JAGS
NOVEMBER 2013–VOL. 61, NO. 11
Olivier Martinaud, MD, PhD Department of Neurology, Rouen University Hospital, Rouen, France Centre National de Référence pour les Malades Alzheimer Jeunes, Lille, Rouen, and France Paris-Salpêtrière Hospitals, France Alaina Borden, MD Department of Neurology, Rouen University Hospital, Rouen, France Dominique Campion, MD, PhD Inserm U1079, Rouen, France Institute for Research and Innovation in Biomedicine, Normandie University, Rouen, France Centre National de Référence pour les Malades Alzheimer Jeunes, Lille, Rouen, and France Paris-Salpêtrière Hospitals, France Department of Research, Rouvray Psychiatric Hospital, Sotteville-lès-Rouen, France Didier Hannequin, MD, PhD Inserm U1079, Rouen, France Institute for Research and Innovation in Biomedicine, Normandie University, Rouen, France Department of Neurology, Rouen University Hospital, Rouen, France Centre National de Référence pour les Malades Alzheimer Jeunes, Lille, Rouen, and France Paris-Salpêtrière Hospitals, France
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study concept and design: Nicolas. Acquisition of subjects and data: Nicolas, Wallon, Salle, Dreano, Martinaud, Borden, Campion, Hannequin. Analysis and interpretation of data: Nicolas, Wallon, Salle, Dreano, Martinaud, Borden, Campion, Hannequin. Preparation of manuscript: Nicolas, Wallon, Borden, Hannequin. Sponsor’s Role: No specific role of the funding source.
REFERENCES 1. Nicolas G, Pottier C, Maltete D et al. Mutation of the PDGFRB gene as a cause of idiopathic basal ganglia calcification. Neurology 2013;80: 181–187. 2. Godefroy O, Roussel M, Leclerc X et al. Deficit of episodic memory: Anatomy and related patterns in stroke patients. Eur Neurol 2009;61:223–229. 3. Petersen RC. Clinical practice. Mild cognitive impairment. N Engl J Med 2011;364:2227–2234. 4. Manyam BV, Walters AS, Narla KR. Bilateral striopallidodentate calcinosis: Clinical characteristics of patients seen in a registry. Mov Disord 2001;16:258–264. 5. Gorelick PB, Scuteri A, Black SE et al. Vascular contributions to cognitive impairment and dementia: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:2672–2713. 6. Sarazin M, Berr C, De Rotrou J et al. Amnestic syndrome of the medial temporal type identifies prodromal AD: A longitudinal study. Neurology 2007;69:1859–1867.
LETTERS TO THE EDITOR
2059
7. McKeith IG, Dickson DW, Lowe J et al. Diagnosis and management of dementia with Lewy bodies: Third report of the DLB Consortium. Neurology 2005;65:1863–1872. 8. Lemos R, Oliveira M, Oliveira J. Reporting a new mutation at the SLC20A2 gene in familial idiopathic basal ganglia calcification. Eur J Neurol 2013;20:e43–e44. 9. Yamada M, Asano T, Okamoto K et al. High frequency of calcification in basal ganglia on brain computed tomography images in Japanese older adults. Geriatr Gerontol Int 2013;13:706–710. 10. Nicolas G, Guillin O, Borden A et al. Psychosis revealing familial idiopathic basal ganglia calcification. Gen Hosp Psychiatry 2012 Oct 30; pii: S0163-8343(12)00280-0. doi: 10.1016/j.genhosppsych.2012.09.008.; [Epub ahead of print].
COMMENTS/RESPONSES MORTALS WHO ARE RECONCILED TO BEING MORTAL To the Editor: Kara and colleagues report that advance care planning (ACP) is associated with lower rates of in-hospital death, higher rates of hospice enrollment, and lower rates of hospice stays lasting less than 3 days among those who enrolled.1 Let’s say that people could be divided generally into those who are more reconciled to the idea of dying and more accepting of a palliative course when death is near and those who are less reconciled and accepting. The former group might be more likely to participate in ACP and at the same time more likely to move to hospice and stay there than those who cannot accept a palliative course. This association might undercut the authors’ assertion that “each aspect of ACP affects end-of-life care”; both measures may be expressions of a single underlying difference in the population. This difference may also partially, and only partially, explain the high rates of satisfaction in hospice and palliative care. Thomas E. Finucane, MD Johns Hopkins Bayview Medical Center, Baltimore, Maryland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Dr. Finucane is responsible for the entire content of this paper. Sponsor’s Role: Not applicable.
REFERENCE 1. Kara E, Bischoff KE, Sudore R et al. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc 2013;61:209–214.
RESPONSE LETTER TO THOMAS FINUCANE, MD To the Editor: We greatly appreciate the letter from Dr. Finucane and agree that our observational study design
2060
LETTERS TO THE EDITOR
allows us to identify only associations between advance care planning (ACP) and aspects of end-of-life care. We state in our paper, “the observational study design meant that only associations could be reported; that ACP causes changes in healthcare use cannot be concluded.” It is possible, even likely, that certain people are more apt to engage in ACP and also more likely to pursue hospice, as Dr. Finucane proposes. However, it is also likely that, in some cases, ACP influences end-of-life care; we write that our data “suggest” this possibility, although they do not prove it. We acknowledge that a prospective randomized controlled trial could be helpful but would be time consuming and expensive to perform on such a large scale as our study. Kara E. Bischoff, MD Department of Medicine, University of California at San Francisco, Moffitt Hospital, San Francisco, California
ACKNOWLEDGMENTS Conflict of Interest: None. Author Contribution: Dr. Bischoff designed and wrote the letter in full. Sponsor’s Role: None.
PERIODONTITIS, EDENTULISM, AND DEMENTIA To the Editor: Stewart and colleagues demonstrate that “periodontitis may be a risk factor for cognitive decline,”1 but they also refer to a prospective relationship between dementia and edentulism 12 years previously. Wouldn’t it be right to think that these individuals with dementia, having been free of dentition for 12 years, would also have been free of periodontitis for that interval? This seems to be indirect evidence that recent or ongoing local inflammation, at least of the structures surrounding the teeth, is not strongly causally related to dementia. Thomas E. Finucane, MD Johns Hopkins Bayview Medical Center, Baltimore, Maryland
NOVEMBER 2013–VOL. 61, NO. 11
JAGS
RESPONSE TO THOMAS FINUCANE To the Editor: The authors thank Dr. Finucane for his letter raising the question regarding the association between edentulism and dementia that was referenced in our article.1 Dr. Finucane’s question refers specifically to the Nun Study cited in our Introduction, one of the few studies to investigate prospectively the association between dementia and measures of oral health. A study of 144 nuns in Milwaukee found that tooth loss was associated with prevalence and incidence of dementia over 12 years of followup.2 The use of the term “edentulism” in our text could be cause for confusion. In the Nun Study, partial (some tooth loss but some teeth remaining) and complete (complete tooth loss) edentulism were combined and referred to collectively in our text as edentulism. Although space limitations prevent a full review of the findings reported in the Nun Study, it concluded that partial edentulism was significantly associated with prevalent and incident dementia. Complete edentulism was investigated only in a cross-sectional analysis and was found to be not significantly associated with prevalent dementia at baseline, although a suggestive finding was reported for nuns without the apolipoprotein E4 allele. Incident disease was investigated using only a grouping of individuals in which those with complete edentulism were combined with those with one to nine remaining teeth, preventing assessment of complete edentulism alone. As was noted, the Nun Study should be interpreted with caution, because causes of tooth loss other than periodontal disease are possible. Moreover, these data do not support ascribing causality to these findings. Robert Stewart, MD Section of Epidemiology, Institute of Psychiatry, King’s College London, London, UK Robert Weyant, DMD, DrPH Department of Dental Public Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania Anne Newman, MD, MPH Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
ACKNOWLEDGMENTS ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: TF is responsible for the entire content of this paper. Sponsor’s Role: Not applicable.
REFERENCE 1. Stewart R, Weyant RJ, Garcia ME, et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to this paper. Sponsor’s Role: None.
REFERENCES 1. Stewart R, Weyant RJ, Garcia ME et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184. 2. Stein PS, Desrosiers M, Donegan SJ et al. Tooth loss, dementia and neuropathology in the Nun Study. J Am Dent Assoc 2007;138:1314–1322.
NOVEMBER 2013–VOL. 61, NO. 11
Olivier Martinaud, MD, PhD Department of Neurology, Rouen University Hospital, Rouen, France Centre National de Référence pour les Malades Alzheimer Jeunes, Lille, Rouen, and France Paris-Salpêtrière Hospitals, France Alaina Borden, MD Department of Neurology, Rouen University Hospital, Rouen, France Dominique Campion, MD, PhD Inserm U1079, Rouen, France Institute for Research and Innovation in Biomedicine, Normandie University, Rouen, France Centre National de Référence pour les Malades Alzheimer Jeunes, Lille, Rouen, and France Paris-Salpêtrière Hospitals, France Department of Research, Rouvray Psychiatric Hospital, Sotteville-lès-Rouen, France Didier Hannequin, MD, PhD Inserm U1079, Rouen, France Institute for Research and Innovation in Biomedicine, Normandie University, Rouen, France Department of Neurology, Rouen University Hospital, Rouen, France Centre National de Référence pour les Malades Alzheimer Jeunes, Lille, Rouen, and France Paris-Salpêtrière Hospitals, France
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study concept and design: Nicolas. Acquisition of subjects and data: Nicolas, Wallon, Salle, Dreano, Martinaud, Borden, Campion, Hannequin. Analysis and interpretation of data: Nicolas, Wallon, Salle, Dreano, Martinaud, Borden, Campion, Hannequin. Preparation of manuscript: Nicolas, Wallon, Borden, Hannequin. Sponsor’s Role: No specific role of the funding source.
REFERENCES 1. Nicolas G, Pottier C, Maltete D et al. Mutation of the PDGFRB gene as a cause of idiopathic basal ganglia calcification. Neurology 2013;80: 181–187. 2. Godefroy O, Roussel M, Leclerc X et al. Deficit of episodic memory: Anatomy and related patterns in stroke patients. Eur Neurol 2009;61:223–229. 3. Petersen RC. Clinical practice. Mild cognitive impairment. N Engl J Med 2011;364:2227–2234. 4. Manyam BV, Walters AS, Narla KR. Bilateral striopallidodentate calcinosis: Clinical characteristics of patients seen in a registry. Mov Disord 2001;16:258–264. 5. Gorelick PB, Scuteri A, Black SE et al. Vascular contributions to cognitive impairment and dementia: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:2672–2713. 6. Sarazin M, Berr C, De Rotrou J et al. Amnestic syndrome of the medial temporal type identifies prodromal AD: A longitudinal study. Neurology 2007;69:1859–1867.
LETTERS TO THE EDITOR
2059
7. McKeith IG, Dickson DW, Lowe J et al. Diagnosis and management of dementia with Lewy bodies: Third report of the DLB Consortium. Neurology 2005;65:1863–1872. 8. Lemos R, Oliveira M, Oliveira J. Reporting a new mutation at the SLC20A2 gene in familial idiopathic basal ganglia calcification. Eur J Neurol 2013;20:e43–e44. 9. Yamada M, Asano T, Okamoto K et al. High frequency of calcification in basal ganglia on brain computed tomography images in Japanese older adults. Geriatr Gerontol Int 2013;13:706–710. 10. Nicolas G, Guillin O, Borden A et al. Psychosis revealing familial idiopathic basal ganglia calcification. Gen Hosp Psychiatry 2012 Oct 30; pii: S0163-8343(12)00280-0. doi: 10.1016/j.genhosppsych.2012.09.008.; [Epub ahead of print].
COMMENTS/RESPONSES MORTALS WHO ARE RECONCILED TO BEING MORTAL To the Editor: Kara and colleagues report that advance care planning (ACP) is associated with lower rates of in-hospital death, higher rates of hospice enrollment, and lower rates of hospice stays lasting less than 3 days among those who enrolled.1 Let’s say that people could be divided generally into those who are more reconciled to the idea of dying and more accepting of a palliative course when death is near and those who are less reconciled and accepting. The former group might be more likely to participate in ACP and at the same time more likely to move to hospice and stay there than those who cannot accept a palliative course. This association might undercut the authors’ assertion that “each aspect of ACP affects end-of-life care”; both measures may be expressions of a single underlying difference in the population. This difference may also partially, and only partially, explain the high rates of satisfaction in hospice and palliative care. Thomas E. Finucane, MD Johns Hopkins Bayview Medical Center, Baltimore, Maryland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Dr. Finucane is responsible for the entire content of this paper. Sponsor’s Role: Not applicable.
REFERENCE 1. Kara E, Bischoff KE, Sudore R et al. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc 2013;61:209–214.
RESPONSE LETTER TO THOMAS FINUCANE, MD To the Editor: We greatly appreciate the letter from Dr. Finucane and agree that our observational study design
2060
LETTERS TO THE EDITOR
allows us to identify only associations between advance care planning (ACP) and aspects of end-of-life care. We state in our paper, “the observational study design meant that only associations could be reported; that ACP causes changes in healthcare use cannot be concluded.” It is possible, even likely, that certain people are more apt to engage in ACP and also more likely to pursue hospice, as Dr. Finucane proposes. However, it is also likely that, in some cases, ACP influences end-of-life care; we write that our data “suggest” this possibility, although they do not prove it. We acknowledge that a prospective randomized controlled trial could be helpful but would be time consuming and expensive to perform on such a large scale as our study. Kara E. Bischoff, MD Department of Medicine, University of California at San Francisco, Moffitt Hospital, San Francisco, California
ACKNOWLEDGMENTS Conflict of Interest: None. Author Contribution: Dr. Bischoff designed and wrote the letter in full. Sponsor’s Role: None.
PERIODONTITIS, EDENTULISM, AND DEMENTIA To the Editor: Stewart and colleagues demonstrate that “periodontitis may be a risk factor for cognitive decline,”1 but they also refer to a prospective relationship between dementia and edentulism 12 years previously. Wouldn’t it be right to think that these individuals with dementia, having been free of dentition for 12 years, would also have been free of periodontitis for that interval? This seems to be indirect evidence that recent or ongoing local inflammation, at least of the structures surrounding the teeth, is not strongly causally related to dementia. Thomas E. Finucane, MD Johns Hopkins Bayview Medical Center, Baltimore, Maryland
NOVEMBER 2013–VOL. 61, NO. 11
JAGS
RESPONSE TO THOMAS FINUCANE To the Editor: The authors thank Dr. Finucane for his letter raising the question regarding the association between edentulism and dementia that was referenced in our article.1 Dr. Finucane’s question refers specifically to the Nun Study cited in our Introduction, one of the few studies to investigate prospectively the association between dementia and measures of oral health. A study of 144 nuns in Milwaukee found that tooth loss was associated with prevalence and incidence of dementia over 12 years of followup.2 The use of the term “edentulism” in our text could be cause for confusion. In the Nun Study, partial (some tooth loss but some teeth remaining) and complete (complete tooth loss) edentulism were combined and referred to collectively in our text as edentulism. Although space limitations prevent a full review of the findings reported in the Nun Study, it concluded that partial edentulism was significantly associated with prevalent and incident dementia. Complete edentulism was investigated only in a cross-sectional analysis and was found to be not significantly associated with prevalent dementia at baseline, although a suggestive finding was reported for nuns without the apolipoprotein E4 allele. Incident disease was investigated using only a grouping of individuals in which those with complete edentulism were combined with those with one to nine remaining teeth, preventing assessment of complete edentulism alone. As was noted, the Nun Study should be interpreted with caution, because causes of tooth loss other than periodontal disease are possible. Moreover, these data do not support ascribing causality to these findings. Robert Stewart, MD Section of Epidemiology, Institute of Psychiatry, King’s College London, London, UK Robert Weyant, DMD, DrPH Department of Dental Public Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania Anne Newman, MD, MPH Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
ACKNOWLEDGMENTS ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: TF is responsible for the entire content of this paper. Sponsor’s Role: Not applicable.
REFERENCE 1. Stewart R, Weyant RJ, Garcia ME, et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to this paper. Sponsor’s Role: None.
REFERENCES 1. Stewart R, Weyant RJ, Garcia ME et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184. 2. Stein PS, Desrosiers M, Donegan SJ et al. Tooth loss, dementia and neuropathology in the Nun Study. J Am Dent Assoc 2007;138:1314–1322.
