COMPARATIVE EFFECTIVENESS OF MCI and DEMENTIA TREATMENTS IN A COMMUNITY-BASED DEMENTIA PRACTICE
Condition: Mild Cognitive Impairment; Dementia; Hypoxia; Hyperhomocysteinemia; Vitamin B 12 Deficiency; Iron Deficiency; Anemia; TBI; Neurodegenerative Disorders; Alzheimer's Disease; Vascular Dementia; Brain Injuries; Tauopathies; Parkinson's Disease; Lewy Body Dementia; Frontotemporal Dementia; TDP-43 Proteinopathies
MeSH terms: Parkinson Disease; Alzheimer Disease; Dementia; Brain Injuries; Frontotemporal Dementia; Aphasia, Primary Progressive; Pick Disease of the Brain; Dementia, Vascular; Tauopathies; Lewy Body Disease; Neurodegenerative Diseases; TDP-43 Proteinopathies; Hyperhomocysteinemia; Iron Deficiencies; Vitamin B 12 Deficiency; Hypoxia; Cognitive Dysfunction
Study type: Observational

Summary: 
      This retrospective study is a more extensive, confirmatory analysis of the cognitive and
      functional outcomes initially seen in 2 groups of MCI/dementia patients in Springfield, MA
      and compares specialized dementia care and a comprehensive treatment approach versus usual
      care delivered in a non-specialist setting.

      The first group of patients (n= 328) was seen by a dementia specialist, who utilized a
      standardized assessment and treatment protocol (CNS). This included comprehensive
      identification and treatment of hypoxia, sleep-disorders, and other cognitively-impairing
      metabolic conditions as well as maximally- dosed FDA-approved medications for dementia,
      depression, and PBA.

      The second group of patients (n= 280) was seen by non-dementia specialists in the community
      and received usual care which did not include comprehensive assessment or treatment of
      underlying metabolic derangements or maximal utilization of currently available medications.

      This study, evaluating date from a larger cohort (n>800) of specialist-treated
      cognitively-impaired patients, will further examine the hypothesis that a comprehensive
      dementia treatment protocol yields cognitive stabilization and/or improvement using already
      available dementia drugs when compared with usual community care.
    

Detailed description: 
      From 2008-2013 more than 5,000 patients have been seen by a community-based
      internist/psychiatrist specializing in treating cognitively impaired adults suffering from
      MCI or dementia due to Alzheimer's Disease, vascular dementia, combined DAT/VAD, FTD, PD,
      LBD, as well as dementia due to traumatic brain injury (TBI), alcoholism and autoimmune
      diseases.

      Cohort 1 includes patients from this specialist practice who were extensively evaluated with
      a standardized protocol assessment aimed at identifying all reversible and treatable
      conditions adversely affecting cognition, and achieving maximum diagnostic accuracy with
      respect to the underlying dementia pathology. The protocol included physical and mental
      status examinations, neuroimaging (PET scans and/or MRI's with volumetrics), lab tests,
      overnight pulse oximetry, in-lab and ambulatory polysomnography, and gold standard
      neuropsychological testing as well as rapid, in-office cognitive testing. The comprehensive
      treatment protocol attempted correction of all modifiable and metabolic derangements, and
      utilized maximally tolerated FDA approved medications and devices.

      Cohort 2 includes patients who were referred by their primary care clinicians or other
      non-dementia specialists to a neuropsychology practice for a standardized cognitive
      evaluation as part of usual care, but were not treated by a dementia specialist.

      This in-depth retrospective analysis is the first attempt to evaluate the comparative
      effectiveness of dementia drugs and other treatment interventions in a cognitively impaired
      patient group whose baseline metabolic abnormalities were identified, treated and maintained
      optimally throughout the course of care versus a patient group not so intensively assessed or
      managed.

      Outcome measures include objective cognitive testing and functional and behavioral
      assessments correlated with prescribed standard dementia medications, reductions in
      benzodiazepine, narcotic and antipsychotic use, as well as with baseline and interval
      measures of oxygenation adequacy, BNP, CRP, IGF-1, homocysteine, methylmalonic acid, iron
      status, Vitamin D 25-OH, and utilization of oxygen and positive airway pressure treatment.
    

Observational model: Cohort
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        Cohort 1: Consecutive patients presenting for care for cognitive impairment in a
        non-academic, non-hospital based, dementia specialty practice in Springfield, MA Cohort 2:
        Convenience sample of patients referred to neuropsychological testing and treated by
        non-dementia specialists in Springfield, MA
      
Keywords: Psuedobulbar affect, PBA