Prof J Cohen-Mansfield), and Minerva Center for Interdisciplinary Study of End of Life (Prof J Cohen-Mansfield),should consider dementia in older people without known dementia who have frequent admissions or who develop delirium. Delirium is common in people with dementia and contributes to cognitive decline. In hospital, care including appropriate sensory stimulation, ensuring fluid intake, and avoiding infections might reduce delirium incidence.Acting now on dementia prevention, intervention, and care will vastly improve living and dying for individuals with dementia and their families, and thus society.
Recent neuropathologic autopsy studies found that 15 to 25% of elderly demented patients have Lewy bodies (LB) in their brainstem and cortex, and in hospital series this may constitute the most common pathologic subgroup after pure Alzheimer's disease (AD). The Consortium on Dementia with Lewy bodies met to establish consensus guidelines for the clinical diagnosis of dementia with Lewy bodies (DLB) and to establish a common framework for the assessment and characterization of pathologic lesions at autopsy. The importance of accurate antemortem diagnosis of DLB includes a characteristic and often rapidly progressive clinical syndrome, a need for particular caution with neuroleptic medication, and the possibility that DLB patients may be particularly responsive to cholinesterase inhibitors. We identified progressive disabling mental impairment progressing to dementia as the central feature of DLB. Attentional impairments and disproportionate problem solving and visuospatial difficulties are often early and prominent. Fluctuation in cognitive function, persistent well-formed visual hallucinations, and spontaneous motor features of parkinsonism are core features with diagnostic significance in discriminating DLB from AD and other dementias. Appropriate clinical methods for eliciting these key symptoms are described. Brainstem or cortical LB are the only features considered essential for a pathologic diagnosis of DLB, although Lewy-related neurites, Alzheimer pathology, and spongiform change may also be seen. We identified optimal staining methods for each of these and devised a protocol for the evaluation of cortical LB frequency based on a brain sampling procedure consistent with CERAD. This allows cases to be classified into brainstem predominant, limbic (transitional), and neocortical subtypes, using a simple scoring system based on the relative distribution of semiquantitative LB counts. Alzheimer pathology is also frequently present in DLB, usually as diffuse or neuritic plaques, neocortical neurofibrillary tangles being much less common. The precise nosological relationship between DLB and AD remains uncertain, as does that between DLB and patients with Parkinson's disease who subsequently develop neuropsychiatric features. Finally, we recommend procedures for the selective sampling and storage of frozen tissue for a variety of neurochemical assays, which together with developments in molecular genetics, should assist future refinements of diagnosis and classification.
The key test for HoNOS is that clinicians should want to use it for their own purposes. In general, it has passed that test. A further possibility, that HoNOS data collected routinely as part of a minimum data set, for example for the Care Programme Approach, could also be useful in anonymized and aggregated form for public health purposes, is therefore testable but has not yet been tested.
Old age is accompanied by an increased likelihood of illness, and old people take a disproportionate amount of selfadministered and prescribed medications. In the USA, people over 65 consume 30% of prescriptions and 40% of over-the-counter remedies, despite making up only 13% of the population 1. In the UK, elderly people comprise only 18% of the population but use 45% of all prescription drugs, some of which are prescribed inappropriately and without proper attention to side-effects 2. Elderly people living in nursing homes are even more likely to receive medications and to experience side-effects 3. Thus, in one year, 97% of elderly nursing home residents received a prescription drug, compared with 71% of patients living in the community 4. Failure to identify side-effects can lead to use of other drugs to treat the symptoms, rather than adjustment of the dose of the drug responsible. Why do side-effects go unnoticed in elderly people? Older people often have low health expectations and are less likely to complain. Patients with cognitive impairment have dif®culties in communicating their discomfort; those living in nursing homes may rely on care staff to alert the physician to possible side-effects. Some side-effects can be mistaken for the effects of old age and age-related illness. This is particularly the case for anticholinergic side-effects, which are among the most common drug-related effects experienced by elderly people living in nursing and residential homes 5,6. This review highlights the need for better understanding, assessment and management of anticholinergic side-effects in elderly people. DRUGS WITH ANTICHOLINERGIC ACTIVITY Blazer et al. 4 reported that, during one year, nearly 60% of nursing home residents had received drugs with anticholinergic (antimuscarinic) activity, compared with 23% of elderly people living in the community. The most frequently prescribed of these drugs were thioridazine, chlorpromazine and diphenoxylate/atropine. Several types of drug can cause anticholinergic side-effects (Box 1). Peters 5 identi®ed 22 categories with signi®cant anticholinergic activity, including those with an anticholinergic
Variability in conceptual and methodological approaches and inconsistencies in the reported findings have prevented firm conclusions from being drawn. However, the literature provided support for a relationship between non-cognitive features in dementia and psychological problems in caregivers, and suggested possible associations between cognitive deficits and some negative care-giver outcomes. New methodological and conceptual approaches are required if decisive evidence is to be forthcoming. This information is a prerequisite for investigations into the causal mechanisms that sustain these relationships, and for rationally designed interventions.
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