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Managing Cognitive Decline in Older Adults With Diabetes

This Physician’s Weekly feature on managing cognitive decline in older adults with diabetes was completed in cooperation with the experts at the American Diabetes Association. More than 25% of Ameri­cans aged 65 and older has diabetes, and the aging of the overall population has been identified as a significant driver of the diabetes epidemic. “Diabetes in older adults is associated with higher mortality, reduced cogni­tive and functional status, and increased risk of institutionaliza­tion,” explains Hermes Florez, MD, PhD, MPH. “Importantly, diabetes has been linked to sig­nificantly higher risks of cogni­tive impairment, a greater rate of cognitive decline, and increased risk of dementia.” While various complications of diabetes are well known and well researched, the effect diabetes has on the brain has historically received relatively little attention. “The risk of both diabetes and cognitive impairment increases with age,” Dr. Florez says. “The presentation of cognitive impairment in people with diabetes can vary, ranging from subtle executive dysfunction to overt dementia and memory loss. We’re starting to see links between diabetes and dementia and Alzheimer’s disease, but researchers are still conducting analyses to further increase our knowledge on these associations.”  Consensus Report on Diabetes in Older Adults In the December 2012 issue of Diabetes Care, the American Diabetes Association released a consensus report on diabetes and older adults. Dr. Florez, who was on the writing group that developed the report, says that an important component to managing older adults with diabetes is the role of cognitive impairment. “For older patients with diabetes, treatments will need to be simplified whenever possible, and caregivers should be involved during consultations. The presence of cognitive...
Delirium Among Hospitalized AD Patients: The Long-Term Impact

Delirium Among Hospitalized AD Patients: The Long-Term Impact

Recent studies show that patients with Alzheimer’s Disease (AD) who are hospitalized are at increased risk for further cognitive decline, institutionalization, and death in the year following their hospital stay. These risks are highest among those who develop delirium while being hospitalized. Little attention has been paid to the consequences of delirium on cognitive deterioration among patients with AD. Most studies have focused on short-term cognitive outcomes, but few have addressed whether these changes result in enduring problems in cognitive function. Examining Long-Term Changes Following Delirium In the August 20, 2012 online issue of the Archives of Internal Medicine, a study by senior investigator Sharon K. Inouye, MD, MPH, myself, and other colleagues explored the long-term trajectory of cognitive decline among older adults with AD who experienced delirium while they were hospitalized. The rate of cognitive deterioration was monitored for up to 5 years before and 5 years after hospitalization. Delirium in patients with AD was independently associated with cognitive deterioration for up to 5 years after hospitalization; the rate was roughly twice that of patients with AD who did not develop delirium while hospitalized. Delirium is a Medical Emergency In our analysis, delirium developed in 56% of the study group. Unfortunately, research suggests that delirium is recognized by physicians in fewer than 30% of hospital patients. Our study serves as an alarm to the long-term dangers of delirium on the development and progression of long-term cognitive impairment. Physicians should handle delirium cases among AD patients as they would a true medical emergency. Strategies to Prevent Delirium Efforts are needed to incorporate delirium prevention routinely into standard practices for...

The 2012 American Academy of Neurology Annual Meeting

New research was presented at the American Academy of Neurology’s 64th annual meeting from April 21-28, 2012 in New Orleans. The features below highlight just some of the studies that emerged from the conference, including diagnosing Alzheimer’s earlier, an investigational drug to reduce MS lesions, a new drug formulation benefits Parkinson’s, and determining the threshold for head trauma. Diagnosing Alzheimer’s Earlier The Particulars: Alzheimer’s disease (AD) currently can only be confirmed definitively upon autopsies after patients have died or with brain tissue biopsies to detect amyloid plaques, tangles, or both. Florbetaben is an investigational agent that may be beneficial when used as a tracer during PET scans to detect amyloid plaques in patients living with AD. Data Breakdown: In a study, more than 200 patients with and without known dementia who were nearing death and willing to donate their brain to science underwent MRI and florbetaben PET scans. Amyloid plaque levels among those who reached autopsy were compared with scan results. Florbetaben scans were found to have 77% sensitivity and 94% specificity in detecting beta-amyloid. Take Home Pearl: Florbetaben, when used as a PET scan tracer to visualize amyloid plaques in the brain, appears to help diagnose AD in those living with the disease. Investigational Drug May Reduce MS Lesions The Particulars: Patients with multiple sclerosis (MS) who have Gd-enhancing brain lesions have limited treatment options. ONO-4641 is an investigational drug that may help reduce lesions in this patient population. Data Breakdown: Researchers randomized patients with relapsing-remitting MS to placebo or 0.05 mg, 0.10 mg, or 0.15 mg of ONO-4641 once daily for 26 weeks in a study. When...

A New Look at Diagnosing Alzheimer’s Disease

More than years ago, the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s and Related Disorders Association (now the Alzheimer’s Association) released diagnostic criteria for Alzheimer’s disease (AD). At the time, AD was thought of only as a dementia. The 1984 criteria stated that the ultimate AD diagnosis was dependent on pathology. Since that time, the basic concepts of AD have changed significantly, and researchers have uncovered important clues on the diagnosis of AD and dementia. Updating Diagnostic Criteria for Alzheimer’s The National Institute of Aging of the NIH and the Alzheimer’s Association recently called a meeting to discuss whether or not the diagnostic criteria required updating. Three subgroups were established to discuss the criteria, based on what would be the biggest changes in the concepts of AD (Table 1). These included that AD starts years and perhaps decades before dementia develops and symptoms are visible. The result of this collaboration was the establishment of new guidelines based on four articles collectively called the “National Institute on Aging/ Alzheimer’s Association Diagnostic Guidelines for Alzheimer’s Disease.” The document was published in the April 22, 2011 online edition of Alzheimer’s & Dementia. “The field is changing rapidly, and the hope is biomarkers will become more widely available and used in diagnoses.” “The pre-symptomatic phase of AD includes people who have laboratory evidence of the disease but no symptoms,” explains Guy M. McKhann, MD, who was a member of the group that updated the diagnostic criteria. “The minimal cognitive impairment (MCI) phase includes people with memory problems who haven’t reached the stage of being demented. The final phase includes those...

An Innovative Model for Dementia Care

The Alzheimer’s Association estimates that about 5.3 million Americans have Alzheimer’s disease. Within this group, roughly eight of 10 people have dementia but live outside of nursing homes. Many of these patients have significant behavioral or psychological symptoms that require medical and psychological care. About 10 million Americans are family caregivers for sufferers of dementia, but these people aren’t typically the focus of efforts to improve care for patients. The HABC Care Model for Dementia In the May 10, 2006 JAMA, my colleagues and I developed and assessed a new collaborative model of care for dementia in which patients received 1 year of care management by an interdisciplinary team that was led by an advanced practice nurse working with family caregivers and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing non-pharmacological management. In this analysis, collaborative care resulted in significant improvements in quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. “Improved dementia care benefits patients, their family caregivers, and the entire healthcare system.” In the January 2011 issue of Aging & Mental Health, we successfully translated the memory care model we developed in the 2006 JAMA study into actual practice. We used the framework of the complex adaptive system and reflective adaptive process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). We essentially extended the definition of “patient” to include family members who enable cognitively impaired individuals to live in the community. Within 12 months of the initial HABC...
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