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Geriatr Gerontol Int 2014
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Comprehensive geriatric assessment in elderly patients with dementia Nayuta Namioka,1 Haruo Hanyu,1 Hirokuni Hatanaka,1 Raita Fukasawa,1 Hirofumi Sakurai1 and Toshihiko Iwamoto2 1
Department of Geriatric Medicine, Tokyo Medical University, Tokyo and 2Department of Geriatric Medicine, International University of Health and Welfare, Yaita, Japan
Aim: We have recently developed and validated a screening test for comprehensive geriatric assessment (CGA) named “Dr. SUPERMAN”. We compared the results obtained by the CGA of patients with Alzheimer’s disease (AD), vascular dementia (VaD) and dementia with Lewy bodies (DLB), and determined the relationship between functional deficits and clinical characteristics in each type of dementia. Methods: We used Dr. SUPERMAN to examine patients with AD (24 men and 53 women, mean age 83.0 ± 5.1 years), VaD (10 men and 12 women, mean age 80.4 ± 5.0 years) and DLB (28 men and 20 women, mean age 81.2 ± 5.5 years). Results: Patients with DLB or VaD had functional deficits more frequently than those with AD in many fields. Significant correlations between functional impairments and clinical characteristics, such as age, sex and Mini-Mental State Examination scores, in the non-AD group (including DLB and VaD) were found in more extensive fields than those in the AD group. Conclusions: Patients with dementia, particularly DLB, have several geriatric problems. Correlations between functional deficits and clinical characteristics differ between the AD group and the non-AD group. Non-AD patients of older age who are male and have advanced dementia are more likely have several functional deficits. In addition to age and severity of dementia, the type of dementia should be considered in the treatments and interventions of elderly patients with dementia. Geriatr Gerontol Int 2014; ••: ••–••. Keywords: Alzheimer’s disease, comprehensive geriatric assessment, dementia, dementia with Lewy bodies, vascular dementia.
Introduction Elderly patients with dementia usually have specific geriatric problems, including falls, gait disturbance, incontinence, eating and swallowing difficulties, malnutrition, and visual and auditory difficulties, in addition to comorbid medical illnesses.1,2 As comprehensive geriatric assessment (CGA) evaluates physical, functional, psychological, and environmental resources and problems, it might be effective for preventing disease or
Accepted for publication 19 November 2013. Correspondence: Dr Haruo Hanyu MD, Department of Geriatric Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. Email: [email protected]
© 2014 Japan Geriatrics Society
complication and for maintaining the health status of demented patients.3 However, there have been relatively few CGA studies examining elderly patients with dementia.4,5 CGA with multiple components and timeconsuming consultation can lead to difficulty in providing primary care. Recently, we have developed a screening test for CGA named “Dr. SUPERMAN”.6 This is a valid and reliable tool for CGA, and is easy to carry out with an average of 10 min to complete. In the present study, we used Dr. SUPERMAN to examine patients with Alzheimer’s disease (AD), vascular dementia (VaD) and dementia with Lewy bodies (DLB), which are three of the most common types of dementia among elderly people in Japan. The aims were to compare the results obtained by CGA among the dementia groups, and to determine the relationship between geriatric problems and clinical characteristics in each dementia group. doi: 10.1111/ggi.12217
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Methods We recruited at random 147 outpatients aged 65 years and older from the Memory Clinic of the Department of Geriatric Medicine at Tokyo Medical University in Tokyo, Japan, and diagnosed probable AD in 77, probable or possible VaD in 22 and probable DLB in 48. A diagnosis was established using the clinical criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDSADRDA)7 for probable AD, the National Institute of Neurologic Disorders and Stroke and l’Association Internationale pour la Recherche et l’Enseignement en Neurosciences (NINDS-AIREN)8 for probable or possible VaD, and the Consortium on DLB International Workshop9 for probable DLB. In addition to brain computed tomography (CT) or magnetic resonance imaging, the majority of patients underwent brain perfusion single photon emission CT to improve the diagnosis of AD,
VaD and DLB. The severity of cognitive impairment was assessed using the Mini-Mental State Examination (MMSE).10 Figure 1 shows the English version of Dr. SUPERMAN. It consists of several geriatric problems as follows: visual function; auditory function; verbal communication; medication adherence; cognitive function; depressive status; functional disturbance of upper and lower extremities; history of falls within 1 year; eating and swallowing functions; urination; basic and instrumental activities of daily living (ADL/IADL), such as toileting, dressing, bathing and shopping; and nutrition. Several questionnaires for each item were adopted using the appropriate gold standards. The details of “Dr. SUPERMAN” were described elsewhere.6,11
Statistical analysis Values are expressed as mean ± SD. Statistical analysis was carried out using one-way analysis of variance with
Figure 1 The English version of Dr. SUPERMAN.
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© 2014 Japan Geriatrics Society
CGA in dementia
Table 1 Demographic characteristics of the three dementia groups
Age (years) Sex (male/female) Education (years) Duration of dementia (years) MMSE
AD (n = 77)
VaD (n = 22)
DLB (n = 48)
83.0 ± 5.1 24/53 11.5 ± 2.6 3.6 ± 1.2 19.5 ± 4.0
80.4 ± 5.0* 10/12 10.6 ± 2.7 3.2 ± 1.0 19.1 ± 3.6
81.2 ± 5.5 28/20* 12.1 ± 2.8 3.4 ± 1.1 19.6 ± 4.3
Values are expressed as mean ± SD. *P < 0.05 compared with the Alzheimer’s disease (AD) group. DLB, dementia with Lewy bodies; MMSE, Mini-Mental State Examination; VaD, vascular dementia.
the post-hoc Scheffé’s F-test and χ2-test. To determine the relationship between each functional item and the clinical characteristics, multiple regression analysis was carried out with each item as a dependent variable, and age, sex (male = 1, female = 2) and MMSE scores as independent variables in the AD group and non-AD group. The non-AD group, including 22 patients with VaD and 48 patients with DLB, was analyzed together because of the relatively small sample size of VaD. For medication adherence and history of falls, two-level scores were used; that is, 0 = no problem (or absence) and 1 = major problem (or presence); whereas for the other items, three-level scores were used; that is, 0 = no problem, 1 = minor problem and 2 = major problem. Among the items, cognitive function was excluded from this analysis because all participants were demented. A P-value of less than 0.05 was considered to show a statistically significant difference.
Results Table 1 shows the demographic characteristics of the three dementia groups. The patients in the VaD group were significantly younger than the patients in the AD group. The DLB group had a higher proportion of men, whereas the AD group had a higher proportion of women, with a significant difference between the two groups (χ2 = 6.57, P < 0.05). There were no significant differences in the level of education, duration of dementia and MMSE scores among the groups. The patients were treated with cholinesterase inhibitors, a small amount of antipsychotic drugs and several kinds of medications for comorbidities. Table 2 shows the comparisons of the frequency of each problem among the three groups. The DLB group showed significantly higher frequencies of minor or major problems than the AD group in several items, including visual function, verbal communication, medication adherence, depression, upper and lower extremity functions, history of falls, urination, and impairment of ADL/IADL function. The VaD group showed signifi© 2014 Japan Geriatrics Society
cantly higher frequencies of history of falls than the AD group. No significant differences were found in any of the functions between the DLB group and the VaD group. There were no significant differences in auditory function, eating and swallowing function, and nutrition between the three groups. The results of multiple regression analysis for each item in the AD group and non-AD group are shown in Tables 3 and 4, respectively. In the AD group, there were significant correlations between age and medication adherence and lower extremity function, and between the MMSE scores and verbal communication, urination, and ADL/IADL function. In contrast, more items correlated significantly with clinical characteristics in the non-AD group than in the AD group as follows: between age and auditory function, verbal communication, medication adherence and lower extremity function, and between sex, medical adherence and ADL/ IADL function, and between the MMSE scores and verbal communication, medication adherence, upper and lower extremity functions, urination, and ADL/ IADL function. When the DLB and VaD groups were analyzed separately, relationships between functional impairments and clinical characteristics were found in more extensive fields in the DLB group than in the VaD group.
Discussion We found that patients with DLB or VaD had functional deficits more frequently than those with AD in many fields. Significant correlations between functional impairments and clinical characteristics, such as age, sex and MMSE scores, were found in more extensive fields in the non-AD group (including DLB and VaD) than in the AD group. These results show that several geriatric problems are more likely found in patients with DLB and VaD, particularly in those of older age, who are male and have advanced dementia. In our previous study of 76 elderly outpatients without dementia (29 men and 47 women, mean age |
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Table 2 Comparisons of the frequency of each functional deficit among the three groups
Visual function
Auditory function
Verbal communication
Medication adherence Depression
Upper extremity function
History of falls Lower extremity function
Eating and swallowing function
Urination
ADL/IADL function
Nutrition
No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem No problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem Absence Presence No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem
AD
VaD
DLB
Analysis
61 (79%) 13 (17%) 3 (4%) 47 (61%) 23 (30%) 7 (9%) 39 (51%) 29 (38%) 9 (11%) 34 (44%) 43 (56%) 46 (60%) 26 (34%) 5 (6%) 75 (98%) 1 (1%) 1 (1%) 50 (65%) 27 (35%) 27 (35%) 39 (51%) 11 (14%) 63 (82%) 12 (16%) 2 (2%) 48 (62%) 20 (26%) 9 (12%) 41 (53%) 26 (34%) 10 (13%) 60 (78%) 13 (17%) 4 (5%)
15 (75%) 4 (20%) 1 (5%) 14 (70%) 5 (25%) 1 (5%) 7 (35%) 12 (60%) 1 (5%) 9 (45%) 11 (55%) 8 (40%) 8 (40%) 4 (20%) 18 (90%) 2 (10%) 0 (0%) 7 (35%) 13 (65%) 5 (25%) 11 (55%) 4 (20%) 14 (70%) 5 (25%) 1 (5%) 9 (45%) 6 (30%) 5 (25%) 7 (35%) 8 (40%) 5 (25%) 17 (85%) 1 (5%) 2 (10%)
25 (52%) 20 (42%) 3 (6%) 26 (54%) 19 (40%) 3 (6%) 12 (25%) 25 (52%) 11 (23%) 12 (25%) 36 (75%) 15 (31%) 22 (46%) 11 (23%) 39 (81%) 9 (19%) 0 (0%) 14 (29%) 34 (71%) 16 (33%) 15 (31%) 17 (36%) 30 (63%) 15 (31%) 3 (6%) 13 (27%) 20 (42%) 15 (31%) 10 (21%) 21 (44%) 17 (35%) 33 (69%) 12 (25%) 3 (6%)
AD < DLB**
NS
AD < DLB* AD < DLB* AD < DLB** AD < DLB** AD < DLB*** AD < VaD* AD < DLB*
NS
AD < DLB** AD < DLB**
NS
*P < 0.05, **P < 0.01, ***P < 0.0001. AD, Alzheimer’s disease; ADL, activities of daily living; DLB, dementia with Lewy bodies; IADL, instrumental activities of daily living; NS, not significant; VaD, vascular dementia.
83.2 ± 4.9 years), the specific geriatric problems shown by Dr. SUPERMAN were as follows: visual difficulty (30%), auditory difficulty (28%), communication difficulty (6%), poor medication adherence (19%), depressive status (39%), functional disturbances of the upper (5%) and lower (68%) extremities, history of falls (28%), eating and swallowing difficulties (18%), impairment of ADL/IADL function (38%), and nutritional problems (20%; unpubl. data). Our patients with dementia had higher frequencies of geriatric problems than those without dementia, particularly communication difficulty, poor medication adherence, history of falls and impaired ADL/IADL function. Several studies have shown that people with dementia have a doubled 4
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to threefold risk of falls.12–14 In addition to diseasespecific motor impairments, behavioral disturbances and neuroleptic drugs, disturbances of the executive function and attention might also be associated with risk of falls.15,16 The risk factor for falls is reported to differ depending on the type and severity of dementia.17 In a prospective study by Allan et al., the incidence of falls in DLB patients was approximately threefold higher than that in AD patients, consistent with the present findings.15 As several studies showed that cognitive impairment is closely associated with functional status in the elderly,18–20 impaired ADL/IADL function is more likely present in patients with dementia. © 2014 Japan Geriatrics Society
CGA in dementia
Table 3 Multiple regression analysis for each item in the Alzheimer’s disease group
Visual function Auditory function Verbal communication Medication adherence Depression Upper extremity function History of falls Lower extremity function Eating and swallowing function Urination ADL/IADL Nutrition
Age
Sex
MMSE
0.167 0.197 0.196 0.638*** 0.089 −0.133 0.111 0.372* 0.098 −0.091 0.206 0.124
0.098 0.138 0.134 0.106 −0.105 0.055 0.096 0.184 −0.125 −0.042 0.008 0.206
−0.034 0.186 −0.353* −0.067 −0.12 −0.181 −0.121 −0.179 −0.262 −0.46** −0.418** −0.01
Values indicate standardized coefficient. *P < 0.01, **P < 0.001, ***P < 0.0001. ADL, activities of daily living; IADL, instrumental activities of daily living; MMSE, Mini-Mental State Examination.
Table 4 Multiple regression analysis for each item in the non-Alzheimer’s disease group
Visual function Auditory function Verbal communication Medication adherence Depression Upper extremity History of falls Lower extremity function Eating and swallowing function Urination ADL/IADL Nutrition
Age
Sex
MMSE
0.198 0.596**** 0.336** 0.424*** −0.02 −0.181 0.184 0.353** 0.173 0.182 0.199 −0.072
0.177 0.012 0.048 −0.253* −0.227 −0.185 −0.026 0.051 −0.055 −0.101 −0.293** 0.082
0.026 0.005 −0.404*** −0.266* −0.237 −0.422*** −0.031 −0.42*** −0.218 −0.34** −0.678**** −0.064
Values indicate standardized coefficient. *P < 0.05, **P < 0.01, ***P < 0.001, ****P < 0.0001. ADL, activities of daily living; IADL, instrumental activities of daily living; MMSE, Mini-Mental State Examination.
Although the MMSE scores were similar among the three dementia groups, communication difficulty, poor medication adherence and impaired ADL/IADL function were found more frequently in patients with DLB than in those with AD. These findings suggest that these functions might be associated with other cognitive domains not assessed by the MMSE, such as the frontal executive function. As expected, depression was found more frequently in patients with DLB than in those with AD. Impairment of urinary function, such as incontinence, could partly be associated with autonomic dysfunction, which was involved in the early stage of DLB. Impaired upper or lower extremity function frequently © 2014 Japan Geriatrics Society
found in patients with DLB might be associated with motor impairment, such as gait disturbance and parkinsonian syndrome. As it is reported that DLB patients show visual signs and symptoms, including defects in eye movement, pupillary function and complex visual functions,21 visual functional impairment revealed by CGA was found more frequently in patients with DLB than in those with AD. Some studies showed shorter survival of DLB patients than AD patients.22,23 In a previous study, we found that DLB patients had a greater risk of admission (or death) and institutionalization because of the most common fall-related injuries and aspiration pneumonia than AD24 patients. Considering |
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previous studies and the present findings, we need to direct more attention to the treatment and primary care of elderly patients with dementia, particularly those with DLB. In general, aging and cognitive impairment are accompanied by an increase in deficits in several geriatric functions. As shown in the present study, age was associated with poor medication adherence and lower extremity dysfunction, and MMSE scores were associated with communication difficulty, urinary dysfunction, and impaired ADL/IADL function in both the AD and non-AD groups. In addition, in the non-AD group, age was associated with auditory and communication dysfunctions, sex was associated with poor medication adherence and impaired ADL/IADL function, and MMSE scores were associated with poor medication adherence and upper and lower extremity dysfunctions. The reason that medication adherence and impaired ADL/IADL function correlated significantly with sex in the non-AD group, but not in the AD group remains unclear. The present results suggest that non-AD patients of older age who are male and have advanced dementia more likely have functional deficits in many fields. The present study had several limitations. First, we did not examine comorbidity of the dementia groups. Elderly patients with dementia usually have several comorbid medical illnesses.1,2 The number and severity of concomitant diseases might be associated with functional decline. Second, the study population comprised selected patients from outpatients of our Memory Clinic, and the severity of dementia was mild to moderate (the mean MMSE score of each group was approximately 19 points). Therefore, it might not be applicable to admitted or institutionalized patients with more advanced dementia. Third, the sample size of the VaD group was small, and the patients were recruited from a single hospital. As the enrolment of participants was at random, selection bias was thought to be minimized. The severity of parkinsonism likely affects functional impairments in the DLB group. However, as we analyzed 48 patients with DLB and 22 patients with VaD together to compare their results with those obtained by the CGA of 77 patients with AD, we did not determine the effect of signs of parkinsonism in functional impairments. Finally, the present study had a cross-sectional approach. A recent study by Pilotto et al. showed that information collected in a standardized CGA was effective in predicting short- and long-term mortality risk in elderly patients with dementia.5 A longitudinal multicenter study with a larger sample size will be required in the future. Despite these limitations, we found that patients with dementia, particularly DLB, have several geriatric problems revealed by a screening test for CGA named Dr. SUPERMAN. Correlations between each functional 6
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deficit and clinical characteristics, such as age, sex and severity of dementia, differ between AD and non-AD patients. Non-AD patients of older age who are men and have advanced dementia more likely have functional impairments in many fields. In addition to age and severity of dementia, the type of dementia could be an important factor to consider for treatments and interventions of elderly patients with dementia.
Acknowledgements We are indebted to Maya Vardaman and Associate Professor Edward F Barroga (DVM, PhD) of the Department of International Medical Communications of Tokyo Medical University for their editorial review of the English manuscript.
Disclosure statement The authors declare no conflict of interest.
References 1 Doraiswamy PM, Leon J, Cummings JL, Marin D, Neumann PJ. Prevalence and impact of medical comorbidity in Alzheimer’s disease. J Geront Medical Sci 2002; 3: M173–M177. 2 Sakurai H, Hanyu H, Kanetaka H et al. Prevalence of coexisting diseases in patients with Alzheimer’s disease. Geriatr Gerontol Int 2010; 10: 216–217. 3 Stuck AE, Siu AL, Wieland GW, Adams J, Rubenstein L. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342: 1032–1036. 4 Riccio D, Solinas A, Astara G, Mantovani G. Comprehensive geriatric assessment in female elderly patients with Alzheimer disease and other types of dementia. Arch Gerontol Geriatr 2007; 44 (Suppl 1): 343–353. 5 Pilotto A, Sancarlo D, Panza F et al. The multidimensional prognostic index (MPI), based on a comprehensive geriatric assessment, predicts short- and long-term mortality in hospitalized older patients with dementia. J Alzheimer Dis 2009; 19: 191–199. 6 Iwamoto T, Hanyu H, Umahara T, Sakurai H, Kanaya K. The English version of the newly developed comprehensive geriatric assessment initiative “Dr. SUPERMAN” – Its usefulness and limitations. Geriatr Gerontol Int 2013; 13: 811–812. 7 McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology 1984; 34: 939–944. 8 Roman GC, Tatemichi TK, Erkinjuntti T et al. Vascular dementia: diagnostic criteria for research studies: report of the NINDS-AIREN International Workshop. Neurology 1993; 43: 250–260. 9 McKeith IG, Dickson DW, Lowe J et al. Consortium on DLB. Diagnosis and management of dementia with Lewy bodies. Third report of the DLB consortium. Neurology 2005; 65: 1863–1872. © 2014 Japan Geriatrics Society
CGA in dementia 10 Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–198. 11 Ohnuma T, Kanetaka H, Iwamoto T. Establishment of a short-form screening test for cognitive decline as part of a newly developed comprehensive geriatric assessment initiative named “Dr. Superman”. Nippon Ronen Igakkai Zasshi 2012; 49: 241–249. 12 Baker NL, Cook MN, Arrichi M, Bullock R. Hip fracture risk and subsequent mortality among Alzheimer’s disease patients in the United Kingdom, 1988–2007. Age Ageing 2011; 40: 49–54. 13 Haasum Y, Fastbom J, Fratiglioni L, Johnell K. Undertreatment of osteoporosis in persons with dementia? A population-based study. Osteoporosis Int 2012; 23: 1061– 1068. 14 Melton LJ, Beard CM, Kokmen E et al. Fracture risk in patients with Alzheimer’s disease. J Am Geriatr Soc 1994; 42: 614–619. 15 Mirelman A, Herman T, Brozgol M et al. Executive function and falls in older adults: new findings from a five-year prospective study link fall risk to cognition. PLoS ONE 2012; 7: e40297. 16 Montero-Odasso M, Verghese J, Beauchet O, Hausdorff JM. Gait and cognition: a complementary approach to understanding brain function and the risk of falling. J Am Geriatr Soc 2012; 60: 2127–2136.
© 2014 Japan Geriatrics Society
17 Allan LM, Ballard CG, Rowan EN, Kenny RA. Incidence and prediction of falls in dementia: a prospective study in older people. PLoS ONE 2009; 4: e5521. 18 Barber-Gateau P, Fabrigoule C. Disability and cognitive impairment in the elderly. Disabil Rehabil 1997; 19: 175– 193. 19 Stuck AE, Walthert JM, Nikolaus T, Bula CJ, Hohmann C, Beck JC. Risk factors for functional status decline in community-living elderly people: a systematic literature review. Soc Sci Med 1999; 48: 445–469. 20 Sauvaget C, Yamada M, Fujiwara S, Sasaki H, Mimori Y. Dementia as a predictor of functional disability: a four-year follow-up study. Gerontology 2002; 48: 226–233. 21 Armstrong RA. Visual signs and symptoms of dementia with Lewy bodies. Clin Exp Optom 2012; 95: 621–630. 22 Williams MM, Xiong C, Morris JC, Galvin JE. Survival and mortality differences between dementia with Lewy bodies vs Alzheimer disease. Neurology 2006; 67: 1935–1941. 23 Olichney JM, Galasko D, Salmon DP et al. Cognitive decline is faster in Lewy body variant than in Alzheimer’s disease. Neurology 1998; 51: 351–357. 24 Hanyu H, Sato T, Hirao K, Kanetaka H, Sakurai H, Iwamoto T. Differences in clinical course between dementia with Lewy bodies and Alzheimer’s disease. Eur J Neurol 2009; 16: 212–217.
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Geriatr Gerontol Int 2014
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Comprehensive geriatric assessment in elderly patients with dementia Nayuta Namioka,1 Haruo Hanyu,1 Hirokuni Hatanaka,1 Raita Fukasawa,1 Hirofumi Sakurai1 and Toshihiko Iwamoto2 1
Department of Geriatric Medicine, Tokyo Medical University, Tokyo and 2Department of Geriatric Medicine, International University of Health and Welfare, Yaita, Japan
Aim: We have recently developed and validated a screening test for comprehensive geriatric assessment (CGA) named “Dr. SUPERMAN”. We compared the results obtained by the CGA of patients with Alzheimer’s disease (AD), vascular dementia (VaD) and dementia with Lewy bodies (DLB), and determined the relationship between functional deficits and clinical characteristics in each type of dementia. Methods: We used Dr. SUPERMAN to examine patients with AD (24 men and 53 women, mean age 83.0 ± 5.1 years), VaD (10 men and 12 women, mean age 80.4 ± 5.0 years) and DLB (28 men and 20 women, mean age 81.2 ± 5.5 years). Results: Patients with DLB or VaD had functional deficits more frequently than those with AD in many fields. Significant correlations between functional impairments and clinical characteristics, such as age, sex and Mini-Mental State Examination scores, in the non-AD group (including DLB and VaD) were found in more extensive fields than those in the AD group. Conclusions: Patients with dementia, particularly DLB, have several geriatric problems. Correlations between functional deficits and clinical characteristics differ between the AD group and the non-AD group. Non-AD patients of older age who are male and have advanced dementia are more likely have several functional deficits. In addition to age and severity of dementia, the type of dementia should be considered in the treatments and interventions of elderly patients with dementia. Geriatr Gerontol Int 2014; ••: ••–••. Keywords: Alzheimer’s disease, comprehensive geriatric assessment, dementia, dementia with Lewy bodies, vascular dementia.
Introduction Elderly patients with dementia usually have specific geriatric problems, including falls, gait disturbance, incontinence, eating and swallowing difficulties, malnutrition, and visual and auditory difficulties, in addition to comorbid medical illnesses.1,2 As comprehensive geriatric assessment (CGA) evaluates physical, functional, psychological, and environmental resources and problems, it might be effective for preventing disease or
Accepted for publication 19 November 2013. Correspondence: Dr Haruo Hanyu MD, Department of Geriatric Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. Email: [email protected]
© 2014 Japan Geriatrics Society
complication and for maintaining the health status of demented patients.3 However, there have been relatively few CGA studies examining elderly patients with dementia.4,5 CGA with multiple components and timeconsuming consultation can lead to difficulty in providing primary care. Recently, we have developed a screening test for CGA named “Dr. SUPERMAN”.6 This is a valid and reliable tool for CGA, and is easy to carry out with an average of 10 min to complete. In the present study, we used Dr. SUPERMAN to examine patients with Alzheimer’s disease (AD), vascular dementia (VaD) and dementia with Lewy bodies (DLB), which are three of the most common types of dementia among elderly people in Japan. The aims were to compare the results obtained by CGA among the dementia groups, and to determine the relationship between geriatric problems and clinical characteristics in each dementia group. doi: 10.1111/ggi.12217
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Methods We recruited at random 147 outpatients aged 65 years and older from the Memory Clinic of the Department of Geriatric Medicine at Tokyo Medical University in Tokyo, Japan, and diagnosed probable AD in 77, probable or possible VaD in 22 and probable DLB in 48. A diagnosis was established using the clinical criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDSADRDA)7 for probable AD, the National Institute of Neurologic Disorders and Stroke and l’Association Internationale pour la Recherche et l’Enseignement en Neurosciences (NINDS-AIREN)8 for probable or possible VaD, and the Consortium on DLB International Workshop9 for probable DLB. In addition to brain computed tomography (CT) or magnetic resonance imaging, the majority of patients underwent brain perfusion single photon emission CT to improve the diagnosis of AD,
VaD and DLB. The severity of cognitive impairment was assessed using the Mini-Mental State Examination (MMSE).10 Figure 1 shows the English version of Dr. SUPERMAN. It consists of several geriatric problems as follows: visual function; auditory function; verbal communication; medication adherence; cognitive function; depressive status; functional disturbance of upper and lower extremities; history of falls within 1 year; eating and swallowing functions; urination; basic and instrumental activities of daily living (ADL/IADL), such as toileting, dressing, bathing and shopping; and nutrition. Several questionnaires for each item were adopted using the appropriate gold standards. The details of “Dr. SUPERMAN” were described elsewhere.6,11
Statistical analysis Values are expressed as mean ± SD. Statistical analysis was carried out using one-way analysis of variance with
Figure 1 The English version of Dr. SUPERMAN.
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© 2014 Japan Geriatrics Society
CGA in dementia
Table 1 Demographic characteristics of the three dementia groups
Age (years) Sex (male/female) Education (years) Duration of dementia (years) MMSE
AD (n = 77)
VaD (n = 22)
DLB (n = 48)
83.0 ± 5.1 24/53 11.5 ± 2.6 3.6 ± 1.2 19.5 ± 4.0
80.4 ± 5.0* 10/12 10.6 ± 2.7 3.2 ± 1.0 19.1 ± 3.6
81.2 ± 5.5 28/20* 12.1 ± 2.8 3.4 ± 1.1 19.6 ± 4.3
Values are expressed as mean ± SD. *P < 0.05 compared with the Alzheimer’s disease (AD) group. DLB, dementia with Lewy bodies; MMSE, Mini-Mental State Examination; VaD, vascular dementia.
the post-hoc Scheffé’s F-test and χ2-test. To determine the relationship between each functional item and the clinical characteristics, multiple regression analysis was carried out with each item as a dependent variable, and age, sex (male = 1, female = 2) and MMSE scores as independent variables in the AD group and non-AD group. The non-AD group, including 22 patients with VaD and 48 patients with DLB, was analyzed together because of the relatively small sample size of VaD. For medication adherence and history of falls, two-level scores were used; that is, 0 = no problem (or absence) and 1 = major problem (or presence); whereas for the other items, three-level scores were used; that is, 0 = no problem, 1 = minor problem and 2 = major problem. Among the items, cognitive function was excluded from this analysis because all participants were demented. A P-value of less than 0.05 was considered to show a statistically significant difference.
Results Table 1 shows the demographic characteristics of the three dementia groups. The patients in the VaD group were significantly younger than the patients in the AD group. The DLB group had a higher proportion of men, whereas the AD group had a higher proportion of women, with a significant difference between the two groups (χ2 = 6.57, P < 0.05). There were no significant differences in the level of education, duration of dementia and MMSE scores among the groups. The patients were treated with cholinesterase inhibitors, a small amount of antipsychotic drugs and several kinds of medications for comorbidities. Table 2 shows the comparisons of the frequency of each problem among the three groups. The DLB group showed significantly higher frequencies of minor or major problems than the AD group in several items, including visual function, verbal communication, medication adherence, depression, upper and lower extremity functions, history of falls, urination, and impairment of ADL/IADL function. The VaD group showed signifi© 2014 Japan Geriatrics Society
cantly higher frequencies of history of falls than the AD group. No significant differences were found in any of the functions between the DLB group and the VaD group. There were no significant differences in auditory function, eating and swallowing function, and nutrition between the three groups. The results of multiple regression analysis for each item in the AD group and non-AD group are shown in Tables 3 and 4, respectively. In the AD group, there were significant correlations between age and medication adherence and lower extremity function, and between the MMSE scores and verbal communication, urination, and ADL/IADL function. In contrast, more items correlated significantly with clinical characteristics in the non-AD group than in the AD group as follows: between age and auditory function, verbal communication, medication adherence and lower extremity function, and between sex, medical adherence and ADL/ IADL function, and between the MMSE scores and verbal communication, medication adherence, upper and lower extremity functions, urination, and ADL/ IADL function. When the DLB and VaD groups were analyzed separately, relationships between functional impairments and clinical characteristics were found in more extensive fields in the DLB group than in the VaD group.
Discussion We found that patients with DLB or VaD had functional deficits more frequently than those with AD in many fields. Significant correlations between functional impairments and clinical characteristics, such as age, sex and MMSE scores, were found in more extensive fields in the non-AD group (including DLB and VaD) than in the AD group. These results show that several geriatric problems are more likely found in patients with DLB and VaD, particularly in those of older age, who are male and have advanced dementia. In our previous study of 76 elderly outpatients without dementia (29 men and 47 women, mean age |
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Table 2 Comparisons of the frequency of each functional deficit among the three groups
Visual function
Auditory function
Verbal communication
Medication adherence Depression
Upper extremity function
History of falls Lower extremity function
Eating and swallowing function
Urination
ADL/IADL function
Nutrition
No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem No problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem Absence Presence No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem No problem Minor problem Major problem
AD
VaD
DLB
Analysis
61 (79%) 13 (17%) 3 (4%) 47 (61%) 23 (30%) 7 (9%) 39 (51%) 29 (38%) 9 (11%) 34 (44%) 43 (56%) 46 (60%) 26 (34%) 5 (6%) 75 (98%) 1 (1%) 1 (1%) 50 (65%) 27 (35%) 27 (35%) 39 (51%) 11 (14%) 63 (82%) 12 (16%) 2 (2%) 48 (62%) 20 (26%) 9 (12%) 41 (53%) 26 (34%) 10 (13%) 60 (78%) 13 (17%) 4 (5%)
15 (75%) 4 (20%) 1 (5%) 14 (70%) 5 (25%) 1 (5%) 7 (35%) 12 (60%) 1 (5%) 9 (45%) 11 (55%) 8 (40%) 8 (40%) 4 (20%) 18 (90%) 2 (10%) 0 (0%) 7 (35%) 13 (65%) 5 (25%) 11 (55%) 4 (20%) 14 (70%) 5 (25%) 1 (5%) 9 (45%) 6 (30%) 5 (25%) 7 (35%) 8 (40%) 5 (25%) 17 (85%) 1 (5%) 2 (10%)
25 (52%) 20 (42%) 3 (6%) 26 (54%) 19 (40%) 3 (6%) 12 (25%) 25 (52%) 11 (23%) 12 (25%) 36 (75%) 15 (31%) 22 (46%) 11 (23%) 39 (81%) 9 (19%) 0 (0%) 14 (29%) 34 (71%) 16 (33%) 15 (31%) 17 (36%) 30 (63%) 15 (31%) 3 (6%) 13 (27%) 20 (42%) 15 (31%) 10 (21%) 21 (44%) 17 (35%) 33 (69%) 12 (25%) 3 (6%)
AD < DLB**
NS
AD < DLB* AD < DLB* AD < DLB** AD < DLB** AD < DLB*** AD < VaD* AD < DLB*
NS
AD < DLB** AD < DLB**
NS
*P < 0.05, **P < 0.01, ***P < 0.0001. AD, Alzheimer’s disease; ADL, activities of daily living; DLB, dementia with Lewy bodies; IADL, instrumental activities of daily living; NS, not significant; VaD, vascular dementia.
83.2 ± 4.9 years), the specific geriatric problems shown by Dr. SUPERMAN were as follows: visual difficulty (30%), auditory difficulty (28%), communication difficulty (6%), poor medication adherence (19%), depressive status (39%), functional disturbances of the upper (5%) and lower (68%) extremities, history of falls (28%), eating and swallowing difficulties (18%), impairment of ADL/IADL function (38%), and nutritional problems (20%; unpubl. data). Our patients with dementia had higher frequencies of geriatric problems than those without dementia, particularly communication difficulty, poor medication adherence, history of falls and impaired ADL/IADL function. Several studies have shown that people with dementia have a doubled 4
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to threefold risk of falls.12–14 In addition to diseasespecific motor impairments, behavioral disturbances and neuroleptic drugs, disturbances of the executive function and attention might also be associated with risk of falls.15,16 The risk factor for falls is reported to differ depending on the type and severity of dementia.17 In a prospective study by Allan et al., the incidence of falls in DLB patients was approximately threefold higher than that in AD patients, consistent with the present findings.15 As several studies showed that cognitive impairment is closely associated with functional status in the elderly,18–20 impaired ADL/IADL function is more likely present in patients with dementia. © 2014 Japan Geriatrics Society
CGA in dementia
Table 3 Multiple regression analysis for each item in the Alzheimer’s disease group
Visual function Auditory function Verbal communication Medication adherence Depression Upper extremity function History of falls Lower extremity function Eating and swallowing function Urination ADL/IADL Nutrition
Age
Sex
MMSE
0.167 0.197 0.196 0.638*** 0.089 −0.133 0.111 0.372* 0.098 −0.091 0.206 0.124
0.098 0.138 0.134 0.106 −0.105 0.055 0.096 0.184 −0.125 −0.042 0.008 0.206
−0.034 0.186 −0.353* −0.067 −0.12 −0.181 −0.121 −0.179 −0.262 −0.46** −0.418** −0.01
Values indicate standardized coefficient. *P < 0.01, **P < 0.001, ***P < 0.0001. ADL, activities of daily living; IADL, instrumental activities of daily living; MMSE, Mini-Mental State Examination.
Table 4 Multiple regression analysis for each item in the non-Alzheimer’s disease group
Visual function Auditory function Verbal communication Medication adherence Depression Upper extremity History of falls Lower extremity function Eating and swallowing function Urination ADL/IADL Nutrition
Age
Sex
MMSE
0.198 0.596**** 0.336** 0.424*** −0.02 −0.181 0.184 0.353** 0.173 0.182 0.199 −0.072
0.177 0.012 0.048 −0.253* −0.227 −0.185 −0.026 0.051 −0.055 −0.101 −0.293** 0.082
0.026 0.005 −0.404*** −0.266* −0.237 −0.422*** −0.031 −0.42*** −0.218 −0.34** −0.678**** −0.064
Values indicate standardized coefficient. *P < 0.05, **P < 0.01, ***P < 0.001, ****P < 0.0001. ADL, activities of daily living; IADL, instrumental activities of daily living; MMSE, Mini-Mental State Examination.
Although the MMSE scores were similar among the three dementia groups, communication difficulty, poor medication adherence and impaired ADL/IADL function were found more frequently in patients with DLB than in those with AD. These findings suggest that these functions might be associated with other cognitive domains not assessed by the MMSE, such as the frontal executive function. As expected, depression was found more frequently in patients with DLB than in those with AD. Impairment of urinary function, such as incontinence, could partly be associated with autonomic dysfunction, which was involved in the early stage of DLB. Impaired upper or lower extremity function frequently © 2014 Japan Geriatrics Society
found in patients with DLB might be associated with motor impairment, such as gait disturbance and parkinsonian syndrome. As it is reported that DLB patients show visual signs and symptoms, including defects in eye movement, pupillary function and complex visual functions,21 visual functional impairment revealed by CGA was found more frequently in patients with DLB than in those with AD. Some studies showed shorter survival of DLB patients than AD patients.22,23 In a previous study, we found that DLB patients had a greater risk of admission (or death) and institutionalization because of the most common fall-related injuries and aspiration pneumonia than AD24 patients. Considering |
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previous studies and the present findings, we need to direct more attention to the treatment and primary care of elderly patients with dementia, particularly those with DLB. In general, aging and cognitive impairment are accompanied by an increase in deficits in several geriatric functions. As shown in the present study, age was associated with poor medication adherence and lower extremity dysfunction, and MMSE scores were associated with communication difficulty, urinary dysfunction, and impaired ADL/IADL function in both the AD and non-AD groups. In addition, in the non-AD group, age was associated with auditory and communication dysfunctions, sex was associated with poor medication adherence and impaired ADL/IADL function, and MMSE scores were associated with poor medication adherence and upper and lower extremity dysfunctions. The reason that medication adherence and impaired ADL/IADL function correlated significantly with sex in the non-AD group, but not in the AD group remains unclear. The present results suggest that non-AD patients of older age who are male and have advanced dementia more likely have functional deficits in many fields. The present study had several limitations. First, we did not examine comorbidity of the dementia groups. Elderly patients with dementia usually have several comorbid medical illnesses.1,2 The number and severity of concomitant diseases might be associated with functional decline. Second, the study population comprised selected patients from outpatients of our Memory Clinic, and the severity of dementia was mild to moderate (the mean MMSE score of each group was approximately 19 points). Therefore, it might not be applicable to admitted or institutionalized patients with more advanced dementia. Third, the sample size of the VaD group was small, and the patients were recruited from a single hospital. As the enrolment of participants was at random, selection bias was thought to be minimized. The severity of parkinsonism likely affects functional impairments in the DLB group. However, as we analyzed 48 patients with DLB and 22 patients with VaD together to compare their results with those obtained by the CGA of 77 patients with AD, we did not determine the effect of signs of parkinsonism in functional impairments. Finally, the present study had a cross-sectional approach. A recent study by Pilotto et al. showed that information collected in a standardized CGA was effective in predicting short- and long-term mortality risk in elderly patients with dementia.5 A longitudinal multicenter study with a larger sample size will be required in the future. Despite these limitations, we found that patients with dementia, particularly DLB, have several geriatric problems revealed by a screening test for CGA named Dr. SUPERMAN. Correlations between each functional 6
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deficit and clinical characteristics, such as age, sex and severity of dementia, differ between AD and non-AD patients. Non-AD patients of older age who are men and have advanced dementia more likely have functional impairments in many fields. In addition to age and severity of dementia, the type of dementia could be an important factor to consider for treatments and interventions of elderly patients with dementia.
Acknowledgements We are indebted to Maya Vardaman and Associate Professor Edward F Barroga (DVM, PhD) of the Department of International Medical Communications of Tokyo Medical University for their editorial review of the English manuscript.
Disclosure statement The authors declare no conflict of interest.
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