms of dementia severity, gender and care setting. We used the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS) to measure anxiety and the Brief COPE to measure coping strategies. RESULTS: Use of dysfunctional coping strategies (Wald = 7.3, p = 0.007) and HADS depression caseness (Wald = 14.0, p < 0.001) were the only factors that predicted HADS anxiety caseness on logistic regression. LIMITATIONS: Anxious caregivers may be more likely to report their coping strategies negatively; these results do not clarify direction of causality. CONCLUSIONS: Dysfunctional coping strategies and depression appear to be the most important factors predicting caregiver anxiety. Addressing coping strategies may be a helpful intervention for managing caregiver anxiety.