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Objective: The objective of this study was to evaluate peer support and reminiscence therapy, separately and together, in comparison with usual care for people with dementia and their family carers., Design: Factorial pragmatic randomised trial, analysed by treatment allocated, was used for this study., Setting: The trial ran in Community settings in England., Participants: People with dementia and their family carers were the participants., Interventions: Treatment as usual (TAU) plus one of the following: one-to-one peer support to family carers from experienced carers (Carer Supporter Programme; CSP), group reminiscence therapy (Remembering Yesterday, Caring Today; RYCT) for people with dementia and carers, both or neither., Main Outcome Measures: Primary outcomes included health-related quality of life (SF-12) for carers and quality of life (QoL-AD) for people with dementia; secondary outcomes included quality of relationship for carers and people with dementia; both were collected by blinded assessors at baseline, 5 and 12 months (primary end point)., Results: Of 291 pairs recruited, we randomised 145 (50%) to CSP (71% uptake) and 194 (67%) to RYCT (61% uptake). CSP and RYCT, separately or together, were not effective in improving primary outcomes or most secondary outcomes. For CSP versus 'no CSP', adjusted difference in means was 0.52 points on the SF-12 (95% CI -1.28 to 2.32) and -0.08 points on the QoL-AD (95% CI -1.70 to 1.56). For RYCT versus 'no RYCT', the difference was 0.10 points on the SF-12 (95% CI -1.72 to 1.93) and 0.51 points on the QoL-AD (95% CI -1.17 to 2.08). However, carers reported better relationships with the people with dementia (difference 1.11, 95% CI 0.00 to 2.21, p=0.05). Comparison of combined intervention with TAU, and of intervention received, suggested differential impacts for carers and persons with dementia., Conclusions: There is no evidence from the trial that either peer support or reminiscence is effective in improving the quality of life., Trial Registration Number: ISRCTN37956201; Results., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Depression is common in dementia but the evidence base for appropriate drug treatment is sparse and equivocal. We aimed to assess efficacy and safety of two of the most commonly prescribed drugs, sertraline and mirtazapine, compared with placebo., Methods: We undertook the parallel-group, double-blind, placebo-controlled, Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) trial in participants from old-age psychiatry services in nine centres in England. Participants were eligible if they had probable or possible Alzheimer's disease, depression (lasting ≥4 weeks), and a Cornell scale for depression in dementia (CSDD) score of 8 or more. Participants were ineligible if they were clinically critical (eg, suicide risk), contraindicated to study drugs, on antidepressants, in another trial, or had no carer. The clinical trials unit at King's College London (UK) randomly allocated participants with a computer-generated block randomisation sequence, stratified by centre, with varying block sizes, in a 1:1:1 ratio to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks (outcomes to 39 weeks were also assessed), assessed with a mixed linear-regression model adjusted for baseline CSDD, time, and treatment centre. This study is registered, number ISRCTN88882979 and EudraCT 2006-000105-38., Findings: Decreases in depression scores at 13 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (mean difference 1·17, 95% CI -0·23 to 2·58; p=0·10) or mirtazapine (0·01, -1·37 to 1·38; p=0·99), or between participants in the mirtazapine and sertraline groups (1·16, -0·25 to 2·57; p=0·11); these findings persisted to 39 weeks. Fewer controls had adverse reactions (29 of 111 [26%]) than did participants in the sertraline group (46 of 107, 43%; p=0·010) or mirtazapine group (44 of 108, 41%; p=0·031), and fewer serious adverse events rated as severe (p=0·003). Five patients in every group died by week 39., Interpretation: Because of the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants, with usual care, for first-line treatment of depression in Alzheimer's disease should be reconsidered., Funding: UK National Institute of Health Research HTA Programme., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Anxiety is extremely common in dementia and can lead to social exclusion, excess disability and associated problems including high physical dependency, problems in the patient/carer relationship, and increased cognitive and behavioural difficulties. Despite this, there is little research on the detection or management of anxiety in dementia, and nothing from the perspective of people with dementia or their carers., Methods: This study aimed to conceptualize users', carers' and staff views on the causes and management of anxiety in dementia. Eighty-one participants (users, carers and staff) participated in nine focus groups. Results were analysed using a mind-map technique and the 'long table approach'., Results: Themes related to the causes of anxiety included coming to terms with the diagnosis, loss of skills, physical and environmental factors and relationships with others. Themes related to the management of anxiety included coming to terms with the diagnosis, person-centred care, memory aids, enjoyable and distracting activities, management of physical and environmental problems and medication as a last resort., Conclusions: Support around diagnosis, person-centred care, fostering good relationships and engagement in meaningful activity are of great importance to people with dementia and those who care for them. Yet in clinical practice, people with dementia suffering from anxiety may receive no help or else be given medication due to a lack of understanding of what else might help. Developing evidence-based psychological treatments for anxiety in dementia, to improve care and quality of life, should be a priority., (2010 Elsevier B.V. All rights reserved.)

Introduction: Nonpharmacological therapies (NPTs) can improve the quality of life (QoL) of people with Alzheimer's disease (AD) and their carers. The objective of this study was to evaluate the best evidence on the effects of NPTs in AD and related disorders (ADRD) by performing a systematic review and meta-analysis of the entire field., Methods: Existing reviews and major electronic databases were searched for randomized controlled trials (RCTs). The deadline for study inclusion was September 15, 2008. Intervention categories and outcome domains were predefined by consensus. Two researchers working together detected 1,313 candidate studies of which 179 RCTs belonging to 26 intervention categories were selected. Cognitive deterioration had to be documented in all participants, and degenerative etiology (indicating dementia) had to be present or presumed in at least 80% of the subjects. Evidence tables, meta-analysis and summaries of results were elaborated by the first author and reviewed by author subgroups. Methods for rating level of evidence and grading practice recommendations were adapted from the Oxford Center for Evidence-Based Medicine., Results: Grade A treatment recommendation was achieved for institutionalization delay (multicomponent interventions for the caregiver, CG). Grade B recommendation was reached for the person with dementia (PWD) for: improvement in cognition (cognitive training, cognitive stimulation, multicomponent interventions for the PWD); activities of daily living (ADL) (ADL training, multicomponent interventions for the PWD); behavior (cognitive stimulation, multicomponent interventions for the PWD, behavioral interventions, professional CG training); mood (multicomponent interventions for the PWD); QoL (multicomponent interventions for PWD and CG) and restraint prevention (professional CG training); for the CG, grade B was also reached for: CG mood (CG education, CG support, multicomponent interventions for the CG); CG psychological well-being (cognitive stimulation, multicomponent interventions for the CG); CG QoL (multicomponent interventions for PWD and CG)., Conclusion: NPTs emerge as a useful, versatile and potentially cost-effective approach to improve outcomes and QoL in ADRD for both the PWD and CG., (Copyright © 2010 S. Karger AG, Basel.)

Objectives: There have been few longitudinal studies investigating the impact of coping on psychological morbidity in caregivers of people with dementia. Findings have been inconsistent and little attention has been paid to anxiety in caregivers. We explored the hypothesis that the relationship between caregiver burden and anxiety and depression is mediated by coping style., Methods: As part of the LASER-AD study, 93 (73.8%) people with Alzheimer's disease and their family caregivers recruited at baseline were re-interviewed 1 year later. Sampling aimed to ensure that the participants were representative of people living in the UK with Alzheimer's disease in terms of dementia severity, gender and care setting. We used the Hospital Anxiety and Depression Scale, the Zarit Burden scale and the Brief COPE to measure coping strategies., Results: Using fewer emotion-focused strategies and more problem-focused strategies (but not dysfunctional strategies) mediated the relationship between caregiver burden and anxiety a year later, after controlling for potential confounders, in a well-fitting structural equation model (chi(2)=0.93, df=3, p=0.82; NFI=1.0, RFI=0.97, IFI=1.0, TLI=1.1, RMSEA=0.0). Using fewer emotion focused strategies also predicted higher psychological morbidity in general. The hypothesised relationship was not proved for depression., Conclusions: Using emotion-focussed coping strategies in response to caregiver burden seemed to protect caregivers from developing higher anxiety levels a year later; however using problem-focussed strategies did not. Our results suggest that a psychological intervention package to emphasise emotion-focused coping may be a rational approach to reduce anxiety in dementia caregivers. Studies are needed to test such interventions.

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

Background: Quality of Life (QoL) is a key outcome in dementia., Aim: To compare care recipients' (CR) and caregivers' (CG) views on CRs' QoL and identify determinants., Methods: CRs and CGs completed the Quality of Life - Alzheimer's Disease (QOL-AD) scale., Results: One hundred and ninety-one CR/CG dyads were interviewed. There were differences between determinants of the CRs and CGs views about QoL. Family-CGs rated CRs' QoL higher when CRs had fewer depressive symptoms, less irritability, less apathy, less daily living impairment and lived at home. Fewer depressive symptoms, living at home and taking acetylcholinesterase-inhibitors (AChEI) predicted higher CR rated QoL., Conclusion: Proxy ratings in dementia do not replicate CRs' views of QoL. This is the first study to employ a validated QoL measure for people with dementia taking AChEIs. Randomised controlled trials are needed before drawing conclusions about their effect on QoL. Interpretation of correlations between QoL and symptoms should be cautious as QoL is designed to reflect the impact of psychological and physical symptoms., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

Background: Caregivers of people with dementia (CGPD) frequently have anxiety symptoms but little is known about the relationship of anxiety with coping strategies., Method: 126 people with Alzheimer's disease (AD) and their family caregivers living in the community were recruited from local psychiatric services, the voluntary sector and care homes. Sampling was designed to ensure that the sample was epidemiologically representative in terms of dementia severity, gender and care setting. We used the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS) to measure anxiety and the Brief COPE to measure coping strategies., Results: Use of dysfunctional coping strategies (Wald = 7.3, p = 0.007) and HADS depression caseness (Wald = 14.0, p < 0.001) were the only factors that predicted HADS anxiety caseness on logistic regression., Limitations: Anxious caregivers may be more likely to report their coping strategies negatively; these results do not clarify direction of causality., Conclusions: Dysfunctional coping strategies and depression appear to be the most important factors predicting caregiver anxiety. Addressing coping strategies may be a helpful intervention for managing caregiver anxiety.

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

The degeneration of dopaminergic cells in dementia with Lewy bodies (DLB) may provide an important source of additional free radical generation. As a result, the oxidative stress status in DLB could be significantly enhanced. Subsequently, the levels of endogenous antioxidants, which are an indirect measure of free radical activities, may be different in DLB patients when compared with Alzheimer's disease (AD) patients and controls. In this preliminary study, we measured the activities of superoxide dismutase (SOD), catalase (CAT), glutathione (GLU) and total antioxidant capacity in the blood of DLB, AD and control subjects. The state of nigrostriatal dopaminergic system was also assessed in vivo by using a radioactive ligand with an affinity for the dopamine pre-synaptic receptors and by imaging with single-photon emission tomography. Data obtained showed a decrease in dopamine pre-synaptic receptors in all the brain regions of DLB patients. The levels of SOD did not differ significantly between DLB, AD and control subjects. However, GLU levels were significantly higher in the DLB patients when compared with AD patients (p < 0.05) and controls (p < 0.01). CAT blood levels were also higher in DLB when compared with AD, but this did not reach statistical significance. The results suggest that a different oxidative stress state may exist in DLB. This may occur due to increased free radical production from the degeneration of dopaminergic cells and auto-oxidation of dopamine, the availability of which may be maintained in early-stage DLB disease as a result of the compensatory increase in its turnover from the remaining dopaminergic cells., (Copyright 2003 S. Karger AG, Basel)

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

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

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

Previous studies have linked reduced survival in dementia with male sex, older age, longer duration of illness and increased severity of cognitive impairment. However, little is known about the potential influence of social factors (such as life events and social support) on the outcome of dementia. Sixty recently admitted patients with dementia (27 in-patients and 33 day patients) were given detailed psychiatric and social assessments. These included information on life events and social supports. At follow-up, 3 years later, data were collected on outcome. The hypotheses were that adverse life events and lack of social support would be associated with reduced survival. Nearly half the patients (48%) died during the follow-up period. The experience of life events before the first assessment was not associated with outcome. However, receiving meals on wheels (p=0.01) was associated with reduced survival, while attending a day centre (p=0.06) and having support from relatives (p=0.06) were associated with increased survival. Higher dependency (p=0.004) and poorer physical health (p=0.07) were associated with reduced survival. These results suggest that factors related to social support are associated with the outcome of dementia. In particular, receiving meals on wheels or home help may be a marker of a lack of social support, which influences outcome. Further studies are required to examine these associations in more detail., (Copyright 2000 John Wiley & Sons, Ltd.)

Objective: To compare the performance of patients with frontotemporal dementia (FTD) and Alzheimer's disease (AD) on a range of simple neuropsychological tests., Design: A battery of neuropsychological tests easily applied at the bedside, consisting of traditional tests of memory, attention and executive function, were given together with tests of motor sequencing and examination of frontal release signs. In addition, we devised a theoretically motivated test of dual attention-a story with distraction which also contained a 'social dilemma'., Setting: Specialist memory and cognitive disorders clinic., Patients: 12 patients with FTD and 12 patients with AD, matched for overall level of dementia on the Mini-Mental State Examination, were selected., Results: In general, the difference in results between FTD and AD patients was small. However, a composite score derived from the presence of a grasp and pout reflex, the number of perseverations during category fluency for animals and response to the social dilemma within the two stories produced a sensitivity of 83.3% and specificity of 91.6%. There was also a highly significant difference between patients with FTD and AD in scores achieved on the Clinical Dementia Rating Scale reflecting the marked change in behaviour that patients with FTD suffer, even at a stage when memory functions are well preserved., Conclusion: Traditional neuropsychological tests were poor at differentiating cases of FTD and AD; however, a composite (SIFTD) score appears potentially useful but requires prospective validation. Better methods of assessing the changes in comportment that characterize the early stages of FTD are required.