Extreme behavioural and psychological symptoms of dementia: a case study

BACKGROUND

The seven tiered behavioural and psychological symptoms of dementia (BPSD) model of service delivery has been used by inpatient units. The classification of each tier is broadly defined and not always agreed upon by clinicians. The case study uses novel approach by combining the BPSD classification criteria with clinical presentation to identify the clinical characteristics of the case and match these characteristics against the BPSD classification. This process was enhanced by using case specific measures such as the Neuropsychiatric Inventory (NPI) and Cohen Mansfield Agitation Inventory (CMAI) scales and key clinical data.

CASE PRESENTATION

A case study of 76 year old male diagnosed with mixed Alzheimer's and Vascular dementia. The clinical presentation of the symptomatology was deemed to be extreme, thus fitting into the seventh tier (Extreme) of the BPSD model of service delivery. The case is considered to fit into the Extreme BPSD category given the high levels of aggression, which were consistently reflected in high scores on NPI and CMAI, as well as long length of inpatient stay (over 3 years). The average number of Pro re nata (PRN) psychotropics medications per month was 56 and seclusion episodes of 6 times per month, with each episode lasting on average 132 min shows severity of behaviours. His level of aggression had resulted in environmental damage and staff injuries.

CONCLUSION

We recommend patient clinical characteristics, relevant hospital data and specific measures should be used to develop consensus around defining and classifying cases into Extreme BPSD.

Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A Systematic Review

OBJECTIVE

To synthesize recommendations on assessing and managing behavioral and psychological symptoms of dementia (BPSDs) in existing clinical practice guidelines on dementia care to learn from and adapt recommendations to a Canadian context and language for describing BPSDs.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Moderate to high-quality clinical practice guidelines on dementia care that made 1 or more recommendations on BPSD assessment or management.

METHODS

We searched MEDLINE, Embase, JBI EBM, PsycINFO, AgeLine, and gray literature for clinical practice guidelines on dementia care making recommendations on BPSD, published between January 1, 2011, and October 13, 2022. Two independent reviewers conducted study screening and data abstraction. Four independent reviewers completed quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool; included guidelines had a mean overall AGREE II score ≥4.

RESULTS

Our systematic review identified 23 moderate to high-quality clinical practice guidelines (264 recommendations). The mean overall quality score on the AGREE II tool ranged from 4 to 6.5. Recommendations were clearly presented (mean clarity of presentation score 73.5%), but guideline applicability was not consistently addressed (mean applicability score 39.3%). BPSD was the most prevalent term describing neuropsychiatric symptoms (number of guidelines [n] = 14). People with lived experience contributed to 6 guidelines (26.1%). Ten guidelines (43.5%) described 1 or more health equity considerations. Guidelines made recommendations for assessing and managing agitation (n = 12), aggression (n = 10), psychosis (n = 11), depression (n = 9), anxiety (n = 5), apathy (n = 6), inappropriate sexual behavior (n = 3), nighttime behavior (n = 5), and eating disturbances (n = 3). There was substantial variability in recommendation statements, evidence quality assigned to each statement, and strength of recommendations.

CONCLUSIONS AND IMPLICATIONS

There are several moderate to high-quality clinical practice guidelines making recommendations on BPSD assessment and management, but variability in recommendation statements across guidelines and insufficient consideration of guideline applicability may hamper guideline dissemination and implementation in clinical practice.

Clusterization of Behavioral and Psychological Symptoms of Dementia as Assessed by Neuropsychiatric Inventory: A Case Against the Use of Principal Component Analysis

Background

The term Behavioral and Psychological Symptoms of Dementia (BPSD) covers a group of phenomenologically and medically distinct symptoms that rarely occur in isolation. Their therapy represents a major unmet medical need across dementias of different types, including Alzheimer's disease. Understanding of the symptom occurrence and their clusterization can inform clinical drug development and use of existing and future BPSD treatments.

Objective

The primary aim of the present study was to investigate the ability of a commonly used principal component analysis to identify BPSD patterns as assessed by Neuropsychiatric Inventory (NPI).

Methods

NPI scores from the Aging, Demographics, and Memory Study (ADAMS) were used to characterize reported occurrence of individual symptoms and their combinations. Based on this information, we have designed and conducted a simulation experiment to compare Principal Component analysis (PCA) and zero-inflated PCA (ZI PCA) by their ability to reveal true symptom associations.

Results

Exploratory analysis of the ADAMS database revealed overlapping multivariate distributions of NPI symptom scores. Simulation experiments have indicated that PCA and ZI PCA cannot handle data with multiple overlapping patterns. Although the principal component analysis approach is commonly applied to NPI scores, it is at risk to reveal BPSD clusters that are a statistical phenomenon rather than symptom associations occurring in clinical practice.

Conclusions

We recommend the thorough characterization of multivariate distributions before subjecting any dataset to Principal Component Analysis.

Diagnoses and Treatment of Behavioral and Psychological Symptoms of Dementia Among Racially and Ethnically Diverse Persons Living with Dementia

Background

Behavioral and psychological symptoms of dementia (BPSD) and prescribed central nervous system (CNS) active drugs to treat them are prevalent among persons living with Alzheimer's disease and related dementias (PLWD) and lead to negative outcomes for PLWD and their caregivers. Yet, little is known about racial/ethnic disparities in diagnosis and use of drugs to treat BPSD.

Objective

Quantify racial/ethnic disparities in BPSD diagnoses and CNS-active drug use among community-dwelling PLWD.

Methods

We used a retrospective cohort of community-dwelling Medicare Fee-for-Service beneficiaries with dementia, continuously enrolled in Parts A, B and D, 2017-2019. Multivariate logistic models estimated rates of BPSD diagnosis and, conditional on diagnosis, CNS-active drug use.

Results

Among PLWD, 67.1% had diagnoses of an affective, psychosis or hyperactivity symptom. White (68.3%) and Hispanic (63.9%) PLWD were most likely, Blacks (56.6%) and Asians (52.7%) least likely, to have diagnoses. Among PLWD with BPSD diagnoses, 78.6% took a CNS-active drug. Use was highest among whites (79.3%) and Hispanics (76.2%) and lowest among Blacks (70.8%) and Asians (69.3%). Racial/ethnic differences in affective disorders were pronounced, 56.8% of white PLWD diagnosed; Asians had the lowest rates (37.8%). Similar differences were found in use of antidepressants.

Conclusions

BPSD diagnoses and CNS-active drug use were common in our study. Lower rates of BPSD diagnoses in non-white compared to white populations may indicate underdiagnosis in clinical settings of treatable conditions. Clinicians' review of prescriptions in this population to reduce poor outcomes is important as is informing care partners on the risks/benefits of using CNS-active drugs.

Diagnosis of behavioral symptoms as a predictor of institutionalization among Medicaid patients with dementia

OBJECTIVES

Behavioral symptoms are commonly observed in the course of dementia. This study aimed to assess the association of the diagnosis of a cluster of behavioral symptoms (e.g., agitation, aggression, psychotic symptoms, and delirium/wandering) with the likelihood of subsequent institutionalization.

METHODS

A retrospective cohort study of adults aged 65 and above diagnosed with dementia identified in the IBM® MarketScan® Multistate Medicaid database between October 01, 2015, and September 30, 2019, was conducted. The index date was defined as the first diagnosis date of dementia. The presence or absence of behavioral symptoms was identified in the 6 months prior to the index date (baseline). Institutionalization was evaluated 12 months (follow-up) post the index date. The association between diagnosed behavioral symptoms during the baseline period and institutionalization in the follow-up period was assessed using a multivariable logistic regression, adjusting for baseline sociodemographic and clinical characteristics.

RESULTS

The study cohort included 40,714 patients with dementia. A diagnosis of behavioral symptoms was found among 2,067 (5.1%) patients during the baseline period. An increased likelihood of institutionalization was found during the follow-up among patients with agitation and aggression in baseline (OR = 1.51 (95% CI: 1.18-1.92)) compared to patients without these symptoms at baseline. Patients with psychotic symptoms in baseline had significantly higher odds of getting institutionalized during the follow-up compared to patients without psychotic symptoms in baseline (OR = 1.36 (95% CI: 1.20-1.54)). Similarly, patients with symptoms of delirium and wandering in baseline had a higher likelihood of institutionalization than patients without these symptoms at baseline (OR = 1.61 (95% CI: 1.30-1.99)).

CONCLUSION

Several diagnosed behavioral symptoms were associated with a higher risk of institutionalization among older adults with dementia and should be considered when planning treatment strategies for the effective management of the condition.

'There's no straight line…' a consumer-informed intervention for FTD family care partners: the STELLA-FTD pilot study

OBJECTIVES

Behavioral symptoms and communication challenges are particularly apparent in frontotemporal degenerative (FTD) dementias. There is a paucity of psychoeducation programming specifically tailored to the needs of families with FTD. We revised an existing intervention to meet the needs of these families.

METHODS

We used a quasi-experimental approach. In Phase 1, we sought consumer input about an existing intervention. In Phase 2, we modified the intervention based on the qualitative findings from Phase 1 and tested the revised intervention (STELLA-FTD) for feasibility, acceptability and early-stage efficacy. Outcome for Phase 2 included feasibility data and care partner reactivity to upsetting behaviors. Secondary outcomes included data from unobtrusive sleep monitoring. An inductive analysis of transcripts from the Phase 2 STELLA-FTD focus group provides guidance for future revisions.

RESULTS

Fifteen family care partners participated in the Phase 1 focus groups; sixteen care partners enrolled in Phase 2. Testing in Phase 2 revealed that the care partners found our consumer-informed revised intervention both feasible and acceptable. The post-intervention findings suggest STELLA-FTD has the potential to reduce care partner reactivity to upsetting behaviors and to decrease care partner burden. Sleep did not change over the 8-week intervention.

CONCLUSIONS

The revised STELLA-FTD intervention was found to be feasible and acceptable, and has potential to improve care partner burden for families living with FTD. Providing the intervention via telehealth maximized access and engaged rehabilitation specialists in providing disease management content. Future revisions will include examination of efficacy and mechanism of action (OHSU IRB # 00022721, ClinicalTrials.gov NCT05338710).

Effect of Nordic Sensi® Chair on Behavioral and Psychological Symptoms of Dementia in Nursing Homes Residents: A Randomized Controlled Trial

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are present in most people with dementia (PwD), including Alzheimer's disease. There is consensus that non-pharmacological therapies represent the first line of treatment to address BPSD.

OBJECTIVE

We explore the efficacy of the use of a rocking chair (Nordic Sensi® Chair, NSC) in the treatment of BPSD in nursing home residents with moderate and severe dementia.

METHODS

We carried out a 16-week randomized, single-blind, controlled, clinical trial with PwD admitted to nursing homes. Participants were assigned to a treatment group (n = 40) that received three times a week one session per day of 20 minutes in the NSC and a control group (n = 37). The Neuropsychiatric Inventory-Nursing Home (NPI-NH) was used as primary efficacy outcome. Occupational distress for the staff was evaluated using the NPI-NH Occupational Disruptiveness subscale (NPI-NH-OD). Statistical analyses were conducted by means of a Mixed Effects Model Analysis.

RESULTS

Treatment with the NSC was associated with a beneficial effect in most of BPSD, as reflected by differences between the treatment and control group on the NPI-NH total score (mean change score -18.87±5.56 versus -1.74±0.67, p = 0.004), agitation (mean change score -2.32±2.02 versus -0.78±1.44, p = 0.003) and irritability (mean change score -3.35±2.93 versus -1.42±1.31, p = 0.004). The NPI-NH-OD total score also improved the most in the treatment group (mean change score -9.67±7.67 versus -7.66±6.08, p = 0.003).

CONCLUSIONS

The reduction in overall BPSD along with decreased caregiver occupational disruptiveness represent encouraging findings, adding to the potential of nonpharmacological interventions for nursing home residents living with dementia.

Gait analysis as a robust pain behavioural endpoint in the chronic phase of the monoiodoacetate-induced knee joint pain in the rat

The monoiodoacetate-induced rat model of osteoarthritis knee pain is widely used. However, there are between-study differences in the pain behavioural endpoints assessed and in the dose of intraarticular monoiodoacetate administered. This study evaluated the robustness of gait analysis as a pain behavioural endpoint in the chronic phase of this model, in comparison with mechanical hyperalgesia in the injected (ipsilateral) joint and development of mechanical allodynia in the ipsilateral hind paws. Groups of Sprague-Dawley rats received a single intraarticular injection of monoiodoacetate at 0.5, 1, 2 or 3 mg or vehicle (saline) into the left (ipsilateral) knee joint. An additional group of rats were not injected (naïve group). The pain behavioural methods used were gait analysis, measurement of pressure algometry thresholds in the ipsilateral knee joints, and assessment of mechanical allodynia in the ipsilateral hind paws using von Frey filaments. These pain behavioural endpoints were assessed premonoiodoacetate injection and for up to 42-days postmonoiodoacetate injection in a blinded manner. Body weights were also assessed as a measure of general health. Good general health was maintained as all rats gained weight at a similar rate for the 42-day study period. In the chronic phase of the model (days 9-42), intraarticular monoiodoacetate at 3 mg evoked robust alterations in multiple gait parameters as well as persistent mechanical allodynia in the ipsilateral hind paws. For the chronic phase of the monoiodoacetate-induced rat model of osteoarthritis knee pain, gait analysis, such as mechanical allodynia in the ipsilateral hind paws, is a robust pain behavioural measure.

Symptom-level modelling unravels the shared genetic architecture of anxiety and depression

Depression and anxiety are highly prevalent and comorbid psychiatric traits that cause considerable burden worldwide. Here we use factor analysis and genomic structural equation modelling to investigate the genetic factor structure underlying 28 items assessing depression, anxiety and neuroticism, a closely related personality trait. Symptoms of depression and anxiety loaded on two distinct, although highly genetically correlated factors, and neuroticism items were partitioned between them. We used this factor structure to conduct genome-wide association analyses on latent factors of depressive symptoms (89 independent variants, 61 genomic loci) and anxiety symptoms (102 variants, 73 loci) in the UK Biobank. Of these associated variants, 72% and 78%, respectively, replicated in an independent cohort of approximately 1.9 million individuals with self-reported diagnosis of depression and anxiety. We use these results to characterize shared and trait-specific genetic associations. Our findings provide insight into the genetic architecture of depression and anxiety and comorbidity between them.

Increased prevalence of impulse control disorder symptoms in endocrine diseases treated with dopamine agonists: a cross-sectional study

INTRODUCTION

Impulse control disorders (ICDs) have been described as a side effect of dopamine agonists (DAs) in neurological as well as endocrine conditions. Few studies have evaluated the neuropsychological effect of DAs in hyperprolactinemic patients, and these have reported a relationship between DAs and ICDs. Our objective was to screen for ICD symptoms in individuals with DA-treated endocrine conditions.

MATERIALS AND METHODS

A cross-sectional analysis was conducted on 132 patients with pituitary disorders treated with DAs (DA exposed), as well as 58 patients with pituitary disorders and no history of DA exposure (non-DA exposed). Participants responded to the full version of the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease (QUIP).

RESULTS

Compared with the non-DA-exposed group, a higher prevalence of DA-exposed patients tested positive for symptoms of any ICD or related behavior (52% vs. 31%, p < 0.01), any ICD (46% vs. 24%, p < 0.01), any related behavior (31% vs. 17%, p < 0.05), compulsive sexual behavior (27% vs. 14%, p < 0.04), and punding (20% vs. 7%, p < 0.02) by QUIP. On univariate analysis, DA treatment was associated with a two- to threefold increased risk of any ICD or related behavior [odds ratio (OR) 2.43] and any ICD (OR 2.70). In a multivariate analysis, independent risk factors for any ICD or related behavior were DA use (adjusted OR 2.22) and age (adjusted OR 6.76). Male gender was predictive of the risk of hypersexuality (adjusted OR 3.82).

DISCUSSION

Despite the QUIP limitations, a clear sign of increased risk of ICDs emerges in individuals with DA-treated pituitary disorders. Our data contribute to the growing evidence of DA-induced ICDs in endocrine conditions.

Assessment of children in the autistic spectrum disorder that carry the Thr92Ala-DIO2 polymorphism

INTRODUCTION

A polymorphism in the type 2 deiodinase (Thr92Ala-DIO2) gene has been associated with behavioral and cognitive dysfunction as well as neurodegeneration and oxidative stress in the central nervous system.

OBJECTIVE

To test whether the minor allele (Ala92) frequency (MAF) is increased in children in the autism spectrum disorder (ASD), and whether carriers of the minor allele exhibit more severe symptoms and/or worse adaptive behavior.

STUDY DESIGN

ASD children were evaluated at baseline and yearly throughout the study by psychologists using the following tools: autism behavior checklist, Vineland Adaptative Behaviour Scales II, non-verbal intelligence test SON-R 21/2-7, SON-R 6-40, Weschler scale for intelligence, and autism treatment evaluation checklist.

SETTINGS

Academic outpatient mental health facility in Sao Paulo, Brazil.

PARTICIPANTS

ASD boys and girls younger than 18 years of age. 132 consecutive ASD children, mostly boys (~ 80%); ~ 50% was classified as verbal. Exclusion criteria were coexistence of sensory and/or physical impairment, or any associated genetic syndromes.

RESULTS

Median follow-up was for an uninterrupted period of 937 days (139-1375 days), which did not vary significantly among the genotypes. The MAF was 47% in ASD patients vs. 51% in a local reference population with similar ethnic background; the clinical severity and progression were not affected by the minor allele. Carriers of the minor allele exhibited higher adaptive behavior in the domains "daily living skills" and "communication", which correlated positively with the dose of the minor allele.

CONCLUSION

The MAF is not different in ASD children, but carriers of the Thr92Ala-DIO2 polymorphism exhibited higher adaptive behavior.

Global Psychotrauma Screen (GPS): psychometric properties in two Internet-based studies

Background: Potentially traumatic stressors can lead to various transdiagnostic outcomes beyond PTSD alone but no brief screening tools exist for measuring posttraumatic responses in a transdiagnostic manner. Objective: Assess the psychometric characteristics of a new 22-item transdiagnostic screening measure, the Global Psychotrauma Screen (GPS). Method: An internet survey was administered with English speaking participants recruited passively via the website of the Global Collaboration on Traumatic Stress (GC-TS) (nGC-TS  = 1,268) and actively via Amazon's MTurk (nMTurk  = 1,378). Exploratory factor analysis, correlational analysis, sensitivity and specificity analysis, and comparisons in response between the two samples and between male and female respondents were conducted. Results: Exploratory factor analysis revealed a single factor underlying symptom endorsements in both samples, suggesting that such problems may form a unitary transdiagnostic, posttraumatic outcome. Convergent validity of the GPS symptom and risk factors was established with measures of PTSD and dissociative symptoms in the MTurk sample. Gender differences were seen primarily at the item level with women more often endorsing several symptoms and specific risk factors in the MTurk sample, and the GC-TS recruited sample endorsed more symptoms and risk factors than the MTurk sample, suggesting that the GPS may be sensitive to group differences. A GPS symptom cut-off score of 8 identified optimized sensitivity and specificity relative to probable PTSD based on PCL-5 scores. Conclusions: The current results provide preliminary support for the validity of the GPS as a screener for the concurrent measurement of several transdiagnostic outcomes of potentially traumatic stressors and the apparent unifactorial structure of such symptoms is suggestive of a single or unitary posttraumatic outcome. Future research is needed to evaluate whether similarly strong psychometric properties can be yielded in response to completion of the GPS in other languages.

Shorter Chain Triglycerides Are Negatively Associated with Symptom Improvement in Schizophrenia

Schizophrenia is a serious mental disorder requiring lifelong treatment. While medications are available that are effective in treating some patients, individual treatment responses can vary, with some patients exhibiting resistance to one or multiple drugs. Currently, little is known about the causes of the difference in treatment response observed among individuals with schizophrenia, and satisfactory markers of poor response are not available for clinical practice. Here, we studied the changes in the levels of 322 blood plasma lipids between two time points assessed in 92 individuals diagnosed with schizophrenia during their inpatient treatment and their association with the extent of symptom improvement. We found 20 triglyceride species increased in individuals with the least improvement in Positive and Negative Syndrome Scale (PANSS) scores, but not in those with the largest reduction in PANSS scores. These triglyceride species were distinct from the rest of the triglyceride species present in blood plasma. They contained a relatively low number of carbons in their fatty acid residues and were relatively low in abundance compared to the principal triglyceride species of blood plasma.

Testing the Impact of FFC-AL-EIT on Psychosocial and Behavioral Outcomes in Assisted Living

BACKGROUND

This study tested the impact of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) on: (1) care interactions between residents and direct care staff; and (2) behavior and psychological symptoms associated with dementia among residents.

DESIGN

This was a randomized controlled trial.

SETTING

A total of 59 assisted living facilities in Maryland, Pennsylvania, and Massachusetts participated.

PARTICIPANTS

The sample included 550 mostly White (98%), female (69%) residents with a mean age of 89.30 (standard deviation = 7.63) years.

INTERVENTION

The four-step FFC-AL-EIT intervention was implemented by a function focused care nurse facilitator working with a facility champion over 12 months. The steps included: (1) environment and policy assessments; (2) education; (3) establishing resident function focused care service plans; and (4) mentoring and motivating.

MEASURES

Resident descriptive data (e.g., age, sex, education, and comorbidities), depression, agitation, resistiveness to care, and the quality of care interactions were obtained at baseline and 4 and 12 months. Treatment fidelity data included environment and policy assessments, performance of function focused care by staff, and service plan assessments.

RESULTS

There was a significant positive treatment effect related to depression, agitation, resistiveness to care, and quality of care interactions with either less decline or some improvement in these behaviors and symptoms in the treatment versus control group.

CONCLUSION

The study provides some statistical support, which may not necessarily be clinically significant evidence, for psychosocial outcomes of residents and care interactions between staff and residents in assisted living settings.

InterRAI Child and Youth Mental Health-Screener (ChYMH-S): A Psychometric Evaluation and Validation Study

Mental health concerns among children are pervasive, with one in five in North America experiencing a mental health issue. Unfortunately, only about a quarter will receive the support they need. interRAI is an organization of expert researchers and clinicians who develop integrated assessment systems to improve evaluation for vulnerable populations. The interRAI Child and Youth Mental Health Screener (ChYMH-S) is a brief screener that provides an initial assessment for early identification, triaging, and prioritization of services. This study assesses the psychometric properties of the ChYMH-S. Data from children aged 4-18 years across Ontario mental health agencies were obtained. The screener demonstrated strong inter-item reliability on all measured scales and good convergent validity with the Behaviour Assessment System for Children, with all hypothesized comparisons demonstrating positive, significant correlations. Overall, results provide initial support for the reliability and convergent validity of the ChYMH-S in detecting mental health concerns in child populations.

Behavioural and emotional profile of children in residential care in Greece

Previous research has shown the harmful effects that out of home care can have on children. Specifically, institutionalized children experience high rates of developmental and psychological problems, and therefore special attention is needed so that a fast intervention can be achieved and further complications can be prevented. This paper focuses on building the psychological and behavioural profile of children living in four residential care units in western Greece, in respect to gender, age and nationality. 153 children (88 children in residential care and 65 children rearing in their families) participated in the study. The children age ranged from 6 to 18 years. Children's behavioural profile was assessed through Child Βehaviour Checklist 6-18 (CBCL 6-18) and was afterwards analyzed with respect to variables such as age, gender and nationality. Children in residential care had higher rates of clinical/borderline range symptoms in Internalizing, Externalizing and Total Problems scale than their counterparts rearing at home. Specifically, they were more withdrawn/ depressed and tended to indicate more rule-breaking behaviour. Both genders showed vulnerability in Internalizing behaviour scale, but girls presented higher rates than boys in the clinical range in Externalizing behaviour scale (22% vs 12%) and Total Problems scale (24% vs 5%). Finally, adolescents in residential care exhibit more internalizing symptoms in clinical range than younger children (22% vs 0%), whereas children of Greek nationality were more vulnerable than children of other nationalities, especially in externalizing behavioural symptoms (28% vs 6%). Our study suggests that children in residential care are at high risk for developing mental health issues. The finding that children are more withdrawn and depressed underlines the possible difficulties in establishing confident relations with peers and adults and can destruct their orientation towards social reality, exhibit mistrust to other people and cause insecurity for their future. There is a lack of longitudinal studies investigating children who have lived in institutions in Greece. Such studies would possibly reveal protective or aggravating parameters that have a positive or negative impact on the development of those children and the transition to adult life.

Neural Correlates of the Dual-Pathway Model for ADHD in Adolescents

OBJECTIVE

The dual-pathway model has been proposed to explain the heterogeneity in symptoms of attention deficit hyperactivity disorder (ADHD) by two independent psychological pathways based on distinct brain circuits. The authors sought to test whether the hypothesized cognitive and motivational pathways have separable neural correlates.

METHODS

In a longitudinal community-based cohort of 1,963 adolescents, the neuroanatomical correlates of ADHD were identified by a voxel-wise association analysis and then validated using an independent clinical sample (99 never-medicated patients with ADHD, 56 medicated patients with ADHD, and 267 healthy control subjects). The cognitive and motivational pathways were assessed by neuropsychological tests of working memory, intrasubject variability, stop-signal reaction time, and delay discounting. The associations were tested between the identified neuroanatomical correlates and both ADHD symptoms 2 years later and the polygenic risk score for ADHD.

RESULTS

Gray matter volumes of both a prefrontal cluster and a posterior occipital cluster were negatively associated with inattention. Compared with healthy control subjects, never-medicated patients, but not medicated patients, had significantly lower gray matter volumes in these two clusters. Working memory and intrasubject variability were associated with the posterior occipital cluster, and delay discounting was independently associated with both clusters. The baseline gray matter volume of the posterior occipital cluster predicted the inattention symptoms in a 2-year follow-up and was associated with the genetic risk for ADHD.

CONCLUSIONS

The dual-pathway model has both shared and separable neuroanatomical correlates, and the shared correlate in the occipital cortex has the potential to serve as an imaging trait marker of ADHD, especially the inattention symptom domain.

Differences in Staff-Assessed Pain Behaviors among Newly Admitted Nursing Home Residents by Level of Cognitive Impairment

OBJECTIVE

Pain is common among nursing home residents with cognitive impairment and dementia. Pain is often underdiagnosed and undertreated, which may lead to adverse health outcomes. Nonverbal behaviors are valid indicators of pain, but the extent to which these behavioral expressions vary across levels of cognitive impairment is unknown. This study sought to examine differences in the prevalence of pain behaviors among nursing home residents with varying levels of cognitive impairment.

METHODS

The Minimum Data Set, version 3.0, was used to identify newly admitted nursing home residents with staff-assessed pain (2010-2016, n = 1,036,806). Staff-assessed pain behaviors included nonverbal sounds, vocal complaints, facial expressions, and protective body movements or postures over a 5-day look-back period for residents unable or unwilling to self-report pain. The Cognitive Function Scale was used to categorize residents as having no/mild, moderate, or severe cognitive impairment. Modified Poisson models provided adjusted prevalence ratios (aPR) and 95% CIs.

RESULTS

Compared to residents with no/mild cognitive impairments (any pain: 48.1%), residents with moderate cognitive impairment (any pain: 42.4%; aPR: 0.94 [95% CI 0.93-0.95]) and severe cognitive impairment (any pain: 38.4%; aPR: 0.86 [95% CI 0.85-0.88]) were less likely to have any pain behavior documented. Vocal pain behaviors were common (43.5% in residents with no/mild cognitive impairment), but less so in those with severe cognitive impairment (20.1%). Documentation of facial expressions and nonverbal pain behaviors was more frequent for residents with moderate and severe cognitive impairment than those with no/mild cognitive impairment.

CONCLUSIONS

The prevalence of behaviors indicative of pain differs by level of cognitive impairment. Pain evaluation and management plays an important role in treatment and care outcomes. Future work should examine how practitioners' perceptions of pain behaviors influence their ratings of pain intensity and treatment choices.

Impact of COVID-19 pandemic on mental health of young people and adults: a systematic review protocol of observational studies

INTRODUCTION

Since the WHO declared COVID-19 as a pandemic, the spread of the new coronavirus has been the focus of attention of scientists, governments and populations. One of the main concerns is the impact of this pandemic on health outcomes, mainly on mental health. Even though there are a few empirical studies on COVID-19 and mental health, so far, there is no systematic review about the impact of COVID-19 on mental health of young people and adults yet. We aim to critically synthesise the scientific evidence about the impact of the COVID-19 pandemic on the mental health of young people and adults.

METHODS AND ANALYSIS

A systematic review will be performed through eight databases: MEDLINE (Medical Literature Analysis and Retrieval System Online), ISI-of-Knowledge, CENTRAL (Cochrane Central Register of Controlled Trials), EMBASE (Excerpta Medica Database), SCOPUS, LILACS (Latin American and Caribbean Health Sciences Literature), PsycINFO (Psychology Information) and CNKI (Chinese National Knowledge Infrastructure), from inception until 30 June 2020. No restriction regarding the publication date, setting or languages will be considered. Preliminary search strategies were carried out on 29 March 2020 and will be updated in June 2020. The primary outcomes will be the prevalence and the severity of psychological symptoms in young people and adults (>18 years old) resulting from the impact of COVID-19 pandemic. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Pooled standardised mean differences and 95% CIs will be calculated. The risk of bias of the observational studies will be assessed through the Methodological Index for Non-Randomised Studies (MINORS). Additionally, if sufficient data are available, a meta-analysis will be conducted. Heterogeneity between the studies will be determined by the I² statistics. Subgroup analyses will also be performed. Publication bias will be checked with funnel plots and Egger's test. Heterogeneity will be explored by random-effects analysis.

ETHICS AND DISSEMINATION

Ethical assessment was not required. Findings will be disseminated through peer-reviewed publication and will be presented at conferences related to this field.

PROSPERO REGISTRATION NUMBER

CRD42020177366.

Rasch analysis of the PANSS negative subscale and exploration of negative symptom trajectories in first-episode schizophrenia - data from the OPTiMiSE trial

The observed heterogeneity in negative symptom treatment response may be partly attributable to inadequate measurement tools or limitations in methods of analysis. Previous Item Response Theory models of the Positive and Negative Syndrome Scale (PANSS) have only examined samples of chronic patients and with mixed results. We examined the scalability of the negative subscale embedded in the PANSS and subsequently explored negative symptom trajectories across four weeks of amisulpride treatment. Data were derived from the OPTiMiSE trial comprising 446 patients with first-episode schizophrenia or schizophreniform disorder. Using the Rasch Model to examine psychometric properties of the PANSS negative subscale, we found that the composite score across items was not an adequate measure of negative symptom severity. Consequently, we chose an exploratory statistical approach involving Principal Component Analysis which yielded one significant component clustering into two significant symptom trajectories: 1) Subtle but constant decrease in negative symptom severity (N = 323; 72%), and 2) symptom instability across visits (N = 19; 4%). Explorative analytic methods as presented here may pave the way for more efficient and sensitive methods of analyzing negative symptom response in research and in clinical practice.

How interindividual differences shape approach-avoidance behavior: Relating self-report and diagnostic measures of interindividual differences to behavioral measurements of approach and avoidance

Responding to stimuli in ambiguous environments is partially governed by approach-avoidance tendencies. Imbalances in these approach-avoidance behaviors are implicated in many mental disorders including anxiety disorders, phobias and substance use disorders. While factors biasing human behavior in approach-avoidance conflicts have been researched in numerous experiments, a much-needed comprehensive overview integrating those findings is missing. Here, we systematically searched the existing literature on individual differences in task-based approach-avoidance behavior and aggregated the current evidence for the effect of self-reported approach/avoidance traits, anxiety and anxiety disorders, specific phobias, depression, aggression, anger and psychopathy, substance use and related disorders, eating disorders and habits, trauma, acute stress and, finally, hormone levels (mainly testosterone, oxytocin). We highlight consistent findings, underrepresented research areas and unexpected results, and detail the amount of controversy between studies. We discuss potential reasons for ambiguous results in some research areas, offer practical advice for future studies and highlight potential variables such as task-related researcher decisions that may influence how interindividual differences and disorders drive automatic approach-avoidance biases in behavioral experiments.

Bilateral basal ganglia infarcts presenting as rapid onset cognitive and behavioral disturbance

We describe a rare case of a patient with rapid onset, prominent cognitive and behavioral changes who presented to our rapidly progressive dementia program with symptoms ultimately attributed to bilateral basal ganglia infarcts involving the caudate heads. We review the longitudinal clinical presentation and neuropsychological testing for this patient, and discuss the implicated basal ganglia and frontal lobe neuroanatomy.

Factor structure and psychometric properties of the Greek version of Saving Inventory-Revised (SI-R) in a non-clinical sample

Hoarding disorder is a debilitating condition that results from difficulty or inability to discard possessions and the need to save items and leads to cluttered living space. It impedes normal everyday functioning and causes significant distress and dysfunction. The aim of the current study was to validate the Greek version of the Saving Inventory-Revised (SI-R) in a non-clinical sample of 554 Greek adults. Factor structure and psychometric properties were investigated. Common exploratory (EFA) and confirmatory factor analysis (CFA) were used to explore the factor structure of the data. A three-factor solution was emerged for the Greek SI-R Which appears to cover the clinical dimensions of the phenomenon and consists of clutter, difficulty discarding and acquisition dimensions. This finding is in accordance with the original English version as well as other adaptations of the instrument in other languages. Some items cross loaded but such findings of cross loading items are also reported in related literature. The Greek version of the SI-R exhibits satisfactory internal consistency and good test retest reliability (stability). The current study also aimed to gather evidence towards the convergent and discriminant validity of Greek SI-R. Findings showed no correlation with measurements of different constructs such as anxiety, depression and non-hoarding obsessive compulsive symptoms but also only partial correlation with measurements of relative clinical constructs, such as hoarding items in obsessive compulsive inventories. Current findings suggest that the Greek SI-R can be a useful tool in the detection and evaluation of hoarding symptoms in Greek population.

Assessment of irritability in school-aged children by pediatric, family practice, and psychiatric providers

BACKGROUND

Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication.

OBJECTIVE

Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability.

METHODS

A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed.

RESULTS

In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups.

CONCLUSION

This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.