Journal of Alzheimer’s Disease 42 (2014) 193–200 DOI 10.3233/JAD-140174 IOS Press
193
Characteristics of Alzheimer’s Disease among Patients in Taiwan, Hong Kong, and Beijing Yuan-Han Yanga,b,c , Huali Wangd , Linda Lame , Wai-Chi Chanf , Xin Yud , Tao Lid , Wen-Fu Wangg,h , Pai-Yi Chiui , Yu-Te Linj , Chaur-Jong Huk , Jong-Ling Fuhl,m and John C. Morrisn,o,p,∗ a Department
of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan b Department of and Master’s Program in Neurology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan c Mentality Protection Center, Fo Guang Shan Compassion Foundation, Taiwan d Dementia Care and Research Center, Peking University Institute of Mental Health, Beijing, China e Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, China f Department of Psychiatry, University of Hong Kong, Hong Kong g Department of Neurology, Changhua Christian Hospital,Changhua, Taiwan h Center for General Education, Central Taiwan University of Science and Technology, Taichung, Taiwan i Department of Neurology, Lin Shin Hospital, Taichung, Taiwan j Section of Neurology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan k Department of Neurology, Shung Ho Hospital, Taipei Medical University, New Taipei City, Taiwan 1 Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan m Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan n Charles F. and Joanne Knight Alzheimer Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA o Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA p Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
Accepted 21 March 2014
Abstract. In order to obtain data from patients with Alzheimer’s disease dementia and their informants in a uniform manner and to foster further research among the Chinese and other races, we have conducted an international study to recruit patients diagnosed with Alzheimer’s disease (AD) from Taiwan, Hong Kong, and Beijing. The Uniform Data Set was translated into Chinese and administrated to AD patients and their informants. A total of 1,107 AD dementia patients were recruited, including 691 from Taiwan, 244 from Beijing, and 172 from Hong Kong. There were differences in the AD patients: gender (p = 0.099), education (p < 0.001), age (p < 0.001), and handedness (p = 0.007). For informants, age (p = 0.679), gender (p = 0.117), education (p < 0.001), and living together or not (p < 0.001) differed in the three samples. Although three areas across the Taiwan Strait are ethnic Chinese, the clinical picture for patients and informants are very different. Further study is needed to clarify the significance of clinical characteristics in Chinese societies. Keywords: Alzheimer’s disease, Beijing, Hong Kong, informant, Taiwan, uniform data set ∗ Correspondence to: John C. Morris, MD, Knight Alzheimer’ Disease Research Center, 4488 Forest Park Avenue, Suite 130, St. Louis, MO 63108, USA. Tel.: +1 314 286 2881; Fax: +1 314 286 2763; E-mail: [email protected].
ISSN 1387-2877/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
194
Y.-H. Yang et al. / Characteristics of Alzheimer’s Disease among Patients in Taiwan, Hong Kong, and Beijing
INTRODUCTION It is predicted that the worldwide prevalence of Alzheimer’s disease (AD) dementia will rise to 42.3 million in 2020, 81.1 million by 2040, and 457 million by 2050 [1]. China has the largest population in the world. By the end of 2008, the number of Chinese aged 60 years and above was already 159.89 million, accounting for 12% of the total Chinese population [2], ensuring that it will have the greatest number of cases with dementia in the world [1]. People in Taiwan and Hong Kong are ethnic Chinese and are likewise facing increasing elderly populations that will consequently lead to an increasing prevalence of AD. Studies on the prevalence of dementia in Taiwan [3–5] and in Hong Kong [6] have mostly been done decades ago, while the most recent study of dementia in Beijing has been published six years ago [7]. These prevalence studies have focused on reporting the prevalence of dementia but lack information about the characteristics of the patients and informants. It thus is not known whether there are differences in referral patterns, sampling and detection, or other selection biases that could preclude comparisons of Chinese patients with AD dementia. Originally, the Uniform Data Set (UDS), containing several individual forms, was designed to provide clinical and cognitive data from persons with AD dementia and cognitively healthy control individuals who were assessed at federally-funded Alzheimer Disease Centers (ADCs) in the United States to support collaborative research initiatives [8]. The UDS Form A (A1 to A5) assesses demographic characteristics of the patient and the informant and the family history of dementia and the health history of the patient. Form B (B1 to B9) is used in the neurological evaluation, motor function, behavioral and functional assessment, and determination of the presence or absence of dementia (and, when present, its severity), and a diagnostic appraisal. Form C is a neuropsychological battery. Form D provides the clinical diagnoses regarding dementia. In order to assess possible heterogeneity in data gathering and to promote data sharing in the Chinese society, the UDS was translated into simple and traditional Chinese versions. Form A (A1 to A5) was administered at dementia programs in Taiwan, Hong Kong, and Beijing to obtain data on AD in a uniform manner. Although people in Taiwan, Hong Kong, and Beijing are ethnic Chinese, the different living situations, cultural background, geographic characteristics, and socio-economic status may give these
areas specific characteristics. This study will report updated information on AD and compare the information among the three areas. MATERIALS AND METHODS The study was conducted from June 30, 2011 to December 31, 2012 in Hong Kong by Linda Lam, a senior psychiatrist, at the Chinese University of Hong King; in Beijing by Huali Wang, a senior psychiatrist, at the Peking University Institute of Mental Health; and in Taiwan by Yuan-Han Yang, a senior neurologist, at Kaohsiung Medical University Hospital and his colleague at other medical centers in Taiwan [9]. AD patients in Taiwan were recruited from medical centers and area hospitals by neurologists, in Hong Kong from a medical and research center by psychiatrists, and in Beijing from a medical center by psychiatrists. The UDS was translated into Chinese by Yuan-Han Yang and back-translated by a psychologist to make sure the accuracy. Given the different cultural backgrounds for Asian countries, the demographic data, language, and race of the UDS was adapted accordingly. Meanwhile, in order to make the UDS practical, Form A (from A1 to A5), was selected to be conducted in the three areas, Taiwan, Hong Kong, and Beijing. The A1 component is the patient’s demographic data, including information on gender, race, ethnicity, and marital status. The A2 component is the informant’s demographic data, including relationship with the patients and number and frequency of visits made by the informant to the patient. Form A3 is the patient’s family history related to dementia or AD, with focus on the illness as experienced by the patient’s first-degree relatives. Ascertaining the illness referred to a progressive loss of memory and cognition, often described as senility, dementia, Alzheimer disease, hardening of the arteries, or other causes that compromised the patient’s social or occupational functioning and from which they did not recover. Forms A4 and A5 are the patient’s medications and health history, respectively. Patients All of the patients received a comprehensive medical evaluation, including clinical history, physical and neurologic examinations, brain computed tomography (CT) or magnetic resonance imaging (MRI), and blood chemistry examinations to exclude other possible causes to current cognitive status. In all three areas, the diagnosis of AD was based on the National Institute
Y.-H. Yang et al. / Characteristics of Alzheimer’s Disease among Patients in Taiwan, Hong Kong, and Beijing
of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) criteria [10] and incorporated information from the Mini-Mental Status Examination (MMSE) [11], clinical dementia rating (CDR), and sum of CDR boxes (CDR-SB) [12]. Patients with other conditions possibly contributing to the diagnosis of AD were excluded. Evaluation All of the procedures were approved by the respective Institutional Review Boards (IRBs) in the six sites in Taiwan, at Peking University Institute of Mental Health, and at the Chinese University. All of the participants or their legal representative provided written informed consent. Each patients was administered the exams by a senior neuropsychologist and an experienced physician based on information from a knowledgeable source, usually a spouse or an adult child. Statistical analysis Data analysis was performed using the SPSS (version 12.0.1 for Windows, SPSS Inc., Chicago, IL, USA). All statistical tests were two-tailed and an alpha of 0.05 was taken to indicate significance. Descriptive statistical analyses were conducted for all continuous variables with mean ± SD. All the data were sent to Dr. Yuan-Han Yang for the statistical analyses.
195
RESULTS A total of 1,107 AD patients were recruited during the study period, including 691 from Taiwan, 244 from Beijing, and 172 from Hong Kong. Taiwan and Hong Kong were similar in terms of basic demographic characteristic (Table 1). The mean age of the AD patients was different among the three areas (p < 0.001), and the AD patients in Beijing (72.1 ± 8.7 years old) were younger (p < 0.001) than those from Taiwan (79.3 ± 7.7) and Hong Kong (80.1 ± 7.4). The educational level of AD patients in Beijing (11.5 ± 4.6 years) were higher (p < 0.001) compared to patients in Taiwan (6.3 ± 5.1) and in Hong Kong (3.2 ± 3.9). The AD patients in Beijing (CDR-SB = 3.9 ± 4.6 and MMSE = 21 ± 6.8) were less severely impaired (p < 0.001) compared to those in Taiwan (CDRSB = 6.9 ± 3.7 and MMSE = 15.7 ± 6.5) and in Hong Kong (CDR-SB = 9.0 ± 4.5 and MMSE = 14.6 ± 9.1) (Table 1). In terms of handedness, there were also differences among the three areas (p = 0.007), with Hong Kong having the least proportion of left-handed patients (1.2%), compared to Taiwan (3.5%) and Beijing (3.8%) (Table 1). In the demographic characteristics of informants, age (p = 0.679) and gender (p = 0.117) were similar in the three areas. Most informants were female with mean age of 57.5 ± 13.7 years in Taiwan, 56.9 ± 15.4 years in Beijing, and 56.5 ± 13.6 years in Hong Kong. The educational level was significantly different (p < 0.001) with 11.8 ± 4.5 years in Taiwan, 13.9 ± 3.2 years in Beijing, and 10.4 ± 5.4 years in Hong Kong.
Table 1 Demographic characteristics of the patients Gender Female, (n/N, %) Age, year N, mean ± SD Education, year N, mean ± SD CDR-SB N, mean ± SD MMSE N, mean ± SD Handedness Left- handed n/N, % Right-handed n/N, % Ambidextrous n/N, % Unknown handed n/N, %
Taiwan
Beijing
Hong Kong
p value
446/691 64.5% N = 690 79.3 ± 7.7 N = 677 6.3 ± 5.1 6.9 ± 3.7 N = 691 15.7 ± 6.5 N = 673
155/244 63.5% N = 244 72.1 ± 8.7 N = 241 11.5 ± 4.6 3.9 ± 4.6 N = 244 21.0 ± 6.8 N = 247
125/172 72.7% N = 170 80.1 ± 7.4 N = 162 3.2 ± 3.9 9.0 ± 4.5 N = 163 14.6 ± 9.1 N = 172
0.099
24/691 3.5% 654/691 94.6% 11/691 1.6% 2/691 0.3%
9/234 3.8% 221/234 94.4% 4/234 1.7% 0
2/172 1.2% 166/172 96.5% 0
193
Characteristics of Alzheimer’s Disease among Patients in Taiwan, Hong Kong, and Beijing Yuan-Han Yanga,b,c , Huali Wangd , Linda Lame , Wai-Chi Chanf , Xin Yud , Tao Lid , Wen-Fu Wangg,h , Pai-Yi Chiui , Yu-Te Linj , Chaur-Jong Huk , Jong-Ling Fuhl,m and John C. Morrisn,o,p,∗ a Department
of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan b Department of and Master’s Program in Neurology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan c Mentality Protection Center, Fo Guang Shan Compassion Foundation, Taiwan d Dementia Care and Research Center, Peking University Institute of Mental Health, Beijing, China e Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, China f Department of Psychiatry, University of Hong Kong, Hong Kong g Department of Neurology, Changhua Christian Hospital,Changhua, Taiwan h Center for General Education, Central Taiwan University of Science and Technology, Taichung, Taiwan i Department of Neurology, Lin Shin Hospital, Taichung, Taiwan j Section of Neurology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan k Department of Neurology, Shung Ho Hospital, Taipei Medical University, New Taipei City, Taiwan 1 Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan m Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan n Charles F. and Joanne Knight Alzheimer Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA o Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA p Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
Accepted 21 March 2014
Abstract. In order to obtain data from patients with Alzheimer’s disease dementia and their informants in a uniform manner and to foster further research among the Chinese and other races, we have conducted an international study to recruit patients diagnosed with Alzheimer’s disease (AD) from Taiwan, Hong Kong, and Beijing. The Uniform Data Set was translated into Chinese and administrated to AD patients and their informants. A total of 1,107 AD dementia patients were recruited, including 691 from Taiwan, 244 from Beijing, and 172 from Hong Kong. There were differences in the AD patients: gender (p = 0.099), education (p < 0.001), age (p < 0.001), and handedness (p = 0.007). For informants, age (p = 0.679), gender (p = 0.117), education (p < 0.001), and living together or not (p < 0.001) differed in the three samples. Although three areas across the Taiwan Strait are ethnic Chinese, the clinical picture for patients and informants are very different. Further study is needed to clarify the significance of clinical characteristics in Chinese societies. Keywords: Alzheimer’s disease, Beijing, Hong Kong, informant, Taiwan, uniform data set ∗ Correspondence to: John C. Morris, MD, Knight Alzheimer’ Disease Research Center, 4488 Forest Park Avenue, Suite 130, St. Louis, MO 63108, USA. Tel.: +1 314 286 2881; Fax: +1 314 286 2763; E-mail: [email protected].
ISSN 1387-2877/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
194
Y.-H. Yang et al. / Characteristics of Alzheimer’s Disease among Patients in Taiwan, Hong Kong, and Beijing
INTRODUCTION It is predicted that the worldwide prevalence of Alzheimer’s disease (AD) dementia will rise to 42.3 million in 2020, 81.1 million by 2040, and 457 million by 2050 [1]. China has the largest population in the world. By the end of 2008, the number of Chinese aged 60 years and above was already 159.89 million, accounting for 12% of the total Chinese population [2], ensuring that it will have the greatest number of cases with dementia in the world [1]. People in Taiwan and Hong Kong are ethnic Chinese and are likewise facing increasing elderly populations that will consequently lead to an increasing prevalence of AD. Studies on the prevalence of dementia in Taiwan [3–5] and in Hong Kong [6] have mostly been done decades ago, while the most recent study of dementia in Beijing has been published six years ago [7]. These prevalence studies have focused on reporting the prevalence of dementia but lack information about the characteristics of the patients and informants. It thus is not known whether there are differences in referral patterns, sampling and detection, or other selection biases that could preclude comparisons of Chinese patients with AD dementia. Originally, the Uniform Data Set (UDS), containing several individual forms, was designed to provide clinical and cognitive data from persons with AD dementia and cognitively healthy control individuals who were assessed at federally-funded Alzheimer Disease Centers (ADCs) in the United States to support collaborative research initiatives [8]. The UDS Form A (A1 to A5) assesses demographic characteristics of the patient and the informant and the family history of dementia and the health history of the patient. Form B (B1 to B9) is used in the neurological evaluation, motor function, behavioral and functional assessment, and determination of the presence or absence of dementia (and, when present, its severity), and a diagnostic appraisal. Form C is a neuropsychological battery. Form D provides the clinical diagnoses regarding dementia. In order to assess possible heterogeneity in data gathering and to promote data sharing in the Chinese society, the UDS was translated into simple and traditional Chinese versions. Form A (A1 to A5) was administered at dementia programs in Taiwan, Hong Kong, and Beijing to obtain data on AD in a uniform manner. Although people in Taiwan, Hong Kong, and Beijing are ethnic Chinese, the different living situations, cultural background, geographic characteristics, and socio-economic status may give these
areas specific characteristics. This study will report updated information on AD and compare the information among the three areas. MATERIALS AND METHODS The study was conducted from June 30, 2011 to December 31, 2012 in Hong Kong by Linda Lam, a senior psychiatrist, at the Chinese University of Hong King; in Beijing by Huali Wang, a senior psychiatrist, at the Peking University Institute of Mental Health; and in Taiwan by Yuan-Han Yang, a senior neurologist, at Kaohsiung Medical University Hospital and his colleague at other medical centers in Taiwan [9]. AD patients in Taiwan were recruited from medical centers and area hospitals by neurologists, in Hong Kong from a medical and research center by psychiatrists, and in Beijing from a medical center by psychiatrists. The UDS was translated into Chinese by Yuan-Han Yang and back-translated by a psychologist to make sure the accuracy. Given the different cultural backgrounds for Asian countries, the demographic data, language, and race of the UDS was adapted accordingly. Meanwhile, in order to make the UDS practical, Form A (from A1 to A5), was selected to be conducted in the three areas, Taiwan, Hong Kong, and Beijing. The A1 component is the patient’s demographic data, including information on gender, race, ethnicity, and marital status. The A2 component is the informant’s demographic data, including relationship with the patients and number and frequency of visits made by the informant to the patient. Form A3 is the patient’s family history related to dementia or AD, with focus on the illness as experienced by the patient’s first-degree relatives. Ascertaining the illness referred to a progressive loss of memory and cognition, often described as senility, dementia, Alzheimer disease, hardening of the arteries, or other causes that compromised the patient’s social or occupational functioning and from which they did not recover. Forms A4 and A5 are the patient’s medications and health history, respectively. Patients All of the patients received a comprehensive medical evaluation, including clinical history, physical and neurologic examinations, brain computed tomography (CT) or magnetic resonance imaging (MRI), and blood chemistry examinations to exclude other possible causes to current cognitive status. In all three areas, the diagnosis of AD was based on the National Institute
Y.-H. Yang et al. / Characteristics of Alzheimer’s Disease among Patients in Taiwan, Hong Kong, and Beijing
of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) criteria [10] and incorporated information from the Mini-Mental Status Examination (MMSE) [11], clinical dementia rating (CDR), and sum of CDR boxes (CDR-SB) [12]. Patients with other conditions possibly contributing to the diagnosis of AD were excluded. Evaluation All of the procedures were approved by the respective Institutional Review Boards (IRBs) in the six sites in Taiwan, at Peking University Institute of Mental Health, and at the Chinese University. All of the participants or their legal representative provided written informed consent. Each patients was administered the exams by a senior neuropsychologist and an experienced physician based on information from a knowledgeable source, usually a spouse or an adult child. Statistical analysis Data analysis was performed using the SPSS (version 12.0.1 for Windows, SPSS Inc., Chicago, IL, USA). All statistical tests were two-tailed and an alpha of 0.05 was taken to indicate significance. Descriptive statistical analyses were conducted for all continuous variables with mean ± SD. All the data were sent to Dr. Yuan-Han Yang for the statistical analyses.
195
RESULTS A total of 1,107 AD patients were recruited during the study period, including 691 from Taiwan, 244 from Beijing, and 172 from Hong Kong. Taiwan and Hong Kong were similar in terms of basic demographic characteristic (Table 1). The mean age of the AD patients was different among the three areas (p < 0.001), and the AD patients in Beijing (72.1 ± 8.7 years old) were younger (p < 0.001) than those from Taiwan (79.3 ± 7.7) and Hong Kong (80.1 ± 7.4). The educational level of AD patients in Beijing (11.5 ± 4.6 years) were higher (p < 0.001) compared to patients in Taiwan (6.3 ± 5.1) and in Hong Kong (3.2 ± 3.9). The AD patients in Beijing (CDR-SB = 3.9 ± 4.6 and MMSE = 21 ± 6.8) were less severely impaired (p < 0.001) compared to those in Taiwan (CDRSB = 6.9 ± 3.7 and MMSE = 15.7 ± 6.5) and in Hong Kong (CDR-SB = 9.0 ± 4.5 and MMSE = 14.6 ± 9.1) (Table 1). In terms of handedness, there were also differences among the three areas (p = 0.007), with Hong Kong having the least proportion of left-handed patients (1.2%), compared to Taiwan (3.5%) and Beijing (3.8%) (Table 1). In the demographic characteristics of informants, age (p = 0.679) and gender (p = 0.117) were similar in the three areas. Most informants were female with mean age of 57.5 ± 13.7 years in Taiwan, 56.9 ± 15.4 years in Beijing, and 56.5 ± 13.6 years in Hong Kong. The educational level was significantly different (p < 0.001) with 11.8 ± 4.5 years in Taiwan, 13.9 ± 3.2 years in Beijing, and 10.4 ± 5.4 years in Hong Kong.
Table 1 Demographic characteristics of the patients Gender Female, (n/N, %) Age, year N, mean ± SD Education, year N, mean ± SD CDR-SB N, mean ± SD MMSE N, mean ± SD Handedness Left- handed n/N, % Right-handed n/N, % Ambidextrous n/N, % Unknown handed n/N, %
Taiwan
Beijing
Hong Kong
p value
446/691 64.5% N = 690 79.3 ± 7.7 N = 677 6.3 ± 5.1 6.9 ± 3.7 N = 691 15.7 ± 6.5 N = 673
155/244 63.5% N = 244 72.1 ± 8.7 N = 241 11.5 ± 4.6 3.9 ± 4.6 N = 244 21.0 ± 6.8 N = 247
125/172 72.7% N = 170 80.1 ± 7.4 N = 162 3.2 ± 3.9 9.0 ± 4.5 N = 163 14.6 ± 9.1 N = 172
0.099
24/691 3.5% 654/691 94.6% 11/691 1.6% 2/691 0.3%
9/234 3.8% 221/234 94.4% 4/234 1.7% 0
2/172 1.2% 166/172 96.5% 0
![[Hong Kong]health database in Hong Kong.](/assets/img/hold.png)
