The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia

Neuropsychiatric aspects of Parkinson's disease

Previous studies of the neuropsychiatric aspects of Parkinson"s disease were frequently methodologically inadequate. Small sample sizes, selection bias, lack of diagnostic criteria of Parkinson"s disease, different definitions and assessment of neuropsychiatric symptoms, and lack of control groups seriously questioned the validity of and ability to generalize the results from many studies. During the past decade, however, several of these methodological issues have been addressed. Recent studies have found that mild cognitive impairment is very common, and dementia, depression, and psychotic symptoms develop in a large proportion of patients. Neuropsychiatric symptoms are important determinants of mortality and disease progression, as well as of the patients quality of life and course of disease, caregiver distress, and nursing home admission. Few adequately designed treatment trials have been published, but available evidence suggests that depression and hallucinations may be effectively treated using new antidepressants and atypical antipsychotic agents without worsening of parkinsonism.

Cholinergic therapy for neuropsychiatric symptoms in neurologic disorders

Acetylcholine is a modulatory central nervous system (CNS) neurotransmitter involved in diverse brain processes. Historically, drugs that increase CNS cholinergic transmission have been investigated primarily for relieving cognitive symptoms in Alzheimer"s disease (AD). Emerging from these efforts are recent findings that several cholinesterase-inhibitor agents also have a beneficial effect on selected noncognitive symptoms in AD, such as apathy, psychosis, and purposeless motor behaviors. The broad psychotropic effects of cholinergic agents observed in AD and other degenerative conditions highlight potential symptom-based therapeutic indications for these drugs across a variety of neurologic disorders.

Range of neuropsychiatric disturbances in patients with Parkinson's disease

OBJECTIVES

Disturbances of cognition and emotion are common in patients with Parkinson's disease. Most previous studies of psychopathology in Parkinson's disease have focused on a single psychiatric diagnosis or condition. The objective of this study was to describe the range of neuropsychiatric symptoms in a representative sample of patients with Parkinson's disease.

METHODS

The sample of 139 patients was drawn from an epidemiological study of Parkinson's disease in Rogaland county, Norway, and represented 93% of those who had survived during the 4 years since the initial assessment. The diagnosis of Parkinson's disease was based on published criteria. Neuropsychiatric symptoms were assessed using the neuropsychiatric inventory, a caregiver based structured interview, which assesses severity and frequency of 10 psychiatric symptoms present during the past month.

RESULTS

At least one psychiatric symptom was reported in 61% of the sample. The most common behaviours were depression (38%) and hallucinations (27%), and the least common symptoms were euphoria and disinhibition. The highest mean scores were found for depression, apathy, and hallucinations. Factor analysis showed that hallucinations, delusions, and irritability clustered into one factor, and apathy and anxiety constituted another factor. Psychiatric symptoms were more common among patients living in nursing homes compared with home dwelling patients, and correlated with stage of disease and cognitive impairment, but not with age or duration of disease. No relation to left or right sided parkinsonism was found.

CONCLUSION

This study emphasises the importance of psychiatric symptoms in Parkinson's disease, which were present in most patients. Clinicians should focus on the emotional and cognitive disturbances in addition to the motor manifestations of the disease.

Assessing frontal lobe behavioral syndromes with the frontal lobe personality scale

Reliability and construct validity are reported for the Frontal Lobe Personality Scale (FLOPS), a brief neurobehavior rating scale. The FLOPS Family form was completed by family members of 24 frontal lobe brain-damaged patients, 15 non-frontal lobe brain- damaged patients, and 48 healthy controls. Intrascale reliability was demonstrated (internal consistency.96; split half.93). Validity studies of frontal lobe patients post-lesion compared to their pre-lesion status, to healthy controls, and of frontal lobe patients pre- and post-lesion compared to non-frontal lobe patients pre- and post-lesion, indicated that frontal lobe patients post-lesion showed significantly more frontal behavior than (a) pre-lesion frontal lobe patients, (b) healthy controls, and (c) post-lesion non-frontal lobe patients. The FLOPS appears to be useful for quantifying frontal lobe behavior in clinical and research settings.

Revised memory and behavior problems checklist in Taiwanese patients with Alzheimer's disease

The Revised Memory and Behavior Problems Checklist (RMBPC) is a 24-item caregiver report that measures observable behavioral and memory problems in dementia patients and their caregivers' reaction to these problems. The purpose of the present study was to evaluate the applicability of the RMBPC for use in Taiwanese patients with Alzheimer's disease (AD). The subjects included 76 AD patients (39 men and 37 women, mean age 72.3) and their caregivers (34 men and 42 women, mean age 53.5) who participated in a comprehensive assessment at the Veterans General Hospital-Taipei. The Chinese version of the Cognitive Abilities Screening Instrument was administered to the patients. Their caregivers rated the RMBPC and the short version of the Geriatric Depression Score (GDS). To assess the test-retest reliability, 30 caregivers rated a second RMBPC 3 days after the first evaluation. The mean score for the frequency rating on the RMBPC was 32.63 (SD = 12.44, range = 5-61) and the mean reaction score was 10.96 (SD = 11.53). The reaction score was significantly correlated with the GDS score (r = .363, p = .001). The Cronbach's alpha coefficients for frequency and reaction scores were .816 and .895 respectively. The test-retest reliabilities of total frequency and reaction scores were significantly correlated; overall correlations were .89 for frequency (p < .001) and .74 for reaction (p < .001). These findings suggest that the RMBPC be recommended as a reliable tool to assess behavioral and memory disturbance in Taiwanese AD patients.

Depression and dementia: comorbidities, identification, and treatment

Depression is a highly prevalent concomitant of dementia. Concurrent depression (DD) can meet full criteria for a disorder or take the form of a depressive syndrome. Although phenomenologic overlap can confound diagnosis, careful assessment demonstrates that a true depressive component is present in a substantial percentage of dementia cases. DD has been associated with excess disability, increased caregiver burden, and greater mortality. Efficacy studies have demonstrated high placebo response rates, indicating transience of many depressive symptoms, and adverse cognitive effects of older antidepressants. Studies demonstrating that new antidepressants can be efficacious and improve cognitive functioning are reviewed.

Apolipoprotein E genotype and noncognitive symptoms in Alzheimer's disease

BACKGROUND

The apolipoprotein E (ApoE) epsilon 4 allele confers significant risk for Alzheimer's disease and is associated with a greater amyloid burden in the brain. Future treatments may target molecular mechanisms associated with this allele, and it is important to define any phenotypic characteristics that correspond to this genotype. We sought to clarify the relationship between ApoE status and noncognitive symptoms in Alzheimer's disease patients.

METHODS

Possible and probable Alzheimer's disease patients from a clinical trial (n = 605) were assessed with the 10-item Neuropsychiatric Inventory cross-sectionally prior to treatment, and their ApoE genotype was determined. Among the population studied, the following numbers with specific genotypes were studied: 23-2/3, 17-2/4, 209-3/3, 288-3/4, 68-4/4.

RESULTS

When correlations were controlled for the patient's level of cognitive impairment, there was no relationship between epsilon 4 dose and any of the 10 noncognitive symptoms assessed, including psychosis, mood changes, and personality alterations.

CONCLUSIONS

Among patients with comparable disease severity, the epsilon 4 allele does not confer additional psychiatric morbidity.

Contrasting results between caregiver's report and direct assessment of activities of daily living in patients affected by mild and very mild dementia: the contribution of the caregiver's personal characteristics

OBJECTIVE

To determine the level of agreement between the primary caregiver's report on patient activities of daily living (ADLs) and ADLs assessed directly in a sample of patients affected by very mild and mild dementia and to assess whether this agreement is influenced by the caregiver's depressive symptoms and burden.

PATIENTS AND METHODS

Data were obtained from the baseline sample of the Mild Dementia Longitudinal Study, consisting of 111 consecutive patients affected by dementia with very mild to mild functional impairment (grades .5 and 1 on the Clinical Dementia Rating Scale). As is usual for patients referred to our Alzheimer's Unit, anamnestic, cognitive, functional and behavioral information are collected from the primary caregiver. Along with sociodemographic characteristics, caregivers' depressive symptoms (Beck Depression Inventory Scale) and burden (Nowak and Guest's Caregiver Burden Inventory Scale) were also evaluated. Patients underwent a performance-based assessment of the activities of daily living (DAFS) and direct assessment of physical function with the Physical Performance Test (PPT). Caregiver's report and direct observation have been compared for the following ADLs: dressing, toileting, walking, telephone use, shopping, and money use. Discriminant analyses were conducted to examine the degree of agreement between caregiver-report functional status and performance-based measures and whether additional agreement is attributable to caregiver's burden and depressive symptoms.

RESULTS

The strength of the association between the caregiver's report and performance-based measures of ADLs is high for motor performance (walking), moderate to good for dressing, but only moderate for telephone, money use, and shopping. No association was found for toileting. The discrepancies between caregiver report and performance-based assessment were influenced substantially by the burden caused by demands and restrictions on a caregiver's time.

CONCLUSIONS

With the exception of motor performance (walking), the caregiver's report and the performance-based assessment of functional status measure different aspects of a patient's functional status. Contrasts between the caregiver's report and observed ADL performance in mildly and very mildly demented patients are influenced by the caregiver's burden.

The therapeutic potential of tacrine

Tacrine, a non-competitive inhibitor of acetylcholine esterase, has been approved for the treatment of patients with mild to moderate Alzheimer's disease in 1995. The available evidence suggests that in a substantial proportion of patients tacrine has the potential to improve cognitive functions, to ameliorate behavioural problems, and to delay the time to significant clinical endpoints. Thus, tacrine meets realistic expectations from symptomatic treatment. The major safety concern about tacrine is the probability of liver enzyme elevations and the high frequency of adverse events, particularly gastrointestinal. Findings are presented from an open-label multicentre study showing that tacrine is a safe and manageable compound in private practice.

Frequency and clinical determinants of poststroke depression

BACKGROUND AND PURPOSE

Previous studies have shown a large variation concerning the frequency of poststroke depression. This variation is caused by differences in patient populations, psychiatric assessment methods, and diagnostic criteria. In this study, we evaluated the frequency and clinical correlates of poststroke depression in a large well-defined stroke cohort.

METHODS

We studied a consecutive series of 486 patients with ischemic stroke aged from 55 to 85 years. Of these, 277 patients underwent a comprehensive psychiatric evaluation, including the Present State Examination, from 3 to 4 months after ischemic stroke. The criteria of the Diagnostic and Statistical Manual of Mental Disorders, edition 3, revised (DSM-III-R), were used for the diagnosis of depressive disorders.

RESULTS

The frequency of any depressive disorder was 40.1% (n=111). Major depression was diagnosed in 26.0% (n=72) and minor depression in 14.1% (n=39). Major depression with no other explanatory factor besides stroke was diagnosed in 18.0% (n=49) of the patients. Comparing depressed and nondepressed patients, we found no statistically significant difference in sex, age, education, stroke type, stroke localization, stroke syndrome, history of previous cerebrovascular disease, or frequency of DSM-III-R dementia. According to the multiple logistic regression model, dependency in daily life correlated with the diagnosis of depression (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1 to 3.1) and with the diagnosis of major depression (OR, 2.9; 95% CI, 1.6 to 5.5). A history of previous depressive episodes also correlated with the diagnosis of depression (OR, 2.3; 95% CI, 1.3 to 4.4) and with the diagnosis of major depression (OR, 2.9; 95% CI, 1.6 to 5.5), whereas solely stroke-related major depression correlated only weakly with stroke severity as measured on the Scandinavian Stroke Scale (OR, 1.1; 95% CI, 1.0 to 1.1).

CONCLUSIONS

Clinically significant depression is frequent after ischemic stroke. We emphasize the importance of the psychiatric examination of poststroke patients, especially those with a significant disability and with a history of prior depressive episodes.

Incidence and relationship between behavioural and psychological symptoms in Alzheimer's disease

OBJECTIVES

To evaluate the frequency and type of psychological and behavioural symptoms in Alzheimer's disease (AD) patients in Poland, in various stages of the disease.

METHOD

One hundred and sixty-nine patients with a diagnosis of probable AD in Global Deterioration (GDS) stages 3, 4, 5, 6 and 7 of dementia were examined in a search for behavioural and psychological symptoms.

RESULTS

Behavioural and psychotic symptoms were most often found in GDS stages 5 and 6 of AD, except for depressive disorder, which was observed most frequently in GDS stage 4 and whose frequently decreased towards the terminal stages of dementia. From an analysis of the relationship between behavioural symptoms in the Polish AD patients, the following syndromes may be discriminated: psychotic syndrome (delusions and hallucinations), delusions with aggressive behaviour and hallucinations and anxiety. With more severe dementia, the syndromes, which could be the result of delirium, became more common.

CONCLUSIONS

Diagnosis of delirium should be considered in moderately severe and severe dementia whenever a sudden change in patients' behaviour occurs.

Neuropsychiatric features of corticobasal degeneration

OBJECTIVE

To characterise the neuropsychiatric symptoms of patients with corticobasal degeneration (CBD).

METHODS

The neuropsychiatric inventory (NPI), a tool with established validity and reliability, was administered to 15 patients with CBD (mean (SEM), age 67.9 (2) years); 34 patients with progressive supranuclear palsy (PSP) (66.6 (1.2) years); and 25 controls (70 (0.8) years), matched for age and education. Both patient groups had similar duration of symptoms and mini mental state examination scores. Semantic fluency and motor impairment were also assessed.

RESULTS

Patients with CBD exhibited depression (73%), apathy (40%), irritability (20%), and agitation (20%) but less often had anxiety, disinhibition, delusions, or aberrant motor behaviour (for example, pacing). The depression and irritability of patients with CBD were more frequent and severe than those of patients with PSP. Conversely, patients with PSP exhibited significantly more apathy than patients with CBD. The presence of high depression and irritability and low apathy scale scores correctly differentiated the patients with CBD 88% of the time. The irritability of patients with CBD was significantly associated with disinhibition (r=0.85) and apathy (r=0.72). In CBD, apathy was associated with disinhibition (r=0.67); disinhibition was associated with aberrant motor behaviour (r=0.68) and apathy (r=0.67); and aberrant motor behaviour with delusions (r=1.0). On the other hand, depression was not associated with any other behaviour, suggesting that it has a different pathophysiological mechanism. Symptom duration was associated with total motor scores (r=0.69). However, total motor score was not associated with any behaviour or cognitive scores.

CONCLUSIONS

The findings indicate that frontosubcortical pathways mediating cognition, emotion, and motor function in CBD are not affected in parallel. Patients with CBD and PSP have overlapping neuropsychiatric manifestations, but they express distinctive symptom profiles. Evaluating the behavioural abnormalities of parkinsonian patients may help clarify the role of the basal ganglia in behaviour.

Clinical trials and therapy

Parallel-group studies have established the efficacy of cholinesterase inhibitors in Alzheimer's disease, at least for short-term cognitive and clinical global enhancement. Noncognitive outcomes are currently under scrutiny. Time to reach clinical milestones may be a more useful trial design for new studies aiming to delay appearance or progression of disease.

Hallucinations

Hallucinations, sensory perceptions without environmental stimuli, occur as simple experiences of auditory, gustatory, olfactory, tactile, or visual phenomena as well as mixed- or complex experiences of more than one simple phenomenon. The nature of the hallucination assists localization, differential diagnosis, and treatment planning. In particular, the presence of persistent visual hallucinations of persons with Parkinson's disease predicts dementia, rapid deterioration, permanent nursing home placement, and death. Hallucinations in persons with Alzheimer's disease are often associated with serious behavioral problems and predict a rapid cognitive decline. Theories of the etiology of hallucinations include (1) stimulation, e.g., neurochemical, electrical, seizure, and ephaptic, and (2) inhibition, e.g., destruction of normally inhibitory functions, resulting in disinhibition as in the Charles Bonnet and phantom limb syndromes. Functional neuroimaging procedures suggest anatomical associations for hallucinations. While hallucinations may be a symptom of medical, neurologic, and psychiatric disorders, they may also occur in a wide range of human experiences.

Behavioral differences between frontotemporal dementia and Alzheimer's disease: a comparison on the BEHAVE-AD rating scale

Frontotemporal dementia (FTD) is a dementing syndrome characterized by the occurrence of neuropsychiatric features early in the clinical course. Patients with Alzheimer's disease (AD) also have neuropsychiatric symptoms, but these symptoms typically emerge later in the course after the development of memory and other cognitive impairment. The BEHAVE-AD, an instrument developed to evaluate neuropsychiatric features in dementia, may help characterize the behavioral features of FTD and differentiate FTD from AD. This study evaluated BEHAVE-AD results of 29 patients with the diagnosis of FTD compared to those of 29 patients with the diagnosis of probable AD of similar dementia severity. The FTD patients had significantly worse global BEHAVE-AD scores compared to the AD patients. Verbal outbursts and inappropriate activity characterized the FTD patients, and three BEHAVE-AD subscales correctly classified 69% of the patients. The assessment of neuropsychiatric symptoms with a standardized scale or inventory can help distinguish dementia patients with FTD and AD.

Factors associated with psychotic symptoms in Alzheimer's disease

OBJECTIVES

Many clinical and biological factors have been reported to be associated with the presence of psychosis in patients with Alzheimer's disease, although the associations were variable. The aim of this study was to clarify factors associated with the presence of psychosis in patients with Alzheimer's disease.

METHODS

Psychiatric functioning was studied in 228 patients with Alzheimer's disease based on the results of the behavioural pathology in Alzheimer's disease rating scale or the neuropsychiatric inventory. The effects of sex, education level, age, duration of illness, cognitive function, and apolipoprotein E genotype were investigated for dichotomous psychotic status with a multiple logistic regression analysis.

RESULTS

Of the 228 patients with Alzheimer's disease, 118 (51.8%) showed evidence of delusions or hallucinations. Of these, 94 had delusions only, three had hallucinations only, and 21 had both. Older age, female sex, longer duration of illness, and more severe cognitive impairment were the factors independently associated with the presence of psychosis. The presence of psychosis was not significantly related to either educational level or apolipoprotein E genotype.

CONCLUSIONS

Age, sex, and severity of illness were independent factors associated with the presence of psychosis in patients with Alzheimer's disease. The reason why some patients with Alzheimer's disease develop psychosis remains unclear. There may be distinctive subtypes of Alzheimer's disease or the presence of individual factors which affect the development of psychosis.

Assessing the impact of neuropsychiatric symptoms in Alzheimer's disease: the Neuropsychiatric Inventory Caregiver Distress Scale

OBJECTIVES

To develop an adjunct scale to the Neuropsychiatric Inventory (NPI) for assessing the impact of neuropsychiatric symptoms in Alzheimer's disease (AD) patients on caregiver distress.

DESIGN

Cross-sectional descriptive and correlational study.

SETTING

University out-patient memory disorders clinics.

PARTICIPANTS

Eighty-five AD subjects and their caregivers (54 spouses, 31 children).

MEASUREMENTS

The NPI and NPI Caregiver Distress Scale (NPI-D) were used to assess neuropsychiatric symptoms in AD patients and related caregiver distress, respectively. Criterion validity of the NPI-D was examined (N = 69) by comparison with an abridged version of the Relatives' Stress Scale (RSS'), a general measure of caregiver stress, using item clusters that had previously been correlated to behavioral disturbances in demented patients. Test-retest (n = 20) and inter-rater reliability (n = 16) of the NPI-D were also assessed.

RESULTS

Test-retest and interrater reliability of the NPI-D were both adequate. Overall, caregiver NPI-D distress ratings were correlated significantly with the RSS' (r = .60, P < .001). RSS' ratings correlated strongly with NPI scores (r = .64, P < .001), even after controlling for degree of cognitive impairment based on the Mini-Mental State Exam (MMSE) score (r = .61). MMSE scores showed a moderate correlation to RSS' ratings (-.30, P = .02), but this association was markedly attenuated when controlling for the degree of neuropsychiatric disturbance based on the NPI score (r = -. 14). NPI-D ratings for 9 of 10 NPI symptom domains correlated most strongly with either NPI symptom severity or total (frequency x severity) scores. Agitation, dysphoria, irritability, delusions, and apathy were the symptoms most often reported to be severely distressing to caregivers.

CONCLUSIONS

The NPI-D provides a reliable and valid measure of subjective caregiver distress in relation to neuropsychiatric symptoms measured by the NPI. Neuropsychiatric alterations are more strongly associated than cognitive symptoms to caregiver distress. The NPI-D may be useful in both clinical and research settings for assessing the contribution to caregiver distress of neuropsychiatric symptoms in AD patients.

Psychotic symptoms and physically aggressive behavior in Alzheimer's disease

OBJECTIVE

To examine the relationship between psychotic symptoms and subsequent physically aggressive behavior in outpatients with Alzheimer's disease.

DESIGN

This observational study used a time series design to measure the presence and frequency of physically aggressive behavior over a 52-week period. Multiple regression models were used to evaluate delusions and hallucinations, assessed at baseline, as predictors of physical aggression, controlling for demographic and clinical variables.

SETTING AND PARTICIPANTS

Of 315 consecutive eligible outpatients from the Rush Alzheimer's Disease Center, referred for evaluation for dementia, 270 (86%) participated in the study. All participants met NINCDS/ADRDA criteria for probable Alzheimer's disease; Mini-Mental State Examination scores ranged from 0 to 27, with a mean of 14.9 (SD = 5.6).

MEASUREMENTS

Psychotic symptoms, previous episodes of physical aggression, and demographic variables were measured at baseline through a structured interview with an informant living in the same household. Physically aggressive behavior was measured sequentially at 1-week intervals over a period of 52 consecutive weeks and also through structured informant interviews.

RESULTS

A total of 75 persons had one or more episodes of physical aggression during the 52 weeks of observation. The presence of delusions significantly predicted the presence and frequency of physical aggression. Of participants with high rates of physical aggression (> 1 episode/month), 80% had delusions. This effect was robust, even after controlling for the effects of other clinical variables. By contrast, hallucinations did not reliably predict episodes of physical aggression.

CONCLUSIONS

These data suggest that delusions, but not hallucinations, predict physically aggressive behavior in persons with Alzheimer's disease. In light of the persecutory nature of most delusional ideation in Alzheimer's disease, delusions may be associated with distortions in the perception of threat in common social situations.

Aggressive, socially disruptive and antisocial behaviour associated with fronto-temporal dementia

BACKGROUND

Research suggests an association between frontal and temporal injury and antisocial conduct. We studied the frequency of antisocial behaviours in fronto-temporal dementia (FTD) where pathology is anterior frontal-temporal, compared with Alzheimer's disease (AD) where pathology is primarily posterior temporal-parietal.

METHOD

The presence of antisocial conduct was compared in 22 FTD versus 22 AD subjects. All FTD patients had anterior frontal or temporal hypoperfusion with single photon emission computed tomography, whereas those with AD had posterior temporal-parietal hypoperfusion.

RESULTS

Ten FTD and one AD subject showed antisocial behaviours, which included assault, indecent exposure, shoplifting and hit-and-run driving. Three FTD subjects were arrested. This difference was highly significant (P = 0.004).

CONCLUSIONS

Degeneration of frontal and temporal lobes predisposes to antisocial behaviour. This study supports a relationship between frontal-temporal dysfunction and certain types of antisocial activities.

Frontal behavioral inventory: diagnostic criteria for frontal lobe dementia

OBJECTIVE

To utilize the diagnostic criteria of frontal lobe dementia (FLD).

METHODS

We studied 12 patients with FLD diagnosed clinically, with radiological confirmation in 10 and autopsy confirmation in 2; sixteen patients with Alzheimer's disease matched for stage and severity to FLD and 11 patients with depressive dementia were used as control groups. A 24-item Frontal Behavioral Inventory (FBI) using the most relevant behavioral manifestations of FLD was administered in these populations.

RESULTS

FLD patient scores on the FBI were much higher compared with control groups (AD and DD). Item analysis showed loss of insight, indifference, distractibility, personal neglect and apathy as the most frequent negative symptoms. Perseveration, disinhibition, inappropriateness, impulsivity, and irresponsibility were the most significant positive symptoms. An operational definition of FLD included a minimum FBI score of 27. Only one false positive was shown in the depressive group and none among the AD group, indicating little overlap between patient groups, and a high discriminating value of the FBI.

CONCLUSIONS

The FBI appears to be a useful diagnostic instrument and a method to operate the behavioral criteria of FLD. Further prospective studies are warranted to establish validity.

The assessment and management of behavioural manifestations of dementia: a review and results of a controlled trial

Although the cognitive impairments in dementia are the defining aspect, the non-cognitive changes such as behavioural disturbance and personality change are very common and may cause great distress to the patient and the carer. This article reviews the definition, prevalence and nature of behavioural disturbance in dementia. In addition, we review assessment scales and published reports of psychological, physical and psychosocial management strategies. Finally, we present the results of a successful randomized controlled trial of an individualized intervention package for behavioural manifestations of dementia. We conclude that this approach can help alleviate some of the distressing symptoms of dementia.

Diagnosis of Alzheimer's disease. Report of an International Psychogeriatric Association Special Meeting Work Group under the cosponsorship of Alzheimer's Disease International, the European Federation of Neurological Societies, the World Health Organization, and the World Psychiatric Association

Current knowledge with respect to the diagnosis of Alzheimer's disease (AD) is reviewed. There is agreement that AD is a characteristic clinicopathologic entity that is amenable to diagnosis. The diagnosis of AD should no longer be considered one of exclusion. Rather, the diagnostic process is one of recognition of the characteristic features of AD and of conditions that can have an impact on presentation or mimic aspects of the clinicopathologic picture. The present availability of improved prognosis, management, and treatment strategies makes the proper, and state-of-the-art, diagnosis of AD a clinical imperative in all medical settings. Concurrently, information regarding the relevance and applicability of current diagnostic procedures in diverse cultural settings must continue to accrue.

Manchester and Oxford Universities Scale for the Psychopathological Assessment of Dementia (MOUSEPAD)

BACKGROUND

There is increasing awareness of the importance of psychopathological and behavioural changes in dementia and a need for an instrument to measure these features which achieves an appropriate compromise between brevity and breadth. We describe a newly developed 59-item instrument: the MOUSEPAD.

METHOD

Reliability, sensitivity and validity were examined with 30 carers, each of whom was interviewed four times over six weeks.

RESULTS

For different symptom groups, kappa ranged from 0.43 to 0.93 for test-retest reliability, from 0.56 to 1.0 for inter-rater reliability, and from 0.43 to 0.67 for the validation study.

CONCLUSIONS

The scale may be useful as an outcome measure in drug trials, for correlating psychopathological and behavioural changes with post-mortem findings, and in epidemiological surveys.

Depression in persons with dementia

The prevalence of depression in persons with dementia is controversial. Among 288 outpatients with dementia, a prevalence of 7.4% was found according to the Hamilton Rating Scale for Depression (HRSD), 8.0% using the Geriatric Depression Scale (GDS), and 6.3% according to DSM-IV criteria. Rates and levels of depression tended to be higher in vascular than in Alzheimer's dementia according to the rating scales, but not according to the DSM-IV criteria. Greater cognitive impairment was associated with higher HRSD (but not GDS) scores. Cases of clinical depression did not persist over 12 months' follow-up. These results suggest that clinically significant depression in dementia is less common than previously reported and tends to remit.

Effect of tacrine on behavioral symptoms in Alzheimer's disease: an open-label study

We conducted an open-label study designed to assess the effects of tacrine on behavioral changes in patients with Alzheimer's disease (AD). Twenty-eight subjects completed a baseline evaluation and at least one assessment during treatment. Behavioral symptoms and cognitive function were assessed with the Neuropsychiatric Inventory (NPI) and Mini-Mental State Examination (MMSE), respectively. The mean NPI score at the maximum individual dose of tacrine attained was markedly decreased (behavior improved, compared to baseline). Symptoms of anxiety, apathy, hallucinations, aberrant motor behaviors, and disinhibition were most responsive. Subject stratification by dementia severity revealed a substantially reduced mean NPI score only in the group with moderate dementia, independent of cognitive response. Over half of the subjects with cognitive improvement had a marked reduction in behavioral symptoms, particularly apathetic behaviors. These data suggest that tacrine may be beneficial for selected behavioral symptoms in AD patients, particularly at higher doses and in those with moderate cognitive deficits.

The depressions of Alzheimer's disease: sorting, pharmacotherapy, and clinical advice

Research describing wide prevalence variation of Alzheimer's disease (AD) and comorbid depression is explained in light of subsyndromal depressions, the use of standardized diagnostic instruments and procedures, and the subcortical and cortical components of mood. There appear to be several "depressions" of AD. Against this backdrop, double-blind, placebo-controlled studies of antidepressant use in AD are reviewed and methodologic problems identified. Evidence for efficacy in controlled trials is weak, but open-label trials are, as expected, more encouraging. The potential efficacy of new agents for the depressions of AD receive comment. A heuristic model makes use of the conclusions developed, the stage of illness, and a preliminary classification scheme for the depressions of AD; this model provides a rational basis for thinking about medication selection for AD depressions. Clinical decisions are illustrated.