Physical fitness and dementia risk in the very old: a study of the Lothian Birth Cohort 1921

 Sibbett, R. A., Russ, T.C.,  Allerhand, M., Deary, I.J., &  Starr, J. M. | 2018| Physical fitness and dementia risk in the very old: a study of the Lothian Birth Cohort 1921 |BMC Psychiatry |  18 | 285 |

A new article in the BMC Psychiatry examines physical fitness and dementia risk in the very old (participants aged 79 at starting point of the study). Unlike previous studies whch have found an association with old age and dementia risk, this study found that lower fitness beyond age 79 was not a risk factor for subsequent dementia.



Previous studies have demonstrated that individual measures of fitness – such as reduced pulmonary function, slow walking speed and weak handgrip – are associated with an increased risk of dementia. Only a minority of participants included in these studies were aged over 80. The aim of this study was therefore to investigate the association between physical fitness and dementia in the oldest old.


Subjects (n = 488) were enrolled in the Lothian Birth Cohort 1921 and aged 79 at baseline. Dementia cases arising after enrolment were determined using data from death certificates, electronic patient records and clinical reviews. Fitness measures included grip strength, forced expiratory volume in 1 s (FEV1) and walking speed over 6 m, measured at 79 years. Dementia risk associated with each fitness variable was initially determined by logistic regression analysis, followed by Cox regression analysis, where death was considered as a competing risk. APOE ε4 status, age, sex, height, childhood IQ, smoking, history of cardiovascular or cerebrovascular disease, hypertension and diabetes were included as additional variables. Cumulative incidence graphs were calculated using Aalen-Johansen Estimator.


Although initial results indicated that greater FEV1 was associated with an increased risk of dementia (OR (odds ratio per unit increase) 1.93, p = 0.03, n = 416), taking into account the competing risk of mortality, none of the fitness measures were found to be associated with dementia; FEV1 (HR (hazard ratio per unit increase) 1.30, p = 0.37, n = 416), grip strength (HR 0.98, p = 0.35, n = 416), walking speed (HR 0.99, p = 0.90, n = 416). The presence of an APOE ɛ4 allele was however an important predictor for dementia (HR 2.85, p < 0.001, n = 416). Cumulative incidence graphs supported these findings, with an increased risk of dementia for APOE ɛ4 carriers compared with non-carriers. While increased FEV1 was associated with reduced risk of death, there was no reduction in risk for dementia.


In contrast to previous studies, this study found that lower fitness beyond age 79 was not a risk factor for subsequent dementia. This finding is not explained by those with poorer physical fitness, who would have been more likely to develop dementia, having died before onset of dementia symptoms.

The full article can be read at BMC Psychiatry

Alzheimer’s one day may be predicted during eye exam

Using technology similar to what is found in many eye doctors’ offices, researchers have detected evidence suggesting Alzheimer’s in older patients who had no symptoms of the disease | JAMA Ophthalmology | Story via ScienceDaily


Significant brain damage from Alzheimer’s disease can occur years before any symptoms such as memory loss and cognitive decline appear. Scientists estimate that Alzheimer’s-related plaques can build up in the brain two decades before the onset of symptoms, so researchers have been looking for ways to detect the disease sooner.

In a new study published in the journal JAMA Ophthalmology,  researchers used a noninvasive technique — called optical coherence tomography angiography — to examine the retinas in eyes of 30 study participants with an average age in the mid 70s, none of whom exhibited clinical symptoms of Alzheimer’s. One of the authors of the study says “This technique has great potential to become a screening tool that helps decide who should undergo more expensive and invasive testing for Alzheimer’s disease prior to the appearance of clinical symptoms.”

In previous studies, researchers examining the eyes of people who had died from Alzheimer’s have reported that the eyes of such patients showed signs of thinning in the center of the retina and degradation of the optic nerve.

Full story at ScienceDaily

Full reference: O’Bryhim BE et al. | Association of Preclinical Alzheimer Disease With Optical Coherence Tomographic Angiography Findings | JAMA Ophthalmology | August 23rd 2018

Dementia friendly patient identification wrist bands

A Senior Healthcare Assistant (HCA) and Dementia Champion within the Royal Preston Hospital Emergency Department developed an adapted patient identification wristband that supported staff to recognise that a patient may have additional needs related to their diagnosis of dementia | NHS England

A discreet adaptation was made to existing wrist bands to notify any member of staff that the patient has dementia and that they needed to utilise their dementia care training when supporting the patient.


This was achieved by cutting a forget-me-not flower symbol into the patient’s wristband between a patient’s information and the barcode ensuring visibility of the symbol. Further work was undertaken with staff across the emergency and other departments within the hospital to notify them of the changes to the wristband and what the innovation was aiming to achieve.

There has been positive feedback from patients’, their families, friends and carers, as well as health professionals and the general public. The impact of the improvements has been well received by patients, their families and carers as well as staff at the hospital. Qualitative feedback, has shown that they feel patients are treated with dignity and respect by the Emergency Department team.

Full story at NHS England

Clock drawing cognitive test should be done routinely in patients with high blood pressure

A clock drawing test for detecting cognitive dysfunction should be conducted routinely in patients with high blood pressure according to latest research | European Society of Cardiology | via ScienceDaily

Patients with high blood pressure who have impaired cognitive function are at increased risk of developing dementia within five years. Despite this known link, cognitive function is not routinely measured in patients with high blood pressure. Research presented at the European Society of Cardiology Congress 2018 suggests the clock drawing test should be adopted as a routine screening tool for cognitive decline in patients with high blood pressure.


The Heart-Brain study evaluated the usefulness of the clock drawing test compared to the Mini-Mental State Examination (MMSE) to detect cognitive impairment.  For the clock drawing test, patients were given a piece of paper with a 10 cm diameter circle on it. They were asked to write the numbers of the clock in the correct position inside the circle and then draw hands on the clock indicating the time “twenty to four.”

The researchers found a higher prevalence of cognitive impairment with the clock drawing test (36%) compared to the MMSE (21%).

Full story at ScienceDaily



Mindfulness‐based stress reduction for family carers of people with dementia

Liu, Z., Sun, Y. Y., & Zhong, B. L. |2018 | Mindfulness‐based stress reduction for family carers of people with dementia| The Cochrane Library.

A new review from Cochrane posed the question: How effective is mindfulness‐based stress reduction (MBSR) in reducing stress‐related problems of family carers of people with dementia? 


Dementia has become a public health burden worldwide. Caring for people with dementia is highly stressful, thus carers are more likely to suffer from psychological problems, such as depression and anxiety, than general population. Mindfulness‐based stress reduction is a potentially promising intervention to target these issues. More information is needed about whether MBSR can help family carers of people with dementia.

Study characteristics

We searched for evidence up to September 2017 and found five randomised controlled trials (clinical trials where people are randomly assigned to one of two or more treatment groups) comparing MBSR to a variety of other interventions. We reported the effects of MBSR programmes compared with active controls (interventions in which participants received a similar amount of attention to those in the MBSR group, such as social support or progressive muscle relaxation) or inactive controls (interventions in which participants received less attention than those in the MBSR group, such as self help education).

Key results

We were able to analyse study data from five randomised controlled trials involving a total of 201 carers. Findings from three studies (135 carers) showed that carers receiving MBSR may have a lower level of depressive symptoms at the end of treatment than those receiving an active control treatment. However, we found no clear evidence of any effect on depression when MBSR was compared with an inactive control treatment. Mindfulness‐based stress reduction may also lead to a reduction in carers’ anxiety symptoms at the end of treatment. Mindfulness‐based stress reduction may slightly increase carers’ feelings of burden. However, the results on anxiety and burden were very uncertain. We were unable to draw conclusions about carers’ coping strategies and the risk of dropping out of treatment due to the very low quality of the evidence.

None of the studies measured quality of life of carers or people with dementia, or the rate of admission of people with dementia to care homes or hospitals.

Only one included study reported on adverse events, noting one minor adverse event (neck strain in one participant practising yoga at home)

Quality of the evidence

We considered the quality of the evidence to be low or very low, mainly because the studies were small and the way they were designed or conducted put them at risk of giving biased results. Consequently, we have limited confidence in the results.


To summarise, the review provides preliminary evidence on the effect of MBSR in treating some stress‐related problems of family carers of people with dementia. More good‐quality studies are needed before we can confirm whether or not MBSR is beneficial for family carers of people with dementia.

Read the full review at the Cochrane Library here  

Trust-based relations and a holistic approach in advance care planning

Tilburgs, B. et al. | The importance of trust-based relations and a holistic approach in advance care planning with people with dementia in primary care: a qualitative study | BMC Geriatrics (2018) 18:184 

ACP enables individuals to define and discuss goals and preferences for future medical treatment and care with family and healthcare providers, and to record these goals and preferences if appropriate. Because general practitioners (GPs) often have long-lasting relationships with people with dementia, GPs seem most suited to initiate ACP. However, ACP with people with dementia in primary care is uncommon. Although several barriers and facilitators to ACP with people with dementia have already been identified in earlier research, evidence gaps still exist. We therefore aimed to further explore barriers and facilitators for ACP with community-dwelling people with dementia.

A qualitative design, involving all stakeholders in the care for community-dwelling people with dementia, was used. We conducted semi-structured interviews with community dwelling people with dementia and their family caregivers, semi structured interviews by telephone with GPs and a focus group meeting with practice nurses and case managers. Content analysis was used to define codes, categories and themes.

Ten face to face interviews, 10 interviews by telephone and one focus group interview were conducted. From this data, three themes were derived: development of a trust-based relationship, characteristics of an ACP conversation and the primary care setting.

ACP is facilitated by a therapeutic relationship between the person with dementia/family caregiver and the GP built on trust, preferably in the context of home visits. Addressing not only medical but also non-medical issues soon after the dementia diagnosis is given is an important facilitator during conversation. Key barriers were: the wish of some participants to postpone ACP until problems arise, GPs’ time restraints, concerns about the documentation of ACP outcomes and concerns about the availability of these outcomes to other healthcare providers.

ACP is facilitated by an open relationship based on trust between the GP, the person with dementia and his/her family caregiver, in which both medical and non-medical issues are addressed. GPs’ availability and time restraints are barriers to ACP. Transferring ACP tasks to case managers or practice nurses may contribute to overcoming these barriers.

Full document at BMC Geriatrics

Management of behavioral and psychological symptoms in people with Alzheimer’s disease

Kales, H. et al. | Management of behavioral and psychological symptoms in people with Alzheimer’s disease: an international Delphi consensus | Published online: August 2018

Behavioral and psychological symptoms of dementia (BPSD) are nearly universal in dementia, a condition occurring in more than 40 million people worldwide. BPSD present a considerable treatment challenge for prescribers and healthcare professionals. Our purpose was to prioritize existing and emerging treatments for BPSD in Alzheimer’s disease (AD) overall, as well as specifically for agitation and psychosis.

International Delphi consensus process. Two rounds of feedback were conducted, followed by an in-person meeting to ratify the outcome of the electronic process.

2015 International Psychogeriatric Association meeting.

Expert panel comprised of 11 international members with clinical and research expertise in BPSD management.

Consensus outcomes showed a clear preference for an escalating approach to the management of BPSD in AD commencing with the identification of underlying causes. For BPSD overall and for agitation, caregiver training, environmental adaptations, person-centered care, and tailored activities were identified as first-line approaches prior to any pharmacologic approaches. If pharmacologic strategies were needed, citalopram and analgesia were prioritized ahead of antipsychotics. In contrast, for psychosis, pharmacologic options, and in particular, risperidone, were prioritized following the assessment of underlying causes. Two tailored non-drug approaches (DICE and music therapy) were agreed upon as the most promising non-pharmacologic treatment approaches for BPSD overall and agitation, with dextromethorphan/quinidine as a promising potential pharmacologic candidate for agitation. Regarding future treatments for psychosis, the greatest priority was placed on pimavanserin.

This international consensus panel provided clear suggestions for potential refinement of current treatment criteria and prioritization of emerging therapies.

Identifying dementia cases with routinely collected health data

This review finds that routinely collected health-care data sets have the potential to be a cost-effective and comprehensive method of identifying dementia cases in prospective studies | Alzheimer’s & Dementia


Prospective, population-based studies can be rich resources for dementia research. Follow-up in many such studies is through linkage to routinely collected, coded health-care data sets. We evaluated the accuracy of these data sets for dementia case identification.

We systematically reviewed the literature for studies comparing dementia coding in routinely collected data sets to any expert-led reference standard. We recorded study characteristics and two accuracy measures—positive predictive value (PPV) and sensitivity.

We identified 27 eligible studies with 25 estimating PPV and eight estimating sensitivity. Study settings and methods varied widely. For all-cause dementia, PPVs ranged from 33%–100%, but 16/27 were >75%. Sensitivities ranged from 21% to 86%. PPVs for Alzheimer’s disease (range 57%–100%) were generally higher than those for vascular dementia (range 19%–91%).

Linkage to routine health-care data can achieve a high PPV and reasonable sensitivity in certain settings. Given the heterogeneity in accuracy estimates, cohorts should ideally conduct their own setting-specific validation.

Full reference: Wilkinson, T. et al. | Identifying dementia cases with routinely collected health data: A systematic review | Alzheimer’s & Dementia | August 2018 | Volume 14, Issue 8, Pages 1038–1051

Recorded Dementia Diagnoses

Recorded Dementia Diagnoses – July 2018 | NHS Digital

NHS Digital collects and publishes data about people with dementia at each GP practice, so that the NHS (GPs and commissioners) can make informed choices about how to plan their services around their patients needs.

This publication includes the rate of dementia diagnosis. As not everyone with dementia has a formal diagnosis, this statistic compares the number of people thought to have dementia with the number of people diagnosed with dementia, aged 65 and over.

Full detail at NHS Digital


Assessment of delirium in hospital for people with dementia

This report published by the Royal College of Psychiatrists provides a full breakdown of results from a national audit focusing on the identification and assessment of delirium in general hospitals.  It also includes key findings, recommendations, and a discussion of results. 

Key findings

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A high proportion of patients with dementia admitted as emergencies to hospital did not receive an initial assessment for delirium, even after adjustment

After taking account of the greater number of initial assessments identified by the additional questions included in the questionnaire, we found that 32% of patients with dementia, admitted to hospital as an emergency, did not have an initial assessment or screen for delirium. At just under one third of the sample, this remains a very high proportion of people at high risk of delirium and requires improvement.

Questions about initial screen or assessment for delirium are inconsistently interpreted

Variation is apparent in the approach hospitals take to carrying out and recording the assessment of delirium, as questions about an initial screen or assessment for delirium are inconsistently interpreted. In 219 (10%) casenotes, auditors reported no screen, but questions about specific assessments found that it had taken place.  Following adjustment allowing for responses for the follow up questions, results for individual hospitals improved by an average of 19% with individual hospitals seeing increases ranging from to 64 percentage points.

Over a quarter of patients have no confusion or cognitive tests recorded

37% of patients received no confusion or cognitive tests at all, as well as no initial screen.  Cognitive assessment is an important part of comprehensive assessment which all patients with dementia admitted acutely should receive.

Delirium not included in discharge correspondence

Only 48% of patients whose casenotes recorded possible delirium at admission or after initial screening had this recorded on their discharge letter or summary.  All patients who have delirium during admission to hospital should have this information communicated to their General Practitioner (and Primary Care team) on discharge.

Full report: Assessment of delirium in hospital for people with dementia. Spotlight audit 2017 – 2018