Alzheimer Disease: Orrell M

Spector A, Woods B, Orrell M. · Sub-Department of Clinical Health Psychology, University College London, Gower Street, London WC1E 6BT, UK. · Expert Rev Neurother. · Pubmed #18457532 No free full text.

Abstract: In recent years, there has been an increase in the recognition and use of psychosocial interventions for dementia. This has coincided with an increase in high-quality research in the area, and restrictions in the use of drug therapies for Alzheimer's disease in the UK. Cognitive stimulation therapy (CST) is a brief group treatment for people with mild-to-moderate dementia, based on the theoretical concepts of reality orientation and cognitive stimulation. It involves 14 sessions of themed activities which typically run twice a week over a 7-week period. A multicenter, randomized controlled trial showed significant benefits in cognition and participant-rated quality of life when comparing CST versus no treatment. These benefits in cognition were comparable to those gained through medication, and CST also proved to be cost-effective. Influenced by this research, the latest guidelines released by NICE recommended cognitive stimulation only as an intervention for treating the cognitive symptoms of dementia. This perspective describes how CST was developed and evaluated, its use in clinical settings and issues for future investigation, such as individualized CST.

Clare L, Woods RT, Moniz Cook ED, Orrell M, Spector A. · Sub-department of Clinical Health Psychology, University College London, Gower Street, London, UK, WC1E 6BT. · Cochrane Database Syst Rev. · Pubmed #14583963 No free full text.

Abstract: BACKGROUND: Memory problems are a defining feature of the early stages of Alzheimer's disease (AD) and vascular dementia. Cognitive training and cognitive rehabilitation are specific approaches designed to address everyday memory difficulties. OBJECTIVES: The main aim was to evaluate the effectiveness and impact of cognitive training and cognitive rehabilitation interventions aimed at improving memory functioning for people in the early stages of Alzheimer's disease or vascular dementia. The two types of intervention were considered separately. SEARCH STRATEGY: The CDCIG Specialized Register, which contains records from MEDLINE, EMBASE, CINAHL, PsycINFO and many other databases, was searched on 9 April 2003. SELECTION CRITERIA: RCTs comparing cognitive rehabilitation or cognitive training interventions with comparison conditions, and reporting outcomes for the person with dementia and/or the family caregiver, were considered for inclusion. DATA COLLECTION AND ANALYSIS: Six studies reporting cognitive training interventions were included. Statistical analyses were conducted to provide an indication of intervention effect sizes. Data from ordinal scales was treated as continuous, and a fixed effects model was applied in calculating weighted mean differences and 95% confidence intervals. No studies were found that reported a fully individualised cognitive rehabilitation approach. MAIN RESULTS: None of the six studies reporting cognitive training interventions demonstrated any statistically significant effects in any domain, although there were indications of some modest, non-significant effects in various domains of cognitive functioning. REVIEWER'S CONCLUSIONS: The present findings do not provide strong support for the use of cognitive training interventions for people with early-stage AD or vascular dementia, although these findings must be viewed with caution due to the limited number of RCTs available and to the methodological limitations identified, and further well-designed trials would help to provide more definitive evidence. Due to a complete absence of RCTs evaluating an individualised cognitive rehabilitation approach, It is not possible at present to draw conclusions about the efficacy of individualised cognitive rehabilitation interventions for people with early-stage dementia, and further research is required in this area.

Tabet N, Mantle D, Orrell M. · Department of Old Age Psychiatry, Portnalls Unit, Farnborough Hospital, Orpington, Kent BR6 8ND, UK. · Adverse Drug React Toxicol Rev. · Pubmed #10967748 No free full text.

Abstract: Recent research has increasingly suggested a central role for free radical induced tissue damage in the pathogenesis of Alzheimer's disease (AD). In this paper we review evidence for the interaction between free radicals and other major factors/metabolic areas which have also been implicated in AD, including beta-amyloidosis, inflammatory cytokines, mitochondrial dysfunction and metal ions/homocysteine. We hypothesize that free radicals and antioxidants should not be considered in isolation in the aetiology and treatment of AD. It is the reciprocal induction and self-amplifying interplay between all of the above factors which is important in the pathogenesis of this disorder, and to which multi-pharmacological therapeutic strategies should be directed.

Spector A, Davies S, Woods B, Orrell M. · Department of Psychiatry and Behavioural Sciences, University College London, England. · Gerontologist. · Pubmed #10820923 No free full text.

Abstract: The effectiveness of classroom reality orientation (RO) in dementia was evaluated by conducting a systematic literature review. This yielded 43 studies, of which 6 were randomized controlled trials meeting the inclusion criteria (containing 125 subjects.) Results were subjected to meta-analysis. Effects on cognition and behavior were significant in favor of treatment (cognition standardized mean difference [SMD] = -0.59; 95% confidence interval [CI] -0.95(-)-0.22; behavior SMD = -0.64, 95% CI = -1.20(-)-0.08). The evidence indicates that RO has benefits on both cognition and behavior for dementia sufferers. However, a continued program may be needed to sustain potential benefits. Future research should evaluate RO in well-designed multicenter trials.

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.

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.

Spector A, Orrell M. · Department of Mental Health Sciences, University College London, London, UK. · Alzheimer Dis Assoc Disord. · Pubmed #16917186 No free full text.

Abstract: Evaluating quality of life (QoL) in people with dementia has become increasingly valued, for example in assessing the effectiveness of interventions or making treatment decisions. This study compared the QoL of people with dementia as assessed by the individuals and their care staff, and possible factors associated with the discrepancy between ratings. Seventy-six dyads of people with dementia and care staff in 9 residential homes were recruited. People with dementia were interviewed, using the "quality of life-Alzheimer disease" (QoL-AD) and assessed for severity of cognitive impairment. Staff completed the QoL-AD with respect to the person with dementia, and measures assessing their job satisfaction, level of hope, and person-centeredness. Results showed that people with dementia and care staff rated QoL differently. Some items on the QoL-AD ("physical health," "family," and "friends") were rated similarly between the 2 groups and others differently ("ability to do chores," "marriage/closest relationship," "memory," and "life as a whole"). Neither staff factors (hope, person-centeredness, or job satisfaction) nor the severity of cognitive impairment in the people with dementia explained the discrepancy between ratings. However, when data were aggregated within residential settings, a correlation between increased hope in staff and better resident assessed QoL emerged. Care homes should be aware that low staff hope may be linked to lower resident QoL. Effective training and support for care staff may impact on residents' 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.

Thorgrimsen L, Selwood A, Spector A, Royan L, de Madariaga Lopez M, Woods RT, Orrell M. · Department of Psychiatry and Behavioural Sciences, University College London, London, UK. · Alzheimer Dis Assoc Disord. · Pubmed #14657783 No free full text.

Abstract: Quality of life (QoL) is becoming an increasingly used outcome measure in both clinical practice and research. There are now more than 1000 scales available to measure QoL, and it is important that they are assessed for reliability and validity. This study aims to assess the reliability and validity of the Quality of Life-Alzheimer's Disease (QoL-AD) scale, which is dementia specific and brief and uses the patient's own responses. Two separate samples of people with dementia (sample 1, n = 60; sample 2, n = 201) were assessed. Five focus groups were conducted involving both people with dementia and their caregivers; the focus groups showed that people with dementia had higher hopes for their QoL than their caregivers did for them. Questionnaires about the scale were completed by 71 health care professionals working with people with dementia. The scale was found to have good content validity with no additional items required and all items necessary. It also correlated well with the Dementia Quality of Life scale (0.69) and with the Euroqol-5D scale (0.54), indicating good criterion concurrent validity. Construct validity was also good with the principal components analysis showing all 13 items of the QoL-AD loaded on component 1. Interrater reliability was excellent with all Cohen's kappa values >0.70. Internal consistency was excellent with a Cronbach's alpha coefficient of 0.82. Some people with severe dementia and a Mini-Mental State Examination score as low as 3 were able to satisfactorily complete the QoL-AD. The QoL-AD has very good psychometric properties and can be completed with people with a wide range of severity of dementia.

Tabet N, Walker Z, Mantle D, Costa D, Orrell M. · Postgraduate Medical School, Faculty of Health, University of Brighton, Falmer, Brighton BN1 9PH, UK. · Dement Geriatr Cogn Disord. · Pubmed #12714800 No free full text.

Abstract: The degeneration of dopaminergic cells in dementia with Lewy bodies (DLB) may provide an important source of additional free radical generation. As a result, the oxidative stress status in DLB could be significantly enhanced. Subsequently, the levels of endogenous antioxidants, which are an indirect measure of free radical activities, may be different in DLB patients when compared with Alzheimer's disease (AD) patients and controls. In this preliminary study, we measured the activities of superoxide dismutase (SOD), catalase (CAT), glutathione (GLU) and total antioxidant capacity in the blood of DLB, AD and control subjects. The state of nigrostriatal dopaminergic system was also assessed in vivo by using a radioactive ligand with an affinity for the dopamine pre-synaptic receptors and by imaging with single-photon emission tomography. Data obtained showed a decrease in dopamine pre-synaptic receptors in all the brain regions of DLB patients. The levels of SOD did not differ significantly between DLB, AD and control subjects. However, GLU levels were significantly higher in the DLB patients when compared with AD patients (p < 0.05) and controls (p < 0.01). CAT blood levels were also higher in DLB when compared with AD, but this did not reach statistical significance. The results suggest that a different oxidative stress state may exist in DLB. This may occur due to increased free radical production from the degeneration of dopaminergic cells and auto-oxidation of dopamine, the availability of which may be maintained in early-stage DLB disease as a result of the compensatory increase in its turnover from the remaining dopaminergic cells.

Martin MD, Hancock GA, Richardson B, Simmons P, Katona C, Mullan E, Orrell M. · Brian Oliver Centre, Birmingham, UK. · Int Psychogeriatr. · Pubmed #12670059 No free full text.

Abstract: This article describes the met and unmet needs of elderly residents of nursing care (NC) and residential care (RC) settings. Thirty-four residents of an RC home and 40 residents of two NC settings were assessed. Each resident and a respective staff member were interviewed using the Camberwell Assessment of Need for the Elderly (CANE) to indicate the resident's current met and unmet needs. The Clifton Assessment Procedure for the Elderly-Behaviour Rating Scale (CAPE-BRS) was completed by the staff member to indicate the participant's current level of dependency. In addition, the Mini-Mental State Examination was administered to participants and DSM-IV diagnosis was recorded. A high number of needs were found in both RC and NC settings, the level of dependency being proportional to level of need. There was a core set of needs in both samples related to difficulties with accommodation, food preparation, and self-care. Both NC and RC homes were meeting these needs; however, RC residents had a significantly greater level of unmet need for suitable day-time activities. The greatest predictor of type of setting was gender and there were significantly more females in RC. Controlling for gender, participants in NC had greater levels of dependency, particularly problems with apathy and social skills, as measured on the CAPE-BRS. It is possible that-the greater level of social needs in NC residents had led to their placement in the more specialized NC settings. On the other hand, NC settings may be left caring for a group of residents that, because of their specific needs, have been difficult to place into RC. These findings have clinical implications for the future development of continuing care for the elderly. This study also highlighted that there is a substantial need for specialist services to address the unmet needs in these two types of continuing-care settings, such as interventions for social disturbances in NC and suitable daytime activities in RC. The CANE is a useful instrument to evaluate such needs in long-term-care settings.

Spector A, Orrell M, Davies S, Woods B. · No affiliation provided · Nurs Times. · Pubmed #11954530 No free full text.

This publication has no abstract.

Orrell M, Butler R, Bebbington P. · Department of Psychiatry and Behavioural Sciences, University College London, UK. · Int J Geriatr Psychiatry. · Pubmed #10861917 No free full text.

Abstract: Previous studies have linked reduced survival in dementia with male sex, older age, longer duration of illness and increased severity of cognitive impairment. However, little is known about the potential influence of social factors (such as life events and social support) on the outcome of dementia. Sixty recently admitted patients with dementia (27 in-patients and 33 day patients) were given detailed psychiatric and social assessments. These included information on life events and social supports. At follow-up, 3 years later, data were collected on outcome. The hypotheses were that adverse life events and lack of social support would be associated with reduced survival. Nearly half the patients (48%) died during the follow-up period. The experience of life events before the first assessment was not associated with outcome. However, receiving meals on wheels (p=0.01) was associated with reduced survival, while attending a day centre (p=0.06) and having support from relatives (p=0.06) were associated with increased survival. Higher dependency (p=0.004) and poorer physical health (p=0.07) were associated with reduced survival. These results suggest that factors related to social support are associated with the outcome of dementia. In particular, receiving meals on wheels or home help may be a marker of a lack of social support, which influences outcome. Further studies are required to examine these associations in more detail.