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Double-Edged Sword: A Positive Brain Scan Result Heightens Confidence in an Alzheimer’s Diagnosis But Also Leads to Higher Stigma Among Older Adults in a Vignette-Based Experiment
Abstract
Objectives
Early diagnosis of Alzheimer’s disease (AD) using brain scans and other biomarker tests will be essential to increasing the benefits of emerging disease-modifying therapies, but AD biomarkers may have unintended negative consequences on stigma. We examined how a brain scan result affects AD diagnosis confidence and AD stigma.
Methods
The study used a vignette-based experiment with a 2×2×3 factorial design of main effects: a brain scan result as positive or negative, treatment availability and symptom stage. We sampled 1,283 adults ages 65 and older between 11 June and 3 July 2019. Participants (1) rated their confidence in an AD diagnosis in each of four medical evaluations that varied in number and type of diagnostic tools and (2) read a vignette about a fictional patient with varied characteristics before completing the Modified Family Stigma in Alzheimer’s Disease Scale (FS-ADS). We examined mean diagnosis confidence by medical evaluation type. We conducted between-group comparisons of diagnosis confidence and FS-ADS scores in the positive versus negative brain scan result conditions and, in the positive condition, by symptom stage and treatment availability.
Results
A positive versus negative test result corresponds with higher confidence in an AD diagnosis independent of medical evaluation type (all p<0.001). A positive result correlates with stronger reactions on 6 of 7 FS-ADS domains (all p<0.001).
Discussion
A positive biomarker result heightens AD diagnosis confidence but also correlates with more AD stigma. Our findings inform strategies to promote early diagnosis and clinical discussions with individuals undergoing AD biomarker testing.
... This can help mitigate the harmful effects of stigma that may disproportionately impact individuals from different demographic backgrounds. 72 Furthermore, variability in diagnostic confidence and the specifics of tests performed must be considered, as these factors can influence the early diagnosis of AD. 73 It is important to evaluate the potential biases of ML methods to mitigate age-or sex-related risk factors influencing disease detection. Notably, in our present study, we analyzed misclassification proportions as a function of age and sex, and we did not observe consistent differences across test-set folds on average. ...
Background
Alzheimer's disease (AD) is a neurodegenerative disorder that profoundly alters brain function and organization. Currently, there is a lack of validated functional biomarkers to aid in diagnosing and classifying AD. Therefore, there is a pressing need for early, accurate, non-invasive, and accessible methods to detect and characterize disease progression. Electroencephalography (EEG) has emerged as a minimally invasive technique to quantify functional changes in neural activity associated with AD. However, challenges such as poor signal-to-noise ratio—particularly for resting-state (rsEEG) recordings—and issues with standardization have hindered its broader application.
Objective
To conduct a pilot analysis of our custom automated preprocessing and feature extraction pipeline to identify indicators of AD and correlates of disease progression.
Methods
We analyzed data from 36 individuals with AD and 29 healthy participants recorded using a standard 19-channel EEG and features were processed using our custom end-t-end pipeline. Various features encompassing amplitude, power, connectivity, complexity, and microstates were extracted. Unsupervised machine learning (uniform manifold approximation and projection) and supervised learning (random forest classifiers with nested cross-validation) were used to characterize the dataset and identify differences between AD and healthy groups.
Results
Our pipeline successfully detected several new and previously established EEG-based measures indicative of AD status and progression, demonstrating strong external validity.
Conclusions
Our findings suggest that this automated approach provides a promising initial framework for implementing EEG biomarkers in the AD patient population, paving the way for improved diagnostic and monitoring strategies.
INTRODUCTION
How do reactions to a brain scan result differ between Black and White adults? The answer may inform efforts to reduce disparities in Alzheimer's disease (AD) diagnosis and treatment.
METHODS
Self‐identified Black (n = 1055) and White (n = 1451) adults were randomized to a vignette of a fictional patient at a memory center who was told a brain scan result. Measures of stigma and diagnosis confidence were compared between‐groups.
RESULTS
Black participants reported more stigma than White participants on four of seven domains in reaction to the patient at a memory center visit. Black participants’ confidence in an AD diagnosis informed by a brain scan and other assessments was 72.2 points (95% confidence interval [CI] 70.4 to 73.5), which was lower than the respective rating for White participants [78.1 points (95%CI 77.0 to 79.3)].
DISCUSSION
Equitable access to early AD diagnosis will require public outreach and education that address AD stigma associated with a memory center visit.
Despite its global importance and the recognition of dementia as an international public health priority, interventions to reduce stigma of dementia are a relatively new and emerging field. The purpose of this review was to synthesize the existing literature and identify key components of interventions to reduce stigma of dementia. We followed Arksey and O’Malley’s scoping review process to examine peer-reviewed literature of interventions to reduce dementia-related stigma. A stigma-reduction framework was used for classifying the interventions: education (dispel myths with facts), contact (interact with people with dementia), mixed (education and contact), and protest (challenge negative attitudes). From the initial 732 references, 21 studies were identified for inclusion. We found a variety of education, contact, and mixed interventions ranging from culturally tailored films to intergenerational choirs. Findings from our review can inform the development of interventions to support policies, programs, and practices to reduce stigma and improve the quality of life for people with dementia.
Several large clinical trials are underway to discover therapies to delay or prevent the onset of dementia caused by Alzheimer’s disease (AD). A common feature of these trials is that they are testing therapies in people who do not yet have changes in memory or thinking—that is, who are cognitively unimpaired—but who have a biologically defined risk of developing dementia caused by AD. When these trials eventually succeed, it is reasonable to expect the widespread adoption of biomarker and genetic testing of cognitively unimpaired individuals into clinical practice, as well as treatment prescribed to individuals at heightened risk. Here, we report results from two qualitative studies that sought to understand with whom, why, and how individuals share their AD biomarker and genetic testing results, respectively. We found that sharing is common within the confines of close relationships. However, when sharing outside such relationships, people have multiple concerns, including stigma and discrimination. These concerns highlight the need for additional legal protections and policy changes in anticipation of the coming transformation of AD clinical care.
Background
Cognitively normal (CN) older adults participating in Alzheimer’s disease (AD) research increasingly ask for their research results—including genetic and neuroimaging findings—to understand their risk of developing AD dementia. AD research results are typically not returned for multiple reasons, including possible psychosocial harms of knowing one is at risk of a highly feared and untreatable disease.
Objective
We developed materials that convey information about 5-year absolute risk of developing AD dementia based on research results.
Methods
20 CN older adults who received a research brain MRI result were interviewed regarding their wishes for research results to inform material development (Pilot 1). Following material development, 17 CN older adults evaluated the materials for clarity and acceptability (Pilot 2). All participants were community-dwelling older adults participating in longitudinal studies of aging at a single site.
Results
Participants want information on their risk of developing AD dementia to better understand their own health, satisfy curiosity, inform family, and future planning. Some articulated concerns, but the majority wanted to know their risk despite the limitations of information. Participants found the educational materials and results report clear and acceptable, and the majority would want to know their research results after reviewing them.
Conclusion
These materials will be used in a clinical study examining the psychosocial and cognitive effects of offering research results to a cohort of CN older adults. Future AD research may incorporate the return of complex risk information to CN older adults, and materials are needed to communicate this information.
Importance
Clinical guidelines currently recommend against amyloid imaging for cognitively unimpaired persons. The goal of Alzheimer’s disease (AD) prevention, together with advances in understanding the pathophysiology of AD, however, has led to trials testing drugs in cognitively unimpaired persons who show evidence of AD biomarkers. Assuming the eventual success of such trials, millions of patients will be affected. There is a need to understand the effects of biomarker disclosure on those individuals.
Design
The Study of Knowledge and Reactions to Amyloid Testing (SOKRATES) involved 2 semi-structured telephone interviews with individuals who received amyloid PET scan results as part of screening for research participation. Post-disclosure interviews were conducted at 4 to 12 weeks and again 1 year later. Data were collected from November 5, 2014 to November 30, 2016. Interviews were transcribed and coded in NVivo 12.0.
Participants
80 adults aged 65 and older: 50 who received “elevated” and 30 who received “not-elevated” amyloid PET scan results.
Main outcomes
Interviews examined four domains: (1) comprehension of the amyloid PET scan result; (2) implications of the result for sense of self, memory, and future; (3) sharing of results with others; and (4) AD risk-reduction behaviors.
Results
Participants who received an elevated amyloid PET scan result viewed the result as more serious and sensitive than other medical test results given its unique implications for identity, self-determination, and stigma. In contrast, participants who received a not-elevated amyloid PET scan result described feeling relief and reinterpreted perceived memory impairments as normal aging. Participants with elevated amyloid reported contemplating and making more changes to health behaviors and future plans than their peers with not-elevated amyloid.
Conclusions
Clinical practice in the diagnosis and treatment of persons with preclinical AD, a stage of the disease defined by the presence of biomarkers in the absence of cognitive impairment, will need to address matters of identity, stigma, and life-planning.
See Schöll and Maass (doi:10.1093/brain/awz399) for a scientific commentary on this article.
Betthauser et al. present the results of a retrospective analysis of cognitive trajectories in initially unimpaired adults stratified according to PET amyloid and tau status. Individuals with elevated levels of both pathophysiological beta-amyloid and tau show faster cognitive decline during late middle-age than those with one or no elevated biomarkers.
Differences in cognitive performance over time were investigated between neuroimaging biomarker groups for beta-amyloid and tau in initially cognitively unimpaired persons. The combination of pathologic beta-amyloid and tau was detrimental to cognitive decline in preclinical AD during late middle-age. Middle-age health factors likely do not influence AD-related preclinical cognitive decline.
In 2018, there was a recent shift towards a biological definition of Alzheimer's disease (AD), based on biomarkers measured in vivo even before the onset of clinical dementia symptoms. No single biomarker can by itself accurately diagnose AD. A combination of biomarkers assessed through imaging and cerebrospinal fluid (CSF) yields better diagnostic accuracy. Although amyloid PET imaging and CSF levels of amyloid and tau deposits are increasingly used in AD clinical trials to increase diagnostic confidence in enrolled subjects, routine use of these biomarkers in clinical settings is still premature because of the risk of overdiagnosis, increased cost and/or invasiveness of the assessment method. Also, standardization of measures across studies is needed to assure biomarker regulatory approval. Exploring novel biomarkers beyond the amyloid and tau pathologies, and their longitudinal change across the AD continnum are important research avenues for the future.
Background
The increasing number of available point-of-care (POC) tests challenges clinicians regarding decisions on which tests to use, how to efficiently use them, and how to interpret the results. Although POC tests may offer benefits in terms of low turn-around-time, improved patient’s satisfaction, and health outcomes, only few are actually used in clinical practice. Therefore, this study aims to identify which criteria are, in general, important in the decision to implement a POC test, and to determine their weight. Two POC tests available for use in Dutch general practices (i.e. the C-reactive protein (CRP) test and the glycated haemoglobin (HbA1c) test) serve as case studies. The information obtained from this study can be used to guide POC test development and their introduction in clinical practice.
Methods
Relevant criteria were identified based on a literature review and semi-structured interviews with twelve experts in the field. Subsequently, the criteria were clustered in four groups (i.e. user, organization, clinical value, and socio-political context) and the relative importance of each criterion was determined by calculating geometric means as implemented in the Analytic Hierarchy Process. Of these twelve experts, ten participated in a facilitated group session, in which their priorities regarding both POC tests (compared to central laboratory testing) were elicited.
Results
Of 20 criteria in four clusters, the test’s clinical utility, its technical performance, and risks (associated with the treatment decision based on the test result) were considered most important for using a POC test, with relative weights of 22.2, 12.6 and 8.5%, respectively. Overall, the experts preferred the POC CRP test over its laboratory equivalent, whereas they did not prefer the POC HbA1c test. This difference was mainly explained by their strong preference for the POC CRP test with regard to the subcriterion ‘clinical utility’.
Conclusions
The list of identified criteria, and the insights in their relative impact on successful implementation of POC tests, may facilitate implementation and use of existing POC tests in clinical practice. In addition, having experts score new POC tests on these criteria, provides developers with specific recommendations on how to increase the probability of successful implementation and use.
Electronic supplementary material
The online version of this article (10.1186/s12875-018-0893-4) contains supplementary material, which is available to authorized users.
Background
Amyloid PET (aPET) imaging could improve patient outcomes in clinical practice, but the extent of impact needs quantification.
Objective
To provide an aggregated quantitative analysis of the value added by aPET in cognitively impaired subjects.
Methods
Systematic literature searches were performed in Embase and Medline until January 2017. 1,531 cases over 12 studies were included (1,142 cases over seven studies in the primary analysis where aPET was the key biomarker; the remaining cases included as defined groups in the secondary analysis). Data was abstracted by consensus among two observers and assessed for bias. Clinical utility was measured by diagnostic change, diagnostic confidence, and patient management before and after aPET. Three groups were further analyzed: control patients for whom feedback of aPET scan results was delayed; aPET Appropriate Use Criteria (AUC+) cases; and patients undergoing additional FDG/CSF testing.
Results
For 1,142 cases with only aPET, 31.3% of diagnoses were revised, whereas 3.2% of diagnoses changed in the delayed aPET control group (p < 0.0001). Increased diagnostic confidence following aPET was found for 62.1% of 870 patients. Management changes with aPET were found in 72.2% of 740 cases and in 55.5% of 299 cases in the control group (p < 0.0001). The diagnostic value of aPET in AUC+ patients or when FDG/CSF were additionally available did not substantially differ from the value of aPET alone in the wider population.
Conclusions
Amyloid PET contributed to diagnostic revision in almost a third of cases and demonstrated value in increasing diagnostic confidence and refining management plans.
In 2011, the National Institute on Aging and Alzheimer's Association created separate diagnostic recommendations for the preclinical, mild cognitive impairment, and dementia stages of Alzheimer's disease. Scientific progress in the interim led to an initiative by the National Institute on Aging and Alzheimer's Association to update and unify the 2011 guidelines. This unifying update is labeled a “research framework” because its intended use is for observational and interventional research, not routine clinical care. In the National Institute on Aging and Alzheimer's Association Research Framework, Alzheimer's disease (AD) is defined by its underlying pathologic processes that can be documented by postmortem examination or in vivo by biomarkers. The diagnosis is not based on the clinical consequences of the disease (i.e., symptoms/signs) in this research framework, which shifts the definition of AD in living people from a syndromal to a biological construct. The research framework focuses on the diagnosis of AD with biomarkers in living persons. Biomarkers are grouped into those of β amyloid deposition, pathologic tau, and neurodegeneration [AT(N)]. This ATN classification system groups different biomarkers (imaging and biofluids) by the pathologic process each measures. The AT(N) system is flexible in that new biomarkers can be added to the three existing AT(N) groups, and new biomarker groups beyond AT(N) can be added when they become available. We focus on AD as a continuum, and cognitive staging may be accomplished using continuous measures. However, we also outline two different categorical cognitive schemes for staging the severity of cognitive impairment: a scheme using three traditional syndromal categories and a six-stage numeric scheme. It is important to stress that this framework seeks to create a common language with which investigators can generate and test hypotheses about the interactions among different pathologic processes (denoted by biomarkers) and cognitive symptoms. We appreciate the concern that this biomarker-based research framework has the potential to be misused. Therefore, we emphasize, first, it is premature and inappropriate to use this research framework in general medical practice. Second, this research framework should not be used to restrict alternative approaches to hypothesis testing that do not use biomarkers. There will be situations where biomarkers are not available or requiring them would be counterproductive to the specific research goals (discussed in more detail later in the document). Thus, biomarker-based research should not be considered a template for all research into age-related cognitive impairment and dementia; rather, it should be applied when it is fit for the purpose of the specific research goals of a study. Importantly, this framework should be examined in diverse populations. Although it is possible that β-amyloid plaques and neurofibrillary tau deposits are not causal in AD pathogenesis, it is these abnormal protein deposits that define AD as a unique neurodegenerative disease among different disorders that can lead to dementia. We envision that defining AD as a biological construct will enable a more accurate characterization and understanding of the sequence of events that lead to cognitive impairment that is associated with AD, as well as the multifactorial etiology of dementia. This approach also will enable a more precise approach to interventional trials where specific pathways can be targeted in the disease process and in the appropriate people.
Following the development of the first methods to measure the core Alzheimer’s disease (AD) cerebrospinal fluid (CSF) biomarkers total-tau (T-tau), phosphorylated tau (P-tau) and the 42 amino acid form of amyloid-β (Aβ42), there has been an enormous expansion of this scientific research area. Today, it is generally acknowledged that these biochemical tests reflect several central pathophysiological features of AD and contribute diagnostically relevant information, also for prodromal AD. In this article in the 20th anniversary issue of the Journal of Alzheimer’s Disease, we review the AD biomarkers, from early assay development to their entrance into diagnostic criteria. We also summarize the long journey of standardization and the development of assays on fully automated instruments, where we now have high precision and stable assays that will serve as the basis for common cut-off levels and a more general introduction of these diagnostic tests in clinical routine practice. We also discuss the latest expansion of the AD CSF biomarker toolbox that now also contains synaptic proteins such as neurogranin, which seemingly is specific for AD and predicts rate of future cognitive deterioration. Last, we are at the brink of having blood biomarkers that may be implemented as screening tools in the early clinical management of patients with cognitive problems and suspected AD. Whether this will become true, and whether it will be plasma Aβ42, the Aβ42/40 ratio, or neurofilament light, or a combination of these, remains to be established in future clinical neurochemical studies.
Recent studies have supported a role for amyloid positron emission tomography (PET) imaging in distinguishing Alzheimer’s disease (AD) pathology from other pathological protein accumulations leading to dementia. We investigated the clinical utility of amyloid PET in the differential diagnosis of atypical dementia cases and its impact on caregivers. Using the amyloid tracer ¹⁸F-NAV4694, we prospectively scanned 28 patients (mean age 59.3 y, s.d. 5.8; mean MMSE 21.4, s.d. 6.0) with an atypical dementia syndrome. Following a comprehensive diagnostic workup (i.e., history taking, neurological examination, blood tests, neuropsychological evaluation, MRI, and FDG-PET), no certain diagnosis could be arrived at. Amyloid PET was then conducted and classified as positive or negative. Attending physicians were asked to evaluate whether this result led to a change in diagnosis or altered management. They also reported their degree of confidence in the diagnosis. Caregivers were met after disclosure of amyloid PET results and completed a questionnaire/interview to assess the impact of the scan. Our cohort was evenly divided between positive (14/28) and negative (14/28) ¹⁸F-NAV4694 cases. Amyloid PET resulted in a diagnostic change in 9/28 cases (32.1%: 17.8% changed from AD to non-AD, 14.3% from non-AD to AD). There was a 44% increase in diagnostic confidence. Altered management occurred in 71.4% (20/28) of cases. Knowledge of amyloid status improved caregivers’ outcomes in all domains (anxiety, depression, disease perception, future anticipation, and quality of life). This study suggests a useful additive role for amyloid PET in atypical cases with an unclear diagnosis beyond the extensive workup of a tertiary memory clinic. Amyloid PET increased diagnostic confidence and led to clinically significant alterations in management. The information gained from that test was well received by caregivers and encouraged spending quality time with their loved ones.
Recent research has shown the limited effects of intentions on behavior, so that novel methods to facilitate behavior change are needed that do not rely on conscious intentions. Here, it is argued that nonintentional effects on health behavior, such as the effects of habits, impulses, and nonconscious goals, occur through the activation of cognitive structures by specific situations. Interventions should therefore be situated to change these effects, either by changing the critical cognitive structures (training interventions), or by changing which cognitive structures get activated (cueing interventions). The current article presents this framework for situated interventions, as well as examples of interventions of each type. Then, it introduces goal priming as a cueing intervention tool to activate health goals and thus facilitate healthier behavior, even in tempting situations that typically activate short-term hedonic goals. Following a review of empirical evidence, five principles for the effective application of health goal primes are proposed, namely 1) to target individuals who value the primed goals, 2) by activating their specific motivation 3) through effective cues 4) that attract attention at the right time. Finally, 5) an effective goal-directed behavior needs to be known and accessible to the primed individual. These principles are illustrated with examples of different health behaviors in order to facilitate their application for successful behavior change.
Recent developments in diagnostic technology can support earlier, more accurate diagnosis of non-Alzheimer's disease (AD) dementias. To evaluate potential economic benefits of early rule-out of AD, annual medical resource use and costs for Medicare beneficiaries potentially misdiagnosed with AD before their diagnosis of vascular dementia (VD) or Parkinson's disease (PD) were compared with those of similar patients never diagnosed with AD. Study findings indicate that patients with prior AD diagnosis use substantially more medical services every year until their VD/PD diagnosis, resulting in incremental annual medical costs of approximately 14,000. However, after their corrected diagnosis, medical costs converge with those of patients never diagnosed with AD. The observed correlation between timing of correct diagnosis and subsequent reversal in excess costs is strongly suggestive of the role of misdiagnosis of AD-rather than AD comorbidity-in this patient population. Our findings suggest potential benefits from earlier, accurate diagnosis.
Copyright © 2015 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.
The literature on social cognition reports many instances of a phenomenon titled 'social projection' or 'egocentric bias'. These terms indicate egocentric predictions, i.e., an over-reliance on the self when predicting the cognition, emotion, or behavior of other people. The classic method to diagnose egocentric prediction is to establish high correlations between our own and other people's cognition, emotion, or behavior. We argue that this method is incorrect because there is a different way to come to a correlation between own and predicted states, namely, through the use of theoretical knowledge. Thus, the use of correlational measures is not sufficient to identify the source of social predictions. Based on the distinction between simulation theory and theory theory, we propose the following alternative methods for inferring prediction strategies: independent vs. juxtaposed predictions, the use of 'hot' mental processes, and the use of participants' self-reports.
Biomarkers of brain Aβ amyloid deposition can be measured either by cerebrospinal fluid Aβ42 or Pittsburgh compound B positron emission tomography imaging. Our objective was to evaluate the ability of Aβ load and neurodegenerative atrophy on magnetic resonance imaging to predict shorter time-to-progression from mild cognitive impairment to Alzheimer's dementia and to characterize the effect of these biomarkers on the risk of progression as they become increasingly abnormal. A total of 218 subjects with mild cognitive impairment were identified from the Alzheimer's Disease Neuroimaging Initiative. The primary outcome was time-to-progression to Alzheimer's dementia. Hippocampal volumes were measured and adjusted for intracranial volume. We used a new method of pooling cerebrospinal fluid Aβ42 and Pittsburgh compound B positron emission tomography measures to produce equivalent measures of brain Aβ load from either source and analysed the results using multiple imputation methods. We performed our analyses in two phases. First, we grouped our subjects into those who were 'amyloid positive' (n = 165, with the assumption that Alzheimer's pathology is dominant in this group) and those who were 'amyloid negative' (n = 53). In the second phase, we included all 218 subjects with mild cognitive impairment to evaluate the biomarkers in a sample that we assumed to contain a full spectrum of expected pathologies. In a Kaplan-Meier analysis, amyloid positive subjects with mild cognitive impairment were much more likely to progress to dementia within 2 years than amyloid negative subjects with mild cognitive impairment (50 versus 19%). Among amyloid positive subjects with mild cognitive impairment only, hippocampal atrophy predicted shorter time-to-progression (P < 0.001) while Aβ load did not (P = 0.44). In contrast, when all 218 subjects with mild cognitive impairment were combined (amyloid positive and negative), hippocampal atrophy and Aβ load predicted shorter time-to-progression with comparable power (hazard ratio for an inter-quartile difference of 2.6 for both); however, the risk profile was linear throughout the range of hippocampal atrophy values but reached a ceiling at higher values of brain Aβ load. Our results are consistent with a model of Alzheimer's disease in which Aβ deposition initiates the pathological cascade but is not the direct cause of cognitive impairment as evidenced by the fact that Aβ load severity is decoupled from risk of progression at high levels. In contrast, hippocampal atrophy indicates how far along the neurodegenerative path one is, and hence how close to progressing to dementia. Possible explanations for our finding that many subjects with mild cognitive impairment have intermediate levels of Aβ load include: (i) individual subjects may reach an Aβ load plateau at varying absolute levels; (ii) some subjects may be more biologically susceptible to Aβ than others; and (iii) subjects with mild cognitive impairment with intermediate levels of Aβ may represent individuals with Alzheimer's disease co-existent with other pathologies.
Self-regulation is a complex process that involves consumers’ persistence, strength, motivation, and commitment in order to be able to override short-term impulses. In order to be able to pursue their long-term goals, consumers typically need to forgo immediate pleasurable experiences that are detrimental to reach their overarching goals. Although this sometimes involves resisting to simple and small temptations, it is not always easy, since the lure of momentary temptations is pervasive. In addition, consumers’ beliefs play an important role determining strategies and behaviors that consumers consider acceptable to engage in, affecting how they act and plan actions to attain their goals. This dissertation investigates adequacy of some beliefs typically shared by consumers about the appropriate behaviors to exert self-regulation, analyzing to what extent these indeed contribute to the enhancement of consumers’ ability to exert self-regulation.
To identify factors contributing to laboratory overutilisation in an academic medical department, and to assess the effect of an educational feedback strategy on inappropriate test-ordering behaviour.
The records of 426 patients admitted during a 6-month period were reviewed. The usefulness of 25 investigations (haematology, basic biochemistry and arterial blood gases) was assessed according to implicit criteria. Trainees' acquaintance with investigation costs was assessed via a multiple-choice questionnaire. The medical staff was informed about their test-ordering behaviour, cost awareness and the factors associated with overuse of diagnostic tests. The test-ordering behaviour of the same doctors was reassessed on 214 patients managed during 6 months after the intervention.
Overall, 24 482 laboratory tests were ordered before the intervention (mean 2.96 tests/patient/day). Among those, 67.9% were not considered to have contributed towards management of patients (mean avoidable 2.01 tests/patient/day). Patient age >/=65 years, hospitalisation beyond 7 days and increased case difficulty (death or inability to establish a diagnosis) were factors independently associated with overuse of laboratory tests. Senior trainees ordered more laboratory examinations, but the percentage of avoidable tests requested by junior trainees was higher. A moderate and disparate level of trainees' awareness about the cost of common laboratory examinations was disclosed. The avoidable tests/patient/day were significantly decreased after the intervention (mean 1.58, p = 0.002), but containment of unnecessary ordering of tests gradually waned during the semester after the intervention.
Repeated audit, continuous education and alertness of doctors, on the basis of assessment of factors contributing to laboratory overutilisation, result in restraining the redundant ordering of tests in the hospital setting.
Objectives:
The use of laboratory tests increases worldwide, and to some extent their use is likely to be inappropriate. Although primary care is responsible for a substantial proportion of requests, this sector is less extensively investigated than hospitals.
Methods:
We tested the effect of six combinations of four interventions applied to 313 primary care clinics, using vitamin D as model test (253,762 vitamin D results). We evaluated the changes in test numbers in the six intervention groups compared to the control group, and whether interventions resulted in more homogenous test use within groups or affected the distribution of test results. All interventions included information on vitamin D testing guidelines. Four groups were exposed to a non-interruptive alert in the ordering IT-system and in two groups this was supplemented by an interruptive alert. Half of the groups received monthly feedback reports.
Results:
Application of alerts, irrespective of the combination with feedback reports, resulted in significantly reduced test numbers (maximum -46%). Guidelines either alone or combined with feedback reports did not cause significant difference from the control group. The within-group requesting pattern changed significantly for only two of the groups. The distribution of low and normal vitamin D results within groups showed no signs of more appropriate use of the test in any of the groups.
Conclusions:
Some of the interventions reduced the number of tests, but there were no indications of improved adherence to the guidelines. The interventions may have led to under-utilization of the test and thus should be used with care.
Objective
The symptoms and prognosis of Alzheimer's disease (AD) dementia contribute to the public's negative reactions toward individuals with AD dementia and their families. But what if, using AD biomarker tests, diagnosis was made before the onset of dementia, and a disease-modifying treatment was available? This study tests the hypotheses that a “preclinical” diagnosis of AD and treatment that improves prognosis will mitigate stigmatizing reactions.
Methods
A sample of U.S. adults were randomized to receive one vignette created by a 3 × 2 × 2 vignette-based experiment that described a person with varied clinical symptom severity (Clinical Dementia Rating stages 0 (no dementia), 1 (mild), or 2 (moderate)), AD biomarker test results (positive vs negative), and disease-modifying treatment (available vs not available). Between-group comparisons were conducted of scores on the Modified Family Stigma in Alzheimer's Disease Scale (FS-ADS).
Results
The sample of 1,817 adults had a mean age two years younger than that of U.S. adults but was otherwise similar to the general adult population. The response rate was 63% and the completion rate was 96%. In comparisons of randomized groups, mild and moderate symptoms of dementia evoked stronger reactions on all FS-ADS domains compared to no dementia (all p < 0.001). A positive biomarker test result evoked stronger reactions on all but one FS-ADS domain (negative aesthetic attributions) compared to a negative biomarker result (all p < 0.001). Disease-modifying treatment had no measurable influence on stigma (all p > 0.05).
Conclusions
The stigmas of dementia spill over into preclinical AD, and availability of treatment does not alter that stigma. Translation of the preclinical AD construct from research into practice will require interventions that mitigate AD stigma to preserve the dignity and identity of individuals living with AD.
Alzheimer disease (AD) is biologically defined by the presence of β-amyloid-containing plaques and tau-containing neurofibrillary tangles. AD is a genetic and sporadic neurodegenerative disease that causes an amnestic cognitive impairment in its prototypical presentation and non-amnestic cognitive impairment in its less common variants. AD is a common cause of cognitive impairment acquired in midlife and late-life but its clinical impact is modified by other neurodegenerative and cerebrovascular conditions. This Primer conceives of AD biology as the brain disorder that results from a complex interplay of loss of synaptic homeostasis and dysfunction in the highly interrelated endosomal/lysosomal clearance pathways in which the precursors, aggregated species and post-translationally modified products of Aβ and tau play important roles. Therapeutic endeavours are still struggling to find targets within this framework that substantially change the clinical course in persons with AD.
Objective
To examine the efficacy of the Dementia Stigma Reduction (DESeRvE) programme, aimed at reducing the general public dementia-related stigma utilising ‘education’ and ‘contact’ approaches.
Methods
A total of 1024 Australians aged between 40 and 87 years (M = 60.8, SD = 10.1) participated in a factorial randomised controlled trial. This trial examined four conditions: online education programme (ED), contact through simulated contact with people with dementia and carers (CT), education and contact (ED+CT) and active control. Cognitive, emotional and behavioural aspects of dementia-related stigma were measured with a modified Attribution Questionnaire, and dementia knowledge was measured with the Dementia Knowledge Assessment Scale at the baseline, immediately and 12 weeks after the completion of the intervention.
Results
All four groups improved (reduction in scores) significantly from baseline to week 12 in dementia-related stigma, and the effects were stronger for those with higher baseline stigma scores. Intervention groups also improved significantly from baseline in dementia knowledge. Especially, the ED (β = .85, SE = .07; p < .001) and ED+CT (β = .78, SE = .08; p < .001) groups at immediate follow-up and CT (β = .21, SE = .09; p < .05) and ED+CT (β = .32, SE = .09; p < .001) at 12-week follow-up showed significant effects.
Conclusions
Findings suggest that DESeRvE can be a valuable tool to enhance public’s dementia knowledge and reduce dementia-related stigma, especially for those with higher levels of stigma. Reduction in stigma, however, may take a longer time to achieve, whereas improvement in dementia knowledge is instant.
Accumulating data from clinical research support that the core Alzheimer disease (AD) cerebrospinal fluid (CSF) biomarkers amyloid β (Aβ42), total‐tau (T‐tau), and phosphorylated tau (P‐tau) reflect key elements of AD pathophysiology. Importantly, a large number of clinical studies very consistently show that these biomarkers contribute with diagnostically relevant information, also in the early disease stages. Recent technical developments have made it possible to measure these biomarkers using fully automated assays with high precision and stability. Standardization efforts have given Certified Reference Materials for CSF Aβ42, with the aim to harmonize results between assay formats that would allow for uniform global reference limits and cut‐off values. These encouraging developments have led to that the core AD CSF biomarkers have a central position in the novel diagnostic criteria for the disease and in the recent National Institute on Aging and Alzheimer's Association biological definition of AD. Taken together, this progress will likely serve as the basis for a more general introduction of these diagnostic tests in clinical routine practice. However, the heterogeneity of pathology in late‐onset AD calls for an expansion of the AD CSF biomarker toolbox with additional biomarkers reflecting additional aspects of AD pathophysiology. One promising candidate is the synaptic protein neurogranin that seems specific for AD and predicts future rate of cognitive deterioration. Further, recent studies brings hope for easily accessible and cost effective screening tools in the early diagnostic evaluation of patients with cognitive problems (and suspected AD) in primary care. In this respect, technical developments with ultrasensitive immunoassays and novel mass spectrometry techniques give promise of biomarkers to monitor brain amyloidosis (the Aβ42/40, or APP669‐711/Aβ42 ratios), and neurodegeneration (tau and neurofilament light proteins) in plasma samples, but future studies are warranted to validate these promising results further.
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Introduction:
Understanding the prevalence of beliefs, attitudes, and expectations about Alzheimer's disease dementia in the public could inform strategies to mitigate stigma.
Methods:
Random sample of 317 adults from the U.S. public was analyzed to understand reactions toward a man with mild-stage Alzheimer's disease dementia.
Results:
In adjusted analyses, over half of respondents expected the person to be discriminated against by employers (55.3%; 95% confidence interval [CI] = 47.0-65.2) and be excluded from medical decision-making (55.3%; 95% CI = 46.9-65.4). Almost half expected his health insurance would be limited based on data in the medical record (46.6%; 95% CI = 38.0-57.2), a brain imaging result (45.6%, 95% CI = 37.0-56.3), or genetic test result (44.7%; 95% CI = 36.0-55.4).
Discussion:
Public education and policies are needed to address concerns about employment and insurance discrimination. Studies are needed to discover how advances in diagnosis and treatment may change Alzheimer's disease stigma.
The general public’s views can influence whether people with Alzheimer’s disease (AD) experience stigma. The purpose of this study was to understand what characteristics in the general public are associated with stigmatizing attributions. A random sample of adults from the general population read a vignette about a man with mild Alzheimer’s disease dementia and completed a modified Family Stigma in Alzheimer’s Disease Scale (FS-ADS). Multivariable ordered logistic regressions were used to examine relationships between personal characteristics and FS-ADS ratings. Older respondents expected that persons with AD would receive less support (OR=0.82, p=.001), have social interactions limited by others (OR=1.13, p=.04), and face institutional discrimination (OR=1.13, p=.04). Females reported stronger feelings of pity (OR=1.57, p=.03) and weaker reactions to negative aesthetic features (OR=0.67, p=.05). Those who believed strongly that AD was a mental illness rated symptoms more severely (OR=1.78, p=.007). Identifiable characteristics and beliefs in the general public are related to stigmatizing attributions toward AD. To reduce AD stigma, public health messaging campaigns can tailor information to subpopulations, recognizable by their age, gender, and beliefs.
Importance:
Cerebral amyloidosis is a key abnormality in Alzheimer disease (AD) and can be detected in vivo with positron emission tomography (PET) ligands. Although amyloid PET has clearly demonstrated analytical validity, its clinical utility is debated.
Objective:
To evaluate the incremental diagnostic value of amyloid PET with florbetapir F 18 in addition to the routine clinical diagnostic assessment of patients evaluated for cognitive impairment.
Design, setting, and participants:
The Incremental Diagnostic Value of Amyloid PET With [18F]-Florbetapir (INDIA-FBP) Study is a multicenter study involving 18 AD evaluation units from eastern Lombardy, Northern Italy, 228 consecutive adults with cognitive impairment were evaluated for AD and other causes of cognitive decline, with a prescan diagnostic confidence of AD between 15% and 85%. Participants underwent routine clinical and instrumental diagnostic assessment. A prescan diagnosis was made, diagnostic confidence was estimated, and drug treatment was provided. At the time of this workup, an amyloid PET/computed tomographic scan was performed, and the result was communicated to physicians after workup completion. Physicians were asked to review the diagnosis, diagnostic confidence, and treatment after the scan. The study was conducted from August 5, 2013, to December 31, 2014.
Main outcomes and measures:
Primary outcomes were prescan to postscan changes of diagnosis, diagnostic confidence, and treatment.
Results:
Of the 228 participants, 107 (46%) were male; mean (SD) age was 70.5 (7) years. Diagnostic change occurred in 46 patients (79%) having both a previous diagnosis of AD and an amyloid-negative scan (P < .001) and in 16 (53%) of those with non-AD diagnoses and an amyloid-positive scan (P < .001). Diagnostic confidence in AD diagnosis increased by 15.2% in amyloid-positive (P < .001; effect size Cohen d = 1.04) and decreased by 29.9% in amyloid-negative (P < .001; d = -1.19) scans. Acetylcholinesterase inhibitors and memantine hydrochloride were introduced in 61 (65.6%) patients with positive scan results who had not previously received those drugs, and the use of the drugs was discontinued in 6 (33.3%) patients with negative scan results who were receiving those drugs (P < .001).
Conclusions and relevance:
Amyloid PET in addition to routine assessment in patients with cognitive impairment has a significant effect on diagnosis, diagnostic confidence, and drug treatment. The effect on health outcomes, such as morbidity and mortality, remains to be assessed.
Unconscious priming effects involve passive activation of internal mental representations that influence judgments and behavior without the person's intention or awareness. An important distinction is between unawareness of the priming stimuli or events per se (as in subliminal priming) and unawareness of the influence of those primes: the latter is the more important and practically relevant of the two forms. Meta-analytic reviews as well as a new wave of subliminal persuasion studies reveal stronger behavior priming effects when the primes correspond to an important or currently active goal of the individual. Recent field studies using incidental priming methods have produced changes in dishonest behavior of investment bankers, as well as reduction of snack purchases by obese grocery store shoppers.
During the past decade, a conceptual shift occurred in the field of Alzheimer’s disease (AD)
considering the disease as a continuum. Thanks to evolving biomarker research and substantial discoveries,
it is now possible to identify the disease even at the preclinical stage before the occurrence
of the first clinical symptoms. This preclinical stage of AD has become a major research focus as the
field postulates that early intervention may offer the best chance of therapeutic success. To date, very
little evidence is established on this “silent” stage of the disease. A clarification is needed about the
definitions and lexicon, the limits, the natural history, the markers of progression, and the ethical
consequence of detecting the disease at this asymptomatic stage. This article is aimed at addressing
all the different issues by providing for each of them an updated review of the literature and evidence,
with practical recommendations.
Background:
The classification of Alzheimer's disease is undergoing a significant transformation. Researchers have created the category of "preclinical Alzheimer's," characterized by biomarker pathology rather than observable symptoms. Diagnosis and treatment at this stage could allow preventing Alzheimer's cognitive decline. While many commentators have worried that persons given a preclinical Alzheimer's label will be subject to stigma, little research exists to inform whether the stigma attached to the label of clinical Alzheimer's will extend to a preclinical disorder that has the label of "Alzheimer's" but lacks the symptoms or expected prognosis of the clinical form.
Research questions:
The present study sought to correct this gap by examining the foundations of stigma directed at Alzheimer's. It asked: do people form stigmatizing reactions to the label "Alzheimer's disease" itself or to the condition's observable impairments? How does the condition's prognosis modify these reactions?
Methods:
Data were collected through a web-based experiment with N = 789 adult members of the U.S. general population (median age = 49, interquartile range, 32-60, range = 18-90). Participants were randomized through a 3 × 3 design to read one of 9 vignettes depicting signs and symptoms of mild stage dementia that varied the disease label ("Alzheimer's" vs. "traumatic brain injury" vs. no label) and prognosis (improve vs. static vs. worsen symptoms). Four stigma outcomes were assessed: discrimination, negative cognitive attributions, negative emotions, and social distance.
Results:
The study found that the Alzheimer's disease label was generally not associated with more stigmatizing reactions. In contrast, expecting the symptoms to get worse, regardless of which disease label those symptoms received, resulted in higher levels of perceived structural discrimination, higher pity, and greater social distance.
Conclusion:
These findings suggest that stigma surrounding pre-clinical Alzheimer's categories will depend highly on the expected prognosis attached to the label. They also highlight the need for models of Alzheimer's-directed stigma that incorporate attributions about the condition's mutability.
Critics of labeling theory vigorously dispute Scheff's (1966) provocative etiological hypothesis and downplay the importance of factors such as stigma and stereotyping. We propose a modified labeling perspective which claims that even if labeling does not directly produce mental disorder, it can lead to negative outcomes. Our approach asserts that socialization leads individuals to develop a set of beliefs about how most people treat mental patients. When individuals enter treatment, these beliefs take on new meaning. The more patients believe that they will be devalued and discriminated against, the more they feel threatened by interacting with others. They may keep their treatment a secret, try to educate others about their situation, or withdraw from social contacts that they perceive as potentially rejecting. Such strategies can lead to negative consequences for social support networks, jobs, and self-esteem. We test this modified labeling perspective using samples of patients and untreated community residents, and find that both believe that "most people" will reject mental patients. Additionally, patients endorse strategies of secrecy, withdrawal, and education to cope with the threat they perceive. Finally, patients' social support networks are affected by the extent to which they fear rejection and by the coping responses they adopt to deal with their stigmatized status.
Placebo effects are widely recognized as having a potent impact upon treatment outcomes in both medical and psychological interventions, including hypnosis. In research utilizing randomized clinical trials, there is usually an effort to minimize or control placebo effects. However, in clinical practice there may be significant benefits in enhancing placebo effects. Prior research from the field of social psychology has identified three factors that may enhance placebo effects, namely: priming, client perceptions, and the theory of planned behavior. These factors are reviewed and illustrated via a case example. The consideration of social-psychological factors to enhance positive expectancies and beliefs has implications for clinical practice as well as future research into hypnotic interventions.
Social science research on stigma has grown dramatically over the past two decades, particularly in social psychology, where researchers have elucidated the ways in which people construct cognitive categories and link those categories to stereotyped beliefs. In the midst of this growth, the stigma concept has been criticized as being too vaguely defined and individually focused. In response to these criticisms, we define stigma as the co-occurrence of its components–labeling, stereotyping, separation, status loss, and discrimination–and further indicate that for stigmatization to occur, power must be exercised. The stigma concept we construct has implications for understanding several core issues in stigma research, ranging from the definition of the concept to the reasons stigma sometimes represents a very persistent predicament in the lives of persons affected by it. Finally, because there are so many stigmatized circumstances and because stigmatizing processes can affect multiple domains of people's li...
Background:
[(11)C]Pittsburgh compound B ([(11)C]PIB) and [(18)F]-2-fluoro-2-deoxy-D-glucose ([(18)F]FDG) PET measure fibrillar amyloid-β load and glucose metabolism, respectively. We evaluated the impact of these tracers on the diagnostic process in a memory clinic population.
Methods:
One hundred fifty-four patients underwent paired dynamic [(11)C]PIB and static [(18)F]FDG PET scans shortly after completing a standard dementia screening. Two-year clinical follow-up data were available for 39 patients. Parametric PET images were assessed visually and results were reported to the neurologists responsible for the initial diagnosis. Outcome measures were (change in) clinical diagnosis and confidence in that diagnosis before and after disclosing PET results.
Results:
[(11)C]PIB scans were positive in 40 of 66 (61%) patients with a clinical diagnosis of Alzheimer's disease (AD), 5 of 18 (28%) patients with frontotemporal dementia (FTD), 4 of 5 (80%) patients with Lewy body dementia, and 3 of 10 (30%) patients with other dementias. [(18)F]FDG uptake patterns matched the clinical diagnosis in 38 of 66 (58%) of AD patients, and in 6 of 18 (33%) FTD patients. PET results led to a change in diagnosis in 35 (23%) patients. This only occurred when prior diagnostic certainty was <90%. Diagnostic confidence increased from 71 ± 17% before to 87 ± 16% after PET (p < .001). Two-year clinical follow-up (n = 39) showed that [(11)C]PIB and [(18)F]FDG predicted progression to AD for patients with mild cognitive impairment, and that the diagnosis of dementia established after PET remained unchanged in 96% of patients.
Conclusions:
In a memory clinic setting, combined [(11)C]PIB and [(18)F]FDG PET are of additional value on top of the standard diagnostic work-up, especially when prior diagnostic confidence is low.
Early diagnosis of mild cognitive impairment and dementia maximizes the potential benefits of early access to specialist therapies and support. Barriers to early diagnosis include late presentation. Research has traditionally focused on people following a formal diagnosis. Very little is known about the perceptions of older people, who, because age is an important risk factor, can be said to be at risk of developing dementia. Changes in cognition, competence, and personality are often dismissed as ‘normal aging.’ The views of older people were explored using qualitative interviews. The findings reinforce existing research evidence that suggests that some older people fear developing the condition. Participants felt uncomfortable with friends or relatives with dementia and were reluctant to contact health professionals about memory problems. There was uncertainty about the causes of dementia, anxieties about loss of self-identity and dignity, and long-term care. Greater understanding of this group's views could help inform information strategies and health and social care policy.
We describe patient perceptions of computed tomography (CT) and their understanding of radiation exposure and risk.
This was a cross-sectional study of acute abdominal pain patients aged 18 years or older. Confidence in medical evaluations with increasing levels of laboratory testing and imaging was rated on a 100-point visual analog scale. Knowledge of radiation exposure was ascertained when participants compared the radiation dose of one abdomen-pelvis CT with 2-view chest radiography. To assess cancer risk knowledge, participants rated their agreement with these factual statements: "Approximately 2 to 3 abdominal CTs give the same radiation exposure as experienced by Hiroshima survivors" and "2 to 3 abdominal CTs over a person's lifetime can increase cancer risk." Previous CT was also assessed.
There were 1,168 participants, 67% women and mean age 40.7 years (SD 15.9 years). Median confidence in a medical evaluation without ancillary testing was 20 (95% confidence interval [CI] 16 to 25) compared with 90 (95% CI 88 to 91) when laboratory testing and CT were included. More than 70% of participants underestimated the radiation dose of CT relative to chest radiography, and cancer risk comprehension was poor. Median agreement with the Hiroshima statement was 13 (95% CI 10 to 16) and 45 (95% CI 40 to 45) with the increased lifetime cancer risk statement. Seven hundred ninety-five patients reported receiving a previous CT. Of 365 patients who reported no previous CT, 142 (39%) had one documented in our electronic medical record.
Patients are more confident when CT imaging is part of their medical evaluation but have a poor understanding of the concomitant radiation exposure and risk and underestimate their previous imaging experience.
Although it is widely assumed that persons with Alzheimer disease (AD) and their family caregivers are victims of stigmatization, family stigma in the area of AD has received surprisingly limited attention. Reliable, valid, and user-friendly scales are a first step in expanding this body of knowledge. The aim of this study was to develop and examine the validity of the Family Stigma in Alzheimer's disease Scale. Interviews were conducted with 185 children of persons with AD. A pool of 100 items was identified from the literature and an earlier qualitative study including 3 dimensions (caregivers' stigma, lay persons' stigma, and structural stigma). Exploratory factor analyses, theoretical relevance, and internal reliability analyses allowed us to reduce the pull to 62 items. Regarding construct validity, statistically significant associations were found between family stigma and caregivers' burden and behavioral problems, in most of the scales. Although further testing is warranted, these findings indicate that the Family Stigma in Alzheimer's disease Scale is a reliable and valid instrument for assessing stigma in the context of AD.
Clinical criteria for the diagnosis of Alzheimer's disease include insidious onset and progressive impairment of memory and other cognitive functions. There are no motor, sensory, or coordination deficits early in the disease. The diagnosis cannot be determined by laboratory tests. These tests are important primarily in identifying other possible causes of dementia that must be excluded before the diagnosis of Alzheimer's disease may be made with confidence. Neuropsychological tests provide confirmatory evidence of the diagnosis of dementia and help to assess the course and response to therapy. The criteria proposed are intended to serve as a guide for the diagnosis of probable, possible, and definite Alzheimer's disease; these criteria will be revised as more definitive information become available.
Accurate clinical staging of dementia in older subjects has not previously been achieved despite the use of such methods as psychometric testing, behavioural rating, and various combinations of simpler psychometric and behavioural evaluations. The Clinical Dementia Rating (CRD), a global rating device, was developed for a prospective study of mild senile dementia--Alzheimer type (SDAT). Reliability, validity, and correlational data are discussed. The CRD was found to distinguish unambiguously among older subjects with a wide range of cognitive function, from healthy to severely impaired.
Dementia is frequent in the elderly and, given the expansion of the aged in our society, is a health problem of increasing importance. The most common cause of dementia in the elderly is Alzheimer's disease. Over the past 15 years, great strides have been made in expanding our knowledge of this disease. Some putative risk factors have been defined, the molecular aspects of the pathologic process are being explored, and numerous experimental therapies are being investigated, but to date, clinical studies have demonstrated only mild symptomatic improvement. However, recent advances offer some hope of discovering interventions which might halt or slow the progression of this devastating disease. The clinical evaluation of a patient with dementia should focus primarily on the discovery of treatable causes or contributing factors which may be ameliorated. The primary care physician plays an important role in diagnosis, in management of psychiatric complications, and in providing guidance and counsel on psychosocial and legal issues.
Participants (i.e., perceivers) unscrambled either memory-related phrases (experimental group) or memory-neutral phrases (control group). Then perceivers read a vignette about a forgetful young, middle-aged, or old target person, after which they rated (a) the target's forgetfulness and (b) how difficult each of 12 tasks (4 low, 4 medium, and 4 high in memory load) would be for the target. High-memory-load tasks were rated as more difficult by perceivers in the experimental group than by perceivers in the control group. Thus, implicit priming of a forgetfulness schema resulted in harsher judgments about how difficult high-memory-load tasks would be for forgetful targets. However, this priming effect was no stronger for old than for young or middle-aged targets.
Alzheimer's disease (AD) starts at a molecular level possibly decades earlier than could be detected by neuropsychological tests (NPTs). Neuropathological and neuroimaging data suggest that amyloid accumulation precedes the clinical onset of AD. Disease-modifying agents would have to be used early to alter the course of AD. Therefore, preclinical diagnosis is necessary. Structural and functional neuroimaging are superior for detection of the earliest stages of AD. Magnetic resonance imaging (MRI) and positron emission tomography (PET) techniques, including amyloid visualization, will have therapeutic importance for prevention as well as intervention as further refinements of current imaging techniques and biochemical markers occur. Neuropsychological tests measure the effect of pathology for an individual based upon norms obtained from an artificial population-often white and relatively highly educated. Unless serial NPTs are performed, the individual is compared to a population to which they may not conform. Neuroimaging can provide objective measures of preclinical disease state and, when measured serially, rate of change. Such information can be used in prevention trials.
Stigma can greatly exacerbate the experience of mental illness. Diagnostic classification frequently used by clinical social
workers may intensify this stigma by enhancing the public's sense of “groupness” and “differentness” when perceiving people
with mental illness. The homogeneity assumed by stereotypes may lead mental health professionals and the public to view individuals
in terms of their diagnostic labels. The stability of stereotypes may exacerbate notions that people with mental illness do
not recover. Several strategies may diminish the unintended effects of diagnosis. Dimensional approaches to diagnosis may
not augment stigma in the same manner as classification. Moreover, regular interaction with people with mental illness and
focusing on recovery may diminish the stigmatizing effects of diagnosis.
Few studies have compared the accuracy of [(18)F]fluorodeoxyglucose (FDG) PET to the accuracy of clinical and pathologic diagnosis in dementia patients.
Forty-four individuals with dementia, cognitive impairment, or normal cognitive function underwent clinical initial evaluation (IE) and PET scanning and were followed up for approximately 4 years until a final evaluation (FE) and 5 years until death and autopsy. Clinical, pathologic, and imaging diagnoses were categorized as Alzheimer disease (AD) or not AD.
Sensitivity of the IE for the pathologic diagnosis of AD was 0.76, and specificity was 0.58; PET had values of 0.84 and 0.74, and FE had values of 0.88 and 0.63. Positive predictive values for IE, PET, and FE were 0.70, 0.81, and 0.76. Negative predictive values were 0.65, 0.78, and 0.80. The diagnosis of AD was associated with a 70% probability of detecting AD pathology; with a positive PET scan this increased to 84%, and with a negative PET scan this decreased to 31%. A diagnosis of not AD at IE was associated with a 35% probability of AD pathology, increasing to 70% with a positive PET scan.
As a diagnostic tool, PET is superior to a baseline clinical evaluation and similar to an evaluation performed 4 years later. Although the addition of [(18)F]fluorodeoxyglucose PET to a clinical diagnosis provides useful information that can affect the likelihood of detecting Alzheimer disease pathology, the value of this technique in the current clinical environment with limited therapeutic options is likely to be modest.
Although it is widely assumed that persons with Alzheimer's disease (AD) are victims of stigmatization, little is known about courtesy stigma or stigma by association and AD. Phone interviews were conducted with 61 caregivers of persons with AD in order to assess four dimensions of stigma by association--interpersonal interaction, concealment, structural discrimination and access to social roles. The participants perceived a minimal amount of stigma directed towards themselves but a considerable percentage reported perceptions of stigma regarding the person with AD. Additionally, participants reported high levels of structural discrimination towards the person with AD and towards themselves. It was found that stigma by association related to AD is especially high in dimensions affecting the delivery of services and the lives of the person with AD.
It has been anecdotally suggested that health care professionals have stigmatic beliefs about persons with Alzheimer's disease (AD). However, the nature and prevalence of those beliefs have yet to be elucidated. The aim of the present study is to examine stigma towards a person with AD among primary care physicians.
A nationally representative sample of 501 family physicians (54.1% female, mean age = 49, mean years in the profession = 21) were interviewed using a computer-assisted telephone interview and a structured questionnaire based on an expanded version of attribution theory.
The findings showed that physicians' discriminatory behavior was especially high in the dimension of avoidance and coercion, but low in the dimension of segregation. Two central emotions (anger-fear and pity) were found to affect participants' tendency to discriminate, as were attributions of dangerousness.
Addressing these factors may require targeted education of health professionals as well as the enforcement of anti-discrimination policies.
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