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BACKGROUND/AIMS: Cognitive impairment no dementia (CIND) describes individuals whose cognitive functioning falls below normal but who do not meet dementia criteria. An important goal within CIND is to identify subgroups that will predictably progress to Alzheimer disease. CIND with amnestic deficits has been associated with high risk of Alzheimer disease but has until now been investigated on a retrospective basis. In this study a prospectively defined amnestic CIND group was characterized on a detailed neuropsychological test battery and on structural magnetic resonance imaging (MRI) measures. METHODS: Amnestic CIND was defined as meeting at least 1 but not all DSM-IV-TR criteria for dementia, scoring > or =1 SD below norms on Rey Auditory Verbal Learning Test delayed recall, having a Clinical Dementia Rating score of 0.5 and a Mini-Mental State Exam score > or =24. This cross-sectional study compared subjects meeting these criteria (n = 25) to age- and education-matched controls (n = 26). The neuropsychological battery included memory and nonmemory measures that were analyzed as continuous variables and dichotomized into impaired (> or =1 SD below controls) versus nonimpaired. MRI scans were evaluated with a global-brain volumetric measure [brain fractional ratio (BFR)] and with visually based medial temporal lobe atrophy (MTA) ratings. RESULTS: Amnestic CIND had neuropsychological impairment in the episodic memory domain and also in nonmemory domains. There were 80% of CIND subjects with multidomain impairment. The most clear-cut nonmemory impairment was in the verbal ability domain, with 64% of subjects affected and a moderate effect size (d = 0.7). On MRI, BFR was lower (74.5 +/- 4.6 vs. 75.5 +/- 4.4) and MTA higher (72 vs. 38% with MTA > or =1) in CIND than in control subjects. BFR correlated with MTA (r = -0.45) and with a composite memory score (r = 0.296). CONCLUSION: A prospective amnestic CIND grouping appears to identify individuals with a multidomain pattern of neuropsychological impairment and with both medial temporal lobe and global brain atrophy. [ABSTRACT FROM AUTHOR]

A consistent body of research suggests that depressive symptoms recur rapidly following termination of pharmacotherapy. The present study hypothesized that this phenomenon is a function of the continued operation of depressive attributional processes. Compared to interventions which directly target depressive cognitions, persons treated solely with medication may relapse sooner as these thought processes remain unaltered. Three groupings of older adults were recruited for the present study. Support was obtained for initial hypotheses as specific negative attributional constructs are elevated among anti-depressant users as compared to control subjects (globality and stability). These results are discussed relative to the hopelessness theory of depression. [ABSTRACT FROM AUTHOR]

Background Survival estimates are integral to care for patients diagnosed with dementia. Few Canadian studies have carried out long-term follow-up of well-described cohorts, analyzing survival related to multiple risk factors. Methods Survival analysis of an inception cohort enrolled at a British Columbia (BC) tertiary dementia referral clinic between 1997 and 1999 was undertaken. Vital status was completed for 168 patients diagnosed with dementia. An evaluation of the effects of demographics, vascular risk factors, cognitive and functional ratings, apolipoprotein 4-status, and cholinesterase use on survival was performed using a log-rank test and time-dependent Cox regression. Survival of this dementia cohort was compared with the age-matched life expectancy of persons in BC. Results In all, 158/168 (94.0%) subjects died over 16.6 years, with a median survival of 7.08 years. Risk factors associated with shorter survival in dementia groups included age of onset ≥80 (hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.05-2.32); greater functional disability (Disability Assessment for Dementia<55% [HR 1.47, 95% CI 1.04-2.08]); and cumulative medical illness severity (Cumulative Illness Rating Scale≥7 [HR 1.51, 95% CI 1.08-2.12)]. Compared with the BC population, years of potential life lost for dementia subjects aged <65 was 15.36 years, and for dementia subjects aged ≥80 it was 1.82 years. Conclusions Survival in dementia subjects is shorter than population life expectancies for each age strata, with greatest impact on younger patients. For people diagnosed with dementia, age ≥80 years, cumulative medical illness severity, and functional disabilities are the most significant survival predictors and can be used to guide prognosis.

Objective: To test the hypothesis that patients with mild to moderate dementia with higher initial cognitive reserve (higher education levels exhibit faster cognitive decline at later stages of disease progression as they approach residential care (RC) placement., Method: Two provincial administrative databases were used. One contained individuals' scores of cognitive functioning (assessed at 6- to 12-month intervals using the Standardized Mini-Mental State Examination, SMMSE, 2007-2014) and education level; the second (BC Ministry of Health Home and Community Care database, 2001-2014) contained individuals' RC placement; N = 10531., Results: During 2.5-0.5 years prior to placement, SMMSE scores of patients with 0-8 years of education dropped slightly (M D 20.6 to 20.0), while patients with 9-12 years and 13+ years of education started higher (M D 21.8 and 21.4), but decreased faster and ended up lower (M D 19.5 and 18.8). Six-months prior to placement, SMMSE scores of all groups dropped almost 2 points., Conclusions: Once cognitive reserve of more highly educated dementia patients is depleted and they approach RC placement, their cognitive functioning deteriorates faster. Finding effective interventions that maintain or enhance cognitive reserve may increase the time in the community for dementia patients.

Presented herein is evidence for criterion, content, and convergent/discriminant validity of the NIMH-Provisional Diagnostic Criteria for depression of Alzheimer's Disease (PDC-dAD) that were formulated to address depression in Alzheimer's disease (AD). Using meta-analytic and systematic review methods, we examined criterion validity evidence in epidemiological and clinical studies comparing the PDC-dAD to Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV), and International Classification of Disease (ICD 9) depression diagnostic criteria. We estimated prevalence of depression by PDC, DSM, and ICD with an omnibus event rate effect-size. We also examined diagnostic agreement between PDC and DSM. To gauge content validity, we reviewed rates of symptom endorsement for each diagnostic approach. Finally, we examined the PDC's relationship with assessment scales (global cognition, neuropsychiatric, and depression definition) for convergent validity evidence. The aggregate evidence supports the validity of the PDC-dAD. Our findings suggest that depression in AD differs from other depressive disorders including Major Depressive Disorder (MDD) in that dAD is more prevalent, with generally a milder presentation and with unique features not captured by the DSM. Although the PDC are the current standard for diagnosis of depression in AD, we identified the need for their further optimization based on predictive validity evidence.

Background: Falls among older adults are an escalating public health issue, which requires a multidisciplinary and multilevel approach to affect systems change to effectively address this problem. The National Council on Aging established the Falls Free® Initiative, enfolding and facilitating statewide Fall Prevention Coalitions. Fall Free® activities included developing the State Policy Toolkit for Advancing Falls Prevention to promote sustainable change by supporting the dissemination and adoption of evidence-based strategies., Purpose: To (1) determine if the policies being implemented were recommended and supported by the Toolkit, (2) identify the perceived barriers and facilitators to implementing policies, and (3) identify Coalitions' current and future fall prevention policy activities., Methods: A 63-item online survey was distributed to State Coalition Leads. Descriptive statistics (frequencies and counts) were used to describe Coalition characteristics and activities., Results: Coalitions had several similarities, and varied greatly in their number of member organizations and members as well as meeting frequencies. Key activities included building partnerships, disseminating programs, and pursuing at least one of the eight National Council on Aging-recommended policy goals. The most commonly reported facilitator was active support from the Coalition Leads, whereas the lack of funding was the most cited barrier., Conclusion: This study serves as the first national census of empirical evidence regarding Falls Coalitions' composition, goals, and activities. Results indicate that Coalitions are actively pursuing evidence-based policies but could benefit from additional technical assistance and resources. Findings support the value of Toolkit recommendations by documenting what is feasible and being implemented. Knowledge about facilitators and barriers will inform future efforts to foster sustainable systems change in states with active Coalitions and encourage Coalitions in other states., (© 2015 Society for Public Health Education.)

Falls are a major health-care concern, and while dual-task performance is widely recognized as being impaired in those at-risk for falls, the underlying neurocognitive mechanisms remain unknown. A better understanding of the underlying mechanisms could lead to the refinement and development of behavioral, cognitive, or neuropharmacological interventions for falls prevention. Therefore, we conducted a cross-sectional study with community-dwelling older adults aged 70-80 years with a history of falls (i.e., two or more falls in the past 12 months) or no history of falls (i.e., zero falls in the past 12 months); n = 28 per group. We compared functional activation during cognitive-based dual-task performance between fallers and non-fallers using functional magnetic resonance imaging (fMRI). Executive cognitive functioning was assessed via Stroop, Trail Making, and Digit Span. Mobility was assessed via the Timed Up and Go test (TUG). We found that non-fallers exhibited significantly greater functional activation compared with fallers during dual-task performance in key regions responsible for resolving dual-task interference, including precentral, postcentral, and lingual gyri. Further, we report slower reaction times during dual-task performance in fallers and significant correlations between level of functional activation and independent measures of executive cognitive functioning and mobility. Our study is the first neuroimaging study to examine dual-task performance in fallers, and supports the notion that fallers have reduced functional brain activation compared with non-fallers. Given that dual-task performance-and the underlying neural concomitants-appears to be malleable with relevant training, our study serves as a launching point for promising strategies to reduce falls in the future.

Objectives: In 2007, a novel pathogenic genetic mutation associated with early onset familial Alzheimer disease was identified in a large First Nation family living in communities across British Columbia, Canada. Building on a community-based participatory study with members of the Nation, we sought to explore the impact and interplay of medicalization with the Nation's knowledge and approaches to wellness in relation to early onset familial Alzheimer disease., Methods: We performed a secondary content analysis of focus group discussions and interviews with 48 members of the Nation between 2012 and 2013. The analysis focused specifically on geneticization, medicalization, and traditional knowledge of early onset familial Alzheimer disease, as these themes were prominent in the primary analysis., Results: We found that while biomedical explanations of disease permeate the knowledge and understanding of early onset familial Alzheimer disease, traditional concepts about wellness are upheld simultaneously., Conclusion: The analysis brings the theoretical framework of "two-eyed seeing" to the case of early onset familial Alzheimer disease for which the contributions of different ways of knowing are embraced, and in which traditional and western ways complement each other on the path of maintaining wellness in the face of progressive neurologic disease.

Objectives: To assess whether resistance training (RT) slows the progression of white matter lesions (WMLs) in older women., Design: Secondary analysis of a 52-week randomized controlled trial of RT, the Brain Power Study., Setting: Community center and research center., Participants: Of 155 community-dwelling women aged 65 to 75 enrolled in the Brain Power Study, 54 who had evidence of WMLs on magnetic resonance imaging (MRI) at baseline were included in this secondary analysis., Intervention: Participants were randomized to once-weekly RT (1× RT), twice-weekly RT (2× RT), or twice-weekly balance and tone (BAT). Assessors were blinded to participant assignments., Measurements: WML volume was measured using MRI at baseline and trial completion., Results: At trial completion, the 2× RT group had significantly lower WML volume than the BAT group (P = .03). There was no significant difference between the BAT group and the 1× RT group at trial completion (P = .77). Among participants in the two RT groups, reduced WML progression over 12 months was significantly associated with maintenance of gait speed (correlation coefficient (r) = -0.31, P = .049) but not with executive functions (r = 0.30; P = .06)., Conclusion: Engaging in progressive RT may reduce WML progression., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Introduction: Freely accessible online tests for the diagnosis of Alzheimer's disease (AD) are widely available. The objective of this study was to evaluate these tests along three dimensions as follows: (1) scientific validity; (2) human-computer interaction (HCI) features; and (3) ethics features., Methods: A sample of 16 online tests was identified through a keyword search. A rating grid for the tests was developed, and all tests were evaluated by two expert panels., Results: Expert analysis revealed that (1) the validity of freely accessible online tests for AD is insufficient to provide useful diagnostic information; (2) HCI features of the tests are adequate for target users, and (3) the tests do not adhere to accepted ethical norms for medical interventions., Discussion: The most urgent concerns raised center on the ethics of collecting and evaluating responses from users. Physicians and other professionals will benefit from a heightened awareness of these tools and their limitations today.

Introduction: Cognitive Testing on Computer (C-TOC) is a novel computer-based test battery developed to improve both usability and validity in the computerized assessment of cognitive function in older adults., Methods: C-TOC's usability was evaluated concurrently with its iterative development to version 4 in subjects with and without cognitive impairment, and health professional advisors representing different ethnocultural groups. C-TOC version 4 was then validated against neuropsychological tests (NPTs), and by comparing performance scores of subjects with normal cognition, Cognitive Impairment Not Dementia (CIND) and Alzheimer disease. C-TOC's language tests were validated in subjects with aphasic disorders., Results: The most important usability issue that emerged from consultations with 27 older adults and with 8 cultural advisors was the test-takers' understanding of the task, particularly executive function tasks. User interface features did not pose significant problems. C-TOC version 4 tests correlated with comparator NPT (r=0.4 to 0.7). C-TOC test scores were normal (n=16)>CIND (n=16)>Alzheimer disease (n=6). All normal/CIND NPT performance differences were detected on C-TOC. Low computer knowledge adversely affected test performance, particularly in CIND. C-TOC detected impairments in aphasic disorders (n=11)., Discussion: In general, C-TOC had good validity in detecting cognitive impairment. Ensuring test-takers' understanding of the tasks, and considering their computer knowledge appear important steps towards C-TOC's implementation.

Background: Falls are the leading cause of older adult injuries and injury-related deaths. Until 2004, the growing public health issue of older adult falls received little national attention. To elevate and focus on the issue, the National Council on Aging launched the Falls Free(®) Initiative, a group of national and state agencies working collaboratively to address older adult falls with evidence-based solutions. Since then, attention to older adult falls has gained significant momentum., Purpose: To describe the steps taken to create the momentum around fall prevention and lessons learned that could be applied to supporting other older adult health-related issues., Method/objectives: The Falls Free(®) Initiative took key steps to promote the older adult falls prevention movement, including initiating organized advocacy and supporting the development of state coalitions through increasing awareness of the issue, promoting evidence-based programs, instituting evaluation, implementing systems change, and providing tailored technical assistance., Results: Through the support of the Falls Free(®) Initiative and many partners, advocacy efforts have increased federal funding for fall prevention, the majority of states have fall prevention coalitions, and thousands of stakeholders are now engaged in fall prevention. Select lessons learned include leveraging compelling data, choosing passionate leaders for the movement, aligning the cause with partner missions, and being inclusive of all stakeholders., Conclusion: Although much progress has been made in the fall prevention movement, the issue is growing along with the aging population. Efforts must continue to gain support from all affected stakeholders to reduce older adult falls and fall-related injuries.

Introduction: One out of three persons aged 65 and older falls annually and 20% to 30% of falls result in injury. The purpose of this cost-benefit analysis was to identify community-based fall interventions that were feasible, effective, and provided a positive return on investment (ROI)., Methods: A third-party payer perspective was used to determine the costs and benefits of three effective fall interventions. Intervention effectiveness was based on randomized controlled trial results. National data were used to estimate the average annual benefits from averting the direct medical costs of a fall. The net benefit and ROI were estimated for each of the interventions., Results: For the Otago Exercise Program delivered to persons aged 65 and older, the net benefit was $121.85 per participant and the ROI was 36% for each dollar invested. For Otago delivered to persons aged 80 and older, the net benefit was $429.18 and the ROI was 127%. Tai chi: Moving for Better Balance had a net benefit of $529.86 and an ROI of 509% and Stepping On had a net benefit of $134.37 and an ROI of 64%., Conclusions: All three fall interventions provided positive net benefits. The ROIs showed that the benefits not only covered the implementation costs but also exceeded the expected direct program delivery costs. These results can help health care funders and other community organizations select appropriate and effective fall interventions that also can provide positive returns on investment., (Published by Elsevier Ltd.)

Objectives: The objective of this study was to characterize patterns of formal health service utilization costs during older adults' transition from community to institutional care., Methods: Participants were 127 adults (age ≥ 65) from the British Columbia sample (N = 2,057) of the Canadian Study of Health and Aging who transitioned from community to institutional care between 1991 and 2001. Health service utilization costs were measured using Cost-Per-Day-At-Risk at five time points: > 12 months, 6-12 months, and ≤ 6 months preinstitutionalization, and ≤ 6 months and 6-12 months postinstitutionalization. Cost-Per-Day-At-Risk was measured for Continuing Care, Medical Services Plan, and PharmaCare costs by calculating total health service use over time, divided by the number of days the participant was alive., Results: Significant differences in Cost-Per-Day-At-Risk were observed for Continuing Care, Medical Services Plan, and PharmaCare costs over time. All health service utilization costs increased significantly during the 6-12 months and ≤ 6 months prior to institutionalization. Postinstitutionalization Continuing Care costs continued to increase at ≤ 6 months before decreasing at 6-12 months, while decreases occurred for Medical Services Plan and PharmaCare costs relative to preinstitutionalization costs., Conclusions: The increases in costs observed during the year prior to institutionalization, characterized by a flurry of health service utilization, provide evidence of distinct cost patterns over the transition period.

This study explored how older Punjabi-speaking South-Asian immigrants (four focus groups; 33 participants) in Surrey, British Columbia, perceive oral health and related problems. Content analysis revealed two umbrella themes: (a) interpretations of mouth conditions and (b) challenges to oral health. The umbrella themes had four sub-themes: damage caused by heat (wai), disturbances caused by caries, coping with dentures, and quality of life. Three challenges were considered: home remedies, Western dentistry, and difficulties accessing dentists. Participants explained oral diseases in terms of a systemic infection (resha), and preferred to decrease imbalances of wai in the mouth with home remedies from India. We conclude that older Punjabi-speaking immigrants interpret oral health and disease in the context of both Western and Ayurvedic traditions, and that they manage dental problems with a mix of traditional remedies supplemented, if possible, by elective oral health care in India, and by emergency dental care in Canada.

Given the rapid aging of the population, we can expect the number of older adult falls and fall-related injuries and deaths to increase exponentially unless we make a serious commitment to providing evidence-based, fall risk screening and assessments, and appropriate interventions to those increasingly at risk. National, state, and local partners are coming together to address this growing public health issue through evidence-based interventions that promote collaboration between public health, health care, and aging service providers. Physical therapists are uniquely positioned to make a significant contribution to this effort and to promote older adult participation in programs and services that can augment or supplement the plan of treatment. The purpose of this special interest paper is to describe the efforts of the National Council on Aging's Falls Free Initiative and the role that physical therapists and other rehabilitation professionals can play in community-based programs aimed at reducing risk and occurrence of falls in later life.

The meaningful consideration of cultural practices, values and beliefs is a necessary component in the effective translation of advancements in neuroscience to clinical practice and public discourse. Society's immense investment in biomedical science and technology, in conjunction with an increasingly diverse socio-cultural landscape, necessitates the study of how potential discoveries in neurodegenerative diseases such as Alzheimer disease are perceived and utilized across cultures. Building on the work of neuroscientists, ethicists and philosophers, we argue that the growing field of neuroethics provides a pragmatic and constructive pathway to guide advancements in neuroscience in a manner that is culturally nuanced and relevant. Here we review a case study of one issue in culturally oriented neuroscience research where it is evident that traditional research ethics must be broadened and the values and needs of diverse populations considered for meaningful and relevant research practices. A global approach to neuroethics has the potential to furnish critical engagement with cultural considerations of advancements in neuroscience.

Purpose: We investigated: (1) the effect of different targeted exercise training on an individual's overall probability for cognitive improvement, maintenance, or decline; and (2) the simultaneous effect of targeted exercise training and baseline function on the dynamics of executive functions when a multistate transition model is used., Methods: Analyses are based on a 12-month randomized clinical trial including 155 community-dwelling women 65-75 years of age who were randomly allocated to once-weekly resistance training (1x RT; n = 54), twice-weekly resistance training (2x RT; n = 52), or twice-weekly balance and tone training (BAT; n = 49). The primary outcome measure was performance on the Stroop test, an executive cognitive test of selective attention and conflict resolution. Secondary outcomes of executive functions were set shifting and working memory., Results: Individuals in the 1x RT or 2x RT group demonstrated a significantly greater probability for improved performance on the Stroop Test (0.49; 95% confidence interval, 0.41-0.57) compared with those in the BAT group (0.25; 95% confidence interval, 0.25-0.40). Resistance training had significant effects on transitions in selective attention and conflict resolution., Conclusions: Resistance training is efficacious in improving a measure of selective attention and conflict resolution in older women, probably more so among those with greater baseline cognitive function., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Online social media is widespread, easily accessible and attracts a global audience with a widening demographic. As a large proportion of adults now seek health information online and through social media applications, communication about health has become increasingly interactive and dynamic. Online health information has the potential to significantly impact public health, especially as the population gets older and the prevalence of dementia increases. However, little is known about how information pertaining to age-associated diseases is disseminated on popular social media platforms. To fill this knowledge gap, we examined empirically: (i) who is using social media to share information about dementia, (ii) what sources of information about dementia are promoted, and (iii) which dementia themes dominate the discussion. We data-mined the microblogging platform Twitter for content containing dementia-related keywords for a period of 24 hours and retrieved over 9,200 tweets. A coding guide was developed and content analysis conducted on a random sample (10%), and on a subsample from top users' tweets to assess impact. We found that a majority of tweets contained a link to a third party site rather than personal information, and these links redirected mainly to news sites and health information sites. As well, a large number of tweets discussed recent research findings related to the prediction and risk management of Alzheimer's disease. The results highlight the need for the dementia research community to harness the reach of this medium and its potential as a tool for multidirectional engagement.

Background: Mild cognitive impairment (MCI) represents a critical window to intervene against dementia. Exercise training is a promising intervention strategy, but the efficiency (i.e., relationship of costs and consequences) of such types of training remains unknown. Thus, we estimated the incremental cost-effectiveness of resistance training or aerobic training compared with balance and tone exercises in terms of changes in executive cognitive function among senior women with probable MCI., Methods: Economic evaluation conducted concurrently with a six-month three arm randomized controlled trial including eighty-six community dwelling women aged 70 to 80 years living in Vancouver, Canada. Participants received twice-weekly resistance training (n = 28), twice weekly aerobic training (n = 30) or twice-weekly balance and tone (control group) classes (n = 28) for 6 months. The primary outcome measure of the Exercise for Cognition and Everyday Living (EXCEL) study assessed executive cognitive function, a test of selective attention and conflict resolution (i.e., Stroop Test). We collected healthcare resource utilization costs over six months., Results: Based on the bootstrapped estimates from our base case analysis, we found that both the aerobic training and resistance training interventions were less costly than twice weekly balance and tone classes. Compared with the balance and tone group, the resistance-training group had significantly improved performance on the Stroop Test (p = 0.04)., Conclusions: Resistance training and aerobic training result in health care cost saving and are more effective than balance and tone classes after only 6 months of intervention. Resistance training is a promising strategy to alter the trajectory of cognitive decline in seniors with MCI., Trial Registration: ClinicalTrials.gov NCT00958867.

Neglect of the mouth can lead to impairment, disability, and discomfort; as a result, it can have a negative impact on quality of life in old age. Some minority groups in North America shoulder a disproportionate burden of dental impairment compared to people of European origins, possibly because of different cultural beliefs and a distrust of Western oral healthcare. This paper explores these factors in elderly Chinese immigrants through a meta-synthesis of selected literature that reveals a dynamic interplay of traditional Chinese beliefs about oral health, immigration, and structural factors mediating access to Western dentistry. It also identifies several conceptual issues and gaps in knowledge, offers avenues of research including the cross-cultural application of two recent models of oral health, and discusses various strategies for improving access to dental services for minority populations.

We report secondary findings from a randomized controlled trial on the effects of exercise on memory in older adults with probable MCI. We randomized 86 women aged 70-80 years with subjective memory complaints into one of three groups: resistance training, aerobic training, or balance and tone (control). All participants exercised twice per week for six months. We measured verbal memory and learning using the Rey Auditory Verbal Learning Test (RAVLT) and spatial memory using a computerized test, before and after trial completion. We found that the aerobic training group remembered significantly more items in the loss after interference condition of the RAVLT compared with the control group after six months of training. In addition, both experimental groups showed improved spatial memory performance in the most difficult condition where they were required to memorize the spatial location of three items, compared with the control group. Lastly, we found a significant correlation between spatial memory performance and overall physical capacity after intervention in the aerobic training group. Taken together, our results provide support for the prevailing notion that exercise can positively impact cognitive functioning and may represent an effective strategy to improve memory in those who have begun to experience cognitive decline.

Background: Comorbid depression is a leading neuropsychiatric complication in the Alzheimer's disease (AD) syndrome. In 2011, diagnostic criteria for AD were revised to include neuropsychiatric symptoms. It has been proposed that adding an antidepressant to existing treatment for AD could provide relief for not only depressive but also cognitive symptoms., Objective: The aim was to quantitatively review published studies to examine the efficacy of selective serotonin reuptake inhibitor (SSRI)/serotonin-noradrenaline (norepinephrine) reuptake inhibitor (SNRI) therapy for alleviation of comorbid, diagnosed depression as well as cognitive decline in AD., Methods: A search of electronic databases was performed. Studies were retained for analysis if SSRI/SNRI antidepressant therapy was compared with placebo among AD patients with comorbid depression. Effect-size (ES) estimates (Hedges' g) were calculated using Comprehensive Meta-Analysis software., Results: From 598 examined studies, 12 SSRI studies met the inclusion criteria, and from these, only six met all criteria, among which five reported sufficient and consistent data to be included in the meta-analysis. Within a random effect model, ES estimates of the first and second nested global analyses were non-significant, non-heterogeneous and small to null at the endpoint for depression, favouring SSRIs, -0.06 and -0.10, respectively (p > 0.05). The ES for global cognition as measured by the Mini-Mental State Examination was negligible (ES = 0.001)., Conclusions: Current evidence does not support the efficacy of SSRI treatment for symptoms of comorbid depression in AD. However, studies differed in terms of criteria for diagnosis of depression, the compound tested and outcome measures for depression. These factors could account for the lack of a clear benefit for depression.

Objective: To determine the frequency of multiple pathology [Alzheimer Disease (AD) plus Vascular Dementia and/or Dementia with Lewy Bodies] in patients enrolled in clinical trials of AD therapy, and to compare the cognitive and functional assessments between patients with pure AD and AD with multiple pathology., Methods: We conducted a retrospective analysis of patients with a clinical diagnosis of AD who were enrolled in AD therapy clinical trials and subsequently received an autopsy for confirmation of their diagnosis from 2000 to 2009. Performance on cognitive screening tests, namely Modified Mini Mental state (3MS) exam, Mini Mental state Exam (MMSE) and Functional Rating Scale (FRS) were compared between patients with pure AD and multiple pathology., Results: Autopsy reports were available for 16/47 (34%) of deceased patients. Of these 16 patients, 5 (31%) had pure AD pathology, 10 (63%) had AD with other pathology, and 1 (6%) had non-AD pathology. Compared to patients with pure AD, patients with AD mixed with other pathology had poorer baseline FRS in problem-solving (p<0.01) and community affairs (p<0.02)., Conclusion: While the strict enrollment criteria for clinical trials identified the presence of AD pathology in the majority of cases (15/16), multiple pathology was more common than pure AD in our series of autopsied patients. Premortem biomarkers that can distinguish between pure AD and AD with multiple pathology will be beneficial in future clinical trials and dementia patient management.

Background: ageing is highly associated with neurodegeneration and atrophy of the brain. Evidence suggests that personality variables are risk factors for reduced brain volume. We examine whether falls-related self-efficacy is independently associated with brain volume., Method: a cross-sectional analysis of whether falls-related self-efficacy is independently associated with brain volumes (total, grey and white matter). Three multivariate regression models were constructed. Covariates included in the models were age, global cognition, systolic blood pressure, functional comorbidity index and current physical activity level. MRI scans were acquired from 79 community-dwelling senior women aged 65-75 years old. Falls-related self-efficacy was assessed by the activities-specific balance confidence (ABC) scale., Results: after accounting for covariates, falls-related self-efficacy was independently associated with both total brain volume and total grey matter volume. The final model for total brain volume accounted for 17% of the variance, with the ABC score accounting for 8%. For total grey matter volume, the final model accounted for 24% of the variance, with the ABC score accounting for 10%., Conclusion: we provide novel evidence that falls-related self-efficacy, a modifiable risk factor for healthy ageing, is positively associated with total brain volume and total grey matter volume., Trial Registration: ClinicalTrials.gov Identifier: NCT00426881.

Background/aim: To estimate the prevalence of mild cognitive impairment (MCI) and its subtypes, taking into account education and health status., Methods: This is the first report of our Study on Aging and Dementia in Mexico. This study included 2,944 elderly individuals 60 years old or more with in-home assessment for cognitive impairment. The prevalence of MCI was based on Petersen criteria. MCI was classified as amnestic of single domain (a-MCI-s) or multiple domain (a-MCI-md) or nonamnestic of single domain (na-MCI-s) or multiple domain (na-MCI-md). In addition to a battery of neuropsychological measures, a self-report depression measure and a medical history including history of stroke, heart disease and other health conditions were recorded., Results: The global estimated prevalence of MCI in the Mexican population was 6.45%. Of these subjects, 2.41% met criteria for a-MCI-s, 2.56% for a-MCI-md, 1.18% for na-MCI-s and 0.30% for na-MCl-md. Women showed a higher prevalence of MCI than men (63.7 vs. 36.3%, respectively). The analysis showed that heart disease [odds ratio (OR) 1.5], stroke (OR 1.2) and depression (OR 2.1) were associated with an increased risk of MCI., Conclusions: The prevalence of MCI in Mexico is similar to that in other countries. The results suggest that stroke, heart disease and depression may have an important role in the etiology of MCI., (Copyright © 2012 S. Karger AG, Basel.)

Introduction: Since 2004 the National Council on Aging (NCOA) has been working in collaboration with a growing number of national, state, and local organizations through the Falls Free(©) Initiative to address the growing public health issue of falls and fall-related injuries among older adults. Through collaborative leadership, evidence-based interventions, practical lifestyle adjustments, and community partnerships we are working to reduce the number of older adult falls., Impact on Industry: The many activities of the national and state coalitions have brought recognition to the issue of fall prevention, education, and training to providers and greater investment in programs and services resulting in tremendous momentum and community activism. While we have yet to realize an impact on rates of falls, this strategic investment in building the infrastructure needed to affect change is the first step toward reducing the growing number of falls among older adults., (Copyright © 2011 National Safety Council and Elsevier Ltd. All rights reserved.)

Objectives: To assess whether the core symptoms of Alzheimer disease (AD) consistently predict patient self-rated quality of life (QOL) as assessed by a variety of QOL measures in a large national sample of AD patients., Design: Cross-sectional., Setting: Fifteen dementia and geriatric clinics across Canada., Participants: Community-living patients with AD (n = 370) with Mini-Mental State Exam (MMSE) scores greater than 10., Measurements: Patients rated their QOL by using two utility indexes, the European QOL-5 Dimensions and the Quality of Well-Being Scale, a global QOL Visual Analog Scale, and the disease-specific QOL-AD instrument. Cognition was assessed with the AD Assessment Scale-Cognitive subscale and MMSE, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory and the Geriatric Depression Scale (GDS). One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between core dementia symptoms and QOL ratings., Results: The QOL measures had only small-to-moderate correlations with each other. For all QOL measures, patient ratings were significantly lower among patients with more depressive symptoms. In multivariable analyses, the GDS score was the only significant independent predictor of patient self-ratings for all four QOL measures., Conclusions: Self-rated symptoms of depression were a consistent independent predictor of patient-rated QOL across diverse QOL measures, while performance-based measures of cognition and informant-based functional status were not. These findings confirm the importance of identifying and treating depression in patients with AD and endorse the use of measures of self-rated depressive symptoms and QOL as outcomes in AD clinical trials.

Objectives: To assess whether the core symptoms of Alzheimer disease (AD) and caregiver factors consistently predict family caregiver ratings of patient quality of life (QOL) as assessed by a variety of QOL measures in a large national sample., Design: : Cross-sectional., Setting: Fifteen dementia and geriatric clinics across Canada., Participants: : Family caregivers (n = 412) of community-living patients with AD of all severities., Measurements: Caregiver ratings of patient QOL using three utility indexes, the European Quality of Life-5 Dimensions, Quality of Well-Being Scale and Health Utilities Index; a global QOL visual analogue scale; a disease-specific measure, the Quality of Life-Alzheimer's Disease; and a generic health status measure, the Short Form-36. Patient cognition was assessed with the cognitive subscale of the Alzheimer's Disease Assessment Scale and Mini-Mental State Examination, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory and the Geriatric Depression Scale. Caregiver burden was assessed with the Zarit Burden Interview and caregiver depression with the Center for Epidemiologic Studies Depression scale. One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between patient dementia symptom and caregiver variables with QOL ratings., Results: In multivariable analyses, caregiver ratings of patient function and depressive symptoms were the only consistent independent predictors of caregiver-rated QOL across the QOL measures., Conclusions: Caregiver ratings of patient function and depression were consistent independent predictors of caregiver-rated QOL, using a spectrum of QOL measures, while measures of patient cognition and caregiver burden and depression were not. These findings support the continued use of caregiver ratings as an important source of information about patient QOL and endorse the inclusion in AD clinical trials of caregiver-rated measures of patient function, depression, and QOL.

Pain in older adults with dementia who reside in long-term care (LTC) facilities tends to be undertreated, despite important guidelines designed to ameliorate this problem. A group of public policy and geriatric pain experts recently concluded that existing guidelines are not being implemented because they fail to take into account policy and resource realities. The group published a set of more feasible guidelines that confront these realities (e.g., a recommendation for very brief pain assessments that can be conducted by nursing staff at least weekly). We asked stakeholders to provide opinions on the possibility of implementation of these guidelines within their LTC facilities. Our results support the feasibility of, interest in, and desirability of implementation. They also support an increased role for nurse leadership in LTC pain management. These results could be used to strengthen advocacy efforts for improvement in pain management., (Copyright 2011, SLACK Incorporated.)

A novel, pathogenic presenilin 1 (PS1) mutation has recently been identified in a large Aboriginal kindred living in dispersed communities throughout British Columbia, Canada. Disseminating genetic information and ensuring that appropriate genetic counseling services are provided to all concerned relatives have posed several unique challenges. These challenges include knowledge exchange and continuity of care in a geographically remote and culturally distinct community. To our knowledge, this is the first time a specific genetic counseling approach has been needed for early-onset familial Alzheimer disease (EOFAD) in a North American Aboriginal community.

Meaningful translation of dementia research findings from the bench to the bedside is dependent on the quality of the knowledge to transfer and the availability and skills of investigators engaged in the knowledge translation process. Although there is no shortage of research on dementia, the latter has been more challenging. Results from a survey of 173 researchers from across Canada suggest that workshops and self-paced online training in dementia knowledge translation are needed to bridge the research-to-practice gap. Sharing information among professionals and with the public and formulating actionable messages to policy makers are primary goals.

This study examines the three facets of psychological resilience (i.e., perceived control, commitment to living, challenge versus stability) as predictors of depressive symptoms over time among spousal caregivers of persons with Alzheimer disease; these resilience factors were considered over and above dementia-related and socio-demographic control variables. A sample of 105 cohabiting spouses of persons diagnosed with probable or possible Alzheimer disease was recruited for this study. Multilevel modeling enabled us to examine baseline resilience, and the direction and magnitude of change in resilience over time, as distinct predictors of depressive symptoms one year later, and change in depressive symptoms between points of measurement. Both Time 1 control and challenge predicted lower levels of depressive symptoms one year later; furthermore, an increase in challenge over this interval predicted lower Time 2 depressive symptoms. In contrast, commitment did not emerge as a statistically significant predictor of caregiver depression. Findings of this study provide general support for the stress process model of caregiving; in particular, the central role of intra-psychic factors as significant predictors of depressive symptoms over time.

Background: There is currently little information on the genetic epidemiology of Alzheimer disease (AD) among North American Aboriginal populations. No cases of familial AD (FAD) in these populations have been published to date., Methods: Here, we describe a large North American Aboriginal kindred with early onset FAD (EOFAD) in which genetic testing was done., Results and Conclusions: A novel Presenilin 1 (PS1) gene mutation (L250F) has been identified. In contrast to the three previously reported families with PS1 codon 250 mutations, affected members of this kindred demonstrate neither myoclonus nor seizures. Furthermore, the identification of a PS1 mutation in a North American Aboriginal kindred presents several unique challenges with respect to knowledge transfer and continuity of care in a geographically remote and culturally distinct community.

Background: Falls are a major health care problem for older people and are associated with cognitive dysfunction. Mild cognitive impairment (MCI) is an increasingly recognized clinical problem. No study has comprehensively compared people with and without MCI for fall risk factors in both the physiological and cognitive domains., Objective: The purpose of this cross-sectional study was to comprehensively compare fall risk factors in community-dwelling older women with and without MCI., Design: A cross-sectional design was used in the study., Methods: Community-dwelling women (N=158) with Folstein Mini Mental State Examination scores of >or=24 participated in the study. The Montreal Cognitive Assessment (MoCA) was used to categorize participants as either having or not having MCI. Each participant's fall risk profile was assessed with the Physiological Profile Assessment (PPA). Three central executive functions were assessed: (1) set shifting was assessed with the Trail Making Test (part B), (2) updating (ie, working memory) was assessed with the Verbal Digits Backward Test, and (3) response inhibition was assessed with the Stroop Colour-Word Test., Results: Both the composite PPA score and its subcomponent, postural sway performance, were significantly different between the 2 groups; participants with MCI had higher composite PPA scores and greater postural sway compared with participants without MCI. Participants with MCI performed significantly worse on all 3 central executive function tests compared with participants without MCI., Limitations: A screening tool was used to categorize participants as having MCI, and fall risk factors were compared rather than the actual incidence of falls., Conclusions: Fall risk screening may be prudent in older adults with MCI.

Here we review issues of patient decision-making and consent to treatment and research by persons with cognitive impairment and dementia. Clinicians and researchers must recognize their primary duty to care for the individual and must clearly distinguish their role as a clinician and/or researcher. Distinctions between standard care and research must be clearly understood by everyone, as must the clinician's role in each. Both actual and perceived conflicts of interest must be avoided. At present there is insufficient evidence to recommend specific methods for determining competency for decision-making, but a diagnosis of cognitive impairment or dementia does not preclude such competence. Competency is not a unitary or static construct and must be considered as the ability to make an informed decision about participation in the particular context of the specific treatment or study. Clinicians and researchers should consider consent as a process involving both the patient with cognitive impairment and his or her family/caregiver, particularly given the potential that competency for decision-making will change over time. As the availability of advance directives remains limited, clinicians and researchers must make efforts to ensure that decisions made by proxies are based on the prior attitudes and values of the patient.

Most ethical guidelines strongly promote disclosure of a diagnosis of dementia to the affected individual, based on the principle of autonomy. Nevertheless, codes of medical ethics allow for various interpretations of this issue and surveys of clinical practice illustrate that such disclosure is by no means the rule. We argue that diagnostic disclosure for persons with dementia must be considered a process that begins when cognitive impairment is first suspected and that evolves over time as information is obtained. Whenever possible and appropriate, this process should involve not only the affected individual but also their family and/or other current or potential future care providers. Once a diagnosis is established it should be disclosed in a manner consistent with the expressed wishes of the patient, using an individualized patient-centered approach that maintains the individual's personal integrity. Diagnostic disclosure of dementia is a process that may require additional time as well as follow-up or referral to other specialists. We recommend that a progressive disclosure process be employed to address issues including: remaining diagnostic uncertainty, treatment options, future plans, financial planning, assigning power of attorney, wills and "living wills", driving privileges and the need for eventual driving cessation, available support services, and potential research participation. The potential for adverse psychological consequences to diagnostic disclosure must be assessed and these should be addressed through education and support of the patient and their family/caregivers throughout the diagnostic disclosure process. At present, few data are available regarding patients' perspectives on the diagnostic disclosure process and its consequences. This limitation and the apparent discrepancies in physician and caregiver opinions about the disclosure process, make it incumbent upon health care professionals to evaluate the diagnostic disclosure process within their practice.

In the era of chronic disease, we are challenged to find therapies that provide symptomatic relief and ideally, alter the course of the underlying disease. In Alzheimer's disease (AD), these issues are complicated by the disease itself, which affects the subject's decision-making capacity for participation in the research. According to established ethical guidelines it is clear that individuals with impaired capacity may participate in research and their risk should be no greater than that which the individual would have in day to day activities with anticipation of benefits within that realm. Decision making processes are complex and involve proxies who themselves have biases about their loved one and the potential for participating in the research. Newer disease-modifying approaches such as immunotherapy have potential for affecting the course of the underlying disease but with greater risk of more significant side effects. Ideally the health care of the subjects is not disadvantaged by research participation. At the same time, trials of potentially riskier therapy are relevant in subjects with the disease. Research for subjects with AD must have appropriate safeguards in place to enable effective progress in innovative therapy for a vulnerable, often elderly population. Recommendations are made which could further our capacity to undertake ethical research in the AD population.

Objectives: This randomized clinical trial aimed to assess the effectiveness of a pyramid-based education for improving the oral health of elders in long-term care (LTC) facilities., Methods: Fourteen facilities matched for size were assigned randomly to an active or control group. At baseline in each facility, care-aides in the active group participated with a full-time nurse educator in a seminar about oral health care, and had unlimited access to the educator for oral health-related advice throughout the 3-month trial. Care-aides in the control group participated in a similar seminar with a dental hygienist but they received no additional advice. The residents in the facilities at baseline and after 3 months were examined clinically to measure their oral hygiene, gingival health, masticatory potential, Body Mass Index and Malnutrition Indicator Score, and asked to report on chewing difficulties., Results: Clinical measures after 3 months were not significantly different from baseline in either group, indicating that education neither influenced the oral health nor the dental hygiene of the residents., Conclusions: A pyramid-based educational scheme with nurses and care-aides did not improve the oral health of frail elders in this urban sample of LTC facilities.

Background: Frailty and fitness are important attributes of older persons, but population samples of their prevalence, attributes, and outcomes are limited., Methods: The authors report data from the community-dwelling sample (n = 9008) of the Canadian Study of Health and Aging, a representative, 5-year prospective cohort study. Fitness and frailty were determined by self-reported exercise and function level and testing of cognition., Results: Among the community-dwelling elderly population, 171 per 1000 were very fit and 12 per 1000 were very frail. Frailty increased with age, so that by age 85 years and older, 44 per 1000 were very frail. The risk for adverse health outcomes increased markedly with frailty: Compared with older adults who exercise, those who were moderately or severely frail had a relative risk for institutionalization of 8.6 (95% confidence interval, 4.9 to 15.2) and for death of 7.3 (95% confidence interval, 4.7 to 11.4). These risks persist after adjustments for age, sex, comorbid conditions, and poor self-rated health. At all ages, men reported higher levels of exercise and less frailty compared with women. Decreased fitness and increased frailty were also associated with poor self-ratings of health (42% in the most frail vs 7% in the most fit), more comorbid illnesses (6 vs 3), and more social isolation (34% vs 29%)., Conclusions: Fitness and frailty form a continuum and predict survival. Exercise influences survival, even in old age. Relative fitness and frailty can be determined quickly in a clinical setting, are potentially useful markers of the risk for adverse health outcomes, and add value to traditional medical assessments that focus on diagnoses.

Our rapidly aging population is expected to place heavy demands on all segments of society, particularly the health care resources needed to attend to health concerns associated with aging. Is this a looming crisis, as some predict, or a challenge to use resources more wisely and to help older adults and their caregivers share in the responsibility for health promotion and chronic disease self-management activities? Community-based organizations serving older adults are uniquely positioned to augment health care providers' health promotion counseling activities and to bridge the gap between the research and practice of health promotion in older adults. They already play a crucial role by providing appropriate health promotion education, screening and referral, service planning, and reinforcement to facilitate self-care activities and behavior changes that promote healthy aging. By increasing teamwork across the network of services for the aging, the health sector, public and private organizations, and academe, there is a great opportunity to enhance the health and well-being of all older Americans.

Background: The application of formal clinical diagnostic criteria for the identification of Alzheimer's Disease (AD) has improved diagnostic sensitivity. However, there remains a need for non-invasive biological markers and laboratory tests, which can facilitate case identification, and the assessment of treatment response. The p97 protein is a secreted protein specifically expressed by amyloid plaque associated reactive microglia that may have AD diagnostic ability. Methods: A quantitative radioimmunoassay was developed to measure serum p97. This study, under a double blind protocol, evaluated the utility of serum p97 as diagnostic test for AD. All subjects were referred to the UBC Clinic for Alzheimer's Disease and Related Disorders (CADRD) for clinical assessment of dementia. A serum p97 sample was obtained at the time of assessment but diagnosis of disease was determined independently of p97 examination. Results: "Possible" and "probable" AD cases (n = 41) and cognitively normal controls (n = 64) showed a highly significant difference in mean p97 concentration (41 vs. 20 ng/ml, p<0.001). There was some overlap in p97 distributions between AD cases and control subjects. The area under the curve (AUC) for the receiver operator curve (ROC) was 0.812. Conclusions: These results further support the specificity of high serum p97 levels in AD and its potential utility as a biological marker in AD. The reproducible elevation of serum p97 in AD underlines the need to further determine its role as a biological marker and diagnostic adjunct for AD.