Objective: To investigate the association between periventricular white mater hyperintensities (PVWMH) and biomarkers of elevated cerebral b-amyloid (Ab) in the Alzheimer's Disease Neuroimaging Initiative, a large prospective multicenter observational study. Methods:The burden of frontal, parietal, and occipital PVWMH on 3T fluid-attenuated inversion recovery MRI was evaluated in 698 cognitively normal participants and participants with mild cognitive impairment (MCI) using a novel semiquantitative visual rating scale. Results were correlated with CSF-Ab, florbetapir-PET, and fluorodeoxyglucose (FDG)-PET.Results: Increased burden of parietal, occipital, and frontal PVWMH was associated with elevated cerebral amyloid evidenced by high florbetapir-PET signal (p , 0.01) and low CSF-Ab (p , 0.01).In logistic regression models, including PVWMH, age, sex, APOE status, vascular risk factors, pulse pressure, vascular secondary prevention medications, education, ethnicity, and race, parietal, occipital, and frontal PVWMH burden was independently associated with high florbetapir-PET uptake (p , 0.05). In a similar logistic regression model, parietal and occipital (p , 0.05) but not frontal (p 5 0.05) PVWMH were independently associated with CSF-Ab. Weaker associations were found between parieto-occipital PVWMH and elevated CSF-tau (p , 0.05) and occipital PVWMH and elevated CSF-phospho-tau (p , 0.05). PVWMH were associated with cerebral hypometabolism on FDG-PET independent of CSF-Ab levels (p , 0.05). Absolute and consistency of agreement intraclass correlation coefficients were, respectively, 0.83 and 0.83 for frontal, 0.78 and 0.8 for parietal, and 0.45 and 0.75 for occipital PVWMH measurements.Conclusions: Increased PVWMH were associated with elevated cerebral amyloid independent of potential confounders such as age, APOE genotype, and vascular risk factors. The mechanisms underlying the association between PVWMH and cerebral amyloid remain to be clarified. Pathologic and imaging studies have shown that in Alzheimer disease (AD), cerebral small vessel disease (SVD) is coexistent in up to 80% and hastens cognitive deterioration.1 Whether this reflects parallel neuronal injury or synergistic worsening of AD pathogenic mechanisms remains unclear. 2There has been recent interest in the putative role of SVD in disruption of physiologic interstitial fluid bulk flow and paravascular mechanisms of b-amyloid (Ab) clearance.3 If SVD is an
With the current push towards using fewer antipsychotics and more non-pharmacological interventions in long-term care, it has become increasingly important for knowledge and best-practice sharing across the province. The “Good Ideas” project began in 2001 in the context of my work as a Royal Ottawa geriatric psychiatry behavioural support outreach nurse to long-term-care facilities in Ottawa. A toolkit was begun as various ideas and tools were found to be useful in the management of behavioural challenges in the care of long term care residents. These non-pharmacological tools can have a significant impact on the management of behavioural challenges. Some were discovered via “out-of-the-box” thinking, some as a result of exploring possibilities on the Web, others were shared with me by colleagues in various roles and settings. I have worked in geriatric psychiatry in various capacities as a nurse at The Royal Ottawa Health Care Group since 1986, and have had the opportunity to accumulate several “good ideas” over time. I found myself carrying various articles, pamphlets, booklets, photos in my workbag and noticed I was being contacted more frequently over time on how to obtain certain items. When these non-pharmacological approaches were implemented, and successful, a common response would be: “what a good idea!” Thus, the name given to the project came to be. Good Ideas has grown over the years as the information has been shared with outreach team members and utilized in their own practice. All contacts are encouraged to share any new “good ideas” they encounter so those too can be added. Originally a hardcopy handout with a list and the resources to outsource items was created and distributed. This evolved into a PowerPoint presentation explaining the usefulness of each tool in specific target behaviours and how to obtain the tool, as well as photos. Later a poster was made and a second version was produced more recently. Currently the project is in the process of being translated to French for our bilingual Ottawa area. The project has circulated among my teammates to be used in education sessions in their long-term-care facilities or as an adjunct to larger full day education sessions on the topic of dementia care. A large colorful hatbox also contains some sample items to add to the hard copies. Good Ideas has been presented at the Regional Geriatric Program Annual Meeting poster presentation Oct 12, 2013, with very positive feedback from participants. Good Ideas is a project in perpetuity, with no stop date planned. It is my hope it will continue to grow long after my retirement date. It promotes the concept of creative thinking about behavioural challenges in dementia care, while supporting that pharmacological intervention should most often be as a last resort.
2) longitudinally with abnormal hippocampal atrophy rates (NEU/ L+). Cut-off points were derived optimizing sensitivity and specificity in discriminating AMY-controls from AMY+ AD patients. Results: Forty-one patients were designated as SNAP using crosssectional and 22 using longitudinal measures (overlap¼12). No patient converted to dementia after 24 months. In addition, 123 were classified as AMY+NEU/C+ and 86 AMY+NEU/L+ (overlap¼63) with the first group showing a higher conversion rate (41 vs 31%). The highest conversion rate was observed for those positive on both neurodegeneration measures (49%). The opposite pattern was observed in the 77 patients designated as AMY+NEU/C-and 114 as AMY+NEU/L-(overlap¼54), with the first group showing a lower conversion rate (16 vs 23%). Thus, when using a crosssectional measure for neurodegeneration, 78% of the converters were placed in the AMY+NEU+ group compared to 59% with a longitudinal measure. Sixty-nine were AMY-NEU/C-and 88 AMY-NEU/L-(overlap¼59). No difference in conversion was observed (1.4-1.7%). Conclusions: Considerable differences in prevalence were observed when defining NEU+ and NEU-groups based on cross-sectional versus longitudinal data. For the SNAP groups no difference was observed in conversion to dementia, and in this respect it is unclear which measure is more appropriate to define SNAP. Perhaps both measures capture neurodegenerative change, but reflect different rates of injury to the hippocampus. Interestingly, for the AMY+NEU+ group a cross-sectional neurodegeneration measure was more closely linked to conversion to dementia than a longitudinal one.
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