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PO5. Genetics, prevention and treatment

Detailed programme, abstracts and presentations

PO5.1. Assessing quality of life in nursing homes: a cross-sectional overview of potential influencing factors

FERNANDES Lia1,4, FERREIRA Ana Rita1, RODRIGUES SIMÕES Mário2, GUEDES Joana3

1University of Porto, Porto, Portugal, 2University of Coimbra, Coimbra, Portugal, 3Higher Institute of Social Work of Porto, Porto, Portugal, 4Hospital Center of S. João of Porto, Porto, Portugal

Introduction: Quality of life (QoL) is increasingly used as a health and quality outcome, so identifying predictors that may successfully improve it is of major importance. In this line, behavioural and psychological symptom (BPSD) are frequently pointed as predictors of poor outcomes, including not only premature institutionalization in nursing homes (NH), but also worse QoL. Despite being reliable targets for intervention, in such settings these remain exceedingly frequent and unidentified symptoms, contributing to residents’ lower QoL.

Aim: To analyse the associations between self-rated QoL and residents’ demographic and clinical characteristics.

Methods: A cross-sectional study was conducted in two NH as part of a larger study. All residents were eligible, unless they were younger than 65years or had a registered diagnosis of major psychiatric illness. Data were collected with Mini-Mental State Examination/MMSE, Geriatric Depression Scale/GDS-15 and Neuropsychiatric Inventory/NPI-10. To assess QoL, EUROHIS-QOL8-index was used. Spearman’s rank correlation coefficients were calculated.

Results: Overall, 74 residents were included, mostly women (68.9%) with a mean age of 84.1 (sd=7.0) years. Sample scored an average of 22.51 (sd=5.11) on MMSE, 5.76 (sd=3.88) on GDS, 7.32 (sd=10.54) on NPI-10, and 58.45% (sd=17.83%) on EUROHIS-QOL. More than half (60.8%) scored for cognitive impairment and 45.9% for clinically relevant BPSD (NPI≥4). Negative correlations were found between EUROHIS-QOL and NPI (rs=-0.349, p=0.002), and and GDS-15 (rs=-0.858, p<0.001), while none was found with MMSE nor age (p=0.091 and p=0.332).

Conclusions: In this sample, a lower QoL was associated with more BPSD and higher self-reported depressive symptomatology. Once these symptoms are reliable targets for a range of individually tailored interventions, the present findings highlight the importance of assess, identify and treat BPSD as a way to improve QoL in NH.

Supported by FCT-Foundation for Science and Technology (PD/BD/114555/2016), ERDF through operation POCI-01-0145-FEDER-007746 funded by Programa Operacional Competitividade Internacionalização-COMPETE2020, National Funds through FCT within CINTESIS, R&DUnit (ref.UID/IC/4255/2013).

PO5.2. Respectful caring for the agitated elderly (recage). A project funded by the European Commission (h2020)

DEFANTI Carlo, FASCENDINI Sara, BAROCCO Federica, ZANNI Mara

Fondazione Europea di Ricerca Biomedica, Gazzaniga, Italy

RECAGE tackles one of the most challenging problems arising in the course of dementia: BPSD. Given the unsatisfactory state of the art in this respect, the major obiective of the project is to assess the effectiveness of an intervention, the Special Care Unit for BPSD (SCU-B), which - although implemented in some countries - is not widespread and, moreover, has not been sufficiently studied so far. We define the SCU-B as "a residential medical structure lying outside a nursing home, e.g. in a general hospital or elsewhere, where persons with dementia (PwD) are temporarily admitted when their BPSD are not amenable to control at home. The mission of the SCU-B is to improve behaviour and to permit, when possible, their coming back home".

RECAGE is articulated in three phases:

1. a prospective, multicentre, observational, cohort study comparing the course of a cohort of 250 PwD followed up by 6 clinical centres endowed with a SCU-B and another cohort of 250 followed by 6 centres lacking this structure. The follow-up will last 3 years and the main endpoints be: change of BPSD over time, quality of life of PwD and their caregivers, time to institutionalisation. A cost-effectiveness analysis will be performed on both cohorts. 

2. a second phase will be dedicated to adapting the model, taking into account the results of the trial, and to writing a consensus document of recommendations for the implementation if new SCU-Bs

3. a third phase will be devoted to making plans for scaling up the intervention in countries taking part in the study.

The Consortium consists in 12 clinical centres located in 7 European Countries (Italy, France, Germany, Belgium, Greece, Switzerland and Norway), a CRO, a medical economist, two Alzheimer Association (from Italy and Greece) and two health Authorities (from Italy and Greece),

PO5.3. Lessons learnt from transnational comparison of three care programs related to challenging behavior in nursing homes

HOLLE Daniela1, GERRITSEN Debby2, LICHTWARCK BjØrn3, HALEK Margareta1, SMALBRUGGE Martin5, ZUIDEMA Sytse6, ZWIJSEN Sandra7

1German Center for Neurodegenerative Diseases (DZNE); University of Witten/Herdecke, Witten, Germany, 2Radboud University Medical Center, Nijmegen, Netherlands, 3Centre for Old Age Psychiatric Research, Innlandet Hospital Trust Ottestad; Institute of Health and Society, Faculty of Medicine, University of Oslo, Ottestad/Oslo, Norway, 5VU University Medical Center, Amsterdam, Netherlands, 6Department General Practice and Elderly Care Medicine, University of Groningen, Groningen, Netherlands, 7Department of General Practice and Elderly Care Medicine; Public Health research institute, VU University Medical Center, Amsterdam, Netherlands

(Inter-)national guidelines emphasize the need for proper analysis of challenging behavior (CB) in nursing home residents with dementia. In several countries, researchers and practitioners have developed care programs for an analysis-focused approach of CB.

The current work compares thecontentandimplementation strategiesfor three care programs from the Netherlands (GRIP), Norway (TIME) and Germany (WELCOME-IdA) using the template for intervention description and replication (TIDieR). This international comparison and analysis resulted inrecommendationsforfuture researchandcurrent practice: (1) Designing and testing these interventions takes many years, for which sufficient time and funding is needed. (2) The implementation of the intervention should be preceded by a local analysis of the implementation climate and the impact of the intervention on organizational processes. (3) Attuning interventions to existing practice is important to obtain sufficient support for implementation. However, by including progressive elements in the intervention as well, this may bring about an important culture shift. (4) To sustain the intervention in routine care, a cycle for evaluation and follow-up training programs that are adapted to local circumstances should be incorporated in the implementation strategy. (5) Working methodologically and interdisciplinary is central for an analysis-focused approach to CB. The theory and skills required for this are still lacking in current practice and need to be included in all European curricula for professions working with people with CB. (6) The benefit of (inter-) national guidelines on CB is to create a common understanding about the management of CB. However, guidelines do not provide tools that convert the general recommendations of the guidelines into methods that can be used in practice. Publication of a guideline should therefore always be accompanied by suggestions for implementation strategies.

PO5.4. Benefits of using Snoezelen stimulation with resident in long-term facilities and with different levels of dementia

SOLÉ Carmen1, CIFRÉ Ignacio2, CELDRÁN Montserrat1, GASPART Marta2, RODRIGUEZ Laura2

1Facultat de Psicologia, Barcelona, Spain, 2FPCEE Blanquerna, Barcelona, Spain

Introduction: The theoretical framework of this project is adjusted to comprehensive and person-centered care. Therapist using a Snoezelen Room adapts to the different needs of those person with dementia in order to achieve improvement in their quality of life or in specific symptomatology such as agitation or apathy. The main objective of this work is to investigate the behavioral and psychological benefits of multisensory stimulation, taking into account if a mild, moderate or severe level of dementia could modify its results. Method: Mixed. Design: Quasi-experimental, with repeated measures intra-subject in several points of the investigation. Subjects: 84 people with dementia. Instruments: Standardized tests and video-recordings. Procedure: Participants were randomly assigned to the Snoezelen room or to the reminiscence sessions (control group). Each group participated in two weekly sessions of 30 minutes for 3 weeks. Each session had a maximum of three residents in each group. Tests were applied in pre and post sessions and sessions 1 and 6 were videotaped. Results: There were significant differences in anxiety, depression and agitation in resident that participated in the Snoezelen room compared with those that attended the reminiscence therapy. Video-recordings analysis showed also an improvement in relaxation behaviors. Conclusions: Multisensory therapy favors emotional adjustment. This study was funded by the Faculty of Psychology, Education Sciences of the Blanquerna School (Ramon Llull University) and Sanitas Mayores.

PO5.5. Challenges of behavioral & psychological symptoms of dementia in both institutionalized and community settings

CHAN Kar Choi

Chinese University of Hong Kong, Hong Kong, Hong Kong

Background: Behavioral and Psychological Symptoms of Dementia (BPSD) are presenting greater challenge than cognitive symptoms in the care process. However, there have been very few studies which focus on the impact of BPSD and how they are managed in both institutionalized and community settings. Therefore, the aim of our study is to fill this knowledge gap by surveying care professionals about problematic BPSD encountered in their practice.

Methods: 103 care professionals who worked in elderly services or nursing homes were invited to complete questionnaires which asked both quantitative and qualitative information about challenging behavioral and psychological scenarios involving their clients. Narratives elicited by open-ended questions were analyzed to identify: 1) target BPSD, 2) emotional impact on carers, and 3) management strategies attempted.  Comparisons were also made between institutionalized and community-dwelling elders with respect to the 3 aforementioned areas.

Results: 47 completed questionnaires were returned; 12 cases were excluded because issues were un-related to BPSD. Of the remaining 35 cases, almost half were males (n=17); 15 resided in nursing homes while the rest lived in the community. Verbal and physical aggressive behaviors (n=21) were the most-cited challenges. Frustration, stress, and feeling of incompetence were the emotional reactions common to carers when confronted by BPSD. Management strategies often involved family members, communication and counselling, or psychiatric consultation. Appeasement and reasoning were strategies more likely used by family carers, although there was no significant difference in BPSD management strategies between institutionalized and community settings. As significant difference was established for emotional impact on carers (X2; p=0.046; p<0.05), it appears that BPSD were more likely to cause fear, uncertain and incompetent feeling among carers in community environment.

Conclusion: This study captured and analyzed qualitative data about BPSD which may help to refine management strategies and carer support in both institutionalized and community settings.

PO5.6. Clincal storytelling as tool to bridge lived experience and scientific evidence in person centered care?

HALLINDER Helena1, JOSEPHSSON Staffan2

1Stockholms Sjukhem, Bromma, Sweden, 2Karolinska Institutet, Stiockholm, Sweden

Students background: Care of elderly persons with dementia raises particular demands on staff's knowledge of handling different situations around the person. Research has shown that staff draw on narrative modes of reasoning to learn how to address everyday situations in a competent way. Little is known on how students in higher education can be facilitated to learn within clinical placement in dementia oriented geriatric care.

Aim: The study aim is to evaluate experiences of clinical storytelling, and outcome of evidence based knowledge translation in students participating in narrative seminars.

Study method: All students from the medical, nursing, physiotherapy, occupational therapy and speech and language pathologist programs with clinical placement in geriatric care, and rehabilitation at a larger clinic were invited to participate in the study. Students participated in case seminars drawing on clinical storytelling with purpose to facilitate learning of situating generic scientific knowledge to the multifaceted every day life of the person with dementia. Data constituted of field notes from each seminar, plus interview transcriptips from interviews with a few students.

Analysis: Qualitative data was analyzed with a qualitative interpretive theoretical framework. In line with this theoretical framework, analysis included thematic analysis generating qualitative hypotheses for further research and theory development. Although the project is ongoing, the seminar field notes and interview data, so far indicate that the assumption that clinical stories exist and are feasible material in learning seminars are proven true. Not only do students bring stories to the table. They also feed in to the story of others to confirm, oppose, relate to theoretical evidence or evoked memories from personal experiences. They felt confirmed and seen and one student stated: “I found the seminars informative and interesting. We raised everyday aspects regarding persons with dementia and cognitive impairment that I have limited experience from since before”.

PO5.7. Digital self-monitoring for people with mild cognitive impairment: the 'Monitor-Mi' study

BARTELS Sara Laureen, VAN KNIPPENBERG Rosalie, VERHEY Frans, DU VUGT Marjolein

Maastricht University, Maastricht, Netherlands

Objective: The Experience Sampling Methodology (ESM) is an innovative technique used to collect information in everyday life. Thus, ESM can reveal pattern of activities and context, related emotions as well as their fluctuations in daily life. To our knowledge, ESM has not been used in MCI yet. Therefore, the primary objective is to evaluate the feasibility and validity of the ESM, specifically implemented in the PsyMate smartphone application, in an MCI population.

Methods/design: 30 participants will be asked to collect ESM data using the PsyMate application on a smartphone over a six-day period. The application will generate eight signals/day. After each signal, short reports of the current mood, subjective cognition, context and appraisals of the situation will be collected. Furthermore, a morning and evening questionnaire will ask the participant to reflect on the last night/day.

Feasibility will be assessed through subjective participants’ ratings of the difficulty, time burden and acceptability of the PsyMate. An observation of the individual performing the application on the smartphone will give further insight.

Validity will be assessed by examining the presence of expected patterns among variables in daily life of the person with MCI and by examining the concordance between ESM measurements and standard retrospective measurements of the same construct.

Discussion: ESM real-life information of people living with MCI may enable the individual, caregiver, clinician as well as research to better understand the condition. Within an intervention, ESM has the potential to promote self-management abilities and modify behavior towards more meaningful and positive activities. This promising self-monitoring smartphone approach could prospectively contribute to an increased patient ownership in therapy. Evaluating the feasibility and validity of the ESM delivered via a smartphone application could thus be an important initial step to develop an innovative technology based intervention to assist people with MCI to self-manage everyday life.

PO5.9. "Activity as an Arena for participation among persons with early oneset dementia"

VIKSTRÖM Sofia, JOESPHSSON Staffan

Karolinska Institutet, Stockholm, Sweden

Aims: The aim of the study was to identify persons with dementias perceived experiences of participation in everyday activities.

Methods: Emperical data was collected through narrative interviews and participatory observation. The study used this methodology to be able to focus on participants´thoughts, values and feelings about their lives in order to gain an understanding of the subjective experience of participation.

The participants of the study, to men and one women, were included through a deliberate choice, to include participants who would abel to and comfortable with participating in a study with a storytelling method. The data collection was mainly carried out in the participant’s home. Narrative analyses was used where rich and wide descreptive material was obtained.

Data was iterratively treated in a dynamic process with the use of the hermeneutic circle.

Results: The analysis generated in three very different stories that represented each participant’s reflections, experiences and feelings about participation. The themes of the stories were given the following headings:

“My chorus group dilemma”, “You see, I can´t read” and "I knew early one that I had dementia”.

Conclusion: The stories showed that participation was described by activities carried out and had been performed earlier in their lives. Participants experience was that they tried to maintain participation through activity. It was important to still be active in the activities they wanted to perform. In this way it was possible to feel a stronger self-image and be involved in their situation. Dilemmas were around how the social environment treatment affected the feeling of participation in all activities. Fears were to be socially excluded and because of that the participants were not completely truthful about their disabilities or problems. They requested an activity arena where they could get to feel important, respected and accepted for the person they are.

PO5.10. Cognitive Stimulation Therapy: Guideline-based adaptation and translation to German

WERHEID Katja1, SCHAUBS-SCHMIDT Barbara2

1Humboldt University, Berlin, Germany, 2Klinikum Ernst von Bergmann, Potsdam , Germany

Cognitive Stimulation Therapy (CST) has beein increasingly spread in Europe and worldwide. Evidence-based guidelines have been developed by Aguirre et al. (2014) to ensure replicability of the intervention in other cultures and adherence to the basic principles of CST, in order to maximize the effectiveness and impact of the adapted programmes. In our project, we adapted and translated the English CST manual to German, following a community-based developmental approach, the five phases of the Formative Method for Adapting Psychotherapy (FMAP).  A pilot study (n=13) with a pre-post comparison of standard scales on cognition, depression, quality of life, and self-efficacy was conducted to evaluate the German manual in two different settings: an ambulant, community-based CST group and another group in a residential home. In both settings, earlier findings of improved cognition as measured by the ADAS-Cog were replicated, with effect sizes in the same range as in international randomized controlled trials. Additionally, we found that self-efficacy was increased in post-test compared to the pre-test, which may add to the view that cognitive stimulation triggers cognition through positive, self-rewarding activation. Our pilot study, albeit small-scaled, may serve as an example for culture-sensitive transfer of psychosocial interventions, and for the use of standardized measures to assess how such interventions may facilitate the growth of competences alongside the slowing of cognitive impairments.

PO5.11. Usefulness of the Locus of Control of Behavior scale for people with dementia

HALSE Ingeborg1, BJØRKLØF Guro Hanevold2, ENGEDAL Knut3, ROKSTAD Anne Marie Mork4, PERSSON Karin3, ELDHOLM Rannveig Sakshaug5, SELBÆK Geir6, BARCA Maria Lage3

1Norwegian National Advisory Unit for Aging and Health, and Department of Geriatric Medicine, Oslo University Hospital-Ullevål and Faculty of Medicine, University of Oslo, Oslo, Norway, 2Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway, 3Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, and Department of Geriatric Medicine, Oslo University Hospital-Ullevål, Oslo, Norway, 4Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, and Faculty of Health Sciences and Social Care, Molde University College, Molde, Molde, Norway, 5Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, 6Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, and Faculty of Medicine, University of Oslo, and Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Ottestad, Norway,

Background: Depression is common among people with dementia, and increased knowledge on coping mechanisms is needed for its prevention and treatment. One such mechanism is the Locus of Control, which predicts depressive symptoms in a wide variety of populations. The Locus of Control of Behavior scale (LoCB) gives an indication of a person’s control orientation, or to which degree one tends to believe outcomes as due to internal or external factors. The LoCB has not previously been applied to people with dementia.

Aim: To examine the usefulness of the LoCB in assessing control orientation among people with dementia.

Method: A group of 551 people with a dementia diagnosis, recruited from memory clinics and day care centers across Norway, were assessed using the LoCB, Montgomery Aasbergs Depression Rating Scale (MADRS), Mini Mental Status Examination-NR (MMSE) and Instrumental Activities of Daily Living (I-ADL). Usefulness of the LoCB was assessed by the proportion of complete responses within predefined groups based on MMSE score (10-14, 15-19, 20-24, 25-27, 28-30). Internal reliability was analyzed by Cronbach’s α. Factors associated with LoCB completion were investigated with logistic regression analysis.

Results: In all, 234 participants completed the LoCB. Proportion of complete responses in the predefined groups were 14% in MMSE 10-14, 34% in MMSE 15-19, 55% in MMSE 20-24, 63% in MMSE 25-27, and 74% in MMSE 28-30. Internal reliability scores were 0.80, 0.73, 0.76, 0.52, and 0.72, respectively. Age, education, MMSE and I-ADL were associated with completion of LoCB, with MMSE being the most strongly associated factor (OR 1,211).

Conclusion: The LoCB appears useful in assessing control orientation for those with MMSE ≥20. MMSE score was the factor most strongly associated with LoCB completion. Although low completion rate among participants with MMSE<20, internal reliability remained high. 

PO5.12. Pain assessment instruments in people with cognitive impairment: systematic review

CANTÓN HABAS Vanesa, MARTOS CALERO Claudia, CARRERA GONZÁLEZ Mª Pilar

Universidad de Córdoba, Cordoba, Spain

Introduction: Nowadays, it is estimated that 47 million people suffer from dementia all over the world. Pain is particularly difficult to identify in cognitively impaired individuals, especially when they are not able to communicate it, because it can manifest itself atypically as agitation and increased confusion.

Objective: To know the existing scientific production regarding scales to valuate the pain in patient with dementia.

Method: systematic review. We queried the mayor Health Science databases: ProQuest, PubMed, Scopus and Cocharne, this last one in order to know whether there was any previous investigation related to the aim of this research’s, but we did not find any result in this regard. The search was carried out between February and April 2018 by using the following key words: “cognitive dysfunction” AND “pain measurement”. The research articles included in the review were observational studies published within the last 5 years in English or Spanish.

Results: Six articles were included in the review. Self-report scales, for example VAS, should be the main option to evaluate the pain in mild dementia. IPT scale, a self-report instrument, can be use also in patient with moderate dementia. However, to valorate the pain that a patient with advance dementia has we can choose between PAINAD and PACSLAC scales. PAINAD is the most useful because it is simple vocabulary and it is also shorter.

Conclusion: The evidence found shows that health personnel should choose a different instrument to valuate the pain depend on the phase of the disease.

PO5.13. Antipsychotics in dementia care: the development of a repeat prescribing tool using a Delphi Consensus method

FOLEY Tony, NAOIHSE Guerin, AISLING Jennings

University College Cork, Cork, Ireland

Background: With Ireland’s aging population, dementia prevalence is rising. Many patients with dementia have behavioural and psychological symptoms (BPSD) and are prescribed antipsychotics, which have serious potential adverse effects.  General Practitioners (GPs) initiate the majority of these medications. International guidelines advocate regular medication review for patients maintained on antipsychotics. However, no standardised monitoring template for Irish GPs exists.   The aim of this study was to create a standardised repeat prescribing monitoring template (RPMT) for antipsychotic prescribing in patients with dementia, using an expert consensus group technique.

Methods: International antipsychotic monitoring templates were first reviewed and evaluated.  Utilizing these, round 1 Delphi questionnaire was finalised following expert review.  In a 2-round Delphi study conducted via email, 14 experts in dementia care (Psychiatrists n=4, Gerontologists n=2, GPs n=8) responded to statements using a 5-point Likert scale. The consensus target for each round was decided. In round 2, the group mean answer for each statement to be re-rated was known to participants. Following further analysis and expert panel review, the RPMT was finalized and designed. 

Results: From 23 items included in total, over the 2 rounds of the Delphi process, 18 items were accepted and 5 were rejected. Of note, patient demographic details, blood investigations, indication for prescription, ECG, drug side-effects, regular medication review and reasons for drug continuation/discontinuation were deemed essential items whereas patient/next of kin consent, urinalysis and BMI were deemed non-essential items.

Conclusion: This RPMT for antipsychotic prescribing in dementia care is relevant and feasible for use by Irish GPs. Part of a larger national project, the findings of this study will be made available to GPs on the www.dementiapathways.ie website.  Further research involving auditing of GPs' prescribing practices will be undertaken, following implementation of the RPMT.

PO5.14a. Affect GRADIOR. An emotion recognition test for older adults with Alzheimer’s disease and amnestic MCI

GARCÍA-CASAL Jesús Antonio1-2, MARTÍNEZ-ABAD Fernando1, SOTO-PÉREZ Felipe2, PEREA-BARTOLOMÉ M. Victoria1, FRANCO-MARTÍN Manuel2

1University of Salamanca - Fundación, 2INTRAS Foundation, Zamora, Spain

Because of the damage to the neural networks involved in the processing of the facial expressions of emotions, a decrease of the ability to identify them has been found in people with dementia and has been related to the evolution of amnestic mild cognitive impairment (aMCI) into AD. A timely detection of emotion recognition deficits could improve the access to treatments having an impact in the quality of life of this people. Emotion recognition assessment could also be useful both for early screening and for differential diagnosis, as emotion recognition abilities may help identify aMCI and Alzheimer´s disease.

The aim of this study was to validate Affect-GRADIOR, a computer-based emotion recognition test, with people with AD (N=84), aMCI (N=59) and healthy older adults (N=69).

There was a significant difference in age between healthy participants, people with aMCI and people with AD. In a simple regression analysis, age had a predictive power over correct answers (R2 = .055; t = -3.497; p = .001), but not over processing speed (R2 = .013; t = -1,694; p = .092). To determine if age explained the variance of Affect-GRADIOR outcomes, a multiple regression analysis (enter method) was performed with total correct answers and total emotion recognition processing speed as dependent variables and the participant based variables as independent variables (age and group). The resulting regression model excluded age as a significant factor.

The diagnostic group (HC, AD or aMCI) explained 21% of the total variance of total correct answers (R2 = .206; F = 27.068; p < .001).

The present study suggests that Affect-GRADIOR emotion recognition test has good psychometric characteristics and high usability and acceptability among older adults with and without cognitive impairment.

PO5.14b. Efficacy of video games for cognitive decline prevention: a meta-analysis

GARCÍA-CASAL Jesús Antonio1, OTERO-OTERO Patricia2, BLANCO-SEOANE Vanessa1, VÁZQUEZ Fernando Lino1

1University of Santiago de Compostela, Santiago de Compostela, Spain, 2University of A Coruña, A Coruña, Spain

Background: Progressive cognitive deficits restrict individual independence and activities of daily living. Video games have emerged as a new opportunity for the delivery of interventions. However, no meta-analysis of randomised controlled trials (RCT) has studied their efficacy to prevent cognitive decline in older adults.

Objectives: To systematically review all existing RCT of video games for older adults, applying meta-analytic techniques to establish their effects on global cognition along with individual cognitive domains.

Methods: A systematic search was undertaken in Medline, PsycInfo, Embase, Cinhal and the Cochrane Central Register of Controlled Trials databases to identify RCT of video game-based interventions for older adults. A meta-analysis was conducted assessing the impact of included interventions on global cognition and cognitive subdomains.

Results: Fourteen articles, depicting 13 RCT met the inclusion criteria. Three were based on casual video games, four on exergames and six on serious video games. The interrater concordance index was substantial (Kappa= 0.78;p= .003). Begg's rank correlation test sorted out the presence of publication bias (Kendall's tau b =  0,059;p= .286, 1-tailed). A small beneficial effect of the interventions was found for speed of processing (SMD= 0.27; 95% CI = 0.06 to 0.47;p= .01; FE). There were no significant improvements in the rest of the variables, even though a subthreshold significant effect size was found for global cognition (SMD= 0.15; 95% CI = 0.07 to 0.23;p= .0002; FE).

Conclusions: The findings from this meta-analysis suggest that video game-based interventions are effective for improving speed of processing in older adults. This may have clinical implications for the prevention of cognitive decline. More research and RCT are needed to assess the efficacy of video games on global cognition. The moderating effect of physical activity should be analysed in future meta-analysis.

PO5.15. Online games for people with memory problems and their carers– observations from CAREGIVERSPRO-MMD

WOLVERSON Emma1, PAULSON Kevin1, DUNN Rosie1, THORPE Jonathan1, ZAFEIRIDI Paraskevi1, HOWE David1, OXTOBY Katie1, WHITE Caroline1, PLATT Rebecca1, VOTIS Konstantinos2, PAKIOKAS Ioannis2, TZOVARAS Dimitrios2

1University of Hull, Hull, United Kingdom, 2The Centre for Research and Technology, Hellas, Thessaloniki, Greece

Games are a source of cognitive stimulation and fun for a large proportion of people.  They have been shown to provide a wide range of health benefits including improving: coordination, problem-solving skills, memory, attention and concentration, and multitasking skills.  The immersive nature of many games encourages substantial periods of engagement known in positive psychology as flow. 

A total of 95 people with CI and their primary carers dyads of have been recruited for the UK arm of the ongoing CAREGIVEPRO-MMD study, and randomised to intervention (n= 49 ) or control (n= 46) groups. Intervention dyads received web-enabled digital tablets (one for the person with CI, one for the carer) providing access to the web-based CAREGIVERSPRO software.

CAREGIVERSPRO features includes two games specifically designed for cognitive stimulation: a complete-the-phrase game and an identify-the-person game.  Furthermore, these games have been adapted to four different languages and regions of Europe.  Additionally, the platform can link to existing online game sites. All interactions by users are logged including sessions spent on specific games and the amount of interaction.

Interaction data are combined with participant demographic data to link game use with individual characteristics.   These data are being used to determine the game characteristics that lead to stronger engagement for the different groups within the trial. Already it has been noted that games that are data driven, such as the person recognition, are abandoned after a period of use as much of the data has been viewed.  This is true for both people with CI and their carers.  However, games with more degrees-of-freedom, such as card games, Mah-jong and jigsaws, yield more sessions and are used over longer periods.   These are further results will be presented, all underpinned by actual user statistics. 

P05.16. Quality of residential care for persons with dementia, five pilot tests approaching BPSD-Act on Dementia WP6

KIRKEVOLD Øyvind1, KRISTIANSEN Kari Midtbø1, DEN BREEJEN Marieke2, VERHAGE Brigitte2, POLITIS Antonis3, MOUGIAS Antonis4, PETROULIA Ioanna5, TRAYKOV Latchezar6, RAYCHEVA Margarita6, MEHRABIAN Shima6, BOTEZAT-ANTONESCU Ileana9, GIURGIUCA Ana10

1Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Oslo / Tønsberg, Norway, 2Ministry of Health, Welfare and Sport, Den Haag, Netherlands, 31st Department of Psychiatry Division of Geriatric Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece, 4Alzheimer Centre of the Greek Psychogeriatric Association "Nestor", Athens, Greece, 5Center for Health Services Research Medical School, National and Kapodistrian University of Athens, Athens, Greece, 6Alexandrovska University Hospital, Department of Neurology, Medical University, Sofia, Bulgaria, 9National Mental Health Centre, Bucharest, Romania, 10Psychiatry Department of the 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania

“Act on Dementia” is a part of the 3rd EU Health Programme, and one of the aims specified is “to provide to the EU Member States clear, evidence-based and tested information and recommendations on how to effect change and improvement in quality of care for people with dementia in residential settings.” 

AD-WP6 has in a report, identified evidence-based improving of quality of care for people with dementia in residential settings focusing on person centred care and behavioural and psychological symptoms in dementia (BPSD). The report revealed that different systematic methods for identifying, analysing, evaluating and approaching BPSD may be efficient ways to implement psychosocial interventions and to optimize prescribing of psychotropic medication. These models are mainly based on the same principles. The countries participating in WP 6 (Bulgaria, Greece, Netherland, Norway and Romania) have different health care systems with different structures and different funding systems, and the use of antipsychotics and routines for prescription of such medication also differ between the countries. Thus, the partners of AD-WP6 have chosen different approaches to reduce BPSD all inspired by the models described in the report.  

The Bulgarian team wants to test the use of an educational program for better management of BPSD and appropriate use of antipsychotics. The Greek team wants to introduce a “tool-box” for prescribing antipsychotics aiming to more optimized prescribing and to raise the awareness of the use of antipsychotics. In Romania an educational project for a better management of BPSD in residential care, will be tested. In the Netherlands and in Norway recommended models for approaching BPSD have been tested and shown to have effect on patient level. These models have not been widely implemented in any of the two countries. Thus, the Netherlands and Norway have decided to focus on programs for implementation of existing models.

PO5.17. General practitioners’ knowledge, attitudes and experiences of managing BPSD: a mixed methods systematic review

JENNINGS Aisling1, FOLEY Tony1, WALSH Kieran2, COFFEY Alice4, BROWNE John5, BRADLEY Colin1

1Dept of General Practice, University College Cork, Cork, Ireland, 2School of Pharmacy, University College Cork, Cork, Ireland, 4Dept of Nursing and Midwifery, University of Limerick, Limerick, Ireland, 5School of Public Health, University College Cork, Cork, Ireland

Objectives: To synthesise the existing published literature on GPs' knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions.

Methods: We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs’ experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). 7 electronic databases were searched from inception to October 2017. Each stage of the review process involved at least two authors working independently. All included studies were independently assessed for methodological validity by two reviewers. The Joanna Briggs Institute checklist for qualitative research was used to assess the quality of the included qualitative studies. As there is no agreed quality assessment tool for descriptive cross-sectional studies an original tool was developed. The meta-ethnographic approach was employed to synthesise the findings of the included studies while preserving the context of the primary data. The GRADE Confidence in the Evidence from Reviews of Qualitative research (CERQual) tool was used to assess the confidence in our individual review findings.

Results: Of the 1,638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs’ experiences of managing BPSD emerged; unmet primary care resource needs, justification of antipsychotic prescribing and the pivotal role of families. A ‘line of argument’ was drawn which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached.

Conclusion: This systematic review offers new insights into GPs’ perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.

PO5.18. Randomised controlled trial of Community Occupational Therapy in Dementia (COTiD-UK) versus usual care

WENBORN Jennifer 1,2, O’KEEFFE Aidan1, OMAR Rumana1, KING Michael1, MOUNTAIN Gail3, MONIZ-COOK Esme4, POLAND Fiona5, MUNDY Jacki2, BURGESS Jane2, SWINSON Tom2, GRAFF Maud6, VERNOOIJ-DASSEN Myrra6, ORRELL Martin Orrell7

1 University College London, London, United Kingdom, 2North East London NHS Foundation Trust, London, United Kingdom,3University of Sheffield, Sheffield, United Kingdom, 4University of Hull, Hull, United Kingdom, 5University of East Anglia, Norwich, United Kingdom, 6Radboud University Medical Centre, Nijmegen, Netherlands, 7University of Nottingham, Nottingham, United Kingdom

Introduction: Community Occupational Therapy in Dementia (COTiD-UK) is an intervention for people with mild to moderate dementia and their family carers. It aims to enhance occupational performance, mood and quality of life for both. The person with dementia and their family carer work in partnership with the occupational therapist to agree and then work on occupationally focused goals.  This UK version was adapted from the Community Occupational Therapy in Dementia intervention developed and found clinically and cost effective in the Netherlands.

Objectives: To assess the clinical and cost effectiveness of COTiD-UK compared to usual care.

Method: Multi-centre, parallel-group, pragmatic randomised controlled trial. Pairs comprising: a person with mild to moderate dementia together with a family carer were recruited; then randomly allocated to receive COTiD-UK or usual care. The COTiD-UK group received up to ten hours of occupational therapy delivered in the person’s home and local community over ten weeks. Participants were assessed at baseline, 12 and 26 weeks; with telephone follow-up with carers at 52 and 78 weeks. The primary outcome was the Bristol Activities of Daily Living Scale at 26 weeks.  Secondary outcome measures included family carer sense of competence; and quality of life, mood and resource use for both. Intervention fidelity was assessed by analysing transcripts of the COTiD-UK sessions. Qualitative data regarding the intervention experience and implementation were collected via semi-structured interviews with participants and with occupational therapists.

Results: 15 National Health Service organisations across England were recruited and 40 occupational therapists were trained to deliver COTiD-UK. 468 pairs were recruited.  The trial results and qualitative analysis are due in May 2018.

Conclusion: If COTiD-UK is found to be clinically and cost effective it has major implications for the future delivery of occupational therapy and dementia services across the UK.

PO5.19. Effects of online self-management support to deal with behavior changes of a relative with dementia: a randomized controlled trial

HUIS IN HET VELD Judith1, WILLEMSE Bernadette2, VAN ASCH Iris2, GROOT ZWAAFTINK Rob3, VERKADE Paul-Jeroen4, TWISK Jos1, VERKAIK Renate6, BLOM Marco3, VAN MEIJEL Berno1,8,9,10, FRANCKE Anneke1,6

1VUmc, Amsterdam, Netherlands, 2Trimbos Institute, Utrecht, Netherlands, 3Dutch Alzheimer’s society, Amersfoort, Netherlands, 4The Geriant Foundation, Region North of Amsterdam, Netherlands, 6Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands, 8Inholland University of Applied Sciences, Amsterdam, Netherlands, 9Parnassia Psychiatric Institute, The Hague, Netherlands, 10GGZ-VS, Academy for Masters in Advanced Nursing Science, Utrecht, Netherlands

Objective: to investigate whether an online self-management support intervention, consisting of tailored personal e-mail contacts with a specialized dementia nurse in combination with online videos and e-bulletins, is more effective than minor interventions without personal e-mail contacts.

Methods: A RCT was conducted involving three intervention arms: (1) a major intervention consisting of e-mail contacts with a nurse, videos and e-bulletins; (2) a medium intervention consisting only of videos and e-bulletins; or (3) a minor intervention consisting only of e-bulletins. Primary outcome was self-efficacy of family caregivers in managing behavior changes of the relative with dementia. Secondary outcomes were family caregivers’ reports of behavior problems in the persons with dementia, and family caregivers’ perceived relationship with their relative with dementia. Measurements were performed with online questionnaires in family caregivers at baseline, six weeks later and twelve weeks after the baseline assessment. A mixed-models analysis was conducted to compare the outcomes of the three interventions arms.

Results: In total, 82 family caregivers were randomly assigned to one of the intervention arms. Family caregivers participating in the major intervention that involved e-mail contacts, alongside videos and e-bulletins, showed a small improvement in self-efficacy at T1. However, this was not statistically significant. In addition, no significant differences were found between the intervention arms on the reported behavior problems in the persons with dementia and the relationship between family caregivers and the person with dementia.

Conclusion: Although no significant differences were found, which might be related to the small sample, e-mail contacts with a nurse in combination with online videos and e-bulletins appear to have small but positive influence on family caregivers’ self-efficacy in managing behavior changes of the person with dementia, just after the intervention. Future research, involving larger samples has to provide more definitive conclusions regarding the added value of personal e-mail contacts.

PO5.20. The (cost)effectiveness of Dementia Care Mapping (DCM) in care homes: Results of the DCM EPIC trial

SURR Claire1, HOLLOWAY Ivana2, WALWYN Rebecca2, GRIFFITHS Alys1, MEADS David2, KELLEY Rachael1, MARTIN Adam2, MCLELLAN Vicki2, BALLARD Clive3, FOSSEY Jane4, BURNLEY Natasha1, CHENOWETH Lynn5, CREESE Byron3, DOWNS Murna6, GARROD Lucy7, GRAHAM Elizabeth2, LILLEY-KELLEY Amanda2, MCDERMID Joanne8, MILLARD Holly4, PERFECT Devon4, ROBINSON Louise9, ROBINSON Olivia1, SHOESMITH Emily1, SIDDIQI Najma10, STOKES Graham1, WALLACE Daphne12, FARRIN Amanda2

1Leeds Beckett University, Leeds, United Kingdom, 2University of Leeds, Leeds, United Kingdom, 3University of Exeter, Exeter, United Kingdom, 4Oxford Health NHS Trust, Oxford, United Kingdom, 5University of New South Wales, Sydney, Australia, 6University of Bradford, Bradford, United Kingdom, 7Oxford Health NHS Trust, Oxford, United Kingdom, 8Kings College London, London, United Kingdom, 9Newcastle University, Newcastle, United Kingdom, 10Bradford District Care Trust, Bradford, United Kingdom, 11HC-One, Hartlepool, United Kingdom, 12Alzheimer's Society, Leeds, United Kingdom

Background: Agitation and other distressing behaviours commonly occur in care home residents with dementia, often resulting from poor quality care. Dementia Care Mapping (DCM) is a practice development tool, used for helping staff to deliver person-centred care. The small number of trials of DCM to date have shown mixed results.

Aims: The DCM EPIC trial, aimed to examine whether DCM is effective and cost effective for reducing agitation and improving other outcomes in care home residents in the UK.

Methods: DCM EPIC was a multi-centre, pragmatic, cluster randomised controlled trial in care 50 UK care homes, recruiting 987 residents with dementia (n=726 baseline, n=261 16-months). Thirty-one care homes were randomised to the DCM intervention and 19 to usual care control. Intervention homes were asked to complete three DCM cycles, delivered by two staff members provided with DCM training. A DCM expert supported them during the first cycle. Trial outcomes were agitation, other behaviours staff may find challenging to support, quality of life and healthcare resource use including medications. Follow-up was at 6- and 16-months. A mixed-methods process evaluation was undertaken in a sub-set of 18 intervention homes.

Results: The primary cross-sectional analysis sample included 675 resident participants. The adjusted mean difference in CMAI score was -2.11 points (45.47 points control/43.35 intervention, 95% confidence interval -4.66 to 0.44, p=0.104). Sensitivity and supportive analyses indicated no differences between treatment arms at 16-months and no statistically significant differences in the closed-cohort between arms on any secondary outcomes at 6-months. DCM was also found not to be cost-effective. Intervention adherence was problematic, with only 26% of homes completing more than one DCM cycle, owing to structural barriers.

Conclusion: DCM was not found to be clinically or cost effective. Future research should consider different, non-staff led, leadership models for DCM implementation.  

PO5.23. Dementia Care Mapping in the care for people with intellectual disability and dementia

SCHAAP Feija1, FINNEMA Evelyn1, DIJKSTRA Geke2, REIJNEVELD Menno3

1Research Group Living, Wellbeing and Care for Older People, NHL Stenden University of Applied Sciences, Leeuwarden, Netherlands, 2Department of Health Sciences, Applied Health Research, University Medical Center Groningen, University of Groningen, Groningen, Netherlands, 3Department of Health Sciences, Community & Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands

The aging of people with intellectual disability (ID) is accompanied by consequences as dementia, which arises earlier and at higher rates than in the general population. This has a large impact on people with ID themselves, their housemates, and their care-staff. The combination of ID and dementia causes a need for methods to support ID-care staff in their work. Dementia Care Mapping (DCM) is perceived to be valuablein supporting dementia care-staff and is promising in ID-care. The aim of this study was to examine the use of DCM in ID-care.

After a successful piloting of DCM in ID-care, the method was implemented in twelve group homes for older people with ID and care-staff in of six organisations in the Netherlands. In a quasi-experimental trial we examined job satisfaction and (dementia-)working skills of ID-care staff (N=242) and quality of life of older people with ID (N=224). We used mixed multilevel methods for analysis. Furthermore, we obtained qualitative data in focus-group discussions and face-to-face interviews with care-staff (N=24), managers (N=10) behavioural specialists (N=7), DCM-ID mappers (N=12), and DCM-trainers (N=2).

ID-care staff, managers and mappers considered that DCM provided new knowledge and skills in the care for people with ID an dementia. However, we found no effects regarding job-satisfaction and working skills of staff and quality of life of clients. Nevertheless, participants intended to continue and expand the use of DCM in their organisations and requested a DCM-version for individual ID-care settings.

Despite that ID-care staff reported that DCM is a valuable method in their daily work, and provides them increasing knowledge and skills in (person-centred) dementia care, we have found no evidence of its effect on job-satisfaction and quality of life. This discrepancy should be the focus of future studies, for example by examining the working mechanisms of DCM in ID-care.

PO5.25. Social cognitive function in mild cognitive impairment and its relationship with limbic structures and perturbed carer relationships

MICHAELIAN Johannes1, MOWSZOWSKI Loren1, GUASTELLA Adam1, HENRY Julie2, DUFFY Shantel1, MCCADE Donna1, NAISMITH Sharon1

1University of Sydney, Sydney, Australia, 2University of Queensland, Brisbane, Australia

Background/Aims: Individuals living with dementia have impaired social cognitive function, which extends to their ability to recognise the emotions and mental states of other people, including those of their caregivers. Older adults that present with Mild Cognitive Impairment (MCI) are at a higher risk of later developing dementia, and also present with social cognitive difficulties. In the present study, we sought to establish whether MCI related difficulties on a validated test of social cognitive function are associated with volumetric changes in key limbic structures including the amygdala and hippocampus, and further investigate the extent of social cognitive dysfunction on the participant-carer relationship. Methods: One hundred and fourteen people with MCI and fifty-two controls completed standard neuropsychological testing including a validated measure of social cognitive function (Reading the Mind in the Eyes Test, RMET), in addition to structural magnetic resonance imaging. Carers of participants completed the Cambridge Behavioural Inventory (CBI-R) to provide an indication of any current behavioural changes. Results: In line with prior work, results indicated that the MCI group were moderately impaired on the RMET compared to the control group (d = 0.44), with the amnestic-MCI over the non-amnestic-MCI subgroup carrying social cognitive deficits (p = 0.03). For control participants, there was a robust correlation between superior RMET performance and hippocampal volume (r = 0.45, p = 0.01), however, for the MCI group this relationship was absent. Within the MCI group, poorer RMET performance robustly correlated with several CBI-R scales. Conclusion: These findings, for the first time show that hippocampal integrity is associated social cognitive function in control participants, and that social cognitive deficits in MCI negatively impact on participant-carer relationships. In a broader clinical sense, screening for social cognitive deficits in MCI is warranted, particularly if incorporated into early intervention programmes, or those targeting caregiver and family education.

PO5.28. Multimodal Treatment for Dementia (MT4D): a systematic review and case study in the UK

CHALFONT Garuth, MILLIGAN Christine, SIMPSON Jane

Lancaster University, Lancaster, United Kingdom

Multimodal non-pharmacological interventions have the potential to complement current pharmacological approaches to improving quality of life for people living with dementia. We sought evidence for their effect on cognitive function. 21 group studies and 5 case studies utilised cognitive, physical, psychological and psychosocial modes as well as nutrition, diet, sleep hygiene, stress reduction, detoxification, hormonal health and oxygen therapy. In 90% of the group interventions, participants in the active conditions experienced cognitive improvements, stability with their dementia or a delay in their decline. The case studies used a personalised medicine approach with in-depth assessments and prescribed as many as 9 modalities. Analyses of Effect Size and Minimal Clinically Important Difference were conducted and the results of these will be reported. In cases where cognitive outcomes were improved, 7 research components tended to be in place which will be presented. We are now undertaking a case study in the UK to develop an intervention protocol for a feasibility study of MT4D in 2019. What do carers and people with dementia need and want from treatment? How do GPs see this multimodal approach fitting into their clinical practice? What is needed to make this possible for people with dementia and mild cognitive impairment? What is the success of complex interventions in the NHS previously? This work is leading to a clinical trial in UK primary care with the goal of bringing a personalised approach for dementia to the public through the GP’s office. This research seeks to determine if this is possible, based on an integrative medicine approach looking at a wide range of possible causes of dementia and treating the patient holistically, including the support they require to take on the various modalities prescribed.

PO5.32. Patterns of white matter hyperintensities associated to cognition in middle-aged cognitively healthy individuals

BRUGULAT-SERRAT Anna1, SALVADÓ Gemma1, BRUGULAT-SERRAT Anna1, SALVADÓ Gemma1, SUDRE Carole H2, GRAU-RIVERA Oriol1, SUÁREZ-CALVET Marc1, FALCON Carles1, SÁNCHEZ-BENAVIDES Gonzalo1, GRAMUNT Nina1, FAURIA Karine1, CARDOSO M. Jorge2, BARKHOF Frederik2,3, MOLINUEVO José Luis1, GISPERT Juan Domingo1

1BarcelonaBeta Brain Research Center, Barcelona, Spain, 2University College London and Dementia Research Centre, UCL, London, United Kingdom, 3VU University Medical Centre, Amsterdam, Netherlands

Background: White matter hyperintensities (WMH) are commonly detected in the brain of elderly individuals and have been associated with a negative impact on multiple cognitive domains. Higher WMH burden increases the risk of progressing to mild cognitive impairment and contributes to the severity of dementia syndromes. This study aims to investigate the impact of global and regional distribution of WMH on episodic memory and executive function in a cohort of middle-aged healthy subjects.

Methods: 561 cognitively healthy adults (44-75 years) were recruited from the ALFA Study [1] and underwent cognitive testing and MRI scanning. Z-scores were calculated from the average of the eight tests administered to obtain summaries of two cognitive domains: memory and executive function. WMH were automatically segmented using jointly T1 and FLAIR MRI scans. Regional WMH volumes were calculated for each brain lobe and four equidistant layers from the ventricles [2]. Non-parametric analyses were performed to study the associations in each cognitive outcome and after correcting for sociodemographic factors.

Results: Memory and executive function were significantly associated with global WMH load. However, after correction for sociodemographic variables these associations did not reach statistical significance. Regionally, lower memory performance was correlated with deep WMH in occipital regions, specifically related to lower paired recall. Deep WMH load in the occipital and frontal areas were associated with lower executive performance.

Conclusions: Deep WMH load, in occipital and frontal areas, impact cognitive performance in middle-aged cognitively-healthy individuals after accounting for known confounders. Our methodological approach of regional WM analysis load is useful to reveal the association between cognition and WMH in strategic brain regions. Control of cardiovascular risk factors associated with WMH may be a useful preventive strategy to reduce or delay cognitive decline.

References:

[1] Molinuevo et al. Alz. & Dement. TRCI 2016

[2] Sudre et al. J Neuroradiol. 2017

PO5.33. Dementia as a result of therapy?

VOGT Hans

Justus Liebig University Gießen, Berlin, Germany

In many studies, dementia and delirium are treated as related and interrelated phenomena of cognitive impairment. Some medical papers explicitly suggest that dementia behaviour (including forgetfulness, restlessness, or aggressiveness) may be due to an underlying delirium mediated or deepened and made chronic by medication. However, this topic is rarely addressed by the numerous scientific publications on Alzheimer's dementia (AD).

Chronic cognitive impairment due to drug toxicity is particularly important and challenging. This problem is a by-product of the increased use of drugs during the past few decades. The elderly have the largest burden of illness, consume the most drugs, are more sensitive to adverse drug reactions, and are the fastest-growing segment of the industrialized world. (Larson et al. 1987)

As early as 1987, geriatrician Eric B. Larson and co-authors pointed out the connection between the handling of medication and the development of dementia syndromes or Alzheimer's disease. However, this awareness still continues to receive too little public and scientific attention.

Delirium is considered the most common and problematic "adverse drug effect" in the elderly and, as such, is a separate (geriatric) syndrome. Regular and simultaneous use of multiple medications increasingly produces such side effects. People over the age of 65 are often excluded from clinical trials because of their "irregular" drug reactions. However, they are the ones who actually take the medication. People of advanced age are more susceptible to side effects and drug interactions than younger people because of, for example, altered (brain) metabolism and weaker organ performance. Older people are not only vulnerable in the pharmacological sense. They are often also socially vulnerable to a partially questionable invasiveness of medical treatment.

Other correlations, for example between medication, "primary diseases" such as Parkinson's disease, transient global amnesia and AD will be included in the presentation.

PO5.34. Adjustment to test, risk and diagnostic disclosures in people with mild cognitive impairment: an observational cohort study

SAUNDERS Stina, RUSS Tom, MUNIZ-TERRERA Graciela, RITCHIE Craig

The University of Edinburgh, Edinburgh, United Kingdom

Mild cognitive impairment (MCI) is a state between normal healthy ageing and dementia with an uncertain prognosis in terms of its risk of progression into dementia. This creates a complex dynamic between what is communicated to the individual about their condition and how the individual perceives the information conveyed to them.

Aim: The aim of the study is to understand whether the way information is conveyed to patients with newly identified MCI at memory assessment services could have an impact on the patients’ clinical outcomes and possibly lead to an altered prognosis. In order to understand the impact of risk disclosure, we focus on specific outcomes for the individual – changes in cognition, anxiety, psychological well-being and adjustment to illness in the short and long term.

Method: This is a longitudinal mixed methods study. The project will recruit 150 participants (from across four sites in the South East region of Scotland) who have been referred to a memory assessment service. The participants are assessed at four time points over 18 months before and after they have been disclosed of test results. The study uses a battery of quantitative assessment measures as well as conducting semi-structured interviews with a subset of participants. Separately, we will also interview doctors at the beginning of the study to examine their views around communicating unspecific test results with poor predictive value to individuals identified with MCI.

Results: The study has just received national ethics approvals and recruitment will commence in May 2018. Baseline assessments are planned to be completed by December 2018 and follow-up assessments by June 2020. The Alzheimer Europe conference will be at the end of the recruitment which will provide an opportunity to share initial cross sectional findings around the immediate impact being informed of potential dementia risk can have on individuals.

PO5.35. Neuroinflammatory biomarkers associated with cognitive impairment in delirium and dementia

FOX Chris, GILL Nigel, FOX Chris, CROSS Jane, MURPHY Declan

UEA, Norwich, United Kingdom

Background: Increasing suggests acute and chronic systemic inflammation may contribute significantly to the progression or even onset of dementia. The development of reliable biomarkers that are effective in identifying the early disease state are needed. Currently only samples obtained from cerebrospinal fluid (CSF) are reliable diagnostically but it is possible that neuroinflammatory processes may also yield biomarkers that can be obtained from serum samples.

Methods: A systematic review and meta-analysis was undertaken using a predefined search strategy. Titles and abstracts of studies were screened to identify those meeting criteria for inclusion. The data was then extracted and coded according to preselected characteristics. The findings from all included studies were synthetized into a standardised extraction form. Meta-analysis was undertaken by calculating the weighted mean difference (WMD) between blood levels patients with dementia, delirium with dementia or delirium alone.

Results: An 18-kDa translocator protein (TSPO) has been identified which is expressed on activated microglia, activated astrocytes and macrophages. This biomarker has been used to quantify neuroinflamation and has demonstrated an ability to differentiate mild cognitive impairment (MCI) from Alzheimer’s dementia (AD). YKL-40, a biomarker expressed on astrocytes in the CSF also appears useful as it increases prevalence is associated with other markers of neurodegeneration such as tau and phosphorylated tau (p-tau). Levels of this biomarker are inversely associated with cortical thickness in the temporal regions of the brain. Unfortunately, levels of TSPO and YKL-40 have not proven useful when sampled from the plasma.

Conclusion: The identification neuroinflammatory biomarkers that can be used both diagnostically and prognostically is clinically useful. Further work is needed to find and develop reliable biomarkers that can be used to differentiate between dementia, delirium with dementia or delirium alone.

PO5.36. Depression and memory impairment

CHRYSIKAKOU Iliana, ZACHARIADIS Andreas, EFTHYMIOPOULOU Catherine

“Apostoli” charitable organization, Holy Archdiocese of Athens, Athens, Greece

This poster presentation is aiming in demonstrating the correlation between depression – like symptoms and memory impairment, in people of the third age, with the final goal to show if depression is either a risk factor or an early symptom of dementia.  

During the last years, there is an increase of life expectancy worldwide, resulting in the increasing number of patients with somatic as well as psychologic disorders related to the third age. 20% of people above 65 years of age will develop depressive symptoms, while more than half of them, already showing depression will not be diagnosed. Quite a large number of people above 65 years, are complaining of having problems in focusing their attention as well as remembering things, which is a fact already proven by several studies showing that memory impairment in depression is due mainly to a reduction in processing speed and working memory. On the other hand, many of the people with dementia do develop depressive mood and other behavioral problems. Contemporary studies, have stated that these patients have started to manifest a depressive mood a long time before memory impairment, was clinically obvious.     

Thus, after carefully reviewing the contemporary scientific literature, we have concluded that depression constitutes a risk factor for developing dementia, if one had a history of depression in adult life, while if depression was present for the first time, in any age above 65 years, it should be considered as an early symptom of dementia, and is due to a psychological response to cognitive deterioration. The final conclusion is that prevention of relapse of depression as well as treating it in time, in people of the third age, can affect positively the progression of dementia. Of course, the relative research is ongoing and further results will be published.

PO5.37. Risk factors for dementia

CHRYSIKAKOU Iliana, ZACHARIADIS Andreas, EFTHYMIOPOULOU Catherine

“Apostoli” charitable organization, Holy Archdiocese of Athens, Athens, Greece

The aim of this presentation is to explore and highlight, the potential presence of risk factors for developing dementia, in people of the third age. Except the risk factors that are beyond control, such as heredity and increasing age, there are also other “modifiable” risk factors for dementia, which are based on everyone’s way of life.   

It has been proven that there are 9 such factors: hearing loss during middle age, incomplete secondary education, smoking, inability to properly resolve depression, lack of physical activity, social isolation, hypertension, obesity and diabetes mellitus type II. These factors can contribute by even by 35% to the development of dementia. The other 65% of the aforementioned risk is supposedly not subject to alteration, by the modification of the way of life.

Risk factors such as hypertension, obesity and diabetes, can be inactivated by proper nutrition and exercise, whereas the maintenance of an active social life, can also reduce the risk for depression. Moreover, if everybody was able to complete one’s secondary education (meaning that people go to school until 15 years of age), this could reduce the appearance of cases of dementia by 8%, whilst the cessation of smoking after 65 years of age, could reduce them by a further 5% and treatment of hearing loss, by 9%.  

The conclusions we have reached, after studying the contemporary scientific literature, are that factors related with one’s way of life, may be very important and may also result to positively or negatively influencing the risk of developing dementia.   Although it would be extremely difficult to eradicate all 9 of them, as mentioned before even if they are reduced by 10%, the result would be less people with dementia.   

PO5.38. Dipeptidyl-peptidase IV inhibitor and reduced risk of dementia among patient with type 2 diabetes mellitus

CHO Jinhyuk2, KIM Young-Gun1, MOON So Young3, HAN Seung Jin4

1Department of Medical Sciences, Ajou University Graduate School, Suwon, Republic of Korea, Gyeonggi-do, Republic of Korea 2Department of Neurology, Incheon Medical Center, Incheon, Republic of Korea, Gyeonggi-do, Republic Of Korea, 3Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea, Suwon, Republic Of Korea, 4Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Republic of Korea, Suwon, Republic Of Korea

Background: Patients with type 2 diabetes showed an increased risk of dementia. Dipeptidyl peptidase-4 inhibitors (DPP-4i) use have shown protective results for dementia in preclinical studies. However, the effects of DPP-4i on dementia have not been elucidated in clinical trial, and one randomized controlled trial is underway to evaluate it. Therefore, we investigated the risk of developing dementia in elderly patients initiated on DPP-4i versus sulfonylurea (SU).

Methods: Using claims database named the Korean National Health Insurance Service Senior cohort, a population-based cohort study was performed. New users of DPP-4i and SU who were aged ≥ 65 years were matched by 1:1 propensity score matching which was calculated with 49 confounding variables. To evaluate the risk of dementia among patients who were prescribed DPP-4i, Kaplan–Meier curves and Cox proportional hazards regression analysis were performed.

Results: After propensity score matching, 7,561 patients on each group were paired. The lower risk of dementia was showed in DPP-4i-treated patients compared to SU-treated patients (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.56-0.79; P < 0.001). Also, HR of Alzheimer’s dementia, and vascular dementia were lower in DPP-4i-treated patients compared with SU-treated patients (HR 0.71; 95% CI 0.57-0.89); P = 0.002 for Alzheimer’s dementia, HR 0.50; 95% CI 0.30-0.85); P = 0.01 for vascular dementia).

Conclusions: Our findings suggest that DPP-4i use decrease the risk of dementia compared with SU. Both Alzheimer’s dementia and vascular dementia were decreased among DPP-4i-treated patients compared with SU-treated patients.

PO5.40. Combination of internal mnemonics, errorless learning, vanishing cues and spaced retrieval to facilitate new learning and memory: a case at the early stages of dementia

KARAVAIOU Eftychia1, MARGIOTI Eleni1, DEMENEGA Christina1, SAKKA Paraskevi1, EMMANOUEL Anna2

1Athens Association of Alzheimer’s disease and Related Disorders, Athens, Greece, 2Psychology Department, City College, the International Faculty of the University of Sheffield, Thessaloniki, Thessaloniki, Greece

Background:Memory interventions that combine more than one cognitive strategies, aim to facilitate new learning and retention of information over time in people with cognitive decline have been found to be significantly effective in neuropsychological rehabilitation. In the present case study, our aim is to present the effectiveness of a combined memory intervention program applied to G who was diagnosed to be at the early stage of Alzheimer’s disease (AD).

Methods: Case G is a female 72 year-old retired pediatrician, complaining about difficulties in recent everyday episodic memory. G underwent a thorough baseline neuropsychological assessment. A combined program incorporating external cues and internal compensatory strategies (such as semantic) grouping, visual peg method compensating for verbal material (shopping lists) gradually faded to visual imagery, verbalization for complex visual figures, errorless learning and spaced retrieval were applied. Pre-intervention and post- intervention comparisons of the scaled scores were conducted. The time duration of the intervention program was for 5 months/twice a week.

Results:The initial neuropsychological evaluation showed her prominent difficulties [2 Standard deviations (SDs) < the average standardized scores] in immediate, learning and recall of verbal [Georgia Verbal Learning Test (GVLT) and Logical Memory] and complex visual material [Rey-Osterrieth Complex Figure Test (ROCFT)]. Moreover, she showed difficulties in executive functions, particularly in abstract symbolization of time. At post-intervention G was found to perform better on the alternative memory tasks reaching the normal average level. These data represent significant change in her cognitive performance.

Discussion: Our results showed that memory interventions that combine more than one cognitive strategies, may enhance memory performance at the early stages of AD.

PO5.45. The sponsor influence on discontinuation, efficacy and safety of cholinesterase inhibitors for Alzheimer’s disease: meta-analysis and meta-regression of randomized placebo-controlled clinical trials

BLANCO-SILVENTE Lidia1, CASTELLS Xavier2, CAPELLÀ Dolors3

1University of Girona, Girona, Spain, 2Unit of Clinical Pharmacology, TransLab Research Group, Department of Medical Sciences, Universitat de Girona, Girona, Spain, 3Unit of Clinical Pharmacology, TransLab Research Group, Department of Medical Sciences, Universitat de Girona, Girona, Spain

Objective: To evaluate the influence of study sponsor on the results of randomized placebo-controlled clinical trials (RPCCT) that have investigated the efficacy and safety of cholinesterase inhibitors (ChEI) as a treatment for patients with Alzheimer’s disease (AD).

Methods: A systematic review and meta-analysis was performed. Primary outcomes were all-cause discontinuation, discontinuation due to adverse events (AE) and efficacy on cognitive function. Secondary outcomes were efficacy on global change, neuropsychiatric symptoms, and functional ability, and safety outcomes. Study design-, patient- and intervention-related covariates were collected. Odds ratio (OR) and Standard mean difference (SMD) with 95% were confidence intervals were calculated. A meta-regression was used to evaluate the effect of sponsor (commercial vs non-commercial) on primary and secondary outcomes. 

Results: Forty-two RPCCT identified had described their sponsor. The majority of studies had a commercial sponsorship (88.1%) and only five were independent. Overall, 16,430 patients were included, of which almost two thirds (63.4%) were women, their mean age was 74.8, and the severity of the disease was on average moderate. Higher doses (75.9%) and fixed dosage (62.1%) were prevailing. The mean length of intervention was around 26 weeks. No statistically significant differences were observed between RPCCT with commercial and non-commercial sponsorship concerning study design-, patient- and intervention-related covariates. Regarding the influence of sponsorship on study outcomes, no effect was observed for all-cause discontinuation (Log OR= 0.151 [-0.448, 0.749]), discontinuation due to AE (Log OR= 0.092 [-0.606, 0.790]), efficacy on cognitive function (Diff SMD= -0.230 [-0.847, 0.388]) nor for any secondary outcome.

Conclusions: The vast majority of RPCCT that have investigated the efficacy and safety of ChEI for AD had a commercial sponsorship. Our results did not suggest an influence of sponsor on discontinuation, efficacy, and safety of ChEI for AD. However, the low number of independent trials does not allow reaching firm conclusions.   

PO5.46. Identifying patients at higher risk of initiating cognitive decline for evaluating amyloid-targeted treatments

TAFAZZOLI Ali1, KANSAL Anuraag1, TAFAZZOLI Ali1, KANSAL Anuraag1, WENG Josh2, ISHAK Jack3

1Evidera, Bethesda, United States, 2Evidera, Waltham, United States, 3Evidera, Montreal, Canada

Background: Many clinical trials of amyloid-targeted treatments are focused on individuals who have normal cognition but are at higher risk, based on β-amyloid and/or ApoE4 status, of developing cognitive impairment. Our objective was to evaluate onset of cognitive decline in these subgroups using disease simulation.

Methods: We studied the disease progression of β-amyloid+ cognitively normal (CN) individuals from the ADNI dataset using the AD Archimedes Condition-Event simulator (AD ACE). The AD ACE is a disease simulator constructed using predictive equations for change in disease biomarkers and clinical scales derived from analyses of ADNI. We analyzed the change in cognitive scales of two patient subgroups (Aβ+/ApoE4+, Aβ+/ApoE4-) over 10 years where individuals had similar level of β-amyloid plaques (florbetapirPET range [1.2,1.3] mcSUVR) and evaluated the role of ApoE4 gene in disease progression. We compared our findings to a linear regression on the change in cognitive scales of the same patient subgroups using the ADNI patient data (N=24 and 22, for Aβ+/ApoE4+ and Aβ+/ApoE4-).

Results: The two patient groups were similar at baseline in terms of their mean age, baseline biomarkers, and cognition scales. The Aβ+/ApoE4- subgroup showed modestly more decline in cognition over 10 years compared to Aβ+/ApoE4+ subgroup (ΔMMSE=0.8,ΔCDRSB=0.7). Our analyses showed that earlier start of cognition decline for Aβ+/ApoE4- patients was the main deriver of the observed difference. We observed consistent, but nonsignificant, behavior for the two subgroups in analysis of the ADNI patient data (slope difference=0.21 points ADAS-Cog13/year). When amyloid status is not considered, ApoE4+ patients were found to decline more quickly than ApoE4- patients.

Conclusions: Our findings suggest that cognitive decline did not differ by ApoE4 status when amyloid burden was equal. Thus, adding ApoE4 status to amyloid status as an inclusion criteria may not be effective in identifying the highest risk population for a clinical trial.

PO5.47. Antioxidant, anti-Alzheimer’s and anti-gastrointestinal disease activities of edible and medicinal plants from Thailand

NANASOMBAT Suree, JUAVIJITJAN Panuwit, THAWILWANG Jullada, PETCHARAT Kanokporn

Department of Biology, Faculty of Science, King Mongkut’s Institute of Technology Ladkrabang, Bangkok, Thailand

Alzheimer’s and gastrointestinal diseases are devastating diseases. The aim of this study was to search for plants with multifunctional activities for a possible prevention or treatment of these diseases. Thus, crude ethanolic extracts of 20 edible and medicinal plants were evaluated for their antioxidant, anti-Alzheimer’s and anti-gastrointestinal disease activitiesagainst gastrointestinal bacteria (Helicobacter pyrori,Listeria monocytogenesand some serotypes ofSalmonella).  Among 20 plant extracts, extracts of makoknum (Spondias pinnata) fruits, cinnamon (Cinnamomum verum) stem bark, myrobalan (Terminalia chebula) fruits, cocoa (Theobroma cacao) seeds and ginger (Zingiber offcinale) rhizomes possessed very strong antioxidant activity of 512.10 - 938.27 mg trolox equivalent/g extract by 2,2'-azino-bis(3-ethylbenzthiazoline-6-sulphonic acid (ABTS) radical cation decolorization method. Total phenolic contents of makoknum, myrobalan, ginger, cinnamon and cocoa were relatively high (123.20 - 281.73 mg gallic acid equivalent/g extract). For evaluation of anti-Alzheimer’s disease, extracts of cocoa and makoknum showed stronger acetylcholinesterase inhibitory activity (73.27 and 71.34 %, respectively), compared to other plant extracts. Extracts of madan (Garcinia schomburgkiana) fruits, ginger and myrobalan also possessed relatively strong acetylcholinesterase inhibitory activity of 67.16, 66.78 and 62.98 %, respectively. In addition, the antibacterial testing revealed that the extracts of calamus (Acorus calamus) rhizomes, carunda (Carissa carandas) fruits, garcinia (Garcinia cowa) leaves, roselle (Hibiscus sabdariffa) flowers, madan (Garcinia schomburgkiana) fruits, cinnamon, makoknum and myrobalan showed broad antimicrobial action against eight pathogenic bacterial strains.Helicobacter pylori(a stomach pathogenic bacterium),Listeria monocytogenesandSalmonellaDerby andSalmonellaRissen were inhibited by madan extract (3.9-7.8 mg/ml MIC). In addition, extracts of lemon grass (Cymbopogon citratus) leaves, cinnamon, cocoa and makoknum inhibited the growth of some serotypes ofSalmonellatested such asS. Agona,S. Enteritidis,S. Derby,S. Rissen andS. Typhimurium (7.8 mg/ml MIC).

 

 
 

Last Updated: Thursday 15 November 2018

 

 
  • Acknowledgements

    The 28th AE Conference in Barcelona received funding under an operating grant from the European Union’s Health Programme (2014-2020). Alzheimer Europe, CEAFA and Fundación Alzheimer España gratefully acknowledge the support of all conference sponsors.
  • European Union
  • Roche
 
 

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