DELAYING TIME TO NURSING HOME PLACEMENT FOR ALZHEIMER'S PATIENTS

A counseling and support program for caregivers whose spouses have Alzheimer’s disease could result in delaying nursing home placement, thus leading to considerable benefit for both the caregiver and the patient, Mary S. Mittelman, DrPH, and colleagues reported in the November 14 Neurology.

The investigators took a random sampling of 406 spouse caregivers who cared for community-dwelling Alzheimer’s patients. The caregivers received a counseling and support intervention that "consisted of six sessions of individual and family counseling, support group participation, and continuous availability of ad hoc telephone counseling," or usual care. Caregivers were enrolled over a 9.5-year period and received structured questionnaires at baseline and every four months for the first year, then every six months thereafter.

Nursing home placement among patients whose spouses received the intervention was 28.3% lower than in the usual care group. "Improvements in caregivers’ satisfaction with social support, response to patient behavior problems, and symptoms of depression collectively accounted for 61.2% of the intervention’s beneficial impact on placement," the investigators pointed out, which indicated that delaying placement "was not accomplished at the expense of caregiver well-being." The median time from baseline to placement was 1,766 days in the intervention group, compared with 1,209 days in the control group, resulting in a model-predicted median time difference of approximately 1.5 years (557 days).

"Our results suggest that with sufficient counseling and support, it is possible to achieve outcomes that are beneficial to most family caregivers, older patients, and society," the researchers stated. "While nursing home placement may be necessary when caregivers are unable or unwilling to manage the care of their relatives at home, it typically does not reduce caregiver distress." Dr. Mittelman and colleagues pointed out that nursing home placement can introduce new stressors for caregivers, such as guilt and the fear that nursing home care will be inadequate. Placement might also increase confusion for dementia patients, who must adapt to a new environment.

"Nevertheless, we recognize that nursing home placement may be the best option for some individuals," the investigators acknowledged. "Caregivers should be supported in decisions to seek placement, and clinicians should be alert to circumstances where placement should be recommended to protect the caregiver’s health and well-being."

Suggested Reading
Mittelman MS, Haley WE, Clay OJ, Roth DL. Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. Neurology. 2006;67:1592-1599.

CONSTRAINT-INDUCED MOVEMENT THERAPY FOR STROKE PATIENTS?

Constraint-induced movement therapy (CIMT) begun three to nine months after a first stroke may yield clinically relevant improvements, according to a study in the November 1 JAMA.

Steven L. Wolf, PhD, PT, and colleagues compared the effects of two-week programs of CIMT versus usual and customary care in 222 patients with predominantly ischemic stroke. One hundred six participants received CIMT, which consisted of "wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand." The remaining 116 patients received usual and customary care that ranged from "no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions," the researchers stated.

Over the course of one year, patients assigned to CIMT showed a 52% reduction—from a mean time of 19.3 to 9.3 seconds—in Wolf Motor Function Test Performance Time, while patients receiving usual and customary care showed a 26% reduction in the same outcome measure, with a decrease from 24.0 to 17.7 seconds. The difference between groups was 34%. Scores on the Motor Activity Log Amount of Use (a 0-to-5 scale) increased from 1.21 to 2.13 in the CIMT group, while scores in the usual care group increased from 1.15 to 1.65. The Motor Activity Log Quality of Movement (also a 0-to-5 scale) measured an increase from 1.26 to 2.23 in the CIMT group, compared to an increase from 1.18 to 1.66 in the usual care group. Lastly, patients receiving CIMT had a decrease of 19.5 in self-perceived hand function difficulty as measured by the Stroke Impact Scale hand domain, as opposed to a decrease of 10.1 in patients assigned to usual care.

Suggested Reading
Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function three to nine months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296:2095-2104.

MULTIPLE SEROTONIN-PATHWAY ABNORMALITIES INCREASE INCIDENCE OF SIDS

Several characteristics of serotonergic (5-hydroxytryptamine [5-HT]) neurons are altered in sudden infant death syndrome (SIDS), researchers reported in the November 1 JAMA. Abnormalities in 5-HT receptor binding in the medulla have previously been linked to SIDS, but the findings published by David S. Paterson, PhD, and colleagues suggest a more extensive pathology. The study also provides insight into why SIDS is more common in males.

Investigators examined samples of frozen medullae from 31 infants who died as a result of SIDS (median age, 16.4 weeks) and 10 who died from other causes, including drowning and heart disease (median age, 12.2 weeks). The number of 5-HT neurons was significantly higher in the rostral medulla and mid medulla of SIDS infants than in the controls. Mean cell density was also significantly higher in SIDS infants than in controls: 0.81 versus 0.54 cells/mm2 in the rostral medulla and 0.55 versus 0.41 cells/mm2 in the mid medulla.

Despite the observed increases, SIDS samples exhibited significantly reduced 5-HT1A receptor binding density in all sections of the medullae, with male SIDS cases displaying significantly lower binding density than the females. A reduced ratio of 5-HT transporter (5-HTT) binding to 5-HT neuron count in the raphe obscurus was also apparent in all SIDS cases, with no differences between male and female samples. The findings suggest "a relative reduction of 5-HTT expression per 5-HT neuron count," said the authors. They concluded that "the synthesis and availability of 5-HT (and by extrapolation, neuron firing) is altered within 5-HT pathways" in SIDS cases.

In an accompanying editorial, Debra Ellyn Weese-Mayer, MD, of the Department of Pediatrics at Rush University Medical Center in Chicago, said current SIDS study pools are not sufficiently representative of the at-risk population. Though National Vital Statistics data indicate a 2.7-fold higher incidence rate in African-Americans as compared to Caucasians, "African-American infants are one key group consistently underrepresented," she said, with many studies being limited in size and utilizing specimens of "primarily white and Hispanic infants recruited from San Diego."

Dr. Weese-Mayer attributes this in part to a "visionary" California statute that does not require informed consent from parents if tissue samples from their child are used for research on sudden and unexpected infant death. "If it were possible for more states to follow the lead of California, sample size and ethnic diversity for these essential SIDS studies would be expanded," she said.

Suggested Reading
Paterson DS, Trachtenberg FL, Thompson EG, et al. Multiple serotonergic brainstem abnormalities in sudden infant death syndrome. JAMA. 2006;296:2124-2132.
Weese-Mayer DE. Sudden infant death syndrome: is serotonin the key factor? JAMA. 2006;296:2143-2144.

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