Search

ObjectiveMost investigations of pharmacotherapy for treating Alzheimer's disease focus on patients with mild-to-moderate symptoms, with little evidence to guide clinical decisions when symptoms become severe. We examined whether continuing donepezil, or commencing memantine, is cost-effective for community-dwelling, moderate-to-severe Alzheimer's disease patients.MethodsCost-effectiveness analysis was based on a 52-week, multicentre, double-blind, placebo-controlled, factorial clinical trial. A total of 295 community-dwelling patients with moderate/severe Alzheimer's disease, already treated with donepezil, were randomised to: (i) continue donepezil; (ii) discontinue donepezil; (iii) discontinue donepezil and start memantine; or (iv) continue donepezil and start memantine.ResultsContinuing donepezil for 52 weeks was more cost-effective than discontinuation, considering cognition, activities of daily living and health-related quality of life. Starting memantine was more cost-effective than donepezil discontinuation. Donepezil-memantine combined is not more cost-effective than donepezil alone.ConclusionsRobust evidence is now available to inform clinical decisions and commissioning strategies so as to improve patients' lives whilst making efficient use of available resources. Clinical guidelines for treating moderate/severe Alzheimer's disease, such as those issued by NICE in England and Wales, should be revisited. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.

Dementia is one of the greatest contemporary health and social care challenges, and novel approaches to the care of its sufferers are needed. New information and communication technologies (ICT) have the potential to assist those caring for people with dementia, through access to networked information and support, tracking and surveillance. This article reports the views about such new technologies of 34 carers of people with dementia. We also held a group discussion with nine carers for respondent validation. The carers' actual use of new ICT was limited, although they thought a gradual increase in the use of networked technology in dementia care was inevitable but would bypass some carers who saw themselves as too old. Carers expressed a general enthusiasm for the benefits of ICT, but usually not for themselves, and they identified several key challenges including: establishing an appropriate balance between, on the one hand, privacy and autonomy and, on the other: maximising safety; establishing responsibility for and ownership of the equipment and who bears the costs; the possibility that technological help would mean a loss of valued personal contact; and the possibility that technology would substitute for existing services rather than be complementary. For carers and dementia sufferers to be supported, the expanding use of these technologies should be accompanied by intensive debate of the associated issues. KEY WORDS--dementia, carers, information technology, qualitative methods. doi: 10.1017/S0144686X1000019X

Author(s): Thomas A. Jackson 1,2,*, John R. F. Gladman 3, Rowan H. Harwood 4, Alasdair M. J. MacLullich 5, Elizabeth L. Sampson 6, Bart Sheehan 7, Daniel H. J. Davis [...]

Abstract We aimed in this study to investigate (1) outdoor wayfinding performance of people with dementia; and (2) which features of the outdoor built environment are used in wayfinding by [...]

Abstract Background The occupational therapy (OT) in care homes study (OTCH) aims to investigate the effect of a targeted course of individual OT (with task training, provision of adaptive equipment, minor environmental adaptations and staff education) for stroke survivors living in care homes, compared to usual care. Methods/Design A cluster randomised controlled trial of United Kingdom (UK) care homes (n = 90) with residents (n = 900) who have suffered a stroke or transient ischaemic attack (TIA), and who are not receiving end-of-life care. Homes will be stratified by centre and by type of care provided and randomised (50:50) using computer generated blocked randomisation within strata to receive either the OT intervention (3 months intervention from an occupational therapist) or control (usual care). Staff training on facilitating independence and mobility and the use of adaptive equipment, will be delivered to every home, with control homes receiving this after the 12 month follow-up. Allocation will be concealed from the independent assessors, but the treating therapists, and residents will not be masked to the intervention. Measurements are taken at baseline prior to randomisation and at 3, 6 and 12 months post randomisation. The primary outcome measure is independence in self-care activities of daily living (Barthel Activities of Daily Living Index). Secondary outcome measures are mobility (Rivermead Mobility Index), mood (Geriatric Depression Scale), preference based quality of life measured from EQ-5D and costs associated with each intervention group. Quality adjusted life years (QALYs) will be derived based on the EQ-5D scores. Cost effectiveness analysis will be estimated and measured by incremental cost effectiveness ratio. Adverse events will be recorded. Discussion This study will be the largest cluster randomised controlled trial of OT in care homes to date and will clarify the currently inconclusive literature on the efficacy of OT for stroke and TIA survivors residing in care homes. Trial registration ISRCTN00757750

Abstract Background Alzheimer's disease (AD) is the commonest cause of dementia. Cholinesterase inhibitors, such as donepezil, are the drug class with the best evidence of efficacy, licensed for mild to moderate AD, while the glutamate antagonist memantine has been widely prescribed, often in the later stages of AD. Memantine is licensed for moderate to severe dementia in AD but is not recommended by the England and Wales National Institute for Health and Clinical Excellence. However, there is little evidence to guide clinicians as to what to prescribe as AD advances; in particular, what to do as the condition progresses from moderate to severe. Options include continuing cholinesterase inhibitors irrespective of decline, adding memantine to cholinesterase inhibitors, or prescribing memantine instead of cholinesterase inhibitors. The aim of this trial is to establish the most effective drug option for people with AD who are progressing from moderate to severe dementia despite treatment with donepezil. Method DOMINO-AD is a pragmatic, 15 centre, double-blind, randomized, placebo controlled trial. Patients with AD, currently living at home, receiving donepezil 10 mg daily, and with Standardized Mini-Mental State Examination (SMMSE) scores between 5 and 13 are being recruited. Each is randomized to one of four treatment options: continuation of donepezil with memantine placebo added; switch to memantine with donepezil placebo added; donepezil and memantine together; or donepezil placebo with memantine placebo. 800 participants are being recruited and treatment continues for one year. Primary outcome measures are cognition (SMMSE) and activities of daily living (Bristol Activities of Daily Living Scale). Secondary outcomes are non-cognitive dementia symptoms (Neuropsychiatric Inventory), health related quality of life (EQ-5D and DEMQOL-proxy), carer burden (General Health Questionnaire-12), cost effectiveness (using Client Service Receipt Inventory) and institutionalization. These outcomes are assessed at baseline, 6, 18, 30 and 52 weeks. All participants will be subsequently followed for 3 years by telephone interview to record institutionalization. Discussion There is considerable debate about the clinical and cost effectiveness of anti-dementia drugs. DOMINO-AD seeks to provide clear evidence on the best treatment strategies for those managing patients at a particularly important clinical transition point. Trial registration Current controlled trials ISRCTN49545035

Background: Physical activity has been positively associated with a range of objectively measured environmental variables. We explored the relationship of walking and other categories of physical activity with objectively measured activity specific environmental variables in a UK population. Methods: We used a geographical information system (GIS) and gender specific multivariate models to relate 13,927 participants' reported levels of physical activity with a range of measures of the environment. Results: Access to green space and area levels of crime were not associated with walking for recreation. Distance to facilities had either no or only a small effect on the uptake of different activities. Odds ratios of cycling for leisure dropped as local traffic density increased for both genders. Compared with the lowest quartile for traffic density the likelihood of reporting any cycling for leisure was OR 0.42, (95% CI 0.32 to 0.52, P < .001) for women and OR 0.41, (95% CI 0.33 to 0.50, P < .001) for men in the highest quartile. Conclusions: We were unable to reproduce results observed in previous studies. Future research should use large representative population samples from multiple areas to maximize environmental variability and if feasible use both objective and subjective measures of physical activity and the environment. [ABSTRACT FROM AUTHOR]

Background and Objectives: Forty percent of residents living in care homes in the United Kingdom have significant depressive symptoms. Care homes can appear to be depressing places, but whether the physical environment of homes directly affects depression in care home residents is unknown. This study explores the relationship between the physical environment and depressive symptoms of older people living in care homes. Research Design and Methods: In a prospective cohort study the physical environment of 50 care homes were measured using the Sheffield Care Environment Assessment Matrix (SCEAM) and depressive symptoms of 510 residents measured using the Geriatric Depression Scale (GDS-15). The study was supplemented with semi-structured interviews with residents living in the care homes. Quantitative data were analyzed using multi-level modeling, and qualitative data analyzed using a thematic framework approach. Results: The overall physical environment of care homes (overall SCEAM score) did not predict depressive symptoms. Controlling for dependency, social engagement, and home type, having access to outdoor space was the only environmental variable to significantly predict depressive symptoms. Residents interviewed reported that access to outdoor space was restricted in many ways: locked doors, uneven foot paths, steep steps, and needing permission or assistance to go outside. Discussion and Implications: We provide new evidence to suggest that access to outdoor space predicts depressive symptoms in older people living in care home. Interventions aimed at increasing access to outdoor spaces could positively affect depressive symptoms in older people. [ABSTRACT FROM AUTHOR]

Aims: Cholinergic deficiency is commonly implicated in the pathophysiology of delirium. We aimed to investigate the relationship between directly measured serum acetylcholinesterase (AChE) activity and (1) clinical features of delirium and (2) outcomes among older hospital patients with delirium. Methods: Hospitalised patients with delirium were recruited, and delirium motor subtype, severity and duration of delirium were measured. Serum AChE activity was measured using a colorimetric assay. Results: The mean AChE activity for the whole sample was 2.46 μmol/μL/min (standard deviation 1.75). Higher AChE activity was associated with increased likelihood of hypoactive delirium rather than the hyperactive or mixed subtype (odds ratio 1.98, 95% confidence interval 1.10-3.59). Conclusion: Higher AChE activity was associated with hypoactive delirium but did not predict outcomes. Simple enhancement of cholinergic neurotransmission may not be sufficient to treat delirium. [ABSTRACT FROM AUTHOR]