When does cognitive decline begin?

Karr, J. E. et al. | When does cognitive decline begin? A systematic review of change point studies on accelerated decline in cognitive and neurological outcomes preceding mild cognitive impairment, dementia, and death |  Psychology and Aging |  Vol 33 (2), 195-218


Older adults who ultimately develop dementia experience accelerated cognitive decline long before diagnosis. A similar acceleration in cognitive decline occurs in the years before death as well.

To evaluate preclinical and terminal cognitive decline, past researchers have incorporated change points in their analyses of longitudinal data, identifying point estimates of how many years prior to diagnosis or death that decline begins to accelerate.

The current systematic review aimed to summarize the published literature on preclinical and terminal change points in relation to mild cognitive impairment (MCI), dementia, and death, identifying the order in which cognitive and neurological outcomes decline and factors that modify the onset and rate of decline.

A systematic search protocol yielded 35 studies, describing 16 longitudinal cohorts, modeling change points for cognitive and neurological outcomes preceding MCI, dementia, or death.

Change points for cognitive abilities ranged from 3–7 years prior to MCI diagnosis, 1–11 years prior to dementia diagnosis, and 3–15 years before death. No sequence of decline was observed preceding MCI or death, but the following sequence was tentatively accepted for Alzheimer’s disease: verbal memory, visuospatial ability, executive functions and fluency, and last, verbal IQ.

Some of the modifiers of the onset and rate of decline examined by previous researchers included gender, education, genetics, neuropathology, and personality. Change point analyses evidence accelerated decline preceding MCI, dementia, and death, but moderators of the onset and rate of decline remain ambiguous due to between-study modeling differences, and coordinated analyses may improve comparability across future studies.

Full detail at American Psychological Association

Multimorbidity: a priority for global health research

This report was undertaken to summarise the existing research evidence about the burden, determinants, prevention, and treatment of multimorbidity | The Academy of Medical Sciences

Image source: acmedsci.ac.uk

The term multimorbidity  refers to the existence of multiple medical conditions in a single individual. For many regions of the world, there is evidence that a substantial, and likely growing, proportion of the adult population is affected by more than one chronic condition.

Health conditions that frequently group together include heart disease, high blood pressure, diabetes, cancer, depression, anxiety, chronic obstructive pulmonary disease (COPD) and chronic kidney disease.  Why this happens is poorly understood, making it difficult to predict which patients may be most in need of preventive or increased care.

The report also highlights how physical conditions, such as type 2 diabetes, can affect mental health, and vice versa. But the division between health services treating mental and physical health often means that patients with physical and mental conditions are at particular risk of poor care.

Full report: Multimorbidity: a priority for global health research | The Academy of Medical Sciences.

See also:

Improving clinical services in the areas of musculoskeletal (MSK), falls, fractures and frailty.

A new guide compiled by the Oxford Academic Health Science Network showcases the extensive range of programmes being delivered by AHSNs to improve clinical services in the areas of musculoskeletal (MSK), falls, fractures and frailty – all key priorities for the NHS 

Image source: http://www.oxfordahsn.org/

Across England’s 15 AHSNs there is a wealth of experience and practical skills in working with NHS organisations to improve services in these clinical pathways. Evaluations have shown that they have led to improved patient outcomes and better use of resources.

The new guide, compiled by Alison Gowdy, Clinical Innovation Adoption Manager at Oxford AHSN, with input from all AHSNs, provides a valuable overview of these projects.

It is hoped the guide will help shape discussions with Sustainability and Transformation Partnerships (STPs), commissioners and providers regarding future work to improve services and patient outcomes in these areas, while enabling others to share in learning to help implement and/or build on an existing, proven concept.

Download the guide here

Advance Care Planning for people with dementia

My future wishes: Advance Care Planning (ACP) for people with dementia in all settings | NHS England | Alzheimer’s Society | tide

future wishes
Image source: http://www.england.nhs.uk

The guide provides signposting, information and support for colleagues in health, social and community care settings, around advance care planning for people living with  dementia. It identifies key actions from the point of an initial diagnosis of dementia through to the advanced condition, in order to highlight and prompt best practice irrespective of care setting.

It also considers situations where it has not been possible to initiate an ACP / future wishes conversation early and provides some tips on how to manage this.

The aim of this resource is to help practitioners, providers and health and social care commissioners:

  • create opportunities for people living with dementia to develop an ACP through
    initiating and / or opening up conversations;
  • ensure advance care planning is fully embedded in wider inclusive, personalised care and support planning for dementia;
  • ensure people living with dementia have the same equal opportunities as those
    diagnosed with other life limiting conditions / diseases, in terms of accessing palliative care services / support.

Full document: My future wishes: Advance Care Planning (ACP) for people with dementia in all settings 

Dementia support guide for councils

This publication highlights some notable and innovative practice by councils in supporting people living with dementia after their diagnosis | Local Government Association | Dementia Action Alliance

The guide offers the following Key learning points:

1. Engage with people with dementia. A forum or regular meeting with people with dementia is an excellent way to build self-sustaining networks and help shape services. Local people often don’t have an awareness of all support in the community. Ensure all feedback and actions from the forum are well publicised. By doing this people feel listened to and actions are taken as a consequence.

2. Offer information in a range of ways. Design information in partnership with people with dementia and/or representative organisations.

3. Build a dementia friendly community. Work with local partners in business, health, the voluntary sector and across local authority departments to ensure that your local area is dementia friendly.

4. The ability to work positively in collaboration across partners and establish common goals of practitioners is crucial.

5. It is beneficial to have an awareness of likely demand on service in order to plan effectively.

6. Consistent workforce development is essential for shared understanding and awareness of services across all sectors.

7. People with dementia and their carers are given the opportunity to think about what ‘home’ means and plan for their future housing needs, alongside financial planning.

8. Informal settings are important for delivering information to people who might not naturally identify dementia in themselves or a loved one.

Full document: Dementia Post diagnosis support

Age UK report: ‘Why call it care when nobody cares?’

Age UK |  2018 | Older people and their families tell politicians about the problems they face with care

A new report by Age UK – ‘Why call it care when nobody cares?’ – summarises the results of a series of listening events the charity  held with older people who are receiving care and their family carers earlier this year. 127 people participated in 13 sessions in total, which took place in the North, Midlands and South of England, in urban and rural places, and in more affluent and poorer areas.

Each of the listening events, were hosted by local Age UKs and had two parts:

  • in the first older people and their family carers talked about their personal experiences of care, highlighted the problems they faced and what would make life better;
  • and in the second they discussed various funding proposals and what they would mean for them and their families.

Age UK designed these events to help policymakers understand the real-life issues facing older people in need of care and their family carers in their constituencies, and to provide an opportunity to discuss potential solutions.  There was much commonality in the issues raised, and the same issues featured throughout the country,  showing that the problems facing adult social care are national.

The top five reasons mentioned the most in the sessions:

1. ‘Too many professional carers are in a rush and there’s no continuity

2. ‘Care often it isn’t very good’

3. ‘Social care is very expensive and often not good value for money’

4. ‘We family carers feel abandoned and unsupported by the NHS and social care’

5. ‘The social care system is dysfunctional and navigating it is a nightmare’

Older people suggested possible solutions to these issues:

1. ‘Everyone should contribute in some way’

2. ‘We’re only willing to pay more if we get a better service in return’

3. ‘We want any extra funds that are raised to be ring-fenced for care’

4. ‘We believe we need a new and better contract with family carers in our society’

5. ‘We older people and our families desperately want security’ (Age UK)

The full news piece can be read at Age UK 

You can read the full Age UK report here 


Older adults who have slower walking speeds may have increased risk for dementia

Research suggests that older adults with slower walking speeds seem to have a greater risk for dementia than those with faster walking speeds. | Journal of the American Geriatrics Society | story via ScienceDaily


Researchers examined information collected from the English Longitudinal Study of Aging. The study included adults aged 60 and older who lived in England. In their study, the researchers used information collected from 2002 to 2015. They assessed participants’ walking speed on two occasions in 2002-2003 and in 2004-2005, and whether or not the participants developed dementia after the tests from 2006-2015. Then, they compared the people who had developed dementia with those who had not.

Researchers discovered that of the nearly 4,000 older adults they studied, those with a slower walking speed had a greater risk of developing dementia. And people who experienced a faster decline in walking speed over a two-year period were also at higher risk for dementia.

Full story at ScienceDaily

Full reference: Hackett, R. A. et al. | Walking Speed, Cognitive Function, and Dementia Risk in the English Longitudinal Study of Ageing |  Journal of the American Geriatrics SocietyMarch 2018


Cognitive decline: Does where you live and how well you sleep matter?

Hunter, J. C. et al. | Neighborhoods, sleep quality, and cognitive decline: Does where you live and how well you sleep matter? | Alzheimer’s and Dementia | April 2018 | Volume 14, Issue 4 | Pages 454–461

New study finds sleep quality and socioeconomic status were associated with cognitive decline.


We evaluated the association between neighborhood socioeconomic status (NSES) and sleep quality on cognitive decline in the Health and Retirement Study.

Health and Retirement Study participants (n = 8090), aged 65+ with DNA and multiple biennial cognitive observations (abbreviated Telephone Interview for Cognitive Status), were included. Participants were grouped into quartiles of NSES and sleep quality scores. We adjusted for apolipoprotein E ε4, demographic, and cardiovascular risk factors. Random effects modeling evaluated cognitive change over time.

NSES and sleep were significantly associated with cognitive decline, and there was a significant interaction between them (P = .02). Significant differences between high/low NSES and high/low sleep quality (P < .0001) were found.

Sleep and NSES were associated with cognitive decline; the association between sleep and cognition appeared stronger among those with low NSES. The association between low NSES, poor sleep quality, and cognitive decline was roughly equivalent to the association between apolipoprotein E ε4 and cognitive decline.

Full article available here

Long-term risk of dementia among people with traumatic brain injury

Brain injuries increase dementia risk, study finds | The Lancet Psychiatry | BBC News

A study published in The Lancet Psychiatry suggests that people who suffer brain injuries are at increased risk of dementia later in life. An analysis of 2.8 million people found those who had one or more traumatic brain injuries were 24% more likely to get dementia than those who had not. The risk was greatest in people who had the injuries in their 20s, who were 63% more likely to get the condition at some point in their life.

Previous research has suggested a link between brain injuries – leading causes of which include falls, motor vehicle accidents, and assaults – and subsequent dementia, but evidence has been mixed.

This new study, which followed people in Denmark over a 36-year period, found those who had experienced even one mild Traumatic Brain Injury (concussion) were 17% more likely to get dementia, with the risk increasing with the number of TBIs and the severity of injury.

Sustaining the injury at a younger age appeared to further increase the risk of getting the condition, the research found.  Those who suffered a TBI in their 30s were 37% more likely to develop dementia later in life, while those who had the injury in their 50s were only 2% more likely to get the condition.

Full story via BBC News

Fann, Jesse R et al. | Long-term risk of dementia among people with traumatic brain injury in Denmark: a population-based observational cohort study | The Lancet Psychiatry | Published: 10 April 2018

See also: Does traumatic brain injury hold the key to the Alzheimer’s disease puzzle? | Azheimers and Dementia | April 2018 | Volume 14, Issue 4 |  pages 431–443


GP visits to care homes reduce hospital admissions by nearly 40%

Transforming health care in nursing homes. An evaluation of a dedicated primary care
service in outer east London | Nuffield Trust

transforming primary
Image source: http://www.nuffieldtrust.org.uk

The Nuffield Trust was commissioned by the Barking and Dagenham,  Havering and Redbridge Clinical Commissioning Groups to evaluate a new primary care service that was being piloted in four nursing homes in the London Borough of Havering that had previously had difficulty accessing GP services.

The service’s main features were the assignment of a single GP practice to all residents; access to health care professionals with expertise in caring for older people with complex needs; extended access beyond normal GP hours; care guidance to nursing home staff; improved medicines management; and new approaches for managing people who are at the end of life.

The evaluation suggests that there are benefits in providing proactive primary care for nursing homes, delivered by a consistent GP within a service that specialises in older people with complex care needs.

This report assesses the impact of the new service on hospital attendance, and details the experiences and views of staff in the nursing homes and health care professionals delivering the new service.

This related article from the Guardian reports on the success of the £400,000 pilot scheme in which a dedicated primary care practice provides 431 residents of care homes with 8am to 8pm, seven-days-a-week GP support.