Alzheimer Disease: Livingston G

Maidment I, Fox C, Livingston G, Katona C. · No affiliation provided · Int J Geriatr Psychiatry. · Pubmed #16353163 No free full text.

This publication has no abstract.

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.

Selwood A, Johnston K, Katona C, Lyketsos C, Livingston G. · Department of Mental Health Sciences, University College London, Archway Campus, Holborn Union Building, Highgate Hill, London, N19 5NL, UK. · J Affect Disord. · Pubmed #17173977 No free full text.

Abstract: BACKGROUND: Caregivers of people with dementia are at high risk of psychological morbidity and associated breakdown in care. Many psychologically based interventions have been designed to help caregivers of people with dementia. More work is needed to identify which, if any, are helpful for such caregivers. METHOD: We conducted a systematic review of the immediate and long term efficacy of different types of psychological interventions for the psychological health of caregivers of people with dementia, using standardized criteria, to assist clinicians in implementing rational, evidence-based management recommendations. We reviewed studies examining the effects of any therapy derived from a psychological approach that satisfied pre-specified criteria. Using the Oxford Centre for Evidence-Based Medicine criteria we rated the quality of each study, extracted data and gave overall ratings to different types of intervention. RESULTS: We identified 244 references in our search of which 62 met our inclusion criteria. LIMITATIONS: Our findings are limited by lack of good quality evidence, with only ten level 1 studies identified. CONCLUSIONS: We found excellent evidence for the efficacy of six or more sessions of individual behavioral management therapy centered on the care recipient's behavior in alleviating caregiver symptoms both immediately and for up to 32 months. Teaching caregivers coping strategies either individually or in a group also appeared effective in improving caregiver psychological health both immediately and for some months afterwards. Group interventions were less effective than individual interventions. Education about dementia by itself, group behavioral therapy and supportive therapy were not effective caregiver interventions.

Livingston G, Katona C. · Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, Wolfson Building, London, UK. · Int J Geriatr Psychiatry. · Pubmed #10713577 No free full text.

Abstract: OBJECTIVES: To report on a Numbers Needed to Treat (NNT) analysis of the literature identified through a systematic review of trials of cholinesterase inhibitors in Alzheimer's Disease. DESIGN: Search of Medline (1966-1998), EMBASE (1994-1999) and Psychlit (1974-1998) using the keywords cholinesterase and placebo dementia. SETTINGS: Double-blind, randomised, placebo-controlled trials. SUBJECTS: People with Alzheimer's Disease. INTERVENTIONS: Drug trials of acetylcholinesterase inhibitors (ChIs).Main outcome measuresAlzheimer's Disease Assessment Scale (Cognitive subscale), Clinician's Interview Based Impression of Change Plus, Mini Mental State Examination, Progressive Deterioration Scale. RESULTS: Small numbers of patients (in most cases between 3 and 7) need to be treated with appropriate dosages of ChIs to ameliorate the clinical symptoms, or postpone deterioration in one of them. CONCLUSIONS: These small NNTs suggest that, despite their expense, the cholinesterase inhibitors have a valuable place in the current clinical management of AD.

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.

Hoe J, Katona C, Orrell M, Livingston G. · University College London, London, UK. · Int J Geriatr Psychiatry. · Pubmed #17380488 No free full text.

Abstract: BACKGROUND: Quality of Life (QoL) is a key outcome in dementia. AIM: To compare care recipients' (CR) and caregivers' (CG) views on CRs' QoL and identify determinants. METHODS: CRs and CGs completed the Quality of Life - Alzheimer's Disease (QOL-AD) scale. RESULTS: One hundred and ninety-one CR/CG dyads were interviewed. There were differences between determinants of the CRs and CGs views about QoL. Family-CGs rated CRs' QoL higher when CRs had fewer depressive symptoms, less irritability, less apathy, less daily living impairment and lived at home. Fewer depressive symptoms, living at home and taking acetylcholinesterase-inhibitors (AChEI) predicted higher CR rated QoL. CONCLUSION: Proxy ratings in dementia do not replicate CRs' views of QoL. This is the first study to employ a validated QoL measure for people with dementia taking AChEIs. Randomised controlled trials are needed before drawing conclusions about their effect on QoL. Interpretation of correlations between QoL and symptoms should be cautious as QoL is designed to reflect the impact of psychological and physical symptoms.

Walker Z, Jaros E, Walker RW, Lee L, Costa DC, Livingston G, Ince PG, Perry R, McKeith I, Katona CL. · University College London and Royal Free Hospitals, London, UK. · J Neurol Neurosurg Psychiatry. · Pubmed #17353255 links to  free full text

Abstract: BACKGROUND: Dementia with Lewy bodies (DLB) is a common form of dementia. The presence of Alzheimer's disease (AD) pathology modifies the clinical features of DLB, making it harder to distinguish DLB from AD clinically during life. Clinical diagnostic criteria for DLB applied at presentation can fail to identify up to 50% of cases. Our aim was to determine, in a series of patients with dementia in whom autopsy confirmation of diagnosis was available, whether functional imaging of the nigrostriatal pathway improves the accuracy of diagnosis compared with diagnosis by means of clinical criteria alone. METHODS: A single photon emission computed tomography (SPECT) scan was carried out with a dopaminergic presynaptic ligand [123I]-2beta-carbometoxy-3beta-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (FP-CIT; ioflupane) on a group of patients with a clinical diagnosis of DLB or other dementia. An abnormal scan was defined as one in which right and left posterior putamen binding, measured semiquantitatively, was more than 2 SDs below the mean of the controls. RESULTS: Over a 10 year period it was possible to collect 20 patients who had been followed from the time of first assessment and time of scan through to death and subsequent detailed neuropathological autopsy. Eight patients fulfilled neuropathological diagnostic criteria for DLB. Nine patients had AD, mostly with coexisting cerebrovascular disease. Three patients had other diagnoses. The sensitivity of an initial clinical diagnosis of DLB was 75% and specificity was 42%. The sensitivity of the FP-CIT scan for the diagnosis of DLB was 88% and specificity was 100%. CONCLUSION: FP-CIT SPECT scans substantially enhanced the accuracy of diagnosis of DLB by comparison with clinical criteria alone.

Regan C, Katona C, Walker Z, Hooper J, Donovan J, Livingston G. · Royal Free & University College Medical School, UCL, Department of Mental Health Sciences, Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW UK. · Neurology. · Pubmed #17060560 No free full text.

Abstract: OBJECTIVE: To test the hypothesis that patients with Alzheimer disease (AD) who have vascular risk factors have a worse prognosis over 18 months vs those without such risk factors. METHODS: A sample of 224 people with AD and their caregivers were recruited purposively to be representative of people with dementia in terms of cognition, sex, and living situations in a longitudinal study of AD. Standardized instruments measuring cognition, functional status, and neuropsychiatric symptoms were used to collect data. Physical examination and relevant blood tests were performed. RESULT: There was no difference in rate of deterioration between people with and without vascular risk factors, except in those who had a cerebrovascular accident (CVA) during the 18-month follow-up (p < 0.001). We considered possible confounders of outcome: sex, age, years of education, severity of dementia, depression, taking cholinesterase inhibitors (AChEIs), and whether those with vascular risk factors were more likely to die, but the results remained unchanged. Stopping AChEIs during the study was associated with cognitive and functional decline (p < 0.001). CONCLUSIONS: Vascular risk factors as measured clinically and biochemically do not significantly increase deterioration at 18 months in people with Alzheimer disease who have a low burden of cerebrovascular risk factors. However, cerebrovascular events are associated with more rapid decline. Vascular risk factors may contribute to the expression of Alzheimer disease initially but are not part of the underlying etiologic process.

Walker AE, Livingston G, Cooper CA, Katona CL, Kitchen GL. · Department of Mental Health Sciences, University College London, London, UK. · Aging Ment Health. · Pubmed #16938688 No free full text.

Abstract: The objective was to explore caregivers' experience of and concerns about the safety of care recipients (CRs) with Alzheimer's disease (AD) living at home. We interviewed family caregivers about their concerns regarding CR's safety, occurrence of risk over the last year and safety measures taken to manage risk. A total of 89 family caregiver/CR dyads participated. All had been recruited as part of a larger longitudinal study based in London and South East Region (LASER) of the UK. Caregivers spent a substantial proportion of the day supervising the CR (mean = 15.5 hours). Most caregivers (39; 81.2%) of the 48/89 CRs left alone worried about their safety. Sixty-one (68.5%) caregivers reported at least one incident in which the CR had been at risk within the past year. A majority (71; 79.8%) had taken measures to prevent risk behaviours. Greater impairment in activities of daily living and the caregiver not being the CR's spouse were associated with more measures being taken. Caregivers themselves provide supervision most of the time for the CR, and are worried when they are left alone. This is realistic as despite caregiver's attempts at managing their CR's risks, including direct supervision, dangerous incidents still frequently occur in people with AD.

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.

Livingston G, Katona C, François C, Guilhaume C, Cochran J, Sapin C. · Camden and Islington Mental Health and Social Care Trust, Department of Mental Health Sciences, University College London, London, UK. · Int Psychogeriatr. · Pubmed #16466593 No free full text.

Abstract: BACKGROUND AND OBJECTIVES: Until recently, attention and treatment strategies have focused mainly on patients in the early phases of Alzheimer's disease (AD). The objectives of this study were to collect information on moderately severe and severe AD patients (Mini-mental State Examination score < 15) in terms of epidemiological, clinical and economic characteristics and disease change in the later stages of AD, and to compare this specific AD population over 6 months with those in the earlier stages. METHODS: This descriptive analysis recruited institutionalized patients and patients living within the community from the city of London and the South-East region of the U.K. Subgroup analyses at baseline and 6 months were performed using the study population from the London and South-East Region Alzheimer's Disease (LASER-AD) Study. Data from a range of clinical scales, a quality of life (QOL) scale and a resource-utilization questionnaire were analyzed. RESULTS: People with moderately severe or severe AD are a heterogeneous group with varying QOL, cognitive and functional disabilities, neuropsychological symptoms and relatively low health care resource consumption. This patient group continued to decline but progression of the disease was observed only in some domains. CONCLUSION: Even at the later stages of AD, patients show varying rates of decline. Improved knowledge about the characteristics and progression of the disease reveals that moderately severe and severe patients cannot be regarded as beyond help and have the potential to experience varying and even high levels of QoL.

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.

Mahoney R, Johnston K, Katona C, Maxmin K, Livingston G. · Camden and Islington Mental Health and Social Care Trust/Department of Mental Health Sciences, University College London, London, UK. · Int J Geriatr Psychiatry. · Pubmed #16315149 No free full text.

Abstract: BACKGROUND: The screening test usually used to detect dementia (Mini Mental State Examination, MMSE) is limited by a ceiling effect and high false positive rates, as are other similar instruments. There is therefore a need for a more sensitive and specific screening tool to aid early detection and diagnosis of dementia. OBJECTIVE: The hypothesis of the study was that the TE4D-Cog would be more sensitive and specific than the MMSE in detecting mild cognitive impairment in patients with AD. METHOD: The TE4D (Test for the Early Detection of Dementia from Depression) was adapted from its original German version for English-speaking populations. This new scale (the TE4D-Cog) was then administered together with the MMSE and the cognitive subscale of the Alzheimer's disease Assessment Scale (ADAS-Cog) to 178 people with a diagnosis of Alzheimer's disease and 25 cognitively intact comparators. The sensitivity and specificity in detecting dementia of the TE4D-Cog and the MMSE were compared in those with mild dementia and those without dementia. RESULTS: The TE4D-cog had high sensitivity with an acceptable specificity and low false positive rate. It also had good concurrent validity, high inter-rater reliability, good internal consistency and strong predictive validity. CONCLUSIONS: The TE4D-Cog is easy to administer, short and acceptable. Results are independent of age, gender and level of education. The TE4D-Cog may therefore be a useful alternative to the MMSE as a dementia screening instrument.

Ryu SH, Katona C, Rive B, Livingston G. · Dept. of Mental Helath Sciences, University College London, London, UK. · Am J Geriatr Psychiatry. · Pubmed #16286441 No free full text.

Abstract: OBJECTIVES: Neuropsychiatric symptoms (NPS) are common in Alzheimer disease (AD). It is important in terms of management to know their natural history and their effects on service use. The authors aimed to determine the persistence and change in severity of NPS over 6 months in participants with AD, and the relationship to initial severity, drug management, use of services, and cost of care. METHODS: NPS scores and data on cognition, psychotropic medication, service use, and costs of care were collected on 224 participants at baseline and on 198 at 6-month follow-up. RESULTS: Of 224 patients, 210 (93.8%) had NPS at baseline; 168 (75.0%) had at least one clinically significant symptom, 118 (80.4%) of whom had persistent significant symptoms at 6-month follow-up. There was no significant change in mean NPS score for any symptom over 6 months, but many individuals became better or worse; 61.2% of those with at least one significant baseline symptom in any domain improved. Those with persistent symptoms had more severe baseline symptoms. Deterioration in NPS was predicted by deterioration in MMSE. Those with at least one clinically significant symptom had higher care costs than those without. CONCLUSIONS: NPS were highly persistent overall, but many individuals became better or worse. Persistence was predicted by having more severe symptoms at baseline. Clinically significant levels of NPS were associated with greater costs of care. The relatively few associations found between specific psychiatric treatments and changes in NPS reflect both undertreatment and the complexity of symptoms.

Mahoney R, Regan C, Katona C, Livingston G. · Dept. of Mental Health Sciences, University College London, Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW, UK. · Am J Geriatr Psychiatry. · Pubmed #16166409 No free full text.

Abstract: OBJECTIVE: There are high rates of stress, distress, and psychological illness in family caregivers of people with dementia. Female caregivers and those caring for people with neuropsychiatric symptoms are particularly at risk. The authors report on the prevalence of anxiety and depression in a sample of family caregivers of people with Alzheimer disease (AD) and compare the characteristics of those who did or did not have those conditions. METHODS: A group of 153 people with AD and their caregivers were interviewed as part of a larger study of AD. RESULTS: In all, 23.5% of caregivers scored at or above caseness level for anxiety, and 10.5%, at levels for depression. Care-recipient (CR) activities of daily living (ADL) impairment, being a caregiver living with the CR, being a female caregiver, reporting a poorer quality of relationship with the CR, and caregivers reporting their health as being poor all predicted anxiety disorder. CR irritability, caregivers reporting poor health, and a poorer quality of relationship with the CR predicted depression. CONCLUSIONS: Clinicians should be aware of the high rates of anxiety as well as depressive symptoms in family caregivers of people with AD, especially in female caregivers. CRs and Caregivers' impaired physical health put them at risk for psychological morbidity and should be treated energetically. A poor-quality relationship between the caregiver and the CR predicts both caregiver depression and anxiety. Caregivers living with the CR are much more likely to be anxious than depressed.

Livingston G, Mahoney R, Regan C, Katona C. · Department of Mental Health Sciences, University College London, Holborn Union Building, Archway Campus, Highgate Hill, London N19 5NL, UK. · Age Ageing. · Pubmed #15863413 links to  free full text

Abstract: BACKGROUND: we developed the Caregivers for Alzheimer's disease Problems Scale (CAPS) comprising common risk factors for anxiety and depression for family carers of people with dementia. OBJECTIVE: to calculate the sensitivity and specificity of the CAPS in order to measure its usefulness in identifying dementia caregivers at risk of anxiety and depression and therefore whether it identifies clinically relevant areas for intervention or highlights the need for support if the problem could not be changed. METHOD: 153 family caregivers were interviewed as part of a larger epidemiologically representative study of people with Alzheimer's disease and their caregivers. Caregiver anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). RESULTS: the CAPS had high sensitivity and specificity in detecting caregivers with screen positive anxiety and depression. Five areas were indicated: neuropsychiatric symptoms and depression in the care-recipient, co-residence and relationships with the care-recipient, and physical health of the caregiver. CONCLUSIONS: awareness of these problems can help clinicians identify those carers most likely to be anxious or depressed and indicate appropriate intervention and support. We recommend that this instrument be used as part of routine assessments of people with dementia and their families.

Regan C, Katona C, Walker Z, Livingston G. · Department of Psychiatry and Behavioural Sciences, University College London, London, UK. · Int J Geriatr Psychiatry. · Pubmed #15717340 No free full text.

Abstract: BACKGROUND: Depression is common in Alzheimer's disease (AD; 5-35%). It is associated with increased disability, cost of care and carer burden. Exercise is known to be associated with a lower prevalence of depression across the age range but little is known about its relationship to depression in AD. AIMS: To investigate exercise and putative risk factors for depression in a community based sample of people with AD representative of the range of cognitive impairment found in the population with dementia. METHODS: Information was collected from 224 people with AD and their caregiver using standardised cognitive, psychological and behavioural instruments. Exercise levels were classified into three categories: absent, moderate, and vigorous, using the previous two weeks exercise levels to confirm regularity and recency. RESULTS: 9/51 (17.6%) depressed participants took exercise compared with 76/173 (43.9%) non-depressed [odds ratio (OR)=2.9, confidence interval (CI)=1.5-5.6, p=0.001]. Not taking part in other activities (hobbies and interests) was associated with depression but less so than lack of exercise. Independent predictors of depression were: lack of exercise (p <0.001, OR=3.4, CI = 1.7-7.2), taking cholinesterase inhibitors (p <0.05, OR=2.4, CI = 1.2-4.9) and having less involvement in hobbies or interests (p <0.05, OR = 1.2, CI = 1.0-1.5). CONCLUSION: None of the traditional risk factors for depression in older people were associated with depression in AD. Taking regular exercise may protect against depression in AD.

Hoe J, Katona C, Roch B, Livingston G. · Centre for Ageing and Mental Health Sciences, Department of Mental Health Sciences, University College London, Archway Campus, Holborn Union Building, Highgate Hill, London N19 5LW, UK. · Age Ageing. · Pubmed #15713856 links to  free full text

Abstract: BACKGROUND: Health-related quality of life (HR-QOL) scales are particularly important in older people as global outcome measures for interventions. It is known that people with mild to moderate dementia can provide valid assessments of their own QOL, but it is unclear whether these instruments are useful in those with severe dementia. OBJECTIVE: We examined the usefulness of the QOL scale in Alzheimer's disease (QOL-AD) in people with severe dementia by considering the ability of older people with a Mini-Mental State Examination (MMSE) score of <12 and their caregivers to complete this scale, as well as its construct validity and internal consistency. METHODS: Data were collected from people with Alzheimer's disease and their caregivers using a range of instruments measuring cognition, mood, behaviour, QOL and functional ability. RESULTS: Of 79 participants and their caregivers, 41 (52%) could complete the QOL-AD. Cognition and functional abilities were significantly higher in the completers than in the non-completers (P < 0.001). The QOL-AD showed internal consistency and construct validity as it correlated with ability to look after self, fewer limitations due to physical health, positive mood status and low levels of apathy. CONCLUSIONS: There is evidence for the validity and reliability of the QOL-AD in people with MMSE scores of 3-11, as well as the practicality of administering the scale in this population. The scale is unlikely to generate useful information for people with MMSE scores of <3. QOL does not decrease as cognition worsens. This throws into question most people's assumption that decreasing cognition worsens QOL. We consider that it may be important to inform the public of this, as living wills are used increasingly in our culture.

Livingston G, Katona C. · Department of Mental Health Sciences/Camden and Islington Mental Health and Social Care Trust, University College London, N19 5LW London, UK. · Int J Geriatr Psychiatry. · Pubmed #15449303 No free full text.

Abstract: INTRODUCTION: Memantine is currently the only treatment approved for moderately severe to severe Alzheimer's disease (AD). There is still some discussion as to its place in clinical practice and many UK clinicians are discouraged for economic reasons from prescribing it. We adopt a 'number needed to treat' (NNT) approach to assess the benefits reported in memantine trials. METHOD: We searched Medline and the Cochrane Dementia and Cognitive Improvement Specialised Register for double-blind, randomised and controlled trials of memantine in AD. If efficacy was only reported in terms of mean change, rather than as number of individuals who responded or were harmed by an intervention, we contacted the drug companies (Merz and Lundbeck) to ask for more data. We also calculated effect size. RESULTS: We found two trials of memantine in AD that met our criteria. We found that NNTs for global outcome were 3 and 6, for cognitive outcome 7 and for activities of daily living 4 and 8. The effect size for memantine varied between 0.32 and 0.62. For NNH memantine was no more harmful than placebo and significantly less so for the outcome of agitation. CONCLUSION: The small NNTs and the lack of harm shown by the NNHs strongly suggest that memantine, as with cholinesterase inhibitors, has a valuable place in the current clinical management of AD. The effect sizes are mainly in the 'medium' range for clinical effect, which also suggests that memantine has a clinical place in terms of cognition and dependency. There remains a need for more studies that examine carer burden, behavioural and psychological effects, and quality of life for both the person with dementia and the caregiver.

Livingston G, Katona C, Roch B, Guilhaume C, Rive B. · Department of Mental Health Sciences/Camden and Islington Mental Health and Social Care Trust, University College London, Archway Campus, London, UK. · Curr Med Res Opin. · Pubmed #15265245 No free full text.

Abstract: BACKGROUND: Loss of independence becomes more marked as Alzheimer's disease (AD) progresses and contributes significantly to its societal and economic burden. Existing measures of functional disability focus either on basic or on instrumental activities of daily living (ADL). It would be more appropriate to combine these but, using existing assessment tools, this would involve considerable quantitative analysis. Recently, a qualitative and pragmatic system of classifying AD patients according to levels of dependency has been developed in a Belgian cohort. OBJECTIVES: To validate independently, in a UK community setting, a functional classification model of AD patients and to explore the relationship between dependency and costs of care using this model. RESEARCH DESIGN AND METHODS: Longitudinal epidemiological study of 224 AD patients. Data were collected at baseline and at 6 months on ADL, global state, cognition, behavioural dimensions, depression, quality of life and resource utilisation using validated instruments. An automatic classification algorithm was performed to allow identification of dependency clusters. The scheme was tested for validity against other simultaneously collected data including health and social care costs. The relationship between dependency and costs of care was explored using ANOVA models. RESULTS: Analysis of the ADL assessment instruments produced three ADL sub-scores by which patients could be classified into one of three disability clusters: ('non-dependent', 'non-dependent with instrumental functional disability', and 'dependent'). Good external validity of the classification scheme was demonstrated by correlation with simultaneously collected data. After a backward selection process on ANOVA model (at a 5% level), institutionalisation and the most dependent status were the most significant cost drivers. CONCLUSIONS: Qualitative classification of AD patients using dependency levels is a simple and validated approach. Applying this approach showed that institutionalisation and the most 'dependent' status were independently and significantly associated with high care cost.