Repeating Same Story Over and Oer Again
Int Psychogeriatr. 2017 Jun; 29(6): 959–966.
Exploration of verbal repetition in people with dementia using an online symptom-tracking tool
Emily Reeve
oneGeriatric Medicine Enquiry Unit, Dalhousie University and Capital Health, Halifax, Nova Scotia, Canada
iiCognitive Turn down Partnership Centre, Kolling Institute of Medical Research, Sydney Medical Schoolhouse, The University of Sydney, New South Wales, Australia
Pierre Molin
threeDivision of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
4Division de gériatrie, Université Laval, Québec, Canada
Amaris Hui
1Geriatric Medicine Research Unit of measurement, Dalhousie University and Majuscule Health, Halifax, Nova Scotia, Canada
Kenneth Rockwood
1Geriatric Medicine Inquiry Unit, Dalhousie University and Capital letter Health, Halifax, Nova Scotia, Canada
iiiSegmentation of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
5DGI Clinical Inc., Halifax, Nova Scotia, Canada
Received 2016 Aug 31; Revisions requested 2016 Oct 9; Revised 2016 Oct 27; Accepted 2016 Nov half dozen.
Abstruse
Groundwork:
Online tools can be used by people with dementia and their caregivers to self-identify and rail troubling symptoms, such as exact repetition. We aimed to explore verbal repetition behaviors in people with dementia.
Methods:
Participants were recruited via an online resource for people with dementia and their caregivers. Respondents were instructed to consummate information about symptoms that are virtually of import to them for tracking over time. In this cantankerous-sectional study, we analyzed data pertaining to individuals with dementia who had at to the lowest degree 3 symptoms selected for tracking.
Results:
Of the 3,573 participants who began a user profile, 1,707 fulfilled criteria for assay. Verbal repetition was identified as a treatment target in 807 respondents (47.3%). Verbal repetition was more frequent in individuals with mild dementia compared to those with moderate and astringent dementia (57.2% vs. 36.0% and 39.ix%, p < 0.01) and in those with Alzheimer'due south illness versus other dementias (65.2% vs. 29.7%, p < 0.001). Repetitive questioning was the most frequent type of verbal repetition (90.5% of individuals with verbal repetition). Exact repetition was most strongly associated with difficulties operating gadgets/appliances (OR 3.65, 95%CI: 2.82–four.72), lack of interest and/or initiative (3.52: two.84–iv.36), misplacing or losing objects (3.25: 2.64–4.01), and lack of attending and/or concentration (2.62: 2.12–3.26).
Conclusions:
Exact repetition is a common symptom in people at all stages of dementia just is about unremarkably targeted for monitoring and handling furnishings in its mild phase. Much research is required to farther elucidate the underlying mechanisms and the effect of different treatment strategies.
Key words: Alzheimer disease, dementia, Internet, caregiver, verbal repetition
Introduction
The clinical expression of disease in dementia varies both within and betwixt individuals. Age, cultural background, co-morbidities, cognitive reserve, compensatory changes, neuropathological features, and disease stage all contribute to the intrinsic heterogeneity of dementia (Cohen-Mansfield, 2000; Rockwood, 2010). Because disease manifestations vary immensely between patients, dementia management needs to take into account the individual and caregiver's dementia experience. The inherent clinical meaningfulness of many standardized tests widely used in retentiveness clinics (due east.one thousand. Montreal Cognitive Cess (MoCA) and Mini-Mental State Exam (MMSE)) may exist important to healthcare providers for diagnosis and management but may not coincide with what caregivers consider to be "clinically meaningful" as these tests often practice not target symptoms of greatest burden or distress (Rockwood, 2010; Shabbir and Sanders, 2014).
Studying heterogeneity in symptoms and presentation of dementia and the response to treatment can atomic number 82 to a amend appreciation of encephalon functioning. Additionally, written report of individual symptom types and a focus on individual goal setting and attainment tin can enhance patient-centered care. To this stop, we have structured aspects of collateral history by employing the SymptomGuide™ (SG), a standardized dementia symptom inventory that tin can be used by caregivers to track symptoms of most importance to them (Rockwood, 2010). This is one way in which online tools offer new approaches for understanding individuals' experiences of dementia (McKechnie et al., 2014; Cristancho-Lacroix et al., 2015). Here, we used SG information to study verbal repetition, a commonly targeted yet poorly studied symptom of dementia.
Verbal repetition in people with dementia is one important manifestation of reduced cognition. It can occur early in dementia and is amidst the behaviors that virtually trouble caregivers (Hwang et al., 2000; Ready et al., 2003; Rockwood et al., 2014). Repetitive verbalizations can have the form of repetitive questions, story-telling, statements, and talk on a topic and repeating words (Melt et al., 2009). Like other symptoms in dementia, verbal repetition behaviors tin can fluctuate and have been reported as a marker of a "bad day," every bit described by caregivers (Rockwood et al., 2014). All the same, niggling is known of how exact repetition manifests in the daily lives of people with dementia.
The purpose of this written report was to characterize exact repetition in a large population of people with dementia online using a symptom-tracking website. The specific objectives were to determine how ofttimes and at which phase of dementia exact repetition was reported as a symptom of interest for tracking disease progression. In addition, we examined how it related to other reported symptoms.
Methods
Design, participants, and instrument
Data for this cross-exclusive study were obtained from an online questionnaire completed by informal caregivers providing aid to customs-domicile care recipients with cerebral harm. Caregivers were spouses, children, or other care providers. The participants were recruited online at world wide web.DementiaGuide.com. This website is a reference for people to learn well-nigh Alzheimer's affliction and dementia and, in particular, the symptoms of dementia. Additionally, it provides a function for users to create a symptom profile, enabling them to rails the changes in symptoms over time; this is called the SymptomGuide™ (SG) (Rockwood, 2010). People who access the SG can either subscribe or complete a questionnaire for gratis access. The SG provides a standardized dementia symptom inventory of 60 symptoms, including verbal repetition, and aims to correspond all stages of cognitive damage. Data is provided about each symptom, such as the phase at which it most usually occurs and typical management strategies. For each symptom, about a dozen descriptors are present, which provide a carte for selection; users tin besides write in their own description if they cull. Users are instructed to select the symptoms that are most relevant to them to track the class of dementia and/or the consequence of treatment. That is, non all symptoms that may be present in the person with dementia volition be selected, but instead, just those viewed by the user to exist a symptom of interest to be tracked over time. Users are asked to indicate the frequency of each symptom. They can besides rank the symptoms every bit virtually to least of import to them. Respondents were likewise able to study a diagnosis of dementia when present and give information most current medications.
The content of DementiaGuide has been independently judged every bit apparent (loftier quality and comprehensive) (Dillon et al., 2013) and the SG has been validated clinically and against the Dependence Scale (Rockwood et al., 2012). The symptom library in SG contains ten descriptions of verbal repetition behaviors as well as the option to write their ain description. These descriptions can be grouped into three categories: repetitive questions, repetitive statements and stories, and verbal perseveration (repetition of the same word or brusk phrase).
The site has been available since September 2006 and we examined information collected until Feb 2015. To enable staging of the severity of dementia (see below), only individuals in whom at least three symptoms were reported were included in analysis. For this report, we likewise excluded people with mild cerebral impairment (i.e. without dementia).
Statistical analysis
In addition to information provided past respondents, each individual had their dementia classified every bit mild, moderate, or severe using a staging algorithm. The staging algorithm was developed using an artificial neural network and has been validated for use in SG (details reported in full previously (Rockwood et al., 2013)). The algorithm requires only descriptions of symptoms reported using the SG to assign each individual as having mild, moderate, or severe dementia, although a minimum of iii symptoms are required.
Data were summarized using descriptive statistics. Testing for significant differences between groups was washed with a Student's t-exam for continuous information and Pearson's χ ii test for categorical data. Statistical software used for the analysis was R v3.02 and a p value of <0.05 was considered meaning.
To test for associations between verbal repetition and other symptoms selected by the users in the SG, odds ratios (ORs) and 95% confidence intervals were calculated using IBM SPSS Statistics version 22. To identify symptoms that were co-reported for tracking with the greatest association with verbal repetition in this exploratory work, nosotros reported those in which the 95% conviction interval was greater than, and did not cross 2.00.
Ethics
The study was approved by the Research Ethics Committee of the Capital District Health Authorisation, Nova Scotia. SG users agreed to terms of use. Respondents gave informed consent to disclose their answers for the purpose of advancing inquiry on dementia. Users are assured that information provided for inquiry purposes volition be presented in an aggregate manner, without any information that could be used to place individuals or respondents personally.
Results
Sample clarification
Of the 3,573 participants who began a user profile, ii,264 completed both a symptom profile in which they targeted symptoms for tracking and a user contour in which they reported patient and care characteristics. Of these ii,264, 1,707 reported a dementia diagnosis, with at to the lowest degree 3 target symptoms and thus were included in the assay. Overall, verbal repetition was the most common of the sixty possible symptoms reported equally a target for monitoring, in 807 individuals (47.2%). When identified, verbal repetition was ranked as the most important symptom in 34.i% and was ane of the top 3 symptoms in 65.iii% in our respondents. Compared to those in whom information technology was not targeted (N = 900), individuals in whom verbal repetition was targeted were significantly older and more than often were women, as well equally have differences in living arrangements and utilize of medications to care for dementia (Table 1).
Tabular array 1.
Subject characteristics
| verbal | verbal | ||
|---|---|---|---|
| repetition | repetition | ||
| targeted | not targeted | ||
| (n = 807) | (n = 900) | p-value | |
| Age: hateful (SD) | 78.5 (vii.4) | 79.3 (8.9) | 0.046 |
| Sex: % women (N) | 66.2 (534) | 61.4 (553) | 0.048 |
| Education: % (Due north) | 0.102 | ||
| More than loftier school | 29.2 (236) | 19.8 (178) | |
| At nearly high school | 21.1 (170) | 20.four (165) | |
| Missing | 49.7 (401) | 61.9 (557) | |
| Living arrangements: % (N) | <0.001 | ||
| Lone | 8.one (65) | half-dozen.four (58) | |
| At home with help | 57.5 (464) | 35.4 (319) | |
| Retirement/nursing home | 6.i (49) | 9.8 (88) | |
| Missing | 28.iv (229) | 48.3 (435) | |
| Treated with a cholinesterase inhibitor: % (N) | 67.0 (412) | 51.eight (335) | <0.001 |
| Missing | half-dozen.two (38) | 5.9 (38) | |
| Blazon of dementia: % (North) | <0.001 | ||
| Alzheimer | 46.2 (373) | 22.i (199) | |
| Lewy Body | 2.0 (16) | four.1 (37) | |
| Frontotemporal | 1.5 (12) | iv.three (39) | |
| Parkinson | 0.ane (1) | i.4 (thirteen) | |
| Vascular | 5.8 (47) | ten.ane (91) | |
| Missing | 44.4 (358) | 57.9 (521) |
The dementia type was specified by users in 828 participants (data missing on 879). For these 828, exact repetition was more frequently targeted in people with Ad than in those with other dementias (373/572; 65.2%, 76/256; 29.7%, p < 0.001). Verbal repetition was targeted beyond all stages, although significantly more and then in patients with mild dementia than in those in the moderate or severe stages (p < 0.001 for both) (Figure 1). This pattern remained in the subgroup of patients with Advert; exact repetition was targeted in 74.2% of people with mild Advertisement, 45.7% of those with moderate Advertising, and 47.9% of those with severe AD (p < 0.001).
Proportion of patients in whom exact repetition was identified equally a target for tracking, past dementia stage.
Description of the episodes
In individuals who targeted exact repetition, repetitive questioning was the nigh common type across all stages (ninety.8%). Repetitive story/data telling (sixty.1%) and verbal perseveration/other (23.eight%) were less frequent (Tabular array 2). The most mutual descriptors were asking repeatedly for details of upcoming events or appointments and asking for the fourth dimension of mean solar day or date. The occurrence of repetitive questioning did not differ significantly beyond the dementia stages (p ≥ 0.066), whereas repetitive stories and information and verbal perseveration were targeted significantly more frequently in individuals with moderate and severe dementia (p < 0.002 mild vs. moderate and mild versus severe for both).
Table ii.
Types of verbal repetition reported as a symptom to rails by stage of dementia (% (n) of patients past stage)
| mild | moderate | severe | all patients | |
|---|---|---|---|---|
| exact repetition description | n = 471 | n = 149 | due north = 187 | northward = 807 |
| Repetitive questioning | 92.1 (434) | 91.3 (136) | 87.2 (163) | 90.8 (733) |
| Asks repeatedly about upcoming events or appointments | 47.iii (223) | 66.iv (99) | 60.iv (113) | 53.9 (435) |
| Asks repeatedly about the time of twenty-four hours or date | 56.7 (267) | 49.0 (73) | 39.half-dozen (74) | 51.3 (414) |
| Asks repeatedly near things that accept already happened | 48.8 (230) | 47.7 (71) | 48.1 (90) | 48.ii (391) |
| Asks repeatedly virtually whether something was done | 48.6 (229) | 41.6 (62) | 49.two (92) | 47.5 (383) |
| Asks repeatedly the aforementioned question - other | 26.8 (126) | 40.3 (60) | 41.2 (77) | 32.6 (263) |
| Repetitive stories/data | 47.6 (224) | 73.eight (110) | 80.7 (151) | 60.1 (485) |
| Tells a story more once during a unmarried conversation | 33.3 (157) | 54.4 (81) | 61.5 (115) | 43.7 (353) |
| Tells the same story at successive encounters with others (week/calendar week) | 27.half dozen (130) | 52.3 (78) | 64.two (120) | 40.6 (328) |
| Tells stories/information despite been told he/she is repeating | 15.7 (74) | 34.2 (51) | 48.vii (91) | 26.8 (216) |
| Tells new information that they accept learned multiple times a mean solar day | 15.i (71) | xxx.ii (45) | 31.0 (58) | 21.six (174) |
| Verbal perseveration and other | 17.8 (84) | 36.2 (54) | 28.9 (54) | 23.viii (192) |
| Says the same word/phrase over and over | 9.3 (44) | 25.5 (38) | 24.half dozen (46) | 15.9 (128) |
| Other descriptor | xi.9 (56) | 20.8 (31) | 11.8 (22) | 13.4 (109) |
The median frequency of verbal repetition was 5.0 episodes/day (range 0.07–624.0) with no statistical difference based on the phase of dementia in the private (p = 0.079).
Associated symptoms
Out of the other symptoms that could exist selected in SG for tracking, verbal repetition was virtually strongly associated with difficulties operating gadgets/appliances (OR three.65, 95% CI: 2.82–iv.72), lack of involvement and/or initiative (3.52: 2.84–four.36), misplacing or losing objects (iii.25: ii.64–4.01), and lack of attention and/or concentration (two.62: ii.12–three.26).
Discussion
Summary of results and comparison with previous literature
We used information collected from an online survey to explore how verbal repetition is experienced in the daily lives of community-dwelling house individuals with dementia and their breezy caregivers. The proportion of individuals in whom verbal repetition was tracked in our online survey (just nether one-half) is within the range of 31%–90% reported in previous studies (Teri et al., 1992; Hope et al., 1997; Hwang et al., 2000; Cullen et al., 2005). This wide range in prevalence estimates may reflect differences in definitions and timeframe/frequency. For example, Hope et al. (1997) inquired nigh repeated requests or demands only, whereas Terri et al. (1992) asked about repeated questions at all in the previous calendar week. Other investigations have relied on formal testing washed in not-conversational and non-clinical settings to describe verbal repetition (Bayles et al., 2004), how these studies relate to the patient's and caregiver's existent-globe experience is unclear. In whatsoever case, it is worth underscoring that we did not inquire virtually prevalence per se – simply whether, when present, information technology was a target for tracking change, e.grand. in response to treatment, or beyond the class of the dementia, or just as a mode for caregivers to share with others who utilise their personal business relationship (such equally family members in other locales) about how the person for whom they were caring was faring.
We have demonstrated that verbal repetition is an important symptom of dementia. When selected for tracking, it was ranked in the top iii symptoms ii-thirds of the fourth dimension. This ascertainment indicates that verbal repetition can cause meaning brunt to caregivers (although non directly measured in this study), and as such it is important to investigate causes and effective management strategies. Unfortunately, even if exact repetition is frequent and of import for patients and their caregivers, few drug trials have measured verbal repetition every bit an outcome. Even so, a double blind, randomized, placebo controlled written report found that verbal repetition does answer to treatment with cholinesterase inhibitors in patients with mild-moderate Advert (Rockwood et al., 2007). Verbal repetition was selected for tracking in individuals at all dementia stages in this study but was more usually selected in people with mild dementia than in those in a moderate or severe stage. Similarly, Hwang et al. (2000) found that exact repetition behaviors were reported early in the disease (within two years of diagnosis) but were not related to historic period of onset or MMSE. These results could reverberate that exact repetition is more common in the early stages of dementia, or that other symptoms go more concerning as the disease progresses and that exact repetition becomes less salient.
Our study besides found that verbal repetition was more likely to be reported in women and in patients with Advertisement. This is contrary to the written report by Hwang et al. (2000) who institute no human relationship to gender or type of dementia but consistent with the one by Cullen et al. (2005) whose information advise that repetitive questions were more common amid women. Whether this gender consequence is related to the dementia process remains unclear. Interestingly, women are more vulnerable to semantic and episodic memory decline in Ad and this could contribute to this miracle (McPherson et al., 1999). On the other mitt, even data on healthy participants suggest that women ask more questions (Fitzpatrick et al., 1995). Thus, if there is a gender difference in repetitive questioning, it could reflect an underlying heterogeneity in the use of linguistic forms in the speech of men and women.
Consistent with previous studies (Hwang et al., 2000; Cullen et al., 2005; Cook et al., 2009), nosotros found that repetitive questioning was the most common type of verbal repetition. Repetitive questioning was targeted as a symptom for tracking at all dementia stages in similar proportions, whereas repetitive story/information telling and exact perseveration were targeted in a greater proportion of individuals with moderate and severe stages of dementia, versus those with mild.
Pathophysiological cause of exact repetition
Our analysis of the symptoms that were most highly associated with repetitive verbalization may provide insight into the underlying pathophysiological cause. Nevertheless, beyond a broadly construed (and therefore less informative) notion of "executive function," no common theme was identified in the top four symptoms: difficulties operating gadgets/appliances, lack of involvement and/or initiative, misplacing or losing objects, and lack of attention and/or concentration. As the majority of respondents completing the online survey are caregivers, we cannot discount the possibility that the symptoms identified as important to the caregiver may be a reflection of caregiver characteristics and non purely due to the symptoms of the individual with dementia.
The associations with lack of attention and difficulties operating gadgets may indicate variants of dysexecutive office, whereas misplacing objects might more strongly suggest retention impairment. Yet, misplacing objects involves both inability to call up where an particular was placed and inappropriate placement of objects which may, again be due to impaired planning or monitoring, as function of a dysexecutive syndrome and not just memory impairment (Hamilton et al., 2009). How verbal repetition arises remains unclear, though studies tend to differentiate repetitive questioning from repetitive storytelling/statements and perseveration. This may exist an important differentiation for future studies to tease out the causative mechanisms as our study constitute that there was a unlike distribution of targeting repetitive questions versus repetitive statements and stories and verbal perseveration across the different stages of dementia.
Repetitive questioning, commonly about upcoming events, whereabouts of people and objects, and temporal orientation, is believed to exist an amnesic behavior. Even though anterograde amnesia is the clinical hallmark of AD, repetitive questioning is not reported in every Ad patient. This suggests that other factors influence its occurrence (Gear up et al., 2003; Cullen et al., 2005; Asp et al., 2006). A perfusion SPECT scan written report in AD patients demonstrated that repetitive questioning positively correlated with greater bilateral cerebral claret flow to the pericallosal regions (Kishimoto et al., 2010). Considering that Advertising patients with astringent retentivity disturbance tend to evidence a decrease of cerebral claret menses in this region, this finding as well suggests that memory dysfunction lonely does not account for repetitive questioning. A separate theory is that repetitive questioning stems from anxiety, agitation, and emotional disturbances and is frequently accompanied with repetitive verbalizations of health complaints, fears, and concerns (Volicer et al., 2001). Our study establish that asking repeatedly for details of upcoming events or appointments was the most frequent manifestations of verbal questions, which lends support to this theory. Or it could reverberate a trouble conceiving how one action entails the side by side, that is, impairments in sequencing (executive dysfunction).
Repetitive stories and statements are thought to be due to disturbances in executive functioning. The inability to shift attention abroad from 1 topic of conversation to another, dumb response inhibition and poor working retention capacity are specifically believed to be related to these exact comportments (Perry et al., 2000; Cook et al., 2009; Miozzo et al., 2013). 1 smaller report (Due north = 54 participants with AD) found an association between higher dysexecutiveness and repetitive statements/stories but not with repetitive questions (Cullen et al., 2005).
In relation to executive operation, recurrent verbal perseverations occur early in the form of AD and has been held to imply frontal lobe involvement rather than memory dysfunction – as demonstrated by the lack of significant clan with general retentivity measures (Bayles et al., 2004; Possin et al., 2005; Pekkala et al., 2007). At the neuropharmacological level, recurrent perseveration and deficits in attentional switching have been attributed to resistance of catecholaminergic and cholinergic activity in the prefrontal cortex (McNamara and Albert, 2004). Information technology is important to note that our definition of verbal repetition excluded morpheme repetitions where patients take harm in their ability to actuate a target lexical item, which relates to linguistic communication processing rather than memory or executive functions (Miozzo et al., 2013).
Strengths, limitations, and future directions
Our approach of using an online resource near dementia for research is innovative and this method allowed us access to caregivers' views of the symptoms of dementia. The utilization of web-based systems for information sharing, online peer support, chance reduction tools, and strategies and fifty-fifty web-based cognitive grooming for people with dementia and their caregivers is expanding; still, the internet's potential clinical applications remain relatively untapped by the medical community in caring for people with dementia (McKechnie et al., 2014; Cristancho-Lacroix et al., 2015; Pot et al., 2015). This study adds to previous research (Rockwood et al., 2012; Rockwood et al., 2015), establishing the feasibility of an online tool that is both a resource for consumers and a real world data-source for inquiry. Nonetheless, data collected online demand to be utilized with prudence.
Our data should exist interpreted with circumspection. For studies of verbal repetition, our sample size is large just is subjective in being observer reported, including on cardinal features such every bit diagnosis, symptoms, and frequencies. We did not systematically inquire about whether exact repetition was nowadays, only if it was targeted as a symptom for tracking over time. In other words, this is not a symptom checklist, just rather a compendium of which symptoms crossed enough of a threshold of importance or business organization to be followed as treatment targets. Likewise, we had no data on non-targeted symptoms. Therefore, we were constrained to look at associations but not prevalence estimates. Moreover, some information on subject'southward characteristics and symptom description were missing, making statistical comparison difficult. Our algorithm to classify patients co-ordinate to their dementia stage as well has limitations. A minimum of three reported symptoms was necessary to employ information technology so that we are non able to comment most associated symptoms when fewer than 3 were specified.
This was a cross-sectional study; nevertheless, data were collected over an 8 yr period (only offset entries were used). Information technology is possible that alterations in guidelines and advances in the intendance of people with dementia occurred throughout this time period, which may have impacted users' responses. However, as the content of the SG and the questions asked remained constant over this period, we believe that our assay remains valid. Additionally, we did not examine the duration that verbal repetition had been experienced. Future research should investigate the duration of symptoms and how the severity and frequency change over time, likewise as the relationship with patients' quality of life and caregiver burden to provide important insight into how we can ameliorate intendance for people with dementia and their caregivers.
Conclusion
Verbal repetition is common in individuals at all stages of dementia but is nearly frequently identified as a symptom of utilise to track in individuals with mild dementia. It was selected as a symptom to track in approximately half of all respondents and two-thirds of those with AD. Repetitive questions were the about mutual type of verbal repetition behaviors and were tracked by similar proportions of users beyond the stages of dementia. Repetitive story/information telling and verbal perseveration were less common only were targeted in a greater proportion of individuals with moderate and severe stages of dementia. As such, at that place may exist different underlying causes of the dissimilar types of verbal repetition. The symptoms seen in association with verbal repetition suggest that reduced executive function and retentivity damage play a role in repetitive verbal behaviors. Further research is needed to meliorate sympathize the basis of this phenomenon and how to all-time care for people with dementia who experience these symptoms and their caregivers.
Conflict of interest
KR founded and has shares in DGI Clinical, a company that has contracts with pharma for individualized outcome measurement and advanced data analytics in Alzheimer illness, Parkinson illness, and other disorders. The information for these analyses were supplied by DGI Clinical, from its website.
Clarification of author roles
E Reeve was involved in conception of the manuscript, conducted data analysis and interpretation, critically reviewed and revised the draft and prepared information technology for submission. P Molin formulated the research question, designed the report and drafted the manuscript. A Hui was involved in concept of the manuscript, contributed to the draft and critically review the draft. One thousand Rockwood designed the study, was involved in interpreting the results, and critically reviewed the manuscript.
Acknowledgments
The authors wish to acknowledge Miranda McMillan for conducting office of the data assay. ER received a fellowship from the Australian National Health and Medical Research Quango and the Australian Research Council (NHMRC-ARC Dementia Research Development Fellow). PM received a fellowship grant from the Laval University Research Chair on Aging for his training in cognitive neurology. KR receives career back up from the Dalhousie Medical Inquiry Foundation as the Kathryn Allen Weldon Professor of Alzheimer Research at Dalhousie University Halifax, Nova Scotia, Canada.
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