Alzheimer's Disease & Dementia
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Alzheimer’s Disease – The Importance of Early Detection

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Published Online: Jun 4th 2011 European Neurological Review, 2008;3(2):18-21 DOI:
Authors: Stephen Todd, Peter Passmore
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Alzheimer’s disease (AD), with its insidious impairment of those most human of faculties – memory, reasoning, judgement and abstraction – exacts a great burden on each individual patient.1 A significant toll is also placed on care-givers – typically the spouse or daughter – as their relative becomes less communicative and more behaviourally disturbed.2,3 This toll is financial, with both direct and indirect costs4,5 as well as psychological6,7 physical,8 and emotional pressures.9

Alzheimer’s disease (AD), with its insidious impairment of those most human of faculties – memory, reasoning, judgement and abstraction – exacts a great burden on each individual patient.1 A significant toll is also placed on care-givers – typically the spouse or daughter – as their relative becomes less communicative and more behaviourally disturbed.2,3 This toll is financial, with both direct and indirect costs4,5 as well as psychological6,7 physical,8 and emotional pressures.9
Dementia, of which AD is the most frequent cause, is also responsible for significant usage of and expenditure on health and social care throughout Europe. It is estimated to be responsible for 11.2% of years lived with disability in people over 60 years of age, compared with 9.5% for stroke, 5.0% for cardiovascular disease and 2.4% for cancer.10 In Europe, the prevalence of AD increases exponentially with age.11,12 The incidence also increases with age,13,14 although perhaps with a plateau in extreme old age.15 There were an estimated 4.916 to 7.6 million17 western Europeans with dementia in 2001, and this could increase to 9.9 million by 204016 or even 16.2 million by 2050,17 driven by the ageing population.
In the UK alone, the total cost of care for late-onset dementia in 2005–2006 is estimated at £17.03 billion (€21.88 billion; US$29.89 billion), to which supported accommodation and informal care costs are the leading contributors.5 One estimate suggests that this cost will treble in the next 25 years.18 Across Europe, the total costs of care per person with dementia, adjusted to 2004 € level,19 range from approximately €6,000 in France20 to €19,500 in Finland.21 One report observes that the annual total costs of care per person with dementia are significantly greater for those in institutional care (€27,620 in 2002) compared with those cared for at home (€5,346 in 2002).22 In Scandinavia, the total annual costs in 2003 US$ were estimated to range from approximately US$7,500 in mild dementia to US$46,350 in severe dementia.21 Informal care costs account for roughly one-third of total costs, and increase markedly with advancing disease severity.21 Therefore, interventions that retard the progressive cognitive impairment of AD and maintain subjects at a higher functional level would be of great economic benefit to health and social care systems, as well as to patients and their care-givers. Thus, there is a growing consensus both nationally23,24 and across Europe25 that early diagnosis and treatment of dementia, including AD, would be beneficial for patients, care-givers and health and social care systems and should become the standard of care. This article reviews the evidence in favour of and against such a consensus.

Scale of the Problem

Despite the burgeoning numbers of people with AD and the spiralling emotional and financial costs associated with them, the disease remains substantially underdiagnosed26–29 and undertreated25,30 in primary care. Perhaps half of all cases of dementia are not diagnosed.5,31,32 Across Europe, there are variations in the time to diagnosis from first symptoms being noticed, ranging from 32 months in the UK to 18 months in Spain and 10 months in Germany.33 Variability is also apparent in the proportion of physicians recommending that treatment be commenced at the time of diagnosis: 51% in the UK, 78% in Germany and 86% in Spain.33 This correlates with the proportion of physicians who believe that treatment delays AD progression: 68% in the UK, 86% in Spain and 87% in Germany.33 Dementia is also under-recognised by other healthcare professionals in primary and community care.34,35 A lack of knowledge about dementia and the available therapeutic options, the assumption that memory loss is a feature of normal ageing, fear of social stigma30 and delay in consultation with a physician36 are among the patient- and care-giver-related barriers to early detection of AD.25 Therefore, significant efforts and investment are required to improve recognition and appropriate assessment of people with dementia in health and social care systems throughout Europe.23,30

Benefits of Early Detection
To the Patient and Care-giver

While many patients and care-givers present early to access pharmacological treatment, this is only one of many benefits, which include provision of diagnosis, information and education, counselling and community support, cognitive training and lifestyle advice.
Pharmacological treatment with the acetylcholinesterase inhibitors (AChEIs) donepezil,37 galantamine38 or rivastigmine39 provides symptomatic benefit in the mild to moderate stages of AD, with improvements in measures of cognition, function and behaviour.40,41 Commencement of therapy at an earlier stage aims to maintain cognitive and functional abilities at the highest possible level when impairments are mildest.42,43 Early commencement of AChEI therapy is supported by the observations that those subjects initially treated with placebo in the landmark randomised trials had worse cognitive and functional outcomes than those who initially received active treatment.44–46 Continuous AChEI therapy is supported by the observation that treatment gaps or ‘drug holidays’ allow symptoms to recur, with diminution or even loss of achieved cognitive gains.46 Delay in institutionalisation,47 improvement in AD patient behavioural symptoms and care-giver distress and burden48,49 and reductions in time spent providing care49–51 are further reported benefits of AChEI therapy.
The N-methyl-D-aspartate receptor antagonist memantine is licensed for use in moderate to severe AD. As healthcare systems and practitioners strive for early diagnosis, it is anticipated that more patients will be diagnosed at the mild stages of disease. However, at present the diagnosis may be made only at a moderate stage of AD. Therefore, the use of memantine, either as monotherapy or in combination with donepezil, may be appropriate at the time of detection.
Despite the continuing debate over the efficacy52 and costeffectiveness53 of AChEIs, there are a number of additional benefits of early diagnosis. First, the patient and his or her care-giver can be involved in discussions regarding diagnosis and prognosis,23 be advised on the help and support available from health and social care, as well as voluntary agencies,23,25,54 and make financial and legal plans for such a time that the patient no longer retains the capacity to make such plans.55 Early detection and treatment of dementia is associated with improved quality of life in patients.56 Second, care-giver counselling sessions, regular support group meetings and the availability of ad hoc telephone counselling, as described in the New York University – Alzheimer’s Disease Research Centre Caregiver Intervention, improve the physical57 and mental58 health of care-givers and delay institutionalisation of AD patients.59 A meta-analysis of studies of care-giver interventions also suggests that psychosocial interventions for care-givers reduce care-giver psychological morbidity and delay the institutionalisation of AD patients.60 Such interventions to support care-givers are strongly supported by the observations that the presence of a co-resident care-giver is strongly protective against patient institutionalisation61,62 and that the absence of a care-giver or significant care-giver stress increases the probability of institutionalisation.61 Third, early provision of community support services reduces institutionalisation.63 However, many care-givers do not use community support services despite poor quality of life and high levels of burden.64 Reluctance to use services may be due to denial of need, fear of invasion of privacy or refusal by the patient.64 Lack of knowledge about available services is also common.64
Fourth, there is an emerging evidence base in the literature to suggest that cognitive training or rehabilitation improves outcomes in patients with dementia. One large study involving over 2,800 subjects that investigated three separate interventions on memory, reasoning or speed of processing reported that the targeted ability was improved by each intervention.65 This effect persisted for up to five years following the intervention.66 However, a Cochrane review of nine trials previously concluded that there was no evidence that cognitive training had either positive or negative effects.67 The combination of cognitive training or rehabilitation with AChEI therapy has also been reported to have significant benefits in cognition, mood and behaviour.68–70 Other small studies suggest beneficial effects of cognitive stimulation71 and computer-based cognitive intervention72 on cognition, behaviour and function. A five-week programme delivered by occupational therapists in the community improved daily functioning of patients with dementia and care-giver burden at 12-week follow-up.73 The programme consisted of cognitive interventions to train patients in the use of aids to compensate for cognitive decline together with behavioural interventions for care-givers in coping and supervision.73 Improvements in the quality of life and health status of both patients and care-givers were noted.74 The intervention was cost-effective, with an estimated saving per patient and care-giver of € 1,748 (£1,279; US$2,641) over three months.75 Fifth, observational and prospective data suggest that physical activity is associated with a reduced prevalence of the subsequent development of dementia, including AD.76–78 AD has adverse effects on physical health, with a higher risk of falls and fractures,79–81 reduced mobility82,83 and poor nutrition.84 A meta-analysis of 30 studies including 2,020 subjects found that exercise training had significant benefits in terms of fitness, physical function, cognition and behavioural symptoms in people with dementia.85 One randomised controlled trial combined an exercise programme for patients with AD with behavioural management training for their care-giver, and reported improved physical health and mood in patients with AD.86
Finally, despite recent disappointing results of clinical trials testing several putative disease-modifying treatments for AD,87–89 there have been some encouraging reports too.90,91 Several additional agents are in evaluation in phase II and III clinical trials. To maximise the therapeutic gain from any successful agent in the future, the development of specialist memory services with the capacity to detect AD at an early stage within health and social care systems will be crucial.23,25 Compelling data in the literature support the role of vascular risk factors in AD, such as hypertension,92 smoking93,94 and diabetes.95 However, as yet there is no convincing evidence of any benefit of modification of such factors on cognitive outcomes.96

To the Health and Social Care System

The benefits to patients with AD and their care-givers of the interventions described in the previous section will additionally benefit health and social care systems. Reductions in or delays to institutionalisation and improved physical and mental health and quality of life of both patients and their care-givers will result in better public health and, potentially, lower costs.24,56 In the UK, health economic calculations estimate that only a modest increase in average quality of life (around 0.01–0.02 quality-adjusted life-years [QALYs]) together with a reduction of 10% in institutionalisation would be required to make the introduction of early diagnosis and intervention services in dementia cost-effective.23 A pilot study to establish such a service, assessing newly diagnosed patients at an early stage of their disease, was feasible and acceptable to patients.56
Recently published guidance from the National Institute for Health and Clinical Excellence (NICE) in the UK recommends implementation of occupational therapy schemes and physical activity for all older people and their carers, together with training of health and social care staff, domiciliary care workers, residential care staff and voluntary workers to improve mental wellbeing.97 However, it was not possible to estimate the cost-effectiveness of this guidance nationally.97 The guidance will have an impact on people with AD and their care-givers.

Further Issues in Early Detection
To Individuals and Their Care-givers

It has been suggested that the early detection of dementia has associated risks that must be addressed in the establishment of memory services.98 False-positive diagnosis or increased referrals to specialist memory services may increase time to assessment and cause distress.99
AChEI therapy has well-established dose-related gastrointestinal and other side effects40 to which individuals may be exposed. As previously noted, the diagnosis or ‘label’ of dementia or AD still carries a social stigma. Additionally, patients who are told their diagnosis at an early stage of the disease may experience adverse outcomes, such as reduced self-esteem and impaired quality of life.100 The perceived benefit of financial or legal planning may lead to inappropriately early loss of control over the patient’s own affairs.101 Care-givers may be exposed to the potential stresses involved in caring for the patient at an earlier stage of the disease. Many care-givers do not interact with support services64 or do not view the offered services as effective. Information about the diagnosis, prognosis and services available is inconsistent.102 Patients with AD continue to drive after receiving the diagnosis, although regulations mandate that driving stop.103 Regulations and guidelines vary across Europe.104 Assessments by physicians105 and neuropsychological testing106 are not sufficiently accurate to determine driving ability. Individuals with AD may stop or be required to stop driving sooner than is necessary from safety considerations. This limits contact with family, friends and services and is predictive of institutionalisation.107,108

To Health and Social Care Services

Increased workload for health and social care services would be expected from a strategy of early detection of dementia, including AD.4,98 Greater numbers of older people will require assessment, and support will have to be provided to more people for a longer time.98 Also, resources will be required to manage those people for whom the process of early detection is deleterious.98 Within primary care, barriers exist to the greater role in providing information and support and monitoring of drug therapy that will result from early detection of AD.109 The same physicians who under-recognise dementia find disclosure of the diagnosis the most arduous.28 Training and education of primary care practitioners will be required to improve competence in these and other areas and to reverse nihilistic attitudes.102,110


Early detection of AD has a number of benefits to patients, their care-givers and health and social care systems. Patients and care-givers receive timely information on the diagnosis and prognosis of the disease and the available support services from both health and social care and voluntary agencies. Counselling services, lifestyle advice, cognitive training and pharmacological therapy may all maintain cognition and function, thereby delaying institutionalisation. Health and social care systems will benefit financially from early detection of AD and delay in institutionalisation. Some risks in the adoption of an early detection policy have been described. These should be addressed in the design and functioning of services to improve the early detection of AD and dementia to the growing number of older people, and their care-givers, throughout Europe. ■
This article was funded by an educational grant from Eisai Europe Ltd.


  1. Corey-Bloom J, Fleischer AS, The natural history of Alzheimer’s disease. In: Burns A, O’Brien J, Ames D (eds), Dementia. 3rd ed., London: Hodder Arnold, 2005:376–86.
  2. Lyketsos CG, Lopez O, Jones B, et al., Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: Results from the Cardiovascular Health Study, JAMA, 2002;288:1475–83.
  3. Schneider J, Murray J, Banerjee S, Mann A, EUROCARE: A crossnational study of co-resident spouse carers for people with Alzheimer’s disease: I—factors associated with carer burden, Int J Geriatr Psychiatry, 1999;14:651–61.
  4. National Audit Office, Improving services and support for people with dementia, London: The Stationary Office, 2007.
  5. Dementia UK, A report into the prevalence and cost of dementia prepared by the personal social services research unit (PSSRU) at the london school of economics and the institute of psychiatry at king’s college london, for the Alzheimer’s Society, London: Alzheimer’s Society, 2007:1–189.
  6. Baumgarten M, Battista RN, Infante-Rivard C, et al., The psychological and physical health of family members caring for an elderly person with dementia, J Clin Epidemiol, 1992;45:61–70.
  7. Rosenthal CJ, Sulman J, Marshall VW, Depressive symptoms in family caregivers of long-stay patients, Gerontologist, 1993;33: 249–57.
  8. Schulz R, Visintainer P, Williamson GM, Psychiatric and physical morbidity effects of caregiving, J Gerontol, 1990;45:P181–91.
  9. Brodaty H, Hadzi-Pavlovic D, Psychosocial effects on carers of living with persons with dementia, Aust N Z J Psychiatry, 1990;24:351–61.
  10. World Health Organization, World health report 2003 – shaping the future, Geneva: WHO, 2003.
  11. Lobo A, Launer LJ, Fratiglioni L, et al., Prevalence of dementia and major subtypes in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group, Neurology, 2000;54:S4–9.
  12. Rocca WA, Hofman A, Brayne C, et al., Frequency and distribution of Alzheimer’s disease in Europe: A collaborative study of 1980–1990 prevalence findings. The EURODEMPrevalence Research Group, Ann Neurol, 1991;30:381–90.
  13. Fratiglioni L, Launer LJ, Andersen K, et al., Incidence of dementia and major subtypes in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group, Neurology, 2000;54:S10–15.
  14. Matthews F, Brayne C, Medical Research Council Cognitive Function and Ageing Study Investigators, The incidence of dementia in England and Wales: Findings from the five identical sites of the MRC CFA study, PLoS Med, 2005;2:e193.
  15. Gao S, Hendrie HC, Hall KS, Hui S, The relationships between age, sex, and the incidence of dementia and Alzheimer disease: A meta-analysis, Arch Gen Psychiatry, 1998;55:809–15.
  16. Ferri CP, Prince M, Brayne C, et al.; Alzheimer’s Disease International, Global prevalence of dementia: A Delphi Consensus Study, Lancet, 2005;366:2112–17.
  17. Wancata J, Musalek M, Alexandrowicz R, Krautgartner M, Number of dementia sufferers in Europe between the years 2000 and 2050, Eur Psychiatry, 2003;18:306–13.
  18. Comas-Herrera A, Wittenberg R, Pickard L, Knapp M. Cognitive impairment in older people: Future demand for long-term care services and the associated costs, Int J Geriatr Psychiatry, 2007;22:1037–45.
  19. Jonsson L, Berr C, Cost of dementia in Europe, Eur J Neurol, 2005;12(Suppl. 1):50–53.
  20. Souetre EJ, Qing W, Vigoureux I, et al., Economic analysis of Alzheimer’s disease in outpatients: Impact of symptom severity, Int Psychogeriatr, 1995;7:115–22.
  21. Jonsson L, Eriksdotter Jonhagen M, Kilander L, et al., Determinants of costs of care for patients with Alzheimer’s disease, Int J Geriatr Psychiatry, 2006;21:449-459.
  22. Scuvee-Moreau J, Kurz X, Dresse A; National Dementia Economic Study Group, The economic impact of dementia in Belgium: Results of the National Dementia Economic Study (NADES), Acta Neurol Belg, 2002;102:104–13.
  23. National Collaborating Centre for Mental Health, Dementia: A NICE-SCIE guideline on supporting people with dementia and their carers in health and social care, London: Royal Psychological Society, 2007.
  24. Department of Health, Transforming the quality of dementia care: Consultation on a national dementia strategy, London: Department of Health, 2008.
  25. Waldemar G, Phung KT, Burns A, et al., Access to diagnostic evaluation and treatment for dementia in Europe, Int J Geriatr Psychiatry, 2007;22:47–54.
  26. O’Connor DW, Pollitt PA, Hyde JB, et al., Do general practitioners miss dementia in elderly patients?, BMJ, 1988;297:1107–10.
  27. Olafsdottir M, Skoog I, Marcusson J, Detection of dementia in primary care: The linkoping study, Dement Geriatr Cogn Disord, 2000;11:223–9.
  28. Maeck L, Haak S, Knoblauch A, Stoppe G, Early diagnosis of dementia in primary care: A representative eight-year follow-up study in lower Saxony, Germany, Int J Geriatr Psychiatry, 2007;22:23–31.
  29. Stoppe G, Sandholzer H, Staedt J, et al., Diagnosis of dementia in primary care: Results of a representative survey in lower Saxony, Germany, Eur Arch Psychiatry Clin Neurosci, 1994;244:278–83.
  30. Vernooij-Dassen MJ, Moniz-Cook ED, Woods RT, et al., Factors affecting timely recognition and diagnosis of dementia across Europe: From awareness to stigma, Int J Geriatr Psychiatry, 2005;20:377–86.
  31. Iliffe S, Booroff A, Gallivan S, et al., Screening for cognitive impairment in the elderly using the mini-mental state examination, Br J Gen Pract, 1990;40:277–9.
  32. Boise L, Camicioli R, Morgan DL, et al., Diagnosing dementia: Perspectives of primary care physicians, Gerontologist, 1999;39: 457–64.
  33. Facing Dementia. Available at: dementiasurvey.html (accessed 13 October 2008).
  34. Bryans M, Keady J, Turner S, et al., An exploratory survey into primary care nurses and dementia care, Br J Nurs, 2003;12: 1029–37.
  35. Manthorpe J, Iliffe S, Eden A, Early recognition of dementia by nurses, J Adv Nurs, 2003;44:183–91.
  36. Wilkinson D, Stave C, Keohane D, Vincenzino O, The role of general practitioners in the diagnosis and treatment of Alzheimer’s disease: A multinational survey, J Int Med Res, 2004;32:149–59.
  37. Birks J, Harvey RJ, Donepezil for dementia due to Alzheimer’s disease, Cochrane Database Syst Rev, 2006;(1):CD001190.
  38. Loy C, Schneider L, Galantamine for Alzheimer’s disease and mild cognitive impairment, Cochrane Database Syst Rev, 2006;(1): CD001747.
  39. Birks J, Grimley Evans J, Iakovidou V, Tsolaki M, Rivastigmine for Alzheimer’s disease, Cochrane Database Syst Rev, 2000;(4):CD001191.
  40. Birks J, Cholinesterase inhibitors for Alzheimer’s disease, Cochrane Database Syst Rev, 2006;(1):CD005593.
  41. Ritchie CW, Ames D, Clayton T, Lai R, Metaanalysis of randomized trials of the efficacy and safety of donepezil, galantamine, and rivastigmine for the treatment of Alzheimer disease, Am J Geriatr Psychiatry, 2004;12:358–69.
  42. Seltzer B, Zolnouni P, Nunez M, et al.; Donepezil “402” Study Group. Efficacy of donepezil in early-stage Alzheimer disease: A randomized placebo-controlled trial, Arch Neurol, 2004;61:1852–6.
  43. Seltzer B, Cholinesterase inhibitors in the clinical management of Alzheimer’s disease: Importance of early and persistent treatment, J Int Med Res, 2006;34:339–47.
  44. Raskind MA, Peskind ER, Wessel T, Yuan W, Galantamine in AD: A 6-month randomized, placebo-controlled trial with a 6-month extension. the galantamine USA-1 study group, Neurology, 2000;54:2261–8.
  45. Farlow M, Anand R, Messina J Jr, et al., A 52-week study of the efficacy of rivastigmine in patients with mild to moderately severe Alzheimer’s disease, Eur Neurol, 2000;44:236–41.
  46. Doody RS, Geldmacher DS, Gordon B, et al.; Donepezil Study Group. Open-label, multicenter, phase 3 extension study of the safety and efficacy of donepezil in patients with Alzheimer disease, Arch Neurol, 2001;58:427–33.
  47. Geldmacher DS, Provenzano G, McRae T, et al., Donepezil is associated with delayed nursing home placement in patients with Alzheimer’s disease, J Am Geriatr Soc, 2003;51:937–44.
  48. Cummings JL, Schneider L, Tariot PN, et al., Reduction of behavioral disturbances and caregiver distress by galantamine in patients with Alzheimer’s disease, Am J Psychiatry, 2004;161:532–8.
  49. Feldman H, Gauthier S, Hecker J, et al.; Donepezil MSAD Study Investigators Group. Efficacy of donepezil on maintenance of activities of daily living in patients with moderate to severe Alzheimer’s disease and the effect on caregiver burden, J Am Geriatr Soc, 2003;51:737–44.
  50. Sano M, Wilcock GK, van Baelen B, Kavanagh S, The effects of galantamine treatment on caregiver time in Alzheimer’s disease, Int J Geriatr Psychiatry, 2003;18:942–50.
  51. Wimo A, Winblad B, Shah SN, et al., Impact of donepezil treatment for Alzheimer’s disease on caregiver time, Curr Med Res Opin, 2004;20:1221–5.
  52. Kaduszkiewicz H, Zimmermann T, Beck-Bornholdt HP, van den Bussche H, Cholinesterase inhibitors for patients with Alzheimer’s disease: Systematic review of randomised clinical trials, BMJ, 2005;331:321–7.
  53. Loveman E, Green C, Kirby J, et al., The clinical and costeffectiveness of donepezil, rivastigmine, galantamine and memantine for Alzheimer’s disease, Health Technol Assess, 2006;10:iii–iv, ix–xi, 1–160.
  54. Woods RT, Moniz-Cook E, Iliffe S, et al.; INTERDEM (Early Detection and Intervention in Dementia) Group, Dementia: Issues in early recognition and intervention in primary care, J R Soc Med, 2003;96:320–24.
  55. Lingler JH, Hirschman KB, Garand L, et al., Frequency and correlates of advance planning among cognitively impaired older adults, Am J Geriatr Psychiatry, 2008;16:643–9.
  56. Banerjee S, Willis R, Matthews D, et al., Improving the quality of care for mild to moderate dementia: An evaluation of the Croydon memory service model, Int J Geriatr Psychiatry, 2007;22: 782–8.
  57. Mittelman MS, Roth DL, Clay OJ, Haley WE, Preserving health of Alzheimer caregivers: Impact of a spouse caregiver intervention, Am J Geriatr Psychiatry, 2007;15:780–89.
  58. Mittelman MS, Roth DL, Coon DW, Haley WE, Sustained benefit of supportive intervention for depressive symptoms in caregivers of patients with Alzheimer’s disease, Am J Psychiatry, 2004;161: 850–56.
  59. Mittelman MS, Haley WE, Clay OJ, Roth DL, Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease, Neurology, 2006;67:1592–9.
  60. Brodaty H, Green A, Koschera A, Meta-analysis of psychosocial interventions for caregivers of people with dementia, J Am Geriatr Soc, 2003;51:657–64.
  61. Brodaty H, McGilchrist C, Harris L, Peters KE, Time until institutionalization and death in patients with dementia. role of caregiver training and risk factors, Arch Neurol, 1993;50:643–50.
  62. Banerjee S, Murray J, Foley B, et al., Predictors of institutionalisation in people with dementia, J Neurol Neurosurg Psychiatry, 2003;74:1315–16.
  63. Gaugler JE, Kane RL, Kane RA, Newcomer R, Early communitybased service utilization and its effects on institutionalization in dementia caregiving, Gerontologist, 2005;45:177–85.
  64. Brodaty H, Thomson C, Thompson C, Fine M, Why caregivers of people with dementia and memory loss don’t use services, Int J Geriatr Psychiatry, 2005;20:537–46.
  65. Ball K, Berch DB, Helmers KF, et al.; Advanced Cognitive Training for Independent and Vital Elderly Study Group. Effects of cognitive training interventions with older adults: A randomized controlled trial, JAMA, 2002;288:2271–81.
  66. Willis SL, Tennstedt SL, Marsiske M, et al.; ACTIVE Study Group. Long-term effects of cognitive training on everyday functional outcomes in older adults, JAMA, 2006;296:2805–14.
  67. Clare L, Woods RT, Moniz Cook ED, et al., Cognitive rehabilitation and cognitive training for early-stage Alzheimer’s disease and vascular dementia, Cochrane Database Syst Rev, 2003;(4):CD003260.
  68. Rozzini L, Costardi D, Chilovi BV, et al., Efficacy of cognitive rehabilitation in patients with mild cognitive impairment treated with cholinesterase inhibitors, Int J Geriatr Psychiatry, 2007;22: 356–60.
  69. Olazaran J, Muniz R, Reisberg B, et al., Benefits of cognitivemotor intervention in MCI and mild to moderate Alzheimer disease, Neurology, 2004;63:2348–53.
  70. Loewenstein DA, Acevedo A, Czaja SJ, Duara R, Cognitive rehabilitation of mildly impaired Alzheimer disease patients on cholinesterase inhibitors, Am J Geriatr Psychiatry, 2004;12:395–402.
  71. Wenisch E, Cantegreil-Kallen I, De Rotrou J, et al., Cognitive stimulation intervention for elders with mild cognitive impairment compared with normal aged subjects: Preliminary results, Aging Clin Exp Res, 2007;19:316–22.
  72. Galante E, Venturini G, Fiaccadori C, Computer-based cognitive intervention for dementia: Preliminary results of a randomized clinical trial, G Ital Med Lav Ergon, 2007;29:B26–32.
  73. Graff MJ, Vernooij-Dassen MJ, Thijssen M,et al., Community based occupational therapy for patients with dementia and their care givers: Randomised controlled trial, BMJ, 2006;333:1196.
  74. Graff MJ, Vernooij-Dassen MJ, Thijssen M, et al., Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: A randomized controlled trial, J Gerontol A Biol Sci Med Sci, 2007;62:1002–9.
  75. Graff MJ, Adang EM, Vernooij-Dassen MJ, et al., Community occupational therapy for older patients with dementia and their care givers: Cost effectiveness study, BMJ, 2008;336:134–8.
  76. Broe GA, Henderson AS, Creasey H, et al., A case-control study of Alzheimer’s disease in Australia, Neurology, 1990;40: 1698–1707.
  77. Laurin D, Verreault R, Lindsay J, et al., Physical activity and risk of cognitive impairment and dementia in elderly persons, Arch Neurol, 2001;58:498–504.
  78. Verghese J, Lipton RB, Katz MJ, et al., Leisure activities and the risk of dementia in the elderly, N Engl J Med, 2003;348:2508–16.
  79. Buchner DM, Larson EB, Falls and fractures in patients with Alzheimer-type dementia, JAMA, 1987;257:1492–5.
  80. Morris JC, Rubin EH, Morris EJ, Mandel SA, Senile dementia of the Alzheimer’s type: An important risk factor for serious falls, J Gerontol, 1987;42:412–17.
  81. Tinetti ME, Doucette J, Claus E, Marottoli R, Risk factors for serious injury during falls by older persons in the community, J Am Geriatr Soc, 1995;43:1214–21.
  82. Krenz C, Larson EB, Buchner DM, Canfield CG, Characterizing patient dysfunction in Alzheimer’s-type dementia, Med Care, 1988;26:453–61.
  83. Magaziner J, Simonsick EM, Kashner TM, et al., Predictors of functional recovery one year following hospital discharge for hip fracture: A prospective study, J Gerontol, 1990;45:M101–7.
  84. Wolf-Klein GP, Silverstone FA. Weight loss in Alzheimer’s disease: An international review of the literature, Int Psychogeriatr, 1994;6:135–42.
  85. Heyn P, Abreu BC, Ottenbacher KJ, The effects of exercise training on elderly persons with cognitive impairment and dementia: A meta-analysis, Arch Phys Med Rehabil, 2004;85: 1694–1704.
  86. Teri L, Gibbons LE, McCurry SM,et al., Exercise plus behavioral management in patients with Alzheimer disease: A randomized controlled trial, JAMA, 2003;290:2015–22.
  87. Holmes C, Boche D, Wilkinson D, et al., Long-term effects of Abeta42 immunisation in Alzheimer’s disease: Follow-up of a randomised, placebo-controlled phase I trial, Lancet, 2008;372: 216–23.
  88. Wilcock GK, Black SE, Hendrix SB, et al.; Tarenflurbil Phase II Study investigators. Efficacy and safety of tarenflurbil in mild to moderate Alzheimer’s disease: A randomised phase II trial, Lancet Neurol, 2008;7:483–93.
  89. Aisen PS, Gauthier S, Vellas B, et al., Alzhemed: A potential treatment for Alzheimer’s disease, Curr Alzheimer Res, 2007;4:473–8.
  90. Doody RS, Gavrilova SI, Sano M, et al.; Dimebon Investigators, Effect of dimebon on cognition, activities of daily living, behaviour, and global function in patients with mild-to-moderate Alzheimer’s disease: A randomised, double-blind, placebocontrolled study, Lancet, 2008;372:207–15.
  91. Lannfelt L, Blennow K, Zetterberg H, et al.; PBT2-201-EURO Study Group, Safety, efficacy, and biomarker findings of PBT2 in targeting abeta as a modifying therapy for Alzheimer’s disease: A phase IIa, double-blind, randomised, placebo-controlled trial, Lancet Neurol, 2008;7:779–86.
  92. Qiu C, Winblad B, Fratiglioni L, The age-dependent relation of blood pressure to cognitive function and dementia, Lancet Neurol, 2005;4:487–99.
  93. Ott A, Andersen K, Dewey ME, et al.; EURODEM Incidence Research Group, Effect of smoking on global cognitive function in nondemented elderly, Neurology, 2004;62:920–24.
  94. Reitz C, den Heijer T, van Duijn C, et al., Relation between smoking and risk of dementia and Alzheimer disease: The Rotterdam Study, Neurology, 2007;69:998–1005.
  95. Biessels GJ, Staekenborg S, Brunner E, et al., Risk of dementia in diabetes mellitus: A systematic review, Lancet Neurol, 2006;5: 64–74.
  96. McGuinness B, Todd S, Passmore P, Bullock R, The effects of blood pressure lowering on development of cognitive impairment and dementia in patients without apparent prior cerebrovascular disease, Cochrane Database Syst Rev, 2006;(2):CD004034.
  97. NICE public health guidance 16, Occupational therapy interventions and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care, London: National Institute for Health and Clinical Excellence, 2008.
  98. Lliffe S, Manthorpe J, The hazards of early recognition of dementia: A risk assessment, Aging Ment Health, 2004;8:99–105.
  99. Gove D, Ethical and legal aspects of dementia in the European Union. In: Warner M, Furnish S, Longley M, Lawlor B (eds), Alzheimer’s Disease: Policy and Practice Across Europe, Oxford: Radcliffe, 2002:27–60.
  100. Pratt R, Wilkinson H, Tell Me the Truth, London: Mental Health Foundation, 2001.
  101. Fearnley K, McLennan J, Weeks D, The right to know? Sharing the diagnosis of dementia, Edinburgh: Alzheimer Scotland Action on Dementia, 1997.
  102. Audit Commission, Forget me not 2002: Developing mental health services for older people in England, London: Audit Commission, 2002.
  103. Tuokko H, Tallman K, Beattie BL, et al., An examination of driving records in a dementia clinic, J Gerontol B Psychol Sci Soc Sci, 1995;50:S173–81.
  104. Rossor MN, Dementia and driving: European national guidelines. EFNS Scientist Panel on Dementia, Eur J Neurol, 2000;7:745.
  105. Ott BR, Anthony D, Papandonatos GD, et al., Clinician assessment of the driving competence of patients with dementia, J Am Geriatr Soc, 2005;53:829–33.
  106. Molnar FJ, Patel A, Marshall SC, et al., Clinical utility of officebased cognitive predictors of fitness to drive in persons with dementia: A systematic review, J Am Geriatr Soc, 2006;54: 1809–24.
  107. Breen DA, Breen DP, Moore JW, et al., Driving and dementia, BMJ, 2007;334:1365–9.
  108. Freeman EE, Gange SJ, Munoz B, West SK, Driving status and risk of entry into long-term care in older adults, Am J Public Health, 2006;96:1254–9.
  109. Iliffe S, Wilcock J, Haworth D, Obstacles to shared care for patients with dementia: A qualitative study, Fam Pract, 2006;23:353–62.
  110. Renshaw J, Scurfield P, Cloke L, Orrell M, General practitioners’ views on the early diagnosis of dementia, Br J Gen Pract, 2001;51:37–8.

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