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Background and Purpose: Stroke is associated with an increased risk of dementia. To assist in the early identification of individuals at high risk of future dementia, numerous prediction models have been developed for use in the general population. However, it is not known whether such models also provide accurate predictions among stroke patients. Therefore, the aim of this study was to determine whether existing dementia risk prediction models that were developed for use in the general population can also be applied to individuals with a history of stroke to predict poststroke dementia with equivalent predictive validity., Methods: Data were harmonized from 4 stroke studies (follow-up range, ≈12-18 months poststroke) from Hong Kong, the United States, the Netherlands, and France. Regression analysis was used to test 3 risk prediction models: the Cardiovascular Risk Factors, Aging and Dementia score, the Australian National University Alzheimer Disease Risk Index, and the Brief Dementia Screening Indicator. Model performance or discrimination accuracy was assessed using the C statistic or area under the curve. Calibration was tested using the Grønnesby and Borgan and the goodness-of-fit tests., Results: The predictive accuracy of the models varied but was generally low compared with the original development cohorts, with the Australian National University Alzheimer Disease Risk Index (C-statistic, 0.66) and the Brief Dementia Screening Indicator (C-statistic, 0.61) both performing better than the Cardiovascular Risk Factors, Aging and Dementia score (area under the curve, 0.53)., Conclusions: Dementia risk prediction models developed for the general population do not perform well in individuals with stroke. Their poor performance could have been due to the need for additional or different predictors related to stroke and vascular risk factors or methodological differences across studies (eg, length of follow-up, age distribution). Future work is needed to develop simple and cost-effective risk prediction models specific to poststroke dementia.

Microbleeds are a marker of cerebrovascular disease however its role in incident post-stroke dementia (PSD) remains unclear. We investigated whether microbleeds are associated with incident PSD, domain-specific cognitive impairment and cognitive decline over a 2-year follow-up; and whether microbleeds interact with acute stroke-related infarcts to synergistically affect cognitive outcomes. In a cohort of patients with first-episode mild ischemic stroke and no pre-stroke dementia, we found patients with 3 or more mixed microbleeds (presence of both lobar and deep) were 4 times more at risk of developing PSD compared to patients with no microbleeds. Patients with strictly lobar microbleeds were 10 times more at risk of developing memory impairment while patients with possible CAA-related microbleeds were 8 times more at risk of developing memory impairment compared to patients with no microbleeds. Microbleeds did not predict cognitive decline at the 2-year follow-up. Acute stroke infarcts were not related to any cognitive outcomes. Microbleeds did not interact with stroke infracts to synergistically affect cognitive outcomes. Our findings suggest that the combined effect of possible CAA and hypertension-related microbleeds play a large and direct role in incident PSD. Management of vasculopathy and amyloid deposition may positively impact cognitive outcomes after stroke., Competing Interests: Declaration of Competing Interest None to disclose., (Copyright © 2020. Published by Elsevier B.V.)

Although many persons with severe dementia (PWSDs) are cared for at home by their family caregivers, few studies have assessed end of life (EOL) care experiences of PWSDs. We present the protocol for the PISCES study (Panel study Investigating Status of Cognitively impaired Elderly in Singapore) which aims to describe the clinical course, health care utilization, and expenditures for community-dwelling PWSDs; and perceived burden, coping, resilience, anticipatory and prolonged grief among their caregivers. This ongoing multi-center prospective longitudinal study is recruiting primary informal caregivers of 250 PWSDs from major restructured public hospitals, community hospitals, home care foundations, and hospices in Singapore. Caregivers are surveyed every four months for two years or until the PWSD passes away and then at eight weeks and six months post-death to assess the bereavement of the caregiver. Survey questionnaires included validated tools to assess PWSDs' quality of life, suffering, behaviors, functional status, resource utilization; and caregiver's satisfaction with care, awareness of prognosis, care preferences, resilience, coping, perceived burden, distress, positive aspects of caregiving, anticipatory grief, and bereavement adjustment. We also conduct qualitative in-depth interviews with a sub-sample of caregivers. The survey data is being linked with medical and billing records of PWSDs. The study has been approved by an ethics board. Results from the study will be disseminated through publications and presentations targeting researchers, policy makers and clinicians interested in understanding and improving EOL care for PWSDs and their caregivers.

The retina offers a unique "window" to study pathophysiological processes of dementia in the brain, as it is an extension of the central nervous system (CNS) and shares prominent similarities with the brain in terms of embryological origin, anatomical features and physiological properties.  The vascular and neuronal structure in the retina can now be visualized easily and non-invasively using retinal imaging techniques, including fundus photography and optical coherence tomography (OCT), and quantified semi-automatically using computer-assisted analysis programs. Studying the associations between vascular and neuronal changes in the retina and dementia could improve our understanding of dementia and, potentially, aid in diagnosis and risk assessment.  This protocol aims to describe a method of quantifying and analyzing retinal vasculature and neuronal structure, which are potentially associated with dementia. This protocol also provides examples of retinal changes in subjects with dementia, and discusses technical issues and current limitations of retinal imaging.

Importance: Amyloid-β positron emission tomography (PET) imaging allows in vivo detection of fibrillar plaques, a core neuropathological feature of Alzheimer disease (AD). Its diagnostic utility is still unclear because amyloid plaques also occur in patients with non-AD dementia., Objective: To use individual participant data meta-analysis to estimate the prevalence of amyloid positivity on PET in a wide variety of dementia syndromes., Data Sources: The MEDLINE and Web of Science databases were searched from January 2004 to April 2015 for amyloid PET studies., Study Selection: Case reports and studies on neurological or psychiatric diseases other than dementia were excluded. Corresponding authors of eligible cohorts were invited to provide individual participant data., Data Extraction and Synthesis: Data were provided for 1359 participants with clinically diagnosed AD and 538 participants with non-AD dementia. The reference groups were 1849 healthy control participants (based on amyloid PET) and an independent sample of 1369 AD participants (based on autopsy)., Main Outcomes and Measures: Estimated prevalence of positive amyloid PET scans according to diagnosis, age, and apolipoprotein E (APOE) ε4 status, using the generalized estimating equations method., Results: The likelihood of amyloid positivity was associated with age and APOE ε4 status. In AD dementia, the prevalence of amyloid positivity decreased from age 50 to 90 years in APOE ε4 noncarriers (86% [95% CI, 73%-94%] at 50 years to 68% [95% CI, 57%-77%] at 90 years; n = 377) and to a lesser degree in APOE ε4 carriers (97% [95% CI, 92%-99%] at 50 years to 90% [95% CI, 83%-94%] at 90 years; n = 593; P < .01). Similar associations of age and APOE ε4 with amyloid positivity were observed in participants with AD dementia at autopsy. In most non-AD dementias, amyloid positivity increased with both age (from 60 to 80 years) and APOE ε4 carriership (dementia with Lewy bodies: carriers [n = 16], 63% [95% CI, 48%-80%] at 60 years to 83% [95% CI, 67%-92%] at 80 years; noncarriers [n = 18], 29% [95% CI, 15%-50%] at 60 years to 54% [95% CI, 30%-77%] at 80 years; frontotemporal dementia: carriers [n = 48], 19% [95% CI, 12%-28%] at 60 years to 43% [95% CI, 35%-50%] at 80 years; noncarriers [n = 160], 5% [95% CI, 3%-8%] at 60 years to 14% [95% CI, 11%-18%] at 80 years; vascular dementia: carriers [n = 30], 25% [95% CI, 9%-52%] at 60 years to 64% [95% CI, 49%-77%] at 80 years; noncarriers [n = 77], 7% [95% CI, 3%-18%] at 60 years to 29% [95% CI, 17%-43%] at 80 years., Conclusions and Relevance: Among participants with dementia, the prevalence of amyloid positivity was associated with clinical diagnosis, age, and APOE genotype. These findings indicate the potential clinical utility of amyloid imaging for differential diagnosis in early-onset dementia and to support the clinical diagnosis of participants with AD dementia and noncarrier APOE ε4 status who are older than 70 years.

Background and Purpose: Although the age-related white matter changes (ARWMC) scale has been advocated to be applicable to both MRI and CT for assessing the severity of WMC, its inter-rater reliability on CT is only fair. We aimed to operationalize the ARWMC scale and investigate the effect of this operationalization on the reliability and validity on MRI and CT., Methods: Operational definitions of the ARWMC scale were derived from Erkinjuntti research criteria for subcortical vascular dementia and Scheltens scale. Using original and operationalized ARWMC scale, eight observers recorded the time for rating per MRI and per CT. We investigated the inter-rater and intrarater reliability as well as validity against volume using data from 97 stroke patients., Results: Inter-rater reliability of the operationalized scale on CT (0.874, 95% confidence interval [0.780-0.934]) was better than the original scale (0.569, 95% confidence interval [0.247-0.775]). Its intrarater reliability on CT (0.869) and reliability on MRI (inter-rater: 0.860; intrarater: 0.838) was comparable with the original scale (CT intrarater: 0.750 and on MRI inter-rater: 0.845; intrarater: 0.853). The time required to administer the operationalized scale (4'2″ for MRI and 1'18″ for CT) was similar to that of the original scale (3'56″ for MRI and 1'16″ for CT). The original scale and operationalized scale also significantly correlated with WMC volume (operationalized scale ρ = 0.613, P < 0.001, original scale ρ = 0.638, P < 0.001)., Conclusion: Operational definitions improve the inter-rater reliability of ARWMC scale on CT, and it correlates with volumetric measurement., (© 2010 The Author(s). European Journal of Neurology © 2010 EFNS.)

Background: The behavioural problems of people with dementia are often considered as one of the most challenging issues in caring. Special Care Units (SCUs) have flourished since the 1980s with the aim of taking care of dementia patients, usually those with Alzheimer's disease, and in particular for those with behavioural problems. Although lacking a standard definition, SCUs are usually situated within nursing homes and commonly include the features of trained staffing, special programming, a modified physical environment, and family involvement. The costs of SCUs are commonly higher than for 'standard' nursing home care. However, evaluat ions of the outcomes of SCUs have yielded conflicting results. A systematic review of this evidence is therefore warranted ., Objectives: To evaluate the effect of SCUs on behavioural problems, mood, use of restraints and psychotropic medication in patients with dementia., Search Strategy: The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL on 6 September 2007 using the search terms: Special Care Units or SCUs. The CDCIG Specialized Register contains records from major healthcare databases including MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and LILACS as well as many ongoing trial databases and grey literature sources., Selection Criteria: All randomized controlled trials (RCTs) in which the outcomes of SCUs were compared against traditional nursing units (nursing homes, skilled nursing facilities) were included., Data Collection and Analysis: Two reviewing authors independently read the full reports of the potentially eligible studies and selected those that met the inclusion criteria. Discrepancies were resolved by discussions among the two reviewing authors. Final consensus was reached with input from a third member of the team when necessary., Main Results: No RCTs meeting the selection criteria were identified. Since it is unlikely, for ethical and practical reasons that an RCT of SCUs will be conducted, a systematic review of non-RCTs using the same protocol and criteria was conducted. There were eight non-RCTs that fulfilled the criteria for inclusion. Only four studies had data which could be extracted for pooling in meta-analysis. Differences between comparator groups in these nonRCTs ? for example in severity of dementia - w ere not adequately adjusted for and were common in the trial which accounted for almost all of the positive outcomes of SCUs (Nobili, 2006)All of the results of the outcomes came only from single studies except for "physical restraint use" at 6 months, which included data from two studies. A small improvement in total Neuropsychiatric Inventory scores, favouring SCU was noted in one study at 6, 12 and 18 months. The use of physical restraints was less common in SCUs at 6 and 12 months (OR= 0.46 (95% CI 0.27 to 0.80), p=0.006; and OR=0.49 (0.27 to 0.88), p=0.02 respectively). Patients in SCUs were less depressed at 3 months than those in traditional nursing home (WMD -6.30 (-7.88 to -4.72) Cornell points, p<0.00001). There was only one observation that favoured the control group: a small but significant effect favouring traditional nursing home care was observed at 6 months in the mean number of psychotropic medications used (WMD 0.20, CI 0.00 to 0.40, z=1.96, P=0.05)., Authors' Conclusions: There are no identified RCTs investigating the effects of SCUs on behavioural symptoms in dementia, and no strong evidence of benefit from the available non-RCTs. It is probably more important to implement best practice than to provide a specialized care environment. The routine collection of data on behaviour, restraint and psychotropic drug use across multiple nursing home settings offers the best modality for formal evaluation of the benefit or otherwise of SCUs.

There have been no data on the performance of the Initiation-Perseveration subtest of the Mattis Dementia Rating Scale (MDRS-IP) in screening poststroke dementia (PSDE). Three months after the index stroke, a research assistant administered the MDRS-IP and Mini-Mental State Examination (MMSE) to 83 Chinese stroke patients with lacunar infarcts who were consecutively admitted to the stroke unit of a general hospital. A psychiatrist, who was blind to the MDRS-IP and MMSE scores, interviewed all 83 patients and made a Diagnostic and Statistical Manual of Mental Disorders (4th edition) diagnosis of dementia, which served as the benchmark for judging the performance of MDRSIP. The optimal cutoff point of MDRS-IP was 22/23. The sensitivity, specificity, and positive and negative predictive values of MDRS-IP, and the area under the receiver operating characteristic curve were 82%, 90%, 0.41, 0.98, and 0.91, respectively. The overall performance of the MDRS-IP was comparable to the MMSE.

Pre-existing dementia among patients with acute stroke is common, and adversely affects outcomes. Only a few studies have been published on prestroke dementia (PSD), none of which have investigated a consecutive stroke cohort in an Asian patient population. The objective of this study was to examine the prevalence and clinical correlates of PSD in Chinese stroke patients in Hong Kong. Close and reliable informants of 289 stroke patients who were consecutively admitted to the medical wards of a university-affiliated regional hospital completed the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) within 1 week after their relative's admission. The presence of PSD was defined as an average IQCODE score of >or= 4.00. In addition, a wide range of demographic and clinical variables were examined and recorded.Twenty-two participants (7.6%) had PSD. The frequency of PSD in the group of subjects (n = 73) who were assessed within 48 hours after their admission was 12.3%. Univariate analysis found that PSD was associated with age, marital status, atrial fibrillation (AF), previous transient ischaemic attack (TIA), leukoaraiosis, and cerebral atrophy index (CAI). Multivariate logistic regression suggested that CAI, age, AF, and past TIA were independent risk factors for PSD. The low prevalence of PSD in Chinese patients in comparison with their Caucasian counterparts may be due to the difference in the time frame of the assessment. Comparative studies involving both Caucasian and Chinese stroke patients are required to further explore the role of AF and TIA in the development of PSD in both Chinese and Caucasian patients.

Background and Purpose: Both dementia and stroke are major health problems in Chinese societies. Stroke is a frequent cause of dementia. Only a few studies have been published on poststroke dementia (PSDE), none of which has investigated a consecutive stroke cohort in Asian patient populations. The objective of this study was to examine the prevalence and clinical correlates of PSDE in Chinese stroke patients in Hong Kong., Methods: Two hundred eighty stroke patients consecutively admitted to the medical wards of a university-affiliated regional hospital were interviewed by a psychiatrist 3 months after stroke. The presence of dementia and vascular dementia was diagnosed according to the Diagnostic and Statistical Manual, 4th edition. In addition, a wide range of demographic and clinical variables were examined., Results: Fifty-five participants (20%) had PSDE. Univariate analysis found that PSDE was associated with age; level of education; prestroke Rankin Scale score; prestroke Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) score; National Institutes of Health Stroke Scale (NIHSS) best language score, dysarthria score, and total score; urinary incontinence; cortical infarct; leukoaraiosis; bilateral lesions; number of lesions; involvement of middle cerebral artery circulation; and cerebral atrophy index. Multivariate logistic regression suggested that prestroke IQCODE score, NIHSS total score, leukoaraiosis, involvement of middle cerebral artery territory, and cerebral atrophy index were independent risk factors of PSDE. After removal of 22 patients with prestroke dementia, which was defined as a prestroke IQCODE score > or =4.0, the frequency of PSDE dropped to 15.5%. Furthermore, involvement of the middle cerebral artery territory and cerebral atrophy index were replaced by level of education and bilateral lesions as independent predictors in the final logistic model., Conclusions: PSDE is common among Chinese stroke patients in Hong Kong. Its frequency is comparable to that in white populations. The clinical determinants of PSDE, after the exclusion of patients with prestroke dementia, include premorbid level of cognitive function, severity of stroke, leukoaraiosis, level of education, and bilateral lesions.

Background: There is growing awareness of the coexistence of Alzheimer's disease and cerebrovascular disease (AD+CVD), however, due to lack of well-defined criteria and treatment guidelines AD+CVD may be underdiagnosed in Asia.Methods: Sixteen dementia specialists from nine Asia Pacific countries completed a survey in September 2014 and met in November 2014 to review the epidemiology, diagnosis and treatment of AD+CVD in Asia. A consensus was reached by discussion, with evidence provided by published studies when available.Results: AD accounts for up to 60% and AD+CVD accounts for 10-20% of all dementia cases in Asia. The reasons for underdiagnosis of AD+CVD include lack of awareness as a result of a lack of diagnostic criteria, misdiagnosis as vascular dementia or AD, lack of diagnostic facilities, resource constraints and cost of investigations. There is variability in the tools used to diagnose AD+CVD in clinical practice. Diagnosis of AD+CVD should be performed in a stepwise manner of clinical evaluation followed by neuroimaging. Dementia patients should be assessed for cognition, behavioural and psychological symptoms, functional staging and instrumental activities of daily living. Neuroimaging should be performed using computed tomography or magnetic resonance imaging. The treatment goals are to stabilize or slow progression as well as to reduce behavioural and psychological symptoms, improve quality of life and reduce disease burden. First-line therapy is usually an acetylcholinesterase inhibitor such as donepezil.Conclusion: AD+CVD is likely to be under-recognised in Asia. Further research is needed to establish the true prevalence of this treatable and potentially preventable disease. [ABSTRACT FROM AUTHOR]

Objectives: Although stroke associated with small vessel disease (SSVD) can induce both motor and cognitive impairment, the latter has received less attention. We aimed to evaluate the frequency of the varying severity levels of cognitive impairment, the determinants of severe cognitive impairment, and the association of cognitive impairment with functional outcome after SSVD.Methods: Consecutive patients admitted to hospital because of SSVD were assessed at 3 months after stroke. We performed a semi-structured clinical interview to screen for cognitive symptoms. Severity of cognitive symptoms was graded according to the Clinical Dementia Rating Scale (CDR). Performance on psychometric tests (Mini-Mental State Examination, Alzheimer's Disease Assessment Scale (cognition subscale), Mattis Dementia Rating Scale (initiation/perseverence subscale; MDRS I/P)) of patients of different CDR gradings was compared with that of 42 healthy controls. Basic demographic data, vascular risk factors, stroke severity (National Institute of Health Stroke Scale; NIHSS), pre-stroke cognitive decline (Informant Questionnaire on Cognitive Decline in the Elderly; IQCODE), functional outcome (Barthel index; BI), Instrumental Activities Of Daily Living; IADL), and neuroimaging features (site of recent small infarcts, number of silent small infarcts, white matter changes) were also compared among the groups. Regression analyses were performed to find predictors of severe cognitive impairment and poor functional outcome.Results: Among the 75 included patients, 39 (52%) complained of cognitive symptoms. The number of patients in each CDR grading was as follows: 39 (52%) had a CDR of 0, 26 (34.7%) had a CDR of 0.5, 10 (13.3%) had a CDR of > or =1. Pre-stroke IQCODE and previous stroke predicted CDR> or =1. The NIHSS was associated with more impaired BI. The NIHSS and MDRS I/P contributed most to impaired IADL.Conclusions: Half of the patients with SSVD complained of varying severity of cognitive problems 3 months after stroke. Pre-stroke cognitive decline and previous stroke predict severe cognitive impairment post stroke. Stroke severity and executive dysfunction contribute most to a poor functional outcome. [ABSTRACT FROM AUTHOR]

Age-related white matter changes (ARWMC) are closely associated with cognitive impairment. Although the ARWMC scale has been widely used to grade white matter changes (WMC) severity, the correlation between this scale and cognitive impairment has not been studied. We aimed to validate the ARWMC scale against cognition in patients with stroke. We determined the severity of WMC for 172 patients with stroke on MRI by volumetric quantification and the ARWMC scale. Two scores (total score and global score) were derived from the ARWMC scale. We assessed executive function and global cognition using the Mattis dementia rating scale-initiation/perseveration subset (MDRS I/P) and mini-mental state examination (MMSE), respectively. We investigated the association between the three WMC measures (volume, total score, and global score) and clinical variables with cognitive impairment using multivariate regression analysis. Even after adjusting for other clinical variables, total score and global score of ARWMC scale were independently associated with MDRS I/P (beta = −0.248, P = 0.001 and beta = −0.218, P = 0.005, respectively) and MMSE (adjusted odds ratio 1.181, 95%CI [1.038-1.343] and adjusted odds ratio 1.740, 95%CI [1.063-2.847], respectively). The ARWMC scale correlates well with cognitive impairment in patients with stroke. [ABSTRACT FROM AUTHOR]