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Objectives: DETERMIND (DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers) is designed to address fundamental, and, as yet unanswered questions about inequalities, outcomes and costs following diagnosis with dementia. These answers are needed to improve the quality of care and equity of access to care, and therefore the quality of life, of people with dementia and their carers.Method: DETERMIND is a programme of research consisting of seven complementary workstreams (WS) exploring various components that may result in unequal dementia care: WS1: Recruitment and follow-up of the DETERMIND cohort-900 people with dementia and their carers from three geographically and socially diverse sites within six months following diagnosis, and follow them up for three years. WS2: Investigation of the extent of inequalities in access to dementia care. WS3: Relationship between use and costs of services and outcomes. WS4: Experiences of self-funders of care. WS5: Decision-making processes for people with dementia and carers. WS6: Effect of diagnostic stage and services on outcomes. WS7: Theory of Change informed strategy and actions for applying the research findings.Outcomes: During the life of the programme, analysing baseline results and then follow-up of the DETERMIND cohort over 3 years, we will establish evidence on current services and practice. DETERMIND will deliver novel, detailed data on inequalities in dementia care and what drives positive and negative outcomes and costs for people with dementia and carers, and identify factors that help or hinder living well with dementia. [ABSTRACT FROM AUTHOR]

Objective: To study the stability and emergence of a range of behavioural and psychological symptoms (BPS), their association with mortality and the effect of covariates on these transitions in a population-based study of cognitively impaired older people with a long follow-up period and large sample size, with a particular focus on apathy.Methods: Data were from a population-based, longitudinal cohort study of ageing. Interviews were conducted at 0, 2, 6, 8 and 10 years with 3626 participants aged 65+. The persistence of 11 BPS and their association with mortality in those with cognitive impairment (MMSE 25 or below) was investigated using multi-state models, allowing us to take into account estimations of the probability of transitions that occurred in the time between interviews.Results: Most BPS were persistent. Apathy was one of the most stable symptoms; in those with apathy, the probability of still having apathy after 1 year is 62%. Apathy, sleep problems, depression, irritability and wandering were most likely to develop. BPS are associated with mortality; in those with apathy, mortality is 3.1 times more likely than in those without apathy. Low cognitive function and dementia were associated with emergence of new symptoms.Conclusions: This population-based, multi-centre study with a follow-up period of 10 years showed that BPS are associated with mortality and most symptoms are persistent. Apathy was characterised by a high prevalence, a high persistence and a strong association with mortality, and has a negative impact on disability, management of other disease and caregiver burden. [ABSTRACT FROM AUTHOR]

Objective Dementia has a multifactorial etiology, but the importance of individual health and lifestyle related risk factors is often uncertain or based on few studies. The goal of this paper is to identify the major modifiable risk factors for dementia as a first step in developing an effective preventive strategy and promoting healthy late life cognitive functioning. Methods A mixed-method approach combined findings from a systematic literature review and a Delphi consensus study. The literature search was conducted in PubMed and updated an earlier review by the United States National Institutes of Health from 2010. We reviewed the available evidence from observational epidemiological studies. The online Delphi study asked eight international experts to rank and weigh each risk factor for its importance for dementia prevention. Results Out of 3127 abstracts, 291 were included in the review. There was good agreement between modifiable risk factors identified in the literature review and risk factors named spontaneously by experts. After triangulation of both methods and re-weighting by experts, strongest support was found for depression, (midlife) hypertension, physical inactivity, diabetes, (midlife) obesity, hyperlipidemia, and smoking, while more research is needed for coronary heart disease, renal dysfunction, diet, and cognitive activity. Conclusions Findings provide good support for several somatic and lifestyle factors and will be used to inform the design of a new multicenter trial into dementia prevention. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective A wide range of behavioural and psychological symptoms (BPSD) are common in dementia, and it has been suggested that groups of correlated symptoms should be studied together. Here, we describe the groups of BPSD that have been identified in the literature and how they have been used to study associations, burden, treatment and underlying biology. Methods The literature database PubMed was searched for articles that identified clusters or factors of BPSD or used previously defined symptom groups. Results Sixty-two studies were included. Generally, the following symptom groups were suggested: affective symptoms, including depression and anxiety; psychosis, including delusions and hallucinations; hyperactivity, including irritability and aggression; and euphoria. Symptoms that did not show consistent results include apathy, eating disturbances, night-time behaviour disturbances, disinhibition and aberrant motor behaviour. Symptom groups differed in their associations, treatment and biology. Conclusions Studies investigating symptom groups show relatively consistent results. Studying symptom groups allows similar symptoms to be studied together, which might strengthen results and may point to differences in their aetiology and treatment. However, a large amount of the individual variability of the symptoms could not be explained by the factors, and authors should carefully address their research question and hypotheses to decide if symptoms should be studied in groups or individually. Clinicians need to consider each symptom in its own right and also to be aware of the interrelations between them when assessing patients and developing strategies for treatment. © 2013 The Authors. International Journal of Geriatric Psychiatry by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Behavioural and psychological symptoms (BPS) are common in the older population and may be an indication of early dementia. We explored the predictive effect of the presence of BPS on the 2-year progression to dementia in a cognitively impaired population aged 65 years and over without dementia at baseline. Methods Twelve symptoms were measured in 2024 participants without dementia at baseline as part of a population-based longitudinal study of ageing. The risk of progression to dementia was predicted in those with cognitive impairment for each individual BPS and using a BPS composite score. Results Wandering and persecution were independently associated with progression to dementia after adjustment for socio-demographic factors, cognitive domains and other BPS. When stratifying by cognitive function, those with low cognition (MMSE 0-18) and 4 or more BPS were more likely to progress to dementia than those without BPS. Conclusions We have shown that some psychiatric symptoms are associated with increased short-term progression to dementia in those with low cognition. The predictive effect of BPS in dementia progression has implications for risk stratification of those at high risk of progression to dementia, along with memory impairment, other cognitive impairment and health variables. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: To explore whether it is possible to detect decline in global scores of cognitive function in the proximity of death whilst simultaneously investigating potential risk profiles. Methods: Using the Mini Mental State Examination in a population study of the oldest old in which 99% of participants have died, a linear and quadratic time-to-death repeated measures random effects models were used to detect decline and potential factors which might indicate individual variation. Results: Decline and acceleration of this decline were detectable in the period before death. Some between person variation was detected in this pattern, which included differences in cognitive performance by age at death (-0.2 (SE=0.02)), sex (-1.2 (SE=0.2)), initial cognitive impairment (-7.5 (SE=0.2)) and mobility (-0.6 (SE=0.2)), in rate of decline by age at death (-0.04 (SE=0.005)), sex (-0.1 (SE=0.06)), initial cognitive impairment (-0.3 (SE=0.07)) and mobility (-0.1 (SE=0.05)) and differences in change in rate of decline by sex (-0.008 (SE=0.004)), initial cognitive impairment (-0.02 (SE=0.04)) and mobility (-0.01 (SE=0.003)). Conclusion: Using an extension of existing methods for exploring terminal decline, the phenomenon of decline in global cognition measures in the proximity of death was clearly detected as well as potential variables which could influence that pattern. Further work is required to explore whether similar methods can be used to detect the onset of the acceleration of this decline in each individual together with the potential to identify individual level factors that can allow clinicians to distinguish between the normal and preterminal phases of change in extreme old age. [ABSTRACT FROM AUTHOR]

Objectives: Investigate the impact of the changes in eligibility within England and Wales (E&W) for prescription within the UK National Health Service for treatment of Alzheimer's disease (AD).Methods: A population-based study in England and Wales with 13,004 individuals measured with MMSE at baseline was used to examine the distributions of individuals within eligibility criteria. Information obtained from informants enabled classification of the study defined dementia cases to ICD10 diagnosis of subtype (AD, dementia with vascular risk, both or other).Results: Fifty six per cent of dementia patients (representing 323,000 individuals in E&W) fall into the new MMSE criteria band. A further 120,000, 20% of dementia patients, are estimated to have disease that is considered too mild for treatment. Further examination of type of dementia showed that those with mixed AD and vascular dementia had similar proportions of dementia cases within the treatable MMSE group as the subgroup with AD alone, though with mixed disease individuals more often score below the lower threshold. There is substantial instability in the eligibility groupings over a short time period.Conclusions: The population impact of new NICE criteria of excluding high MMSE scores is to exclude one in five individuals with AD and a further one in ten of those with a mixed disease. Changing the guidance has almost balanced the loss of treatment for the high MMSE group (13%) with the introduction of treatment for those scoring 10/11 (11%). [ABSTRACT FROM AUTHOR]

Objective: To write a narrative review of the role of primary care physicians in the long-term care of people with dementia living at home, with a focus on psychosocial interventions, the provision of information and carer support, behavioural and psychological symptoms and case management.Methods: The systematic review carried out for the NICE/SCIE Guidelines was updated from January 2006, Cochrane Reviews were identified and other publications found by consultations with experts.Results: In primary care, the long-term care of people with dementia living at home can be structured around several key themes: reframing dementia with a focus on a social model of disability; active use of information sources; supporting carers (caregivers); the management of behavioural and psychological symptoms and a structured case management approach.Conclusions: Caring for people with dementia in primary care demands the same systematic approach as the management of other long-term conditions. The systematic follow-up of both people with dementia and their carers should be integrated into primary care. Reframing dementia, with an emphasis on abilities retained may allow people with dementia and their families to develop more effective coping strategies; an increase in skill mix within primary care is required to deliver this and may also improve the management of behavioural problems. The potential benefits of person-centred interventions, like advance care planning, and alternative models of service delivery, such as a structured, collaborative care approach which promotes integrated case management within primary care, require further evaluation. [ABSTRACT FROM AUTHOR]

Objective To determine the effects of early life education, mid life employment and later life retirement age on the age of onset (AOO) of Alzheimer's disease (AD). Methods Multiple regression analyses were carried out using data for 1320 probable AD cases, of which 382 were males with employment and retirement age data, using informant based information on education and employment. Results No relation was found between years of education, best qualification obtained, or employment variables in males and the AOO of AD. A significant effect of later retirement age in delaying the AOO of AD was seen in males. Conclusions In this study no effect of education or employment was seen, although this may be due to limited variance in the study population. The significant effect of retirement age may have several explanations, the most interesting of which would be the suggestion that active employment later in life allows an individual to prolong their cognitive assets above the threshold for dementia. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To write a narrative review of the roles of primary care practitioners in caring for people with dementia in the community. Methods The systematic review carried out for the NICE/SCIE Guidelines was updated from January 2006, Cochrane Reviews were identified, and other publications found by consultation with experts. Results The insidious and very variable development of dementia syndromes makes recognition of the syndrome problematic in primary care. Dementia is probably under-diagnosed and under treated with an estimated 50% of primary care patients over 65 not diagnosed by their primary care physicians. This problem of under-diagnosis is probably not due to lack of diagnostic skills, but rather to the interaction of case-complexity, pressure on time and the negative effects of reimbursement systems. Primary care physicians often over-estimate the prevalence of dementia syndromes, but in some countries may also overestimate the prevalence of vascular dementia compared with Alzheimer's disease. Diagnosis is a step-wise process which can be aided by use of a cognitive function test, of which there are a number suitable for primary care use. Evidence based practice protocols can enhance detection rates in primary care, and there is growing evidence that communication skills in talking to people with dementia about dementia can be improved. Nevertheless there are multiple obstacles to bringing recognition forward in time, both in public awareness and professional understanding of the early changes in dementia. Conclusions There is insufficient evidence of benefit to justify population screening in primary care but earlier recognition of people with dementia syndrome is possible within primary care. The diagnosis of dementia is a shared responsibility between generalist and specialist disciplines. Primary care physicians should explore patients' ideas and concerns around their symptoms prior to referral and tentatively discuss possible diagnoses. Once the diagnosis has been confirmed, the primary care physician should provide both practical and emotional support to allow the patient and their family to come to terms with living with dementia, and refer them for additional psychosocial support if required. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives Classifications of mild cognitive impairment (MCI) vary in the precision of the defining criteria. Their value in clinical settings is different from population settings. This difference depending on setting is to be expected, but must be well understood if population screening for dementia and pre-dementia states is to be considered. Of importance is the impact of missed diagnosis. The magnitude of missed ‘at-risk’ cases in the application of different MCI criteria in the population is unknown. Methods Data were from the Medical Research Council Cognitive Function and Ageing Study, a large population based study of older aged individuals in the UK. Prevalence and two-year progression to dementia in individuals whose impairment failed to fulfil published criteria for MCI was evaluated. Results Prevalence estimates of individuals not classified from current MCI definitions were extremely variable (range 2.5–41.0%). Rates of progression to dementia in these non-classified groups were also very variable (3.7–30.0%), reflecting heterogeneity in MCI classification requirements. Conclusions Narrow definitions of MCI developed for clinical settings when applied in the population result in a large proportion of individuals who progress to dementia being excluded from MCI classifications. More broadly defined criteria would be better for selection of individuals at risk of dementia in population settings, but at the possibility of high false positive rates. While exclusion may be a good thing in the population since most people are presumably ‘normal’, over-inclusion is more likely to be harmful. Further work needs to investigate the best classification system for application in the population. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Few population-based studies have examined the whole range of subthreshold syndromes and disorders of anxiety and depression in older people. Aims To investigate the co-occurrence of anxiety and depressive syndromes in older people. Associations between these conditions and personal and environmental factors are examined. Method MRC CFAS included 13, 004, age 65 years and above, who completed the initial screening interview. A stratified random subsample of 2, 640 participated in the assessment interview where the Geriatric Mental State Examination (GMS) was administered. The AGECAT diagnostic system was used to generate subthreshold and disorder-level of anxiety and depression as well as the combination of these into eight syndromes categories plus a group without any of the syndromes categories. Prevalences, unadjusted and adjusted odds ratios are calculated for the syndrome categories in relation to cross-sectional personal and environmental factors, and odds ratios of subthreshold and disorders level are estimated. Results The overall prevalence of anxiety and depressive disorders are 3.1% and 9.7% respectively. The overall prevalence of either anxiety or depressive disorder (anxiety disorder with subthreshold depression, mixed anxiety and depressive disorder with subthreshold anxiety) where they overlapped is 8.4%. The highest Odds Ratios unadjusted and adjusted for age and gender, of anxiety and depressive disorders and significant for trend are found for increasing disability. Disability has a strong relationship with all the co-morbid syndrome categories. In all analyses women showed significant higher estimates than men. Conclusions Our study demonstrated high estimates where anxiety and depression occurred in parallel both as disorders and as subthreshold syndromes. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Systematic evidence became available in the late 1990s on efficacy of cholinesterase inhibitors (CHEIs) for patients with mild to moderate Alzheimer's disease (AD) and they began to be used sporadically. Since January 2001 UK based guidelines indicated that one of three cholinesterase inhibitors (CHEIs) could be prescribed for these patients. Since then the cost of prescription in England and Wales has risen. There has been little investigation of uptake at the population level. Objective To estimate the population uptake of CHEIs in a population based study of dementia spanning this period. Design Using data from a 10-year follow up and a later 12 year interview of the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS), a UK population based longitudinal cohort study of people originally aged 65 years and above, we investigated who was taking CHEIs during the period 2001–2004. We sought information from respondents taking part in the study what medication they were taking on a regular basis. Results Only 12, of the 219 individuals who received a study diagnosis of dementia were prescribed CHEIs [5%, 95% Confidence Intervals (CI) 3%–9%]) in 2001/2003 and none of the 28 individuals with a study diagnosis of dementia (0%, 95% CI 0–18%) in 2004 were prescribed CHEIs. Uptake was biased towards individuals with more education and higher social class. Conclusions These data suggest that any impact on AD progression at the population level will be negligible as prescription of CHEIs and uptake in the age group at highest risk is so limited. There is little evidence that this has changed over time. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article discusses geriatric psychiatry as of April 2013, with a focus on the instruments used in measuring behavioural and psychological symptoms of dementia (BPSD). Topics include the Neuropsychiatric Inventory (NPI) questionnaire which measures BPSD, cognitive impairment assessments, and the Behavioral Pathology in Alzheimer’s Disease Scale (BEHAVE-AD).

A letter to the editor is presented which is concerned with dementia.