News for Professionals
Our News for Professionals page is routinely updated with reported research and news helpful for professionals. Please feel free to comment on subjects you would like more information about.
Over the past year, the pharmaceutical company Eli Lilly has generated significant buzz surrounding solanezumab, a monoclonal antibody directed against amyloid B, the peptides implicated in the development of Alzheimer’s disease. Researchers hypothesized that solanezumab might effectively clear amyloid-β, thereby improving memory and other cognitive skills. Unfortunately, this hypothesis has not been substantiated. The announcement of the failure of EXPEDITION 3, a phase 3 trial conducted by Eli Lilly, raises interesting questions about the intense focus on molecules such as amyloid-β and tau to cure Alzheimer’s disease.
Research failure provides an opportunity to review some of the basic questions and assumptions underlying a specific focus of empirical investigation. One question we might ask is whether clearance of amyloid-β or any other agent will actually improve cognition. In the case of Alzheimer’s disease, the prodromal phase is long, and introducing an agent that clears toxic molecules long after the degenerative process has begun, may have little impact on cognitive functioning. At this point, substantial, nonreversible damage has been done. Perhaps, clearance agents might be better understood as possibly lessening the progression of cognitive impairment but not improving cognitive functioning.
Second, Alzheimer’s is clearly a disease that can present in many different ways, and may be better described in terms of subtypes, if not separate diseases. This being the case, how likely is it that one molecule (such as amyloid-β) will explain the entire variance of the disease?
The focus on a specific molecule appears to be too reductionist, and inconsistent with how the brain works at a systems level. Certainly, molecular and cellular processes are very important, but the exclusive focus on them ignores the fact that the brain is far more complex than its molecular structure. For example, there is growing evidence that changes in electrical activity may be associated with Alzheimer’s disease.
We may find more success in combating Alzheimer’s and related dementias by broadening our research approach. More research targeting molecules is needed but should not be conducted at the expense of studies that may improve our understanding of the broader brain systems associated with neurodegenerative diseases.
We have often been asked about the accuracy of cognitive self-assessment screening instruments. The answer to this question is complicated, and might best be considered by first asking a different question – For what purposes are cognitive self-assessment screening instruments best applied? In our view, having reviewed numerous self-assessments, and having developed the Self-Assessment of Cognition (SAC) screener, self-assessments are most helpful in identifying possible cognitive deficits and guiding the user to a professional when a more comprehensive evaluation is indicated. Cognitive self-assessment instruments are not intended as diagnostic tools, nor are they adequate replacements for professional evaluations.
With these caveats in mind, how can you determine if a specific cognitive self-assessment screener is accurate? Your selection of an instrument should be guided by these questions:
- How robust are the instrument psychometrics? That is, how valid and reliable is it?
- How sensitive is the instrument in detecting mild cognitive problems, as well as possible dementia?
- Does the instrument do more than identify memory problems?
- Has it be shown to predict functional issues, such as one’s ability to manage medications, transportation, or finances?
- Is the instrument an online screener with automatic scoring?
- Does it provide a written report, and if so, is the report helpful?
Clearly, not all cognitive self-assessment instruments are equal or interchangeable, and one should be careful before choosing to use one. The BCAT® Research Center developed the SAC, with the above questions in mind. Our aim in creating the SAC was to help older adults and adults: (1) self-identify possible cognitive problems they may have, (2) bring information about possible cognitive deficits to the attention of a healthcare professional (through the SAC report) in order to develop appropriate evaluation and treatment strategies; and (3) use, from the privacy of their homes, an on-demand cognitive screener via the internet.
The SAC can be used as a low-cost, 3-minute tool for identifying possible cognitive problems, and can indicate when one should seek advice from a healthcare professional. To find out more about the SAC, visit here. One can also access it either through the ENRICH® program website.
Dr. William Mansbach, CEO of Mansbach Health Tools (The BCAT) and CounterPoint Health Services, has announced the launch of the ENRICH ® Brain Health Program. This is the latest program from the world-renowned founder of the BCAT - Brief Cognitive Assessment Tool - who also sits on the Maryland Governor’s Alzheimer’s disease Council.
The evidenced-based ENRICH ® brain health programs contains four steps:
(1) an explanation of the six brain-healthy habits to mitigate your risk for dementia;
(2) the free ENRICH® Calculator which measures how well you currently are managing these habits;
(3) the opportunity to take a cognitive self-assessment or schedule a “virtual” BCAT cognitive assessment; and
(4) suggested next steps.
The team at the BCAT developed this program to address the needs of family caregivers, adult children of those with dementia, and others who are concerned about their risk for developing dementia. Modifying risk factors, increasing brain health, and screening are important factors in early detection and perhaps in delaying the onset of cognitive impairment.
For more information, please visit the new website, www.enrichvisits.com.
Thank you for your continued support of the BCAT® Approach. We are excited to announce that the Working Memory Exercise Book (WMEB) - Home Edition, is now available for purchase. Like the WMEB - Professional Edition, the WMEB - Home Edition can be utilized to improve working memory, increase attention and focus, improve cognitive-communication skills, increase safety and success in functional tasks (Instrumental Activities of Daily Living), and provide a buffer against future cognitive decline.
The WMEB - Home Edition can be used by patients, clients, caregivers, and anyone concerned about brain health. For those who are working directly with persons experiencing memory loss, the WMEB - Home Edition can be recommended to the patient directly for restorative care, used as in-between homework assignments, or as part of the discharge process to promote brain health at home. To purchase the WMEB - Home Edition, visit here.
I recently attended a presentation on the new ENRICH® program. I was very much impressed with this unique approach to lowering the risk of dementia. I understand that there are six brain-heathy behaviors that the program emphasizes, and that one of them pertains to smoking. My older patients often ask me if smoking cessation matters given their age and life expectancy. Can you comment on benefits of smoking cessation for older adults? I guess I am looking for talking points to encourage them to quit. Thank you!
Internal medicine physician, Maryland
BCAT Faculty Response
Thank you for your question Melanie. There are a number of reasons why smoking is a risk factor for dementia. Generally speaking, the link between smoking, heart disease, and dementia is quite clear. Smoking cessation for adults and older adults is a health priority, and an important step toward reducing dementia risk. Unfortunately, many people, including smokers and their families, have a passive approach to smoking cessation in older adults. They may say, why bother? Hasn’t the damage been done? You can improve your health and dementia risk when you stop smoking, even in advanced age and after decades of smoking. The Centers for Disease Control (CDC) has put together a very useful publication called, Within 20 Minutes of Quitting. Here are some talking points for your patients the CDC reports, and they may surprise you.
Within 20 minutes after you smoke that last cigarette, your body begins a series of changes that continue for years. Here are some of them:
- 20 minutes after quitting, your heart rate drops.
- 12 hours after quitting, carbon monoxide levels in your blood drop to normal.
- 2 weeks to 3 months after quitting, your heart attack risk begins to drop, and your lung function begins to improve.
- 1 to 9 months after quitting, your coughing and shortness of breath decrease.
- 1 year after quitting, your added risk of coronary heart disease is half that of a smoker’s.
- 15 years after quitting, your risk of coronary heart disease is back to that of a nonsmoker’s.
We hope you find this information helpful. As a reminder, the ENRICH® program website should be up and running by January 23, 2017! Check it out at www.enrichvisits.com to find out how to lower dementia risk.
Recently, the BCAT Research Center announced the development of the ENRICH® website (www.enrichvisits.com). The website should be up and running by mid-January, 2017. There are four “steps” to the ENRICH® program: (1) an explanation of the six brain-healthy habits you can practice to mitigate your risk for dementia; (2) the opportunity to use the ENRICH® Calculator, which measures how well you are currently doing in managing these six brain-healthy behaviors; (3) the opportunity to take a cognitive self-assessment (the SAC) or schedule a “virtual” BCAT cognitive assessment; and (4) a summary of suggested “next steps” using the information you have from the ENRICH® Calculator and SAC or BCAT assessments.
We have received quite a bit of interest and questions regarding the ENRICH® program. There has been particular interest and excitement about the ENRICH® Calculator. Among these queries, three broad questions have been the most asked. Below is an example of each question and our response:
How did you determine what items to put in the ENRICH® Calculator? Good question! Based on a comprehensive review of the literature, a preliminary study conducted by the BCAT Research Center, and the combined clinical experiences of numerous healthcare professionals representing many health disciplines, we identified six healthy habits for mitigating dementia risk, and then we designed the specific items for the calculator.
Why does the ENRICH® Calculator measure only six behaviors? Certainly, one can identify more than six brain-healthy behaviors that could mitigate dementia risk. However, the six we selected and used to develop the ENRICH® Calculator were based on three overriding principles. The first was economy. Decades of healthcare research shows that compliance with health behavior suffers when people are asked to do more than a handful of healthy activities. You might think about this as a “less is more” concept. The second principle was utility. We choose brain-healthy factors that had the most impressive data supporting them. The third principle was association. The six brain-healthy factors we selected are highly associated with other mitigating factors. For example, we did not include questions about diet because diet is highly correlated with the brain-healthy behaviors we did include (e.g., Body Mass Index and systolic blood pressure).
Is the ENRICH® Calculator free? Yes, the calculator is free and can be used as often as one likes. To access it, one simply will be able to go to the ENRICH® website (www.enrichvisits.com). We hope that the site will be “live” in mid-January.
Our Company uses the BCAT Test System and the Working Memory Exercise Book routinely for our older patients. However, we started a new dementia program recently, and we have started using the Brief Cognitive Impairment Scale (BCIS). I know that the BCIS is part of the BCAT Test System, but I know less about the BCIS than the full BCAT. Is there a good resource that describes the development of the BCIS in general, and its factor scores in particular? THANK YOU!
BCAT Faculty Response:
Thank you for your question Melissa, and we are happy that you use the BCAT Approach in general, and now the BCIS. The BCIS is a unique cognitive assessment for a number of reasons, and was designed specifically for identifying strengths and weaknesses in adults and older adults with dementia. First, it can identify those individuals who have severe dementia. This tends to be an overlooked group, and consequently, they often do not receive appropriate rehab and other interventions. They are also most likely to exhibit BPSD (behavioral and psychological symptoms of dementia). Second, the BCIS has three factor scores that can help direct care. Two factors pertain to the ability of the person to cognitively process verbal directions/instructions, and the third factor measures what we call “interpersonal tolerance”. Interpersonal tolerance refers to the ability to tolerate, without getting agitated, social stimulation and interpersonal contact. In this respect, it may be an important predictor of aggression in older adults with dementia, especially during personal care.
To read about the development and psychometrics of the BCIS, click here.
Coming Soon! – www.enrichvisits.com
As most of our readers and subscribers are aware, The BCAT Approach offers several effective systems for assessing and working with people who have memory and other cognitive impairments. Now we are excited to introduce a new public health program called ENRICH®, which approaches cognitive impairment from a perspective of prevention. ENRICH® emphasizes the practice of brain-healthy habits to lower one’s risk for dementia. Practicing these habits during the mid-life years may be critical in preventing the development of Alzheimer’s disease (AD) and other dementias later in life. Of course, one is never too young to start ENRICH® and never too old to stop.
What we know from the scientific literature on dementia is that there are many modifiable risk factors for AD and related dementias. To make it simple, we suggest that people ages 50 and above embrace six healthy lifestyle behaviors. These behaviors are: daily Exercise, No smoking, Routine cognitive stimulation, mood Improvement (especially for depression), hypertension Control, and maintenance of Healthy weight and body fats. One easy way to remember to practice these brain-healthy behaviors is to use this acronym:
Routinely add Cognitive Stimulation
Healthy Weights and Body Fats
A new website based on the ENRICH® program, which will be dedicated to lowering the risk of dementia, is coming this December. The site, www.enrichvisits.com, will have three program features: (1) details about how you can take responsibility for your health by practicing the ENRICH® brain-healthy habits, (2) the ENRICH® Calculator, which is a rapid self-administered tool for helping one determine current dementia risk, and (3) the ability to schedule a BCAT “virtual visit” (a telehealth model) to determine current cognitive functioning.
To learn more about ENRICH®, contact us at firstname.lastname@example.org.
Last month, nearly 500 of you participated in a BCAT national online survey. Let me begin this post by thanking you for your responses. Our empirical investigations often begin with critical input from professionals in the field. Your feedback is very important to us.
At our research center, we are currently engaged in two important projects. First, we are working on the development of a construct called cognitive-functional hardship (CFH) which will help identify at-risk adults and older adults in the community. The term “at-risk” refers to people who have challenges performing everyday tasks due to cognitive impairments, especially in the area of judgment. Second, we are developing a new test of practical judgment. The survey you completed was relevant to both projects. As there were more data collected than could be reported in this brief post, I present a summary in three sections: demographics of survey respondents, specific information about CFH, and your responses about the need for a new test of practical judgment.
Key Demographics of Survey Participants
- Average age: 50 years
- Average number of years of experience in healthcare: 20
- Average number of years in geriatrics: 17
- Healthcare domain: 45% rehab therapists, 11% social workers, 8% nurses, 14% “other” (e.g., physicians, psychologists, geriatric care managers)
- Respondents were from 38 US states, Washington, DC, Europe, Canada, and Africa.
Cognitive-Functional Hardship (CFH)
Cognitive-functional hardship is defined as the difficulty one experiences in independently maintaining one’s home environment and performing (without assistance) everyday activities as a result of cognitive decline. Persons with CFH have difficulties performing activities of daily living (ADLs) and / or instrumental activities of daily living (IADL) because of cognitive deficits. In the survey, we asked respondents to indicate how many deficits in ADL and / or IADL domains would be required for a person to meet the threshold of CFH.
- Of the six ADLs identified (feeding, continence, transferring, toileting, dressing, bathing), respondents indicated that a person with deficits in two or more areas would meet the threshold of CFH.
- Of the eight IADLs identified (using the telephone, shopping, preparing food, housekeeping, doing laundry, using transportation, handling medications, handling finances), respondents indicated that a person with deficits in two or more areas would meet the threshold for CFH.
- Deficits in two or more areas of either variable was deemed necessary and sufficient for a person to meet the threshold for CFH. That is, CFH was defined as two or more deficits in either ADLs or IADLs. When a person has deficits in two ADL areas or two IADL areas, she/he is said to have CFH.
A New Test of Practical Judgment
Unfortunately, there are relatively few brief tests of practical judgment with solid psychometrics. The BCAT Kitchen Picture Test is certainly one of them, but it is designed to identify persons with more severe deficits in judgment. There is also a need for a brief test to identify more subtle deficits in judgment and to predict CFH. While the BCAT and BCAT-SF can be used to predict CFH, our goal is to develop a rapid judgment test that can also be used to identify adults and older adults at risk for ADL and IADL deficits. Once CFH is identified, a plan can be developed to protect vulnerable individuals at-risk for a myriad of problems, including falls, re-hospitalizations, medication errors, and other injuries.
We asked survey respondents whether CFH is a useful construct for identifying risk in adults and older adults. Respondents confirmed that CFH could be important for identifying people at risk for falls at home (81%), re-hospitalization (72%), and medication errors (93%). In addition, respondents indicated that CFH could indicate who would benefit from home care (87%), a caregiver (92%), alternate housing (84%), telehealth (89%), and improved social support (93%).
Lastly, we asked how respondents currently assess judgment. We learned that, while the majority of survey respondents assess practical judgment informally (85%), only 38% use a formal assessment instrument to do so. Once validation studies are complete, we hope that our new test of practical judgment will provide professionals in geriatrics with an effective tool for assessing judgment and predicting CFH.
We plan to share more information about the new judgment instrument and the application of CFH in the near future. Stay tuned!
The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” While mental health is essential to overall health and well-being, mental health problems are often under-recognized and under-treated, especially for older adults. Fortunately, US public health policy, especially as it pertains to persons 50 and older, has made a significant pivot toward advocacy of mental health initiatives. Heightened attention to mental health in this population is justified by high prevalence rates of mental illness, predicted increases in cognitive-functional hardship, and greater caregiver burden. The Centers for Disease Control and Prevention (CDC) estimates that 20% of people 55 years or older experience some type of mental health concern. The CDC highlights the prominence of three mental health concerns for older adults: cognitive impairment, depressive symptoms, and anxiety disorders.
The BCAT Research Center has developed a specific public health initiative that supports routine screening of cognitive and mood functioning. This initiative aligns with the general direction of US public health policies. We call our program “5 for 50”. In five minutes, one can screen for both cognitive and mood problems in people aged 50 and older. The rationale for beginning this screening at age 50 is based on the growing arc of cognitive and mood problems associated with aging, and the importance of introducing mitigation strategies in the form of early detection. These, of course, begin with identification of problems and focused education outreach.
The “5 for 50” program combines administration of the BCAT-SF and the BADS, and addresses the three primary mental health screening targets. The BCAT-SF is an abbreviated or “short form” of the full BCAT that can be administered in 2-3 minutes and has strong psychometric properties. It can be used to identify and differentiate people with normal cognition, mild cognitive impairment, and more significant cognitive impairment (i.e., dementia). The BADS is a brief anxiety and depression scale that can be administered in two minutes or less to identify people with probable depression and anxiety.
We recommend annual “5 for 50” screenings for those with no history of cognitive and mood impairment, and biannual screenings for those with either a history of impairment or active cognitive, depression, and/or an anxiety symptoms.
Antidepressant use has increased dramatically in the United States, with a 400% increase in utilization since 1990. According to the U.S. Centers for Disease Control and Prevention, approximately 11% of teens and adults currently take antidepressants. While one might conclude that the large numbers of prescriptions written for antidepressants indicates an actual dramatic increase in depressive illness, recent data suggest a more complicated interpretation. Antidepressants are front-line medications for treating depression, but they are also prescribed to treat a wide range of medical problems, including pain, insomnia, and anxiety. This may be particularly true for older adults.
In a recently published study, researchers at McGill University investigated antidepressant prescribing patterns among primary care physicians in Quebec, Canada. They analyzed medical records between 2006 and 2016 across 158 physicians and nearly 20,000 patients. What did they find? Only 55% of antidepressant prescriptions were written specifically for depression. Forty-five percent were written for non-depressive indications and multiple disorders. Approximately 18% were written for anxiety, 10% for insomnia, 6% for chronic pain, and 4% for panic disorders. Other studies reveal that antidepressants are also prescribed for migraines, menopause symptoms, premenstrual syndrome, PTSD, eating disorders, ADHD, and digestive system disorders.
One clear concern with off-label use (applications not approved by a regulating body such as the FDA) of medications is that in many cases, efficacy has not been scientifically established. Certainly, clinical trials establishing the safe and effective use of antidepressants in non-depression disorders are best conducted prior to widespread off-label use, not after it. Yet, healthcare professionals may prescribe off-label antidepressants because they have seen benefits in their patients or have heard of benefits observed by colleagues. A review of the research literature shows that more studies are being conducted investigating the efficacy and safety of off-label use of antidepressants. It is likely that effective treatments for non-depression disorders will be empirically validated. If this does indeed occur, than we might rethink calling these agents “antidepressants.”
I am a psychiatrist working in Boston, and I recently attended a seminar at our hospital. The instructor said that if people with schizophrenia live long enough, they invariably develop Alzheimer’s disease. We were told that both schizophrenia and Alzheimer’s share a common molecular background. However, in my training, I learned that the clinical presentations of the diseases are quite different. This has been my personal experience with patients. Can you shed some light on this issue? If you have schizophrenia, will you develop Alzheimer’s disease?
BCAT Faculty Response:
Thank you for your email, David. You ask a very good question, one that researchers have devoted quite a bit of attention to over the past fifteen years. Our understanding is not as clear as we would like, but evidence is emerging to provide some insight. Cognitive impairment is a key clinical feature of both schizophrenia and Alzheimer’s disease. In both disorders, cognitive deficits can be seen in verbal memory, abstract thinking, executive functions, sustained attention, and response inhibition. It is important to note that while a majority of people with schizophrenia develop the disorder in their late teens or early adulthood, others develop it later; late-onset or very late-onset schizophrenia can occur after age 60. Cognitive impairment may be more pronounced in the later onset cases than in early onset ones. Studies show that more than 25% of older adults with schizophrenia have moderate to severe cognitive impairment.
It is true that a significant number of people with schizophrenia have or will develop dementia, but it is unlikely that it is of the Alzheimer’s type. Post-mortem schizophrenia studies have not found an increased incidence in Alzheimer’s disease pathology. That is, the characteristic Alzheimer’s’ plaques and tangles are not consistently present in the brains of people with schizophrenia.
There are two other points to consider. First, the development of cognitive impairment in schizophrenia is distinct from the typical course of Alzheimer’s disease. Many studies have found cognitive impairment in schizophrenia to be relatively static. This is, of course, quite different from what one expects in Alzheimer’s disease, in which cognitive functioning declines gradually. It should be pointed out that other studies have found decline to be progressive but not necessarily fitting a typical Alzheimer’s pattern. Second, life expectancy of people with schizophrenia is much lower than life expectancy of people with Alzheimer’s. Recent longevity data suggests that most people with schizophrenia do not live past 70. Contrast this with Alzheimer’s disease, in which early symptoms generally do not emerge until the 70s. Generally, different symptom onset patterns indicate different diseases.
In our view, the vast majority of people with schizophrenia, regardless of time of onset, have cognitive impairment. Many will meet criteria for dementia, with or without progressive cognitive deficits. However, it is unlikely that the type of dementia is actually Alzheimer’s.
We hope you found this response helpful, and encourage more questions for the BCAT faculty.
The prevalence of cognitive impairment in general, and dementia in particular, is increasing with the expansion of the older adult population in the U.S. and other countries. Because we do not have effective curative medications and treatments, preventive approaches are critical to public health initiatives aimed at mitigating cognitive health problems. At our research center, we receive numerous questions about non-pharmacological strategies for preventing dementia and improving cognition. People are especially curious about cognitive enhancement exercises, physical exercise, and health comorbidities. Lately, however, we have recognized an increase in diet-related questions. One in particular involves the role of blueberries and blueberry supplements in dementia prevention. In other words, does a bowl of blueberries a day keep dementia away?
The answer is complicated. Blueberries contain polyphenolic compounds, which have positive antioxidant and anti-inflammatory effects. Anthocyanin, one of the polyphenolic compounds found in blueberries, has been shown to have lipid-lowering effects and is thought to improve metabolic function. In addition to blueberries, anthocyanins can be found in foods like strawberries, blackberries, cherries, eggplant, plums, raisins, red or purple grapes, red beans, red beets, red apples, red onions, and red cabbage. Maintaining a diet rich in fruits and vegetables is associated with a lowered risk of neurodegenerative disorders. Moreover, there have been some studies reporting improvement in cognitive performance in older adults who consume regular amounts of fruits and vegetables, inclusive of blueberries. Other studies have found that, following blueberry consumption, anthocyanins have been identified in the hippocampus and specific cortical areas.
While this is encouraging news, a few words of caution are in order to put blueberry consumption in context. Based on the available research literature, one can say that consumption of blueberries and other fruits and vegetables can contribute to positive physical, mental, and cognitive health. However, consumption of anthocyanin-rich foods like blueberries, is likely more effective as a preventative strategy than as actual treatment for memory impairment. Even as a preventative measure, it is unclear how many blueberries one needs to eat in order to realize a positive effect. The best approach for mitigating the risk of dementia is a combination of positive overall health, physical exercise, cognitive stimulation (such as the BCAT Working Memory Exercise Book), and proper diet. As for the latter, one should not only eat healthy foods routinely, but also subtract less healthy ones.
I’m a speech therapist, and I use the WMEB almost every day to help my patients improve cognitive communication and basic memory. The Linking Phrase Exercise is one of my favorites. I’ve gotten very good results with it, especially with my stroke patients. As a speech therapist, it makes intuitive sense to me that language could be used to improve visual memory, but I’m not sure I understand how it works. Thanks!
BCAT Faculty Answer:
Thank you for your question, Melanie. The Linking Phrase Exercise was conceived of by the BCAT team a few years ago and then tested for effectiveness with subacute rehab patients. The primary goal of this exercise is to improve functioning and independence by strengthening working memory. The Linking Phrase Exercise does this in a unique way, by using language to improve visual memory skills. Conversely, we found that pairing visual images with words tended to strengthen verbal recall. So, you can us the Linking Phrase Exercise bi-directionally.
In the Linking Phrase Exercise, the patient is visually presented with two images and a “linking phrase.” The two images are not thematically similar, but they are conceptually linked by the phrase. We believe that what makes this exercise effective is that it recruits different parts of the brain (language and visual centers) and provides an associated context to strengthen and increase the recall potential of the memory.
A number of studies support the idea that visual memory for objects can be improved by verbal descriptors. For example, Brown & Lloyd-Jones (2006) found that when people used verbal descriptors, their ability to recall faces improved. Given that dementia can be associated with impaired facial recognition, The Linking Phrase Exercise might have a direct application with faces. In patients who still possess basic language skills, the ability to recognize a caregiver, independent of whether the patient recalls the caregiver’s name, could be enhanced when words are paired with facial cues. To test this, take a picture of a new caregiver. Give the picture to the patient and ask her to describe the picture using a few descriptive words (red hair, glasses, “about age 50”). Repeat this exercise several times to help consolidate the memory. You may find that not only will recognition of the caregiver improve, but the patient may become less anxious or agitated when the caregiver arrives.
Brown, C & Lloyd-Jones, TJ (2006). Beneficial effects of verbalization and visual distinctiveness on remembering and knowing faces. Memory & Cognition, 34(2), 277-286.
The American Psychiatric Association (APA) recently issued practice guidelines for the use of antipsychotics to treat agitation and psychosis in patients with dementia. The primary purpose of these guidelines is to assist healthcare practitioners in effectively addressing the behavioral and psychological symptoms of dementia (BPSD), while simultaneously minimizing health risks. Nowhere is there a greater need for such guidelines than in long-term care settings like nursing homes and assisted living communities, in which dementia and BPSD are highly prevalent. The BCAT Research Center reported that approximately 60% of US nursing home residents have dementia. Furthermore, BPSD, such as physical and verbal aggression, delusions and other perceptual distortions, anxiety, and depression, affect nearly 80% of residents with dementia at some time during their stays. Antipsychotic medications have been considered the first line intervention to treat such symptoms, despite very limited empirical support and a host of negative side effects.
In 2005, the Food and Drug Administration (FDA) determined that the use of atypical or second generation antipsychotic medications for behavioral disturbances in older adults with dementia is associated with increased mortality. In response, the Centers for Medicare and Medicaid Services (CMS) established the National Partnership to Improve Dementia Care, which set specific targets for reducing antipsychotic medication use in American nursing homes. The CMS targets are still in place, and most states have reported resultant decreases in antipsychotic utilization.
While there may be a decrease in antipsychotic utilization, BPSD remain prevalent, underscoring the need for effective behavioral interventions. It is important to subtract unnecessary and potentially harmful psychotropics, but it is equally important to add effective non-pharmacologic interventions. Otherwise, nursing home staff would be left without BPSD mitigation tools, and residents would continue to suffer.
Unfortunately, there are not many proven behavioral programs in use. One of the few evidence-based approaches is the BCAT 3D Behavioral Management Program. The 3D program is a component of the comprehensive BCAT Approach For Resident-Centered Dementia Care (BCAT-DC). The BCAT-DC is used by nursing homes and assisted living communities to provide person-centered behavioral healthcare, thereby empowering and optimizing quality of life for residents with dementia.
The recently issued APA guidelines emphasize the need for programs like 3D to lower or eliminate antipsychotic use. The need for behavioral approaches is most evident in the following recommendations:
- Assess patients for pain and other potentially modifiable contributors. Residents with dementia may not be able to communicate through words. In the absence of words, they often communicate through agitated behaviors. Antipsychotics fail to address the underlying pain.
- Develop a comprehensive treatment plan that includes appropriate non-pharmacologic and pharmacologic interventions. By routinely using behavioral interventions, the temptation to use a “medication first” approach to BPSD is reduced.
- Nonemergency antipsychotic medication should be used to treat agitation or psychosis only when symptoms are severe, dangerous, and/or cause significant distress to the patient. The presence of egosyntonic thoughts and feelings (those that are harmonious with an individual’s ideal self-image) or mild symptoms that do not place the resident or others at risk is not a reason to prescribe antipsychotics
- Taper antipsychotics if there is no significant treatment response after a 4-week trial of an adequate dose. Providers should always consider non-pharmacologic treatments as an alternative or complement to medications, particularly if there is an inadequate response to antipsychotics alone.
- Even in patients who respond well to antipsychotics, consider a drug taper within 4 months. Remember, there is no such thing as a completely benign medication. This is especially true of antipsychotics. The goal should be to prescribe the lowest effective dose for the shortest amount of time, while simultaneously implementing non-pharmacologic interventions.
For more information about the BCAT 3D Behavioral Management Program of the BCAT Dementia Care Program (BCAT-DC), email us at email@example.com.
I recently heard Dr. Mansbach talk at a conference about healthy habits to reduce the risk of developing dementia. He mentioned chronic poor sleep as a potential risk factor, but not one of the six main ones. Can the BCAT faculty share information about the possible relationship between sleep and dementia? There seems to be a lot of talk about it.
St Louis, MO
Thank you for your question, Harold. There is not only a lot of conversation about the relationship between sleep and dementia, but also a growing body of research devoted to the exploration of the nature of the relationship between the two. The hypothesis that the two are linked is based on the observation that people with dementia tend to experience a disruption in the "internal body clock." When this occurs, the sleep cycle is inverted such that there is an increase in night-time wakefulness and daytime somnolence. The correlation between sleep disturbances and dementia is well-documented, but causality and directionality are uncertain. Researchers have begun to explore the possibility that not only can dementia contribute to sleep disturbances, but also chronic poor sleep may contribute to the development of dementia. So what does the science tell us?
As the body sleeps, the brain consolidates memories and performs certain ‘housekeeping’ tasks. During deep or “slow wave” sleep, the neuropathways between the hippocampus and the neocortex are reactivated. It is thought that this process further consolidates memories, “cementing” them in place. This second consolidation phase increases the likelihood that memories will be recalled hours or years later. This may explain why it is hard to recall information the day after a very poor night of sleep. Fitful sleep or an insufficient amount of sleep prevents the body from going into the slow wave stage in which reactivation occurs. In addition to allowing memories to be “cemented,” there is some evidence that deep sleep allows the brain to rid itself of neurotoxins and proteins that can compromise cognitive functioning. One of these neurotoxins appears to be the protein beta-amyloid, which is strongly implicated in the development of Alzheimer’s disease.
A number of animal studies have demonstrated an association between chronic poor sleep and beta-amyloid build-up in the brain. Recently, researchers at UC Berkeley applied the animal study findings to humans. They found that among human participants who did not have dementia, those who experienced the worst sleep had the highest concentrations of beta-amyloid and performed the worst in a memory learning task. Of course, this does not necessarily mean that poor sleep causes a build-up of beta-amyloid, or that beta-amyloid causes problems in memory. The direction of the association could be reversed. In other words, beta-amyloid build-up could cause poor sleep. Another possibility is that a third health variable, such as pain, diabetes, or cardiovascular disease, contributes to both poor sleep and the development of dementia.
The nature of the association between sleep and dementia is uncertain. There is also ambiguity surrounding what constitutes the “right” amount of sleep. It may vary from person to person. One thing that is certain across the board is that sleep plays a vital role in maintaining positive physical and psychological health. Though it has yet to be established that chronic poor sleep necessarily contributes to the development of dementia, there is strong evidence that physical exercise, cognitive stimulation, no smoking, positive mood, healthy heart, and healthy weight may reduce the risk of dementia. Interestingly, these six habits may also improve your sleep!
In future posts we will be talking more about ways to lower risk of dementia.
At the BCAT Research Center, we have been focusing a lot on co-morbid medical conditions in patients with dementia. Part of our effort is in creating positive preventive strategies that could lower or mitigate dementia risk. We believe that a number of metabolic conditions are key to the development of some dementia syndromes. One possible link is Type 2 diabetes and dementia. Three facts to keep in mind: (1) Type 2 diabetes is far more prevalent than Type 1 diabetes (juvenile diabetes); (2) in a general sense, Type 2, which typically develops in adulthood, can be the result of poor life habits, significantly associated with obesity, poor diet, lack of exercise, etc.; (3) persons with Type 2 are seven times more likely to develop some form of dementia than persons without diabetes.
For at least 3 decades, researchers shave explored possible negative health outcomes caused by, or associated with diabetes. In Type 2, persons typically have what is described as “insulin resistant” conditions. They tend to mass produce insulin as a response to the body not sufficiently using available insulin to break down sugars. At the same time, the body produces an enzyme to break insulin down. That is, where there is insulin, there is a substance called insulin degrading enzyme (IDE).
Here’s where it gets interesting. IDE not only regulates insulin levels, but also appears to break down beta amyloid, one of the proteins associated with Alzheimer’s disease (AD). It may be the case that IDE is an important regulator of beta amyloid. However, it appear that IDE preferentially regulates insulin over beta amyloid. So, if the body is producing more insulin, then IDE may be concentrated in degrading insulin at the expense of beta amyloid regulation. This may result in an accumulation of beta amyloid, especially in the hippocampus, which presumably is a trigger for AD.
In some people, brain insulin resistance is a whole-body disease (like in Type 2 diabetes). However, it may be the case that for other people, it is limited to the brain. For the latter group, they can be said to have Type 3 diabetes. Both forms have real-life risk consequences for patients, increasing the likelihood of developing dementia. This is why it is important to practice healthy life habits. This is a natural way to lower dementia risk and promote positive health.
It really is the case that when people take responsibility for their health, they lower their risk for disease. We continue to advocate for brain-healthy habits like cognitive stimulation, physical exercise, sufficient sleep, proper diet, and healthy weight control as preventative measures all of us can practice.
One of the most common problems for residents in assisted living and nursing home facilities is loneliness. It is paradoxical that so many residents, both those with and without dementia (but especially those with dementia) feel loneliness even as they live in social communities. The experience of so many residents can be described as “feeling alone in a crowd.”
Why is this? There are many contributory factors, some of which are resident internal factors while some are environmental. The need for engagement with peers and others can be intensified when people experience important losses – to their social support systems, their places of residence, health statuses (including cognition), and occupational roles. Of course, the association between these losses and loneliness can be compounded when the social environment fails to provide enough opportunities for true engagement for residents.
One of the initiatives we have at the BCAT Research Center is to investigate and create optimal programs that encourage resident engagement. These programs are based on two central assumptions: (1) that both peer-to-peer and staff-to-peer engagement is important in promoting psychological well-being; and (2) optimal engagement should be person-centered. That is, the quality and quantity of engagement differs from person to person, and facilities, if they are to be true communities, must create programs with this in mind.
We define resident engagement in terms of a three-level approach. Each level should be integrated not only in formal activity or recreation programs, but should also be part of routine staff-resident interactions (during personal care, dining, dispensing medications). These levels fall on a continuum of meaningfulness for the individual resident. There can be overlap in the experiences of these levels. We define them as:
- Meaningful engagement – These are interactions and activities that the resident experiences as meaningful to her. The content tends to activate old memories, and tap into former roles and interests (jobs, hobbies). These interactions are relatable for the resident. An example of a tool designed for promoting meaningful engagement is the BCAT MemPics® books series.
- Purposeful engagement – These interactions and activities are about action and participation, though they are not intended to be truly meaningful for the resident. They are doable. The emphasis in on active participation. Certainly they should be fun or enjoyable. Examples are physical exercise and brain games. (Keep in mind that a purposeful engagement interaction for one resident may be a meaningful for another resident.)
- Passive engagement – These are interactions and activities in which the resident has very little active participation. From the standpoint of promoting well-being and reducing loneliness, passive engagement has the lowest value. Examples are “parking” a resident at an activity in which she cannot really participate, providing personal care with a minimum of social interaction and engagement.
Unfortunately in most assisted living and nursing facilities, the majority of activities and interactions are passive engagements, especially for those who have dementia. There is ample evidence that when facilities instead create opportunities for purposeful and meaningful engagement, residents well-being and physical health improves; and instances of behavioral agitation decrease. Therefore, a clear premium should be put on the training of staff and the implementation of these higher-quality activities and interactions.
Understanding specifically how much meaningful and purpose engagement is necessary is to reduce loneliness and improve health outcomes is unclear, and remains an important research focus for the BCAT Research Center. The devil may be in the details, but ultimate success begins with a commitment to the assumptions underlying resident engagement.
In our view, understanding the causal factors of Alzheimer’s disease (AD) is complex, and just focusing on tangles and plaques is too simplistic. We emphasize the importance of identifying risk factors for AD that may or may not contribute to the production of plaques and tangles, but may cause AD and related dementias. Moreover, lifestyle and specific health factors during the mid-life years may be critical in determining whether one develops AD or other dementias.
Two review-based studies provide some insights. In their review of the literature, Barnes and Yaffe (2011) identified seven largely modifiable risk factors for AD. They were physical inactivity, obesity, smoking, low education, depression, diabetes, and hypertension. The researchers estimate that up to half of AD cases worldwide (17 million) and in the US (nearly 3 million) are potentially attributable to these factors. Furthermore, a 10–25% reduction in all of these risk factors could potentially prevent between 1-3 million AD cases worldwide and 184,000–492,000 cases in the US. Similarly, based on a meta-analysis, Jin-Tai Yu and colleagues (2015) identified nine risk factors that might explain up to 67% of AD cases. These were obesity, carotid artery narrowing, low educational achievement, hyperhomocysteine (a type of amino acid), depression, hypertension, frailty, current smoking, and type 2 diabetes (Asian-background populations).
Many of the risk factors identified in these studies are closely correlated. To make it simple, we suggest that people (ages 50 and above) embrace six healthy lifestyle behaviors, and that they integrate them into daily living. These are: physical exercise, no smoking, treat depression if and when it occurs, keep blood pressure within normal ranges, keep weight at healthy levels, and add cognitive challenges to your daily routine (use evidence-based cognitive exercise). One easy way to remember to practice these brain-healthy behaviors is to use this acronym:
- A – Add cognitive stimulation routinely
- N – No smoking
- T – Treat depression
- H – Healthy weight and body fats
- E – Exercise (physical)
- M – Manage hypertension and cardiac health
It is never too early to practice healthy life habits. Moreover, given the increased physical, emotional, and cognitive risks associated with caregiving, ANTHEM provides a pathway for caregivers to stay healthy.
To learn more, watch the ANTHEM video on our BCAT YouTube Channel.
New study published in the Journal of Aging, Neuropsychology, and Cognition shows superiority of BCAT-SF over AD8 in identifying dementia and mild cognitive impairment in long-term care residents
In this empirical research study, the diagnostic accuracy of the Brief Cognitive Assessment Tool – Short Form (BCAT-SF) was compared to the AD8. Both are brief measures that are commonly used in long-term care settings to assess cognitive functioning of residents. Below is the Abstract for the study.
We compared the accuracy of the Brief Cognitive Assessment Tool—Short Form (BCAT-SF) and AD8 in identifying mild cognitive impairment (MCI) and dementia among long-term care residents. Psychometric analyses of 357 long-term care residents (n = 228, nursing home; n = 129, assisted living) in Maryland referred for neuropsychological evaluation evidenced robust internal consistency reliability and construct validity for the BCAT-SF. Furthermore, hierarchical logistic regression and receiver operating characteristic curve analyses demonstrated superior predictive validity for the BCAT-SF in identifying MCI and dementia relative to the AD8. In contrast, previously reported psychometric properties or cut scores for the AD8 could not be cross-validated in this long-term care sample. Based on these findings, the BCAT-SF appears to be a more reliable and valid screening instrument than the AD8 for rapidly identifying MCI and dementia in long-term care residents.
The full text of the study is available here.
The US Preventive Services Task Force (USPSTF) has recently updated its recommendation on the screening of depression in the general adult population. The USPSTF is an independent panel of experts in primary care and prevention. The task force is responsible for systematically reviewing the evidence of the effectiveness of screening for diseases and developing recommendations for clinical preventive services. The recent USPSTF recommendation endorsed its previous call (from 2009) for screening of all individuals at the primary care level for depression, but also added screening of pregnant and postpartum women, regardless of risk factors. They issued the following statement:
“The USPSTF concludes with at least moderate certainty that there is a moderate net benefit to screening for depression in adults, including older adults, who receive care in clinical practices that have adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up after screening,"
This recommendation is based on the body of empirical evidence that shows that early identification of depressive symptoms can lead to effective treatment, assuming that treatment is available. Clinicians can choose among numerous screening instruments. For adults (older than 50) and older adults, the Brief Anxiety and Depression Scale (BADS) is an ideal depression screening tool that is consistent with the USPSTF recommendation. Unlike most depression screening instruments, the BADS is validated for people with or without dementia, can be completed by the patient or as a proxy measure (by a knowledgeable informant), and can be completed in less than three minutes.
Certainly the treatment of depression is very important, as depression is a common and potentially debilitating illness. In addition, there is a possible link between depression (especially chronic depressive episodes) and dementia. As many of you are aware, the BCAT Research Center is a strong advocate for the ANTHEM approach to reducing the risk of cognitive impairment in the older adult years. ANTHEM recognizes that one may reduce the risk of dementia by practicing six healthy habits, beginning in middle-age. The “T” in ANTHEM refers to the importance of identifying and treating depressive episodes. Screening for depression is not only important for treating depression, but could also reduce the risk of dementia in the older adult years.
For more information about the USPSTF recommendation about depression screening, visit this page.