The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia

Measures to Assess the Noncognitive Symptoms of Dementia in the Primary Care Setting

Noncognitive symptoms associated with Alzheimer's disease and related dementias include psychosis, mood disturbances, personality changes, agitation, aggression, pacing, wandering, altered sexual behavior, changed sleep patterns, and appetite disturbances. These noncognitive symptoms of dementia are common, disabling to both the patient and the caregiver, and costly. Primary care physicians will often play a major role in diagnosing and treating dementia and related disorders in the community. Accurate recognition and treatment of noncognitive symptoms is vital. A brief, user-friendly assessment tool would aid in the clinical management of noncognitive symptoms of dementia. Accordingly, we reviewed the available measures for their relevance in a primary care setting. Among these instruments, the Neuropsychiatric Inventory-Questionnaire seems most appropriate for use in primary care and worthy of further investigation.

Olanzapine as a treatment of neuropsychiatric disorders of Alzheimer's disease and other dementias: a 24-month follow-up of 68 patients

Although the core feature of all types of dementia is progressive cognitive disruption, most demented patients also express noncognitive behavioral problems. These noncognitive problems lead to potentially devastating disabilities, and are often a major cause of stress, anxiety and concern for caregivers. Psychotropic drugs are frequently used to control these symptoms, but they have the potential for significant side effects, such as sedation, disinhibition, depression, falls, incontinence, parkinsonisms and akathisias. For 24 months, we monitored 68 outpatients suffering from Alzheimer's disease, vascular dementia, frontal lobe dementia, Parkinson dementia complex, and Lewy body disease. Our purpose was to identify the role and efficacy of olanzapine and the side effects which emerged during the treatment of behavioral alteration resulting from five etiological causes. This paper will discuss the results of this study, and will provide an overview of the existing literature.

Inhibitory attentional control in patients with frontal lobe damage

The performance of a group of frontal lobe lesion and a group of frontal lobe dementia patients was compared with the performance of their respective matched normal control groups on two tests of inhibitory attentional control-the stop-signal reaction time task and a negative priming task. Both patient groups responded significantly slower than their respective normal control groups, but they showed only marginally significant selective impairments on the measures of inhibition. The data suggest that the specific inhibitory processes evaluated by these two tests are, in general, spared in patients with focal frontal lobe lesions or frontal lobe degeneration.

Differential Diagnosis and Clinical Assessment of Patients With Severe Alzheimer Disease

Alzheimer disease (AD) is a progressive degenerative disease that manifests as gradual deterioration in memory and cognition, behavior, and the ability to perform activities of daily living. Accurate diagnosis and continued evaluation of these aspects of AD can help guide therapy for patients in the late stage of the disease. Assessment tools specific for patients with severe AD are available for use in clinical studies.

Parkinson's disease is associated with hippocampal atrophy

Patients with Parkinson's disease (PD) may have hippocampal atrophy compared with controls. We compared hippocampal, and extra-hippocampal volumes between PD, PDD (patients with PD who have mild cognitive impairment or dementia), Alzheimer's disease (AD) and controls using volumetric magnetic resonance imaging (MRI). Participants (10 patients with PD, 10 with PDD, 11 with AD, and 12 control subjects) had an informant interview, neurological examination, and psychometric testing. Established, reliable methods were used to measure the hippocampus, parahippocampal gyrus, temporal, frontal, and parieto-occipital lobes. Correction for intracranial volume was carried out before comparison. There was no age difference between groups (mean age, 74 years). On the Clinical Dementia Rating scale (CDR) cognitive impairment was mild (CDR = 0.5) in the majority of PDD and AD patients. Hippocampal (P < 0.0004) volumes were smaller in the patient groups. Effect sizes compared with the control group were: PD, 0.66; PDD, 1.22; and AD, 1.81. The other volumes did not differ significantly. Among PD and PDD patients, recognition memory (r = 0.54, P = 0.015) and Mini-Mental State Examination scores (r = 0.56, P = 0.01) correlated with left, but not right hippocampal volume. In conclusion, hippocampal volume showed a pattern (Control > PD > PDD > AD) suggesting progressive hippocampal volume loss in PD. Volumetric MRI imaging might provide an early marker for dementia in PD.

Economic evaluation of galantamine in the treatment of mild to moderate Alzheimer's disease in the United States

BACKGROUND

Alzheimer's disease (AD) is estimated to affect up to 11% of those aged > or =65 years in the United States, and the number of patients with AD is predicted to increase over the next few decades as the population ages. The substantial social and economic burden associated with AD is well established, with the cost of management increasing as the disease progresses.

OBJECTIVE

The aim of this study was to evaluate the economic impact of galantamine 16 and 24 mg/d relative to no pharmacologic treatment in the management of mild to moderate AD in the United States based on the concept of need for full-time care (FTC).

METHODS

Calculations were made using the Assessment of Health Economics in Alzheimer's Disease model, which applies predictive equations to estimate the need for FTC and the associated costs. The predictive equations were developed from longitudinal data on patients with AD. Inputs to the equations were derived by analyzing the data from 2 randomized, placebo-controlled, galantamine clinical trials. Resource use (from a payer perspective) was estimated from US clinical trial data, and costs were estimated from several US databases. Analyses were carried out over 10 years, and costs and benefits were discounted at 3%.

RESULTS

In the base case, 3.9 to 4.6 patients need to start treatment with galantamine to avoid 1 year of FTC, depending on dose. Treated patients spent 7% to 8% more time pre-FTC and 12% to 14% less time requiring FTC, resulting in savings of 2408 to 3601 US dollars. Time horizons below 3 years, very high discontinuation rates, or increased survival with galantamine reversed the savings. Conversely, limiting treatment to responders delayed FTC by 6 to 7 months, with savings of approximately 9097 to 11,578 US dollars.

CONCLUSIONS

These results suggest that use of galantamine in patients with AD in the United States could reduce the use of costly resources such as formal home care and nursing homes, leading to cost savings over time.

An open-label extension trial of galantamine in patients with probable vascular dementia and mixed dementia

BACKGROUND

Alzheimer's disease (AD) and vascular dementia (VaD) are the most common types of dementia worldwide. Galantamine, an acetylcholinesterase inhibitor and allosteric nicotinic modulator, has shown broad clinical benefits in patients with mild to moderate dementia due to AD, probable VaD, or AD with cerebrovascular disease (CVD)-so-called mixed dementia.

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety profiles of galantamine 24 mg/d in patients with VaD or AD with CVD over the longer term (>6 months).

METHODS

This was an open-label extension of a 6-month double-blind study of galantamine. Patients who had been randomized to receive galantamine 24 mg/d or placebo in the double-blind phase were eligible to continue open-label treatment with galantamine 24 mg/d for 6 months. The primary efficacy end point was change in cognition, based on scores on the 11-item Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog/11). Secondary measures included changes in functional ability (as measured on the Disability Assessment for Dementia [DAD]) and behavior (as measured on the Neuropsychiatric Inventory [NPI]). Safety and tolerability were also monitored.

RESULTS

Four hundred fifty-nine patients (240 men, 219 women; mean [SE] age, 75.2 [0.33] years) entered the open-label phase. Of these patients, 195 (42.5%) had a diagnosis of probable VaD, and 238 (51.9%) had a diagnosis of AD with CVD; the remainder had an inconclusive diagnosis. At month 12 of the study, improvements from baseline (the start of the double-blind phase) in ADAS-cog/11 scores were observed in both the group that received placebo during the double-blind phase (placebo/galantamine group: -0.3 point; 95% CI, -1.64 to 1.06) and the group that received galantamine during the double-blind phase (galantamine/galantamine group: -0.9 point; 95% CI, -1.73 to 0.03). Improvement in functional ability was demonstrated by statistically significant mean (SE) changes from baseline in DAD score in both the placebo/galantamine group (-7.4 [1.68]; P < or = 0.001) and the galantamine/galantamine group (-3.6 [1.33]; P < or = 0.01). There was no significant change in mean (SE) NPI scores in either group (0.2 [0.98] and 0.1 [0.70], respectively). Galantamine treatment was well tolerated.

CONCLUSIONS

In these patients with VaD and AD with CVD, galantamine treatment produced similar sustained benefits in terms of maintenance of or improvement in cognition (ADAS-cog/11), functional ability (DAD), and behavior (NPI) after 12 months.

A new measurement of activities of daily living for Thai elderly with dementia

BACKGROUND

Activities of daily living (ADL) vary across cultures, and measure of ADL needs to be specific to the population under study. We developed an ADL measure for Thai elderly with dementia and investigated the reliability and validity of this instrument.

MATERIALS AND METHODS

Item construction was accomplished with a panel of neurologists and a rehabilitation medicine physician. One hundred eighty-one subjects were interviewed using the Thai ADL measure. Of this sample, one hundred fifty-nine had dementia according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria. These data were analyzed for internal consistency; concurrent validity was determined by comparison with the Barthel Index, Functional Assessment Questionnaire (FAQ), Thai Mental State Exam (TMSE), and Clinical Dementia Rating (CDR) scale; and discriminant validity was determined by comparison with the Neuropsychiatric Inventory (NPI). Thirty subjects were tested to determine interrater and test-retest reliability.

RESULTS

Thai ADL measure was composed of six basic ADL and seven instrumental ADL. It had high correlation with TMSE scores (r = -.69), CDR scores (r = .81), Barthel Index scores (r = -.80), and FAQ scores (r = .88), and moderate correlation with NPI scores (r = .46). The instrument had high test-retest reliability (intraclass correlation coefficient [ICC] = .92, .89) and high interrater reliability (ICC = .96, .93).

CONCLUSION

The Thai ADL scale is easy to use and it has high reliability. It had high concurrent validity with previously published ADL scales. The methodology used to develop the Thai ADL scale can provide a model for creating culturally competent ADL scales.

Presence of behavioral and psychological symptoms predicts nursing home placement in community-dwelling elders with cognitive impairment in univariate but not multivariate analysis

BACKGROUND

The role of behavioral and psychological symptoms as an independent risk factor of nursing home placement (NHP) in cognitively impaired elders has been controversial.

METHODS

A community sample of 449 cognitively impaired elders and their knowledgeable informants (KIs) was followed for 1 year. Subjects were classified as having dementia (n=330) or mild cognitive impairment (MCI) (n=119) using a neuropsychiatric battery of 4 tests. Subject characteristics (behavioral and psychological symptoms, demographic, health related, and health services use) and KI characteristics were entered into the Cox proportional hazard regression analysis.

RESULTS

The incidence rate of NHP was 8.9%. At baseline, 57.7% of subjects had at least 1 behavioral and psychological symptom. Presence of these symptoms was associated with shorter time to NHP only in a univariate analysis. Other factors significant in the multivariate Cox modeling were being white (hazard ratio [HR] = 2.17), having fair or poor physical health rating (HR= 2.12), having greater numbers of difficulties with activities of daily living (HR = 1.46), and having a physician's diagnosis of dementia (HR = 6.76). An interaction was found between the last 2 variables (HR = 0.59), indicating that among those with a diagnosis of dementia, a greater number of difficulties with activities of daily living delayed time to NHP. KI characteristics were not associated with NHP.

CONCLUSIONS

Behavioral and psychological symptoms were common, but having these symptoms was not an independent risk factor of NHP. Caregiver characteristics may not play as important a role in determining NHP as subject characteristics. Interventions aimed at improving or maintaining physical or cognitive functioning may have better chances of delaying NHP.

Delusions of Japanese patients with Alzheimer's disease

BACKGROUND

Delusions constitute one of the most prominent psychiatric complications in Alzheimer's disease (AD). However, there is little consensus of the prevalence and associated factors for delusions in AD.

AIMS

To reveal the characteristics of delusions among Japanese patients with AD.

METHOD

112 consecutive patients with AD were recruited over a one year period and administered the Neuropsychiatric Inventory (NPI).

RESULTS

Delusions were present in 53 patients (47.3%). Delusions of theft were the most common type of delusion (75.5% of patients with delusions), followed by misidentification delusions and delusions of suspicion. More hallucination, agitation, and female gender were found in the delusions group.

CONCLUSIONS

The authors found a high frequency of delusions, particularly of delusions of theft and suggested that gender was associated with the expression of delusions in Japanese patients with AD.

Differential diagnosis of dementia: clinical examination and laboratory assessment

Recent breakthroughs in putative disease-modifying interventions for Alzheimer's disease (AD) underscore the urgency of making the earliest possible diagnosis. In the absence of a convenient and reliable laboratory test for AD, the clinical assessment is still the cornerstone of the diagnostic approach. This article provides a basis for conducting an assessment within the realities of a busy clinical practice for patients complaining of cognitive decline. The assessment will enable the clinician to diagnose the earliest manifestation of AD.

Analysis of probabilistic classification learning in patients with Parkinson's disease before and after pallidotomy surgery

This study examined the characteristics of probabilistic classification learning, a form of implicit learning previously shown to be impaired in patients with basal ganglia dysfunction (e.g., Parkinson's disease). In this task, subjects learn to predict the weather using associations that are formed gradually across many trials, because of the probabilistic nature of the cue-outcome relationships. Patients with Parkinson's disease, both before and after pallidotomy, and age-matched control subjects, exhibited evidence of probabilistic classification learning across 100 training trials. However, pallidotomy appears to hinder the learning of associations most implicit in nature (i.e., weakly associated cues). Although subjects were most sensitive to single-cue associations when learning the task, there is evidence that cue combinations contribute significantly to probability learning. The utility of multiple dependent measures is discussed.

Quetiapine treatment of psychotic symptoms and aggressive behavior in patients with dementia with Lewy bodies: a case series

The authors describe here the clinical outcomes of quetiapine treatment in nine patients with dementia with Lewy bodies (DLB) who manifested psychotic symptoms and aggressive behavior. Patients who had a score of 3 or higher on any of the three items of the Neuropsychiatric Inventory (NPI), agitation/aggression, hallucinations, and delusions, were given quetiapine 25-75 mg/day. Each patient's clinical status was assessed at baseline and after 4 and 8 weeks of treatment by using the NPI, Mini-Mental State Examination (MMSE), and Simpson-Angus Scale (S-A). Five of nine patients had a positive response with a decline of more than 50% in the sum of scores for three items of the NPI. The other three patients withdrew from quetiapine treatment due to somnolence or orthostatic hypotension. The remaining patient exhibited no clinically significant change in the NPI score. The S-A scale was not affected by quetiapine treatment in any patient. These findings suggest that quetiapine may be effective in treating psychotic symptoms and disruptive behavior in some patients with DLB. Further placebo-controlled, randomized, double-blind trials with this drug are needed to confirm this observation.

Visuospatial impairment in dementia with Lewy bodies and Alzheimer's disease: a process analysis approach

BACKGROUND

Reports of differential impairments on visual-construction tasks in dementia with Lewy bodies (DLB) and Alzheimer's disease (AD) are sometimes controversial, whereas visual-perceptual data are lacking. The existence of different clinical sub-groups of DLB has been hypothesized to explain the discrepancies among the cognitive results. The goal of this study was to compare the visual-perceptual performance of subjects with DLB with predominant psychosis, DLB with predominant parkinsonian features and AD.

METHODS

This is a cross-sectional neuropsychological study with between diagnostic group comparisons. The Benton Judgement Line Orientation (BJLO) test was administered to four DLB patients with predominant psychosis (DLB-psy), four DLB subjects with predominant parkinsonian features (DLB-PD), and 13 patients with AD. An analysis of error types was applied to the results of the BJLO with QO1, QO2, QO3, QO4 (visual attention) errors, as well as VH, IQO, IQOV, and IQOH (visual-spatial perception) errors.

RESULTS

A MANOVA showed significant differences between the DLB, and AD groups on the number of VH (F = 6.049, df = 1,19, p = 0.024), IQOH (F = 4.645, df = 1,19, p = 0.044) and QO1 (F = 4.491, df = 1,19, p = 0.047) errors, but no difference on the total score of the BJLO. Another MANOVA and post hoc Student-Newman-Keuls analyses demonstrated that the DLB-psy sub-group made significantly more VH and IQOH errors than AD and the DLB-PD subjects.

CONCLUSIONS

Subjects with DLB and psychosis have more severe visual-perception (VH errors) impairments than subjects with DLB and predominant parkinsonian features, and AD subjects.

Memantine in moderate-to-severe Alzheimer's disease

BACKGROUND

Overstimulation of the N-methyl-D-aspartate (NMDA) receptor by glutamate is implicated in neurodegenerative disorders. Accordingly, we investigated memantine, an NMDA antagonist, for the treatment of Alzheimer's disease.

METHODS

Patients with moderate-to-severe Alzheimer's disease were randomly assigned to receive placebo or 20 mg of memantine daily for 28 weeks. The primary efficacy variables were the Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus) and the Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory modified for severe dementia (ADCS-ADLsev). The secondary efficacy end points included the Severe Impairment Battery and other measures of cognition, function, and behavior. Treatment differences between base line and the end point were assessed. Missing observations were imputed by using the most recent previous observation (the last observation carried forward). The results were also analyzed with only the observed values included, without replacing the missing values (observed-cases analysis).

RESULTS

Two hundred fifty-two patients (67 percent women; mean age, 76 years) from 32 U.S. centers were enrolled. Of these, 181 (72 percent) completed the study and were evaluated at week 28. Seventy-one patients discontinued treatment prematurely (42 taking placebo and 29 taking memantine). Patients receiving memantine had a better outcome than those receiving placebo, according to the results of the CIBIC-Plus (P=0.06 with the last observation carried forward, P=0.03 for observed cases), the ADCS-ADLsev (P=0.02 with the last observation carried forward, P=0.003 for observed cases), and the Severe Impairment Battery (P<0.001 with the last observation carried forward, P=0.002 for observed cases). Memantine was not associated with a significant frequency of adverse events.

CONCLUSIONS

Antiglutamatergic treatment reduced clinical deterioration in moderate-to-severe Alzheimer's disease, a phase associated with distress for patients and burden on caregivers, for which other treatments are not available.

Nutritional assessment of demented patients: a descriptive study

BACKGROUND AND AIMS

It is well-known that subclinical and overt malnutrition are strong predictive indices of morbidity and mortality in old subjects, particularly in demented ones, and may deeply affect the quality of life. The aim of this study was evaluation of nutritional status in demented patients, as a whole and according to type of dementia, at the moment of hospital admission and before discharge.

METHODS

The study concerns 174 old demented patients, aged 80.2 +/- 8 SD, diagnosed as having Alzheimer's disease, vascular dementia, degenerative and vascular dementia, reversible dementia, and other types of dementia. In each subject, anthropometric measures, body composition analysis by the bioelectric impedance technique, Mini Nutritional Assessment (MNA) and cognitive, functional and affective assessment by conventional geriatric instruments were performed. A blood sample allowed assay of the main biochemical nutritional markers. At the end of the hospitalization period, the same cognitive, functional and nutritional assessment was repeated, in order to evaluate the effects of vitamin and protein supplements and of care during meals.

RESULTS

In all subgroups of demented patients, obtained according to type of dementia, the mean MNA score was indicative of risk for malnutrition. Furthermore, the MNA score was significantly related to severe cognitive impairment, functional status, comorbidity, BMI values, and transferrin and total protein serum levels. Malnourished patients and demented elderly at risk for malnutrition (according to the MNA score) were given oral nutritional supplements during hospitalization, lasting a mean of 45 days. Before discharge, these two subtypes of demented patients showed substantial maintenance of their cognitive, functional and nutritional status, whereas the subgroup of well-nourished demented patients exhibited significant worsening of the nutritional pattern.

CONCLUSIONS

Demented patients show a high percentage of malnutrition, particularly evident in subjects with deeper cognitive impairment. Nutritional status seems to be linked more to functional abilities than to duration of disease. However, nutritional intervention or special care during meals may act in synergy with specific pharmacologic therapy of dementia.

2nd Asia-Pacific regional meeting of the International Working Group on Harmonization of Dementia Drug Guidelines: meeting report

The 2nd Asia-Pacific regional meeting of the International Working Group on Harmonization of Dementia Drug Guidelines (IWGH) was held in Beijing, China in late 2002. Representatives from over a dozen countries convened to present data on dementia within the region and to share information on locally adapted outcome measures for use in dementia clinical trials. The IWGH recognized the competency and capability of many Asian sites and endorsed their inclusion in future multicenter clinical dementia research activities.

Evolution of depressive symptoms in Alzheimer disease: one-year follow-up

The current longitudinal study analyzes the natural course of depressive symptoms in patients with Alzheimer disease (AD). The goals were to identify the clinical and sociodemographic variables related to depressive symptoms, to assess the effect of depressive symptoms on the course of cognitive and functional impairment and on associated neuropsychiatric disorders, and to identify which factors are associated with remission, persistence, and emergence of depressive symptoms at 12 months. A sample of 150 patients with mild or moderate severity was assessed at baseline and at 12 months using the neuropsychologic battery Cambridge Cognitive Examination. The Neuropsychiatric Inventory and Rapid Disability Rating Scale were administered to the caregiver. Prevalence, persistence, and emergence of depressive symptoms at baseline were 51%, 55%, and 20%, respectively. Remission of depressive symptoms at 12 months leads to a decreased frequency of other noncognitive disorders and to a slight improvement in the assessment of global function. The presence of depressive symptoms does not affect the course of cognitive impairment at 12 months, and a psychiatric history of the patient and the number of depressive symptoms at baseline are risk factors for the emergence and persistence of depressive symptoms at 12 months.

Factor analysis of the frontal systems behavior scale (FrSBe)

The Frontal Systems Behavior Scale (FrSBe), formerly called the Frontal Lobe Personality Scale (FLOPS), is a brief behavior rating scale with demonstrated validity for the assessment of behavior disturbances associated with damage to the frontal-subcortical brain circuits. The authors report an exploratory principal factor analysis of the FrSBe-Family Version in a sample including 324 neurological patients and research participants, of which about 63% were diagnosed with neurodegenerative diseases (Huntington's, Parkinson's, and Alzheimer's diseases). The three-factor solution accounted for a modest level of variance (41%) and confirmed a factor structure consistent with the three subscales proposed on the theoretical basis of the frontal systems. Most items (83%)from the FrSBe subscales of Apathy, Disinhibition, and Executive Dysfunction loaded saliently on three corresponding factors. The FrSBe factor structure supports its utility for assessing both the severity of the three frontal syndromes in aggregate and separately.

Familial dementia with Lewy bodies with an atypical clinical presentation

The authors report a case of a 64-year-old male with Alzheimer's disease (AD) and dementia with Lewy bodies (DLB) pathology at autopsy who did not manifest the core symptoms of DLB until very late in his clinical course. His initial presentation of early executive and language dysfunction suggested a cortical dementia similar to frontotemporal lobar degeneration (FTLD). Core symptoms of DLB including dementia, hallucination, and parkinsonian symptoms were not apparent until late in the course of his illness. Autopsy revealed both brainstem and cortical Lewy bodies and AD pathology. Family history revealed 7 relatives with a history of dementia including 4 with possible or probable DLB. This case is unique because of the FTLD-like presentation, positive family history of dementia, and autopsy confirmation of DLB.

A transcultural study of agitation in dementia

Agitation is one of the most troublesome behaviors in demented patients. It is etiologically heterogeneous and has varied associated behaviors. To explore the transcultural differences in the manifestation of agitation, we evaluated 50 consecutive Alzheimer's disease (AD) patients in three countries (Taiwan, Italy, and the United States) using the Neuropsychiatric Inventory (NPI) and the Mini-Mental State Examination (MMSE). In a focused analysis, only patients with composite NPI scores > 2 for agitation were selected, with similar levels of disease severity as measured by the MMSE, from the three groups (n = 15 per group) to evaluate culturally specific correlates of agitation. Agitated Taiwanese had significantly more hallucinations than either Italian or American patients. Agitated Italian patients had significantly more apathy than both Taiwanese and American patients. Cultural factors may influence the manifestation of agitation more than a common underlying neuropathology. Management strategies targeting unique behavioral instigators of agitation may be specific for different ethnic groups.

Behavioural disturbances in dementia patients and quality of the marital relationship

OBJECTIVES

To investigate the relationship between behavioural problems in patients with dementia and changes in the marital relationship.

METHODS

Fifty-three spouse caregivers of patients with dementia participated in the study. Questionnaires and interviews were used to examine caregiver perception of changes in the quality of their relationship. Behavioural disturbances in the patient were measured with the NeuroPsychiatric Inventory (NPI).

RESULTS

Caregivers experienced a deterioration of their relationship, yet at the same time most felt closer to their spouse now than in the past. Regression analysis revealed that patient behavioural problems were, independent of patient cognitive status or functional impairment, associated with deterioration in the quality of the relationship between patient and caregiver. Patient apathy rather than depressive mood was associated with this deterioration. Apathy diminished the amount and reciprocity of interactions between partners.

CONCLUSIONS

These results show that passive behaviour rather than excessive behaviour has most impact on the deterioration of the marital relationship. Intervention programmes should target relationship problems when problem behaviour, especially apathy, is present in patients with dementia.

Prevalence and correlates of behavioral and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive impairment: the Memory and Medical Care Study

BACKGROUND

Little is known about the prevalence and correlates of behavioral and psychiatric symptoms of dementia in community-dwelling elders with dementia or mild cognitive impairment (MCI).

METHODS

512 people with Mini-Mental State Examination (MMSE) scores < 24 or a decline of at least 4 points over two administrations, and their knowledgeable informants (KIs) were enrolled in the MMCS. The classification of subjects as having dementia or MCI was based on a neuropsychological battery of four tests, not a clinical diagnostic evaluation. The sample for this study included 454 subjects (dementia n = 333; MCI n = 121) and their KIs. Demographic and health-related characteristics of subjects and KIs were obtained during KI interviews. Multivariate logistic regression was used in statistical analysis.

RESULTS

Compared to dementia subjects, those classified as MCI had a lower prevalence (47.1% vs 66.1%) of any symptoms (psychosis, depression, or agitation), and of agitation (24.8% vs 45.1%). Symptoms of psychosis and depression also were less prevalent, even though differences did not reach statistical significance. In the dementia group symptoms were associated with a report of a physician's diagnosis of dementia, greater functional impairment, and a KI who was a child/child-in-law. In those with MCI, symptoms were correlated with being white, greater functional impairment, and a younger, less educated, KI.

CONCLUSIONS

Psychiatric and behavioral symptoms were common in community-residing elders with cognitive impairment, but their prevalence and correlates differed by study classification as having dementia or MCI. Identifying and treating these symptoms may benefit patients with cognitive impairment and their families. Longitudinal studies on the predictors, changes in prevalence, and effectiveness of treatments for psychopathology of dementia are needed.

Vascular cognitive impairment

Cerebrovascular disease is the second most common cause of acquired cognitive impairment and dementia and contributes to cognitive decline in the neurodegenerative dementias. The current narrow definitions of vascular dementia should be broadened to recognise the important part cerebrovascular disease plays in several cognitive disorders, including the hereditary vascular dementias, multi-infarct dementia, post-stroke dementia, subcortical ischaemic vascular disease and dementia, mild cognitive impairment, and degenerative dementias (including Alzheimer's disease, frontotemporal dementia, and dementia with Lewy bodies). Here we review the current state of scientific knowledge on the subject of vascular brain burden. Important non-cognitive features include depression, apathy, and psychosis. We propose use of the term vascular cognitive impairment, which is characterised by a specific cognitive profile involving preserved memory with impairments in attentional and executive functioning. Diagnostic criteria have been proposed for some subtypes of vascular cognitive impairment, and there is a pressing need to validate and further refine these. Clinical trials in vascular cognitive impairment are in their infancy but support the value of therapeutic interventions for symptomatic treatment.

Current pharmacologic options for patients with Alzheimer's disease

BACKGROUND: The aim of the current study was to provide general practitioners with an overview of the available treatment options for Alzheimer's disease (AD). Since general practitioners provide the majority of medical care for AD patients, they should be well versed in treatment options that can improve function and slow the progression of symptoms. DESIGN: Biomedical literature related to acetylcholinesterase inhibitors (AChEIs) was surveyed. In the United States, there are four AChEIs approved for the treatment of AD: tacrine, donepezil, rivastigmine, and galantamine. There are other agents under investigation, but at present, AChEIs are the only approved drug category for AD treatment. MEASUREMENTS AND MAIN RESULTS: AD is becoming a major public health concern and underdiagnosis is a significant problem (with only about half of AD patients being diagnosed and only half of those diagnosed actually being treated). Clinical trials have demonstrated that patients with AD who do not receive active treatment decline at more rapid rates than those who do. CONCLUSIONS: Given that untreated AD patients show decline in three major areas (cognition, behavior, and functional ability), if drug treatment is able to improve performance, maintain baseline performance over the long term, or allow for a slower rate of decline in performance, each of these outcomes should be viewed a treatment success.

Efficacy of cholinesterase inhibitors in the treatment of neuropsychiatric symptoms and functional impairment in Alzheimer disease: a meta-analysis

CONTEXT

Cholinesterase inhibitors are the primary treatment for the cognitive symptoms of Alzheimer disease (AD). Cholinergic dysfunction is also associated with neuropsychiatric and functional deficits, but results from randomized controlled trials of cholinesterase inhibitors are conflicting.

OBJECTIVE

To conduct a systematic review and meta-analysis to quantify the efficacy of cholinesterase inhibitors for neuropsychiatric and functional outcomes in patients with mild to moderate AD.

DATA SOURCES

We performed a literature search of trials using MEDLINE (January 1966-December 2001), Dissertations Abstracts On-line, PSYCHINFO, BIOSIS, PubMed, and the Cochrane Controlled Trials Register. We retrieved English- and non-English-language articles for review and collected references from bibliographies of reviews, original research articles, and other articles of interest. We searched for both published and unpublished trials, contacting researchers and pharmaceutical companies.

STUDY SELECTION

We included 29 parallel-group or crossover randomized, double-blind, placebo-controlled trials of outpatients who were diagnosed as having mild to moderate probable AD and were treated for at least 1 month with a cholinesterase inhibitor. Sixteen trials included neuropsychiatric and 18 included functional measures.

DATA EXTRACTION

Two investigators (N.H.T. and J.H.) independently extracted study methods, sources of bias, and outcomes. Neuropsychiatric outcomes were measured with the Neuropsychiatric Inventory (NPI, 0-120 points) and the Alzheimer Disease Assessment Scale, noncognitive (ADAS-noncog, 0-50 points) and were analyzed with the weighted mean difference method. Functional outcomes were measured with several activities of daily living (ADL) and instrumental activities of daily living (IADL) scales and analyzed with the standardized mean difference method.

DATA SYNTHESIS

For neuropsychiatric outcomes, 10 trials included the ADAS-noncog and 6 included the NPI. Compared with placebo, patients randomized to cholinesterase inhibitors improved 1.72 points on the NPI (95% confidence interval [CI], 0.87-2.57 points), and 0.03 points on the ADAS-noncog (95% CI, 0.00-0.05 points). For functional outcomes, 14 trials used ADL and 13 trials used IADL scales. Compared with placebo, patients randomized to cholinesterase inhibitors improved 0.1 SDs on ADL scales (95% CI, 0.00-0.19 SDs), and 0.09 SDs on IADL scales (95% CI, 0.01 to 0.17 SDs). There was no difference in efficacy among various cholinesterase inhibitors.

CONCLUSIONS

These results indicate that cholinesterase inhibitors have a modest beneficial impact on neuropsychiatric and functional outcomes for patients with AD. Future research should focus on how such improvements translate into long-term outcomes such as patient quality of life, institutionalization, and caregiver burden.

Defining "early dementia" and monitoring intervention: what measures are useful in family caregiving?

Measures of cognition are often used to define and measure the progress of dementia and outcomes of intervention. This paper examines whether measures of psychosocial disability used with those of cognition are more useful than measures of cognition alone, particularly in early dementia. A measure of cognition and two instruments of caregiver burden, used as routine clinical outcome measures of three types of Old Age Psychiatry dementia services, were examined. All cases with dementia in a memory clinic (MC; n = 149), a community mental health service for older people (CMHT; n = 120) and a specialist dementia day hospital (DH; n = 118), in one NHS district were followed up at 12 months. Measures of cognition (MMSE), behaviour, caregiver coping (Problem Checklist; PC) and caregiver mood (Hospital Anxiety and Depression Scale; HAD) were taken at baseline (MC, n = 48; CMHT, n = 113; DH, n = 55) and at follow-up (MC, n = 35; CMHT, n = 34; DH, n = 23). At baseline, all three groups had an average MMSE score of "mild impairment" but measures of behaviour and caregiver burden showed subtle between-group differences. At the 12-month follow-up, cognition remained stable in all groups, but the frequency of day-to-day problems increased and caregiver mood deteriorated in families receiving DH support. The use of psychosocial measures of disability in conjunction with those of cognition, are important in the definition and longitudinal measurement of intervention and support in early dementia.

Donepezil for dementia due to Alzheimer's disease

BACKGROUND

Alzheimer's disease is the most common cause of dementia in older people. One of the aims of therapy is to inhibit the breakdown of a chemical neurotransmitter, acetylcholine, by blocking the relevant enzyme. This can be done by a group of chemicals known as cholinesterase inhibitors. However, some (like tacrine) are associated with adverse effects such as hepatotoxicity, but donepezil (E2020, Aricept) is safer.

OBJECTIVES

The objective of this review is to assess whether donepezil improves the well-being of patients with dementia due to Alzheimer's disease.

SEARCH STRATEGY

The Cochrane Dementia and Cognitive Improvement Group's Specialized Register was searched using the terms 'donepezil', 'E2020' and 'Aricept' on 9 October 2002. This Register contains up-to-date records of all major health care databases and many ongoing trial databases. Members of the Donepezil Study Group and Eisai Inc were contacted.

SELECTION CRITERIA

All unconfounded, double-blind, randomized controlled trials in which treatment with donepezil was compared with placebo for patients with mild, moderate or severe dementia due to Alzheimer's disease.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer (JSB ), pooled where appropriate and possible, and the weighted mean differences or Peto odds ratios (95%CI) estimated.

MAIN RESULTS

Sixteen trials are included, involving 4365 participants. The trials were of 12, 24 or 52 weeks duration in selected patients. Available outcome data cover domains including cognitive function and global clinical state, but data on several important dimensions of outcome are unavailable. For cognition there is a statistically significant improvement for both 5 and 10 mg/day of donepezil at 24 weeks compared with placebo (-2.02 points on the ADAS-Cog scale WMD, 95%CI -2.77 to -1.26, p<0.00001; -2.92 points on the ADAS-Cog scale WMD 95% CI -3.74 to -2.10, p<0.00001)and for 10 mg/day donepezil compared with placebo at 52 weeks (1.84MMSE points, 95% CI, 0.53 to3.15, p=0.006). The results show some improvement in global clinical state (assessed by an independent clinician) in people treated with 5 and 10 mg/day of donepezil compared with placebo at 12 and 24 weeks. Benefits of treatment were also seen on measures of activities of daily living and behaviour. There were significantly more withdrawals before the end of treatment from the 10 mg/day (but not the 5 mg/day) donepezil group compared with placebo which may have resulted in some overestimation of beneficial changes at 10 mg/day.A variety of adverse effects were recorded, with more incidents of nausea, vomiting, diarrhoea and anorexia in the 10 mg/day group compared with placebo and the 5 mg/day group, but very few patients left a trial as a direct result of the intervention.

REVIEWER'S CONCLUSIONS

People with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12, 24 or 52 weeks with donepezil experienced benefits in cognitive function, activities of daily living and behaviour. Study clinicians rated global clinical state more positively in treated patients, and measured less decline in measures of global disease severity. Although no significant changes were measured on a patient-rated quality of life scales, the instrument used was crude and possibly unsuited to the task. The additional data now available confirm the findings of the previous issue of this review and extend the evidence for the effectiveness of treatment to at least 52 weeks and to those with severe dementia. More evidence is still needed for the economic efficacy of donepezil, but clinical efficacy is confirmed.

Behavioral and psychological symptoms of dementia: trial design

Behavioral and psychological symptoms in dementia (BPSD) are an important aspect of the disorder that are now receiving more attention. The design of the trials in vascular dementia needs to account for these features. The specific area of BPSD in vascular dementia, their assessment, and relationship to the design of trials are considered in this article.

Gabapentin for the treatment of behavioural alterations in dementia: preliminary 15-month investigation

BACKGROUND

Although the core feature of dementia is progressive cognitive disruption, non-cognitive behavioural problems are expressed in most patients with dementia during the course of their illness. While psychotropic drugs are frequently used to control behavioural symptoms, comorbidities, which are very common in the geriatric population, could often limit their use. Gabapentin may be a potential treatment in such situations.

METHODS

In this open, baseline comparison study 20 patients with probable Alzheimer's disease with behavioural alterations and serious comorbidities (paralytic ileus, open-angle glaucoma, ischaemic cardiopathy, hepatic failure or severe prostatic hyperplasia) received gabapentin for 15 months. Patients were allowed to continue any previous therapy for concurrent diseases. However, concomitant antipsychotic or benzodiazepine intake was not permitted.

RESULTS

Gabapentin appeared to be efficacious and well tolerated in this patient population, and did not appear to interact with other drugs. General benefit is reflected by a reduction of caregiver stress. No patients withdrew before the end of the study and no serious adverse events were reported.

CONCLUSION

The results of this study in patients with probable Alzheimer's disease with behavioural alterations and serious comorbidities indicate that gabapentin provides significant and sustained efficacy in terms of behaviour, with associated reductions in caregiver burden. The results of an ongoing larger, randomised, double-blind study of gabapentin are keenly awaited and may help to provide a safer and more efficacious treatment option for this group of patients.

Non-Pharmacological Interventions in Cognitively Impaired and Demented Patients - A Comparison with Cholinesterase Inhibitors

The present paper reviews studies examining the effects of non-pharmacological stimulation, i.e. bright light, physical activity and tactile stimulation (touch), on cognition, affective behaviour, and the sleep-wake rhythm of impaired and demented elderly, both in a qualitative (narrative) and quantitative (meta-analytic) manner. An extensive search through eight bibliographic data bases (PubMed, Web of Science, ERIC, PsychINFO, Psyndex, Cinahl, Biological Abstracts and Rehabdata) was performed up to August 2002. The primary criterion for inclusion in this review was that studies provided sufficient data to calculate effect-sizes. In the qualitative analysis, all three types of stimulation appeared to improve cognitive functioning. Disturbances in behaviour react positively to bright light and tactile stimulation. Bright light was also beneficial to sleep. Tactile stimulation had, moreover, a beneficial influence on the patient-caretaker relationship. A comparison was made with several representative papers published since 1991 on the effects of acetylcholinesterase inhibitors on cognition and behaviour with representative papers on non-pharmacological stimulation interventions. Data indicated that improvements in cognition and affective behaviour by non-pharmacological interventions (d' = 0.32) and by cholinesterase inhibitors (d' = 0.31) were of similar effect-size. Possible mechanisms underlying the non-pharmacological stimulation effects are discussed and suggestions offered for future research.

An electronic memory aid to support prospective memory in patients in the early stages of Alzheimer's disease: a pilot study

The use of an electronic memory aid (EMA) for patients with mild-to-moderate probable Alzheimer disease is examined in five outpatients aged 58-79 years. The ability to remember to carry out seven tasks at a particular time was evaluated in three experimental conditions: recall without an external memory aid, recall with a written list and recall with support available from an EMA. The use of an EMA significantly improved patients' prospective memory, while the written list and free recall were not useful. Future research that examines the value of using an EMA to help with tasks that are associated with prospective memory with a larger sample of patients within their own home context is suggested.

Cholinesterase inhibitors for dementia with Lewy bodies

BACKGROUND

Dementia with Lewy bodies (DLB) was first described in 1983, and clinical diagnostic criteria were published in the early to mid 1990s. It has been suggested DLB may account for up to 15-25% of cases of dementia among people aged over 65, although autopsy suggests much lower rates. Characteristic symptoms are dementia, marked fluctuation of cognitive ability, early and persistent visual hallucinations and spontaneous motor features of Parkinsonism. Falls, syncope, transient disturbances of consciousness, neuroleptic sensitivity, and hallucinations in other modalities are also common. This combination of features can be difficult to manage as neuroleptics can make the Parkinsonian and cognitive symptoms worse. There is evidence to suggest that the cholinesterase inhibitors may be beneficial in this disorder; small case series indicate that cholinesterase inhibitors are safe, and will improve both cognitive deficits and neuropsychiatric symptoms in DLB.

OBJECTIVES

To assess the use of cholinesterase inhibitors in DLB.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 25 February 2002 using the terms 'lewy body', 'Lewy bodies' and 'Lewy'. This register contains records from all major health care databases and trial databases and is updated regularly.

SELECTION CRITERIA

Randomized, double-blind trials in which treatment with cholinesterase inhibitors was administered and compared with alternative interventions in patients with DLB are included.

DATA COLLECTION AND ANALYSIS

Two reviewers (TP, RW) independently assessed quality of trials according to criteria described in the Cochrane Collaboration Handbook. Each drug was to be examined separately, and together as a group. We also analysed data by time to outcome measurement; short-term (up to one month), medium term (one month up to six months) and long term (Six months and longer). The primary outcome measures of interest are in the following areas: neuropsychiatric features. i.e. psychiatric symptoms and behavioural disturbances, cognitive function, activities of daily living, global assessments, quality of life, including maintaining role and social functioning, effect on carers, safety as measured by incidence of adverse events and side effects, acceptability of treatment as measured by withdrawal from trials, and by patient/carer assessment, institutionalization and death.

MAIN RESULTS

There was one included trial (McKeith 2000f) of rivastigmine compared with placebo on 120 patients. Neuropsychiatric InventoryThe 10-item test found no significant difference between the two groups in change of scores from baseline using intention-to-treat (ITT) analysis at 20 weeks and last observation carried forward (LOCF) analysis. The treatment effect was statistically significant in favour of rivastigmine if only observed cases (OC) were analysed (WMD -6.94, 95% CI -11.59 to -2.29, P=0.003). There were similar results for the NPI-4, with only the OC analysis showing a significant superiority of rivastigmine to placebo at 20 weeks (WMD -3.75, 95%CI -6.62 to -0.88, P=0.01).MMSE:Analysis of these results showed no statistically significant difference between the two groups at 20 weeks.CGC-plus:Analysis of the proportion of patients who had no change or became worse found no statistically significant difference between the two groups at 20 weeks for the ITT, LOCK and OC analyses. Adverse Events:The placebo group experienced significantly fewer adverse events than the treatment group (54/59 vs 46/61,OR 3.52, 95%CI 1.19 to 10.43). However, using ITT analysis of 20-week data, there was no significant difference between the two groups when serious adverse events were considered. There were no significant differences in death rates between the two groups at 20 weeks.Drop-out Rates:Analysis of these results showed no difference between the two groups at 20 weeks using ITT analysis.

REVIEWER'S CONCLUSIONS

Patients with dementia with Lewy bodies who suffer from behavioural disturbance oS CONCLUSIONS: Patients with dementia with Lewy bodies who suffer from behavioural disturbance or psychiatric problems may benefit from rivastigmine if they tolerate it, but the evidence is weak. Further trials using rivastigmine are needed, as are trials of other cholinesterase inhibitors in dementia with Lewy bodies.

Aroma therapy for dementia

BACKGROUND

Complementary therapies have become more commonly used over the last decade and have been applied to a range of health problems, including dementia. Of these, aroma therapy is reported to be the most widely used in the British National Health Service (Lundie 1994) and might be of use for people with dementia for whom verbal interaction may be difficult and conventional medicine of only marginal benefit. Aroma therapy has been used for people with dementia to reduce disturbed behaviour (e.g. Brooker 1997), promote sleep (e.g. Wolfe 1996), and stimulate motivational behaviour (e.g. MacMahon 1998).

OBJECTIVES

To assess the efficacy of aroma therapy as an intervention for people with dementia.

SEARCH STRATEGY

The Cochrane Dementia and Cognitive Improvement Group's Specialized Register was searched on 29 October 2002 to find all relevant trials using the terms: aroma therap*, "aroma therap*", "complementary therap*", "alternative therap*" and "essential oil". The CDCIG Register contains records from all major health care databases and is updated regularly. Additionally, relevant journals were hand searched, and 'experts' in the field of complementary therapies and dementia contacted.

SELECTION CRITERIA

All relevant randomized controlled trials (RCTs) were considered. A minimum length of trial and requirements for a follow-up were not included, and participants in included studies had a diagnosis of dementia of any type and severity. The review considered all trials using fragrance from plants defined as aroma therapy as an intervention with people with dementia. Several outcomes were considered in this review, including cognitive function, quality of life, and relaxation.

DATA COLLECTION AND ANALYSIS

The titles and abstracts extracted by the searches were screened for their eligibility for potential inclusion in the review, which revealed 2 RCTs of aroma therapy for dementia. Neither of these had published results in a form that we could use. However, individual patient data from one trial were obtained (Ballard 2002) and additional analyses performed. Analysis of co-variance was used for all outcomes, using a random effects model.

MAIN RESULTS

The additional analyses conducted revealed a statistically significant treatment effect in favour of the aroma therapy intervention on measures of agitation and neuropsychiatric symptoms.

REVIEWER'S CONCLUSIONS

Aroma therapy showed benefit for people with dementia in the only trial that contributed data to this review, but there were several methodological difficulties with this study. More well designed large-scale RCTs are needed before conclusions can be drawn on the effectiveness of aroma therapy. Additionally, several issues need to be addressed, such as whether different aroma therapy interventions are comparable and the possibility that outcomes may vary for different types of dementia.

Mood stabilizers in Alzheimer's disease: symptomatic and neuroprotective rationales

OBJECTIVE

This paper provides a case study of 'reverse translational research', in which empirical clinical trials focused on relieving psychopathological symptoms of Alzheimer's disease (AD) ultimately led to mechanism-based trials addressing aspects of the underlying pathophysiology of Alzheimer's disease. AD is multi-dimensional in nature, characterized not only by cognitive and functional decline but by neuropsychiatric symptoms that develop commonly and are associated with considerable morbidity. There have been a large number of empirical trials of various pharmacological agents to reduce these symptoms, such as agitation. Although antipsychotics are used most frequently for agitation, the usual effect size is modest, and there is a range of tolerability and/or safety issues, leading to the hope that alternatives can be found. Furthermore, most clinical trials addressing psychopathology have not been mechanism-based and none have attempted an alternative approach, namely, to delay or prevent the emergence of psychopathology.

FINDINGS

The evidence of clinical trials is reviewed regarding the safety, tolerability, and apparent efficacy of the mood stabilizers carbamazepine and valproate for agitation associated with AD. Possible mechanisms of action of valproate are reviewed, leading to the surprising conclusion that neuroprotective properties may account for some of its clinical effects. These mechanisms (including activation of wnt-dependent signaling and upregulation of bcl-2, among others) may be particularly relevant for long-term treatment of AD.

CONCLUSIONS

These clinical and mechanistic findings were combined in the development of a novel clinical trial examining whether chronic valproate therapy can attenuate the clinical progression of AD, which will be implemented by the Alzheimer's Disease Cooperative Study. The design addresses valproate's potential to delay or prevent the onset of agitation in patients lacking agitation to begin with, as well as to slow progressive decline in cognition and daily functioning.

Neuroprotective properties of valproate: potential benefit for AD and tauopathies

Neuropsychiatric disturbances are extremely common in Alzheimer's disease (AD), and represent integral features of the illness, as well as appropriate targets for therapy. We are interested in designing trials aimed at preventing or delaying the emergence of psychopathology in AD. For symptomatic treatment of agitation, mood stabilizers, particularly sodium valproate, have proved to be beneficial in some patients. Since these effects take several weeks to emerge, we considered that they might be dependent on potentially neuroprotective actions of valproate, such as inhibition of apoptosis and slowing of neurofibrillary tangle formation. In this article we present the rationale for testing the neuroprotective potential of valproate experimentally in mouse models of tauopathy and in a clinical trial of patients with AD who lack psychopathology at baseline. Together, these studies will provide important tests of the hypothesis that valproate, either through inhibition of tau phosphorylation or some other mechanism, is a useful therapeutic agent to modify disease progression in AD.

Apathy in Parkinson's disease

OBJECTIVE

To assess apathy in patients with Parkinson's disease and its relation to disability, mood, personality, and cognition.

METHODS

Levels of apathy in 45 patients with Parkinson's disease were compared with a group of 17 similarly disabled patients with osteoarthritis. Additional neuropsychiatric data were collected concerning levels of depression, anxiety, and hedonic tone. Personality was assessed with the tridimensional personality questionnaire. Cognitive testing included the mini-mental state examination, the Cambridge examination of cognition in the elderly, and specific tests of executive functioning.

RESULTS

Patients with Parkinson's disease had significantly higher levels of apathy than equally disabled osteoarthritic patients. Furthermore, within the Parkinson sample, levels of apathy appear to be unrelated to disease progression. The patients with Parkinson's disease with the highest levels of apathy where not more likely to be depressed or anxious than those with the lowest levels of apathy, though they did show reduced hedonic tone. No differences in personality traits were detected in comparisons between patients with Parkinson's disease and osteoarthritis, or between patients in the Parkinson group with high or low levels of apathy. As a group, the patients with Parkinson's disease tended not to differ significantly from the osteoarthritic group in terms of cognitive skills. However, within the Parkinson's disease sample, the high apathy patients performed significantly below the level of the low apathy patients. This was particularly evident on tests of executive functioning.

CONCLUSIONS

Apathy in Parkinson's disease is more likely to be a direct consequence of disease related physiological changes than a psychological reaction or adaptation to disability. Apathy in Parkinson's disease can be distinguished from other psychiatric symptoms and personality features that are associated with the disease, and it is closely associated with cognitive impairment. These findings point to a possible role of cognitive mechanisms in the expression of apathy.

The apathy inventory: assessment of apathy and awareness in Alzheimer's disease, Parkinson's disease and mild cognitive impairment

OBJECTIVE

This study was designed to establish the validity and reliability of the apathy inventory (IA), a rating scale for global assessment of apathy and separate assessment of emotional blunting, lack of initiative, and lack of interest.

METHOD

Information for the IA can be obtained from the patient or from a caregiver. We evaluated 115 subjects using the IA, consisting of 19 healthy elderly subjects, 24 patients with Mild Cognitive Impairment (MCI), 12 subjects with Parkinson's disease (PD) and 60 subjects with Alzheimer's disease (AD).

RESULTS

Internal consistency, item reliability, and between-rater reliability were high. A test-retest reliability study demonstrated that caregiver responses to IA questions were stable over short intervals. A concurrent validity study showed that the IA assesses apathy as effectively as the Neuro Psychiatric Inventory apathy domain. In the caregiver-based evaluation, AD subjects had significantly higher scores than controls, both for global apathy score and for the lack of interest dimension. When the AD patients were subdivided according to diagnostic criteria for apathy, apathetic patients had significantly higher scores than non apathetic patients. With the patient-based evaluations, no differences were found among the AD, MCI and control groups. The scores in the patient-based evaluations were only higher for the PD group versus the control subjects. The results also indicated that AD patients had poor awareness of their emotional blunting and lack of initiative.

CONCLUSIONS

The IA is a reliable method for assessing in demented and non-demented elderly subjects several dimensions of the apathetic syndrome, and also the subject's awareness of these symptoms.

Regional brain atrophy in patients with mild Alzheimer's disease and delusions

BACKGROUND AND OBJECTIVE

The pathophysiology and the neurobiology of the behavioral disturbances in Alzheimer's disease (AD) are far from understood. The aim of the study was to assess whether delusional AD patients have a specific pattern of regional brain atrophy.

METHODS

The setting of the study was the outpatient facility of a memory clinic. Subjects were 41 AD patients with mild dementia severity (Mini-Mental State Exam score of 22 +/- 3, range 18 to 27). Delusions were assessed with the pertinent subscale of the UCLA Neuropsychiatric Inventory (NPI). Nondelusional (n = 22) AD and delusional (n = 19) AD were defined on the basis of absence (NPI delusions subscale = 0) or presence (NPI delusions subscale = 1 or higher) of delusions. Thirteen (68%) of the delusional patients had isolated theft delusions, and 6 (32%) had theft associated with another paranoid delusion (of jealousy or persecution). None of the patients had misidentifications or other delusions of nonparanoid content. Temporal lobe and frontal lobe atrophy were assessed with linear measures (radial width of the temporal horn, rWTH, and frontal index, FI) taken from computed tomographic films. Temporal and frontal asymmetries were computed as right/left ratio of the rWTH and FI.

RESULTS

AD patients without delusions had symmetrical enlargement of both temporal (8.1 +/- 3.9 vs. 8.5 +/- 4.5) and frontal horns (35.8 +/- 4.8 vs. 35.9 +/- 4.6). On the contrary, AD with delusions showed temporal horns larger to the right (9.1 +/- 3.3 vs. 7.7 +/- 3.1, p = .06) and the frontal horn to the left (35.7 +/- 4.3 vs. 37.5 +/- 4.2, p = .02). This different pattern was confirmed with a gender-adjusted repeated measures analysis of variance model interaction term between asymmetry and group: F1,38 = 5.5, p = .03).

DISCUSSION

AD patients with delusions are characterized by a specific pattern of frontal and temporal asymmetry of brain atrophy, whereas nondelusional patients are symmetric. Because the asymmetry pattern of the delusional patients is similar to the physiological pattern of asymmetry of individuals without dementia, the data indicate that the absence of theft delusions in the mild stage of AD rather than their presence is associated with an abnormal asymmetry pattern.

Efficacy of donepezil on behavioral symptoms in patients with moderate to severe Alzheimer's disease

OBJECTIVE

This subanalysis of a large, double-blind, placebo-controlled trial examined the prevalence of behavioral symptoms in moderate to severe Alzheimer's disease (AD), and the effect of treatment with donepezil.

METHODS

Two hundred ninety patients with moderate to severe AD (standardized Mini-Mental State Examination scores 5-17) were randomized to receive 24 weeks of once-daily doses of donepezil 5 mg/day for 28 days, and 10 mg/day thereafter per the clinician's judgment (n = 144), or placebo (n = 146). The outcome measure of interest was the 12-item Neuropsychiatric Inventory (NPI).

RESULTS

Baseline demographics were similar between the treatment groups. Least squares mean (+/- SE) baseline NPI 12-item total scores were 19.55 +/- 1.48 and 19.30 +/- 1.45, respectively. At baseline, the most common symptoms were apathy/indifference (67%), aberrant motor behavior (53%), depression/dysphoria (52%), anxiety (49%), and agitation/aggression (45%). NPI individual item change from baseline scores at Week 24 using a last observation carried forward (LOCF) analysis showed benefits with donepezil treatment compared with placebo for all items, with significant treatment differences for depression/dysphoria, anxiety, and apathy/indifference (p < .05). Symptoms present at baseline that improved significantly for donepezil- compared with placebo-treated patients at Week 24 LOCF included anxiety, apathy/indifference, and irritability/lability (p < .05). When patients who were not receiving psychoactive medications at baseline were analyzed separately, significant improvements in NPI (continued) 12-item total score were observed with donepezil compared with placebo at most visits and at Week 24 LOCF (p < .05).

CONCLUSIONS

Behavioral symptoms of the magnitude observed in this moderate to severe AD population improved with donepezil.

Natural history of dementia associated with lacunar infarctions

BACKGROUND

Lacunar stroke (VaD-L) is the most common stroke subtype associated with vascular dementia (VaD).

OBJECTIVE

To evaluate the rate of cognitive and behavioral changes in patients with probable VaD-L.

METHODS

We measured rates of change on the Mini-Mental State Examination (MMSE), Digit Span, Logical Memory, Controlled Oral Word Association Test, CERAD battery and the Neuropsychiatric Inventory (NPI) of 77 [age at entry 65.9+/-8.1 (mean+/-standard deviation) years] patients with probable VaD, periventricular white matter and basal ganglia lacunae, longitudinally studied for 25.7+/-11 months.

RESULTS

Mean number of follow-up visits was 2.6. Overall annual vascular event rate was 0.25. VaD-L in mildly and moderately impaired patients is characterized by progressive cognitive and behavioral decline. The rate of cognitive and behavioral progression depends on the occurrence of vascular episodes (VE) during the course of the illness [(-1.1) MMSE and (+4.0) NPI points annually without VE vs. (-2.0) and (+10.3) points following VE]. The rates of progression are a function of the severity of the cognitive and behavioral impairment. Impaired cognition is associated with impaired behavior. A subgroup of VaD-L patients runs a progressively deteriorating course despite the absence of clinically apparent new vascular episodes.

CONCLUSION

VaD-L is characterized by cognitive and behavioral decline in 83% of the patients. The rate of decline is determined mainly by the severity of the cognitive and behavioral impairment at baseline and by the occurrence of new vascular episodes.

Rivastigmine in subcortical vascular dementia: an open 22-month study

Further to recent data indicating that patients with vascular dementia (VaD) show a cholinergic deficit, we aimed to determine whether rivastigmine, a dual inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), has any effects on the symptoms of VaD. Patients aged 65-80, with a diagnosis of dementia and probable VaD, received rivastigmine 3-6 mg/day (n=8) or cardioaspirin (n=8) in an open study for 22 months. At 22 months, patients treated with rivastigmine showed significant improvements in executive function and behavioural symptoms (both p<0.05 vs. both baseline and control group), which were reflected in reduced caregiver stress (p<0.05 vs. baseline and controls). Baseline scores of global response, cognition, word fluency and activities of daily living were maintained in patients receiving rivastigmine, and there was no increase in benzodiazepine or neuroleptic intake. In contrast, the control group showed no improvements in any domain, and significant deterioration in global response and executive function (both p<0.05 vs. baseline and rivastigmine group). Side effects in both groups were tolerable and there were no study withdrawals. Long-term rivastigmine treatment appeared to be safe and effective in this patient population. In particular, improvements in domains particularly relevant to this condition were observed. These benefits may reflect the drug's dual inhibitory effects on the cholinergic system, and its particular activity in frontal areas of the brain. A large, double-blind study of rivastigmine in patients with VaD would be worthwhile.

Assessment of behavioral and psychological symptoms of dementia

In spite of their prevalence and persistence, why are behavioral and psychological symptoms of dementia difficult for clinicians to assess and manage? This paper provides an overview of the methodological challenges encountered in measuring behavioral disturbances of dementia. Specifically, conceptual constructs of behavioral and psychological symptoms of dementia, the strengths and weaknesses of the currently existing rating instruments, analytic methodologies, and the utility of technological devices are outlined in the service of formulating future directions in behavioral and psychological symptoms of dementia assessment research.

Depression and Alzheimer's disease: symptom or comorbidity?

Alzheimer's disease is the most frequent form of dementia, where behavioral and cognitive disruption symptoms coexist. Depression, apathy, anxiety, and other conduct disorders are the complaints most often reported by caregivers. Fifty subjects were referred to our Institute with a diagnosis of probable Alzheimer's disease. Cognitive impairment was equally distributed among the subjects. Patients, aged 68 to 76 years old, were randomized to receive inhibitors of cholinesterase (Donepezil, 5 mg/day) alone, or inhibitors of cholinesterase plus selective serotonin reuptake inhibitors (SSRIs) (citalopram HBr, 20 mg/day). We followed up all the patients for one year, with particular concern for neuropsychological aspects associated with eventual behavioral changes. Results indicate that SSRI intake seems to be effective for depression, decreasing it and improving quality of life for both patients and caregivers. Side effects in both groups were few, and there were no study withdrawals. This paper discusses the relationship between dementia and depression, and presents our finding that depressive symptoms, if specifically treated, tend to reduce caregiver stress and improve well-being in patients with Alzheimer's disease.