Behavioral and psychological symptoms of dementia

Agitation and Irritability in Alzheimer's Disease: Evidenced-Based Treatments and the Black-Box Warning

More than five million Americans suffer from Alzheimer's disease (AD), and this number is expected to triple by 2050. While impairments in cognition, particularly memory, are typically the defining features of the clinical syndrome, behavioral symptoms are extremely common, affecting up to 90% of patients. Behavioral symptoms in AD can be difficult to manage and may require a combination of non-pharmacological and pharmacological approaches. The latter is complicated by FDA "black-box warnings" for the medication classes most often used to target these symptoms, and currently there are initiatives in place to limit their use. In this review, we describe common behavioral symptoms of AD-with a particular focus on the challenging symptoms of "agitation" and "irritability"-and discuss evidence-based approaches to their management. Ultimately, multidimensional approaches must be tailored to the patient and their environment, though evidence-based practices should define the treatment of agitation and irritability in AD.

Caregiver report versus clinician impression: disagreements in rating neuropsychiatric symptoms in Alzheimer's disease patients

BACKGROUND

The measurement of neuropsychiatric symptoms (NPS) in dementia is often based on caregiver report. Challenges associated with providing care may bias the caregiver's recognition and reporting of symptoms. Given potential problems associated with caregiver report, clinicians may improve measurement by drawing from a wider array of available data and by applying clinical judgment.

OBJECTIVE

The objective of this study is to evaluate potential disagreements between caregiver report and clinician impression when rating psychopathological manifestations from the same patient with dementia.

METHODS

Three hundred twelve participants (156 patients with Alzheimer's disease [AD] and 156 caregivers) were studied using the Neuropsychiatric Inventory-Clinician Rating Scale. We considered disagreement to be present when caregiver ratings were significantly higher or lower (p < 0.05) than NPS ratings by clinicians of the same patient. To evaluate whether disagreements were related to dementia severity, we repeated comparisons across levels defined by the clinical dementia rating.

RESULTS

The most common disagreements involved ratings of agitation, depression, anxiety, apathy, irritability, and aberrant motor behavior especially in patients with mild dementia. There were fewer discrepancies in moderate or severe dementia. The most consistent disagreements involved global ratings of depression where caregiver scores ranged from +22.5 higher to -4.5 lower than clinician rating.

CONCLUSIONS

Caregivers may have incomplete perception of patient NPS mainly in mild dementia. NPS ratings might be confounded by cultural beliefs, sometimes leading caregiver to interpret symptoms as part of "normal" aging.

Sleep and agitation in nursing home residents with and without dementia

BACKGROUND

The prevalence of dementia in Australian nursing homes is high. A large proportion of residents express themselves through agitated behaviors, with substantial interpersonal and day-to-day variance. One factor that may increase agitation is poor sleep. The current study aimed to determine if sleep influences symptoms of agitation in nursing home residents, and whether this effect differed by dementia status. As benzodiazepines are used widely as hypnotic medication, their impact was also considered.

METHODS

Actigraph devices worn on residents' non-dominant wrists for three days were used to obtain objective measures of sleep. Symptoms of agitation were assessed using staff responses to two standardized questionnaires - the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory - nursing home version (NPI-NH). Presence of dementia and benzodiazepine use were obtained from resident medical charts.

RESULTS

Forty-nine residents (mean age: 85.57 years) from four nursing homes in Tasmania were included in the study. Results indicated that residents were in bed for an average of 11.04 h and slept for 10.14 h per day. Significant relationships between sleep and verbal as well as non-aggressive agitation were found. No relationships between sleep and aggressive agitation were detected. A significant moderation effect of dementia was found, in which residents without dementia expressed verbal agitation when obtaining less sleep, but not residents with dementia. Benzodiazepine use did not result in significantly more sleep.

CONCLUSIONS

These results suggest that sleep could play an important role in explaining agitation, but more research is needed to explore the relationship between sleep and benzodiazepines in nursing home residents.

Apathy in Neurodegenerative Diseases: Recommendations on the Design of Clinical Trials

Apathy is a common feature of neurodegenerative disorders but is difficult to study in a clinical trial setting due to practical and conceptual barriers. Principal challenges include a paucity of data regarding apathy in these disorders, an absence of established diagnostic criteria, the presence of confounding factors (eg, coexisting depression), use of concomitant medications, and an absence of a gold-standard apathy assessment scale. Based on a literature search and ongoing collaboration among the authors, we present recommendations for the design of future clinical trials of apathy, suggesting Alzheimer disease and Parkinson disease as models with relevance across a wider array of neuropsychiatric disorders. Recommendations address clarification of the targeted study population (apathy diagnosis and severity at baseline), confounding factors (mood/cognition, behavior, and treatment), outcome measures, study duration, use of comparators and considerations around environment, and the role of the caregiver and patient assent. This review contributes to the search for an optimal approach to study treatment of apathy in neuropsychiatric disorders.

Depressive symptoms in neurodegenerative diseases

Depressive symptoms are very common in chronic conditions. This is true so for neurodegenerative diseases. A number of patients with cognitive decline and dementia due to Alzheimer’s disease and related conditions like Parkinson’s disease, Lewy body disease, vascular dementia, frontotemporal degeneration amongst other entities, experience depressive symptoms in greater or lesser grade at some point during the course of the illness. Depressive symptoms have a particular significance in neurological disorders, specially in neurodegenerative diseases, because brain, mind, behavior and mood relationship. A number of patients may develop depressive symptoms in early stages of the neurologic disease, occurring without clear presence of cognitive decline with only mild cognitive deterioration. Classically, depression constitutes a reliable diagnostic challenge in this setting. However, actually we can recognize and evaluate depressive, cognitive or motor symptoms of neurodegenerative disease in order to establish their clinical significance and to plan some therapeutic strategies. Depressive symptoms can appear also lately, when the neurodegenerative disease is fully developed. The presence of depression and other neuropsychiatric symptoms have a negative impact on the quality-of-life of patients and caregivers. Besides, patients with depressive symptoms also tend to further decrease function and reduce cognitive abilities and also uses to present more affected clinical status, compared with patients without depression. Depressive symptoms are treatable. Early detection of depressive symptoms is very important in patients with neurodegenerative disorders, in order to initiate the most adequate treatment. We review in this paper the main neurodegenerative diseases, focusing in depressive symptoms of each other entities and current recommendations of management and treatment.

Neuropsychiatric symptoms in Vascular Cognitive Impairment: a systematic review

Neuropsychiatric symptoms or Behavioral and Psychological Symptoms of Dementia (BPSD) are common and invariably appear at some point during the course of the disease, mediated both by cerebrovascular disease and neurodegenerative processes. Few studies have compared the profiles of BPSD in Vascular Cognitive Impairment (VCI) of different subtypes (subcortical or cortical) and clinical stages (Vascular Cognitive Impairment No Dementia [VaCIND] and Vascular Dementia [VaD]).

OBJECTIVE

To review the BPSD associated with different subtypes and stages of VCI using the Neuropsychiatric Inventory (NPI).

METHODS

Medline, Scielo and Lilacs databases were searched for the period January 2000 to December 2014, with the key words: "BPSD AND Vascular Dementia, "NPI AND Vascular Dementia" and "NPI AND VCI. Qualitative analysis was performed on studies evaluating BPSD in VCI, using the Neuropsychiatric Inventory (NPI).

RESULTS

A total of 82 studies were retrieved of which 13 were eligible and thus included. Among the articles selected, 4 compared BPSD in Subcortical Vascular Dementia (SVaD) versus Cortical-Subcortical Vascular Dementia (CSVaD), 3 involved comparisons between SVaD and VaCIND, 1 study analyzed differences between CSVaD and VaCIND, while 5 studies assessed BPSD in CSVaD. Subcortical and Cortical-Subcortical VaD were associated predominantly with Apathy and Depression. VaCIND may present fewer behavioral symptoms than VaD.

CONCLUSION

The profile of BPSD differs for different stages of VCI. Determining the most prevalent BPSD in VCI subtypes might be helpful for improving early diagnosis and management of these symptoms.

Effect of person-centred care on antipsychotic drug use in nursing homes (EPCentCare): study protocol for a cluster-randomised controlled trial

Background

The majority of nursing home residents with dementia experience behavioural and psychological symptoms like apathy, agitation, and anxiety. According to analyses of prescription prevalence in Germany, antipsychotic drugs are regularly prescribed as first-line treatment of neuropsychiatric symptoms in persons with dementia, although guidelines clearly prioritise non-pharmacological interventions. Frequently, antipsychotic drugs are prescribed for inappropriate reasons and for too long without regular reviewing. The use of antipsychotics is associated with adverse events like increased risk of falling, stroke, and mortality. The aim of the study is to investigate whether a person-centred care approach, successfully evaluated in nursing homes in the United Kingdom, can be implemented in German nursing homes and, in comparison with a control group, can result in a clinically relevant reduction of the proportion of residents with antipsychotic prescriptions.

Methods/design

The study is a cluster-randomised controlled trial comparing an intervention group (two-day initial training on person-centred care and ongoing training and support programme) with a control group. Both study groups will receive, as optimised usual care, a medication review by an experienced psychiatrist/geriatrician providing feedback to the prescribing physician. Overall, 36 nursing homes in East, North, and West Germany will be randomised. The primary outcome is the proportion of residents receiving at least one antipsychotic prescription (long-term medication) after 12 months of follow-up. Secondary outcomes are residents’ quality of life, agitated behaviour, as well as safety parameters like falls and fall-related medical attention. A health economic evaluation and a process evaluation will be performed alongside the study.

Discussion

To improve care, a reduction of the current high prescription rate of antipsychotics in nursing homes by the intervention programme is expected.

Trial registration

ClinicalTrials.gov: NCT02295462

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0268-3) contains supplementary material, which is available to authorized users.

Caregiver distress and associated factors in dementia care in the community setting in China

The aim of this study was to investigate caregiver distress in reacting to the care recipient's behavioral and psychological symptoms of dementia (BPSD) and factors contributing to caregiver distress in the community setting in China. One hundred and fifty-two family caregivers of people with dementia in community settings were assessed using the Chinese version of the Neuropsychiatric Inventory-Questionnaire and the Social Support Rating Scale. The prevalence of BPSD and caregiver distress in reacting to BPSD was higher in China than those reported in high income countries. The most common individual BPSD were apathy/indifference, depression/dysphoria and night-time behaviors. Delusions, hallucinations and apathy/indifference were rated as the most distressing to caregivers. BPSD contributed most to caregiver distress. The high level of caregiver distress identified in this study suggests that dementia services and caregiver support should be established in the public healthcare system to target the needs of people with dementia and their caregivers.

Galantamine versus risperidone for agitation in people with dementia: a randomized, twelve-week, single-center study

AIMS

To examine the effects of galantamine and risperidone on agitation in patients with dementia.

METHODS

A total of 100 patients with dementia and neuropsychiatric symptoms (mean age ± SD: 78.6 ± 7.5 years; 67% female) were included in this 12-week, randomized, parallel-group, controlled, single-center trial. The participants received galantamine (n = 50; target dose: 24 mg) or risperidone (n = 50; target dose: 1.5 mg) for 12 weeks.

RESULTS

Both galantamine and risperidone treatment resulted in reduced agitation. However, risperidone showed a significant advantage over galantamine both at week 3 (mean difference in total Cohen-Mansfield Agitation Inventory score: 3.7 points; p = 0.03) and at week 12 (4.3 points; p = 0.01).

CONCLUSIONS

Agitation improved in both groups, even if the treatment effects were more pronounced in the risperidone group; however, the effects on cognition and other aspects of tolerability were stronger with galantamine.

Computerized and virtual reality cognitive training for individuals at high risk of cognitive decline: systematic review of the literature

The aim of this study was to assess the efficacy of cognitive training, specifically computerized cognitive training (CCT) and virtual reality cognitive training (VRCT), programs for individuals living with mild cognitive impairment (MCI) or dementia and therefore at high risk of cognitive decline. After searching a range of academic databases (CINHAL, PSYCinfo, and Web of Science), the studies evaluated (N = 16) were categorized as CCT (N = 10), VRCT (N = 3), and multimodal interventions (N = 3). Effect sizes were calculated, but a meta-analysis was not possible because of the large variability of study design and outcome measures adopted. The cognitive domains of attention, executive function, and memory (visual and verbal) showed the most consistent improvements. The positive effects on psychological outcomes (N = 6) were significant reductions on depressive symptoms (N = 3) and anxiety (N = 2) and improved perceived use of memory strategy (N = 1). Assessments of activities of daily living demonstrated no significant improvements (N = 8). Follow-up studies (N = 5) demonstrated long-term improvements in cognitive and psychological outcomes (N = 3), and the intervention groups showed a plateau effect of cognitive functioning compared with the cognitive decline experienced by control groups (N = 2). CCT and VRCT were moderately effective in long-term improvement of cognition for those at high risk of cognitive decline. Total intervention time did not mediate efficacy. Future research needs to improve study design by including larger samples, longitudinal designs, and a greater range of outcome measures, including functional and quality of life measures, to assess the wider effect of cognitive training on individuals at high risk of cognitive decline.

Rate of dementia diagnoses according to the degree of aging of the population

BACKGROUND

There is a lack of information regarding geographical differences in the incidence and prevalence of dementia diagnosis according to the degree of aging of the population. The objectives of this study were to analyze the rate of dementia diagnoses, and to compare the dementia subtypes and the clinical characteristics of the patients depending on the degree of aging of their municipalities.

METHODS

We used data from the Registry of Dementias of Girona (ReDeGi), containing the cases of dementia diagnosed in the memory clinics of the Health Region of Girona, in Catalonia (Spain), during 2007-2012. The municipalities were classified by a cluster analysis as aged or young municipalities according to their proportion of older people using population ageing indicators. The incidence rates of dementia diagnosis in each type of municipality were compared.

RESULTS

The ReDeGi registered 4,314 cases in the municipalities under surveillance. The clinical incidence of dementia was lower in aged municipalities (4.5 vs. 6.1 cases per 1,000 person-years aged 65 and over). Patients from young municipalities had an increased frequency of behavioral and psychological symptoms of dementia.

CONCLUSIONS

The environment may influence the clinical manifestations of dementia that predispose people to visit health specialists and obtain a diagnosis.

The investigation and comparison of the underlying needs of common disruptive behaviours in patients with Alzheimer's disease

BACKGROUND

Management of the disruptive behaviours is one of the most challenging aspects of caring for patients with Alzheimer's dementia (PwAD). The underlying needs of disruptive behaviours in PwAD had rarely been studied, especially the comparison of the underlying needs of disruptive behaviours in PwAD have never been mentioned.

AIMS AND OBJECTIVES

The purpose of this study was to investigate and compare the underlying needs of five common disruptive behaviours including hoarding, aggressive behaviour, repetitive behaviour, altered eating behaviour and delusion in PwAD, as perceived by family caregivers, and to relate these needs from the perspective of Maslow's hierarchy.

METHODS

An exploratory research design with qualitative data collection techniques was employed. Informed consent was obtained from each participant prior to the data collection. A total of 65 pairs of caregiver-patient with Alzheimer's disease participated in the study. A semi-structured interview guide was used during the interview, and the directed content analysis method was conducted to analyse data.

RESULTS

Four themes related to the underlying needs of the five selected disruptive behaviours emerged from the data, and these included a desire for comfort (physical and psychological), a desire for security (psychological and economic), a need for a sense of belonging (including a need to connect with the outside world and a need for attention) and a need for self-control. These behaviour features were found closely related to Maslow's hierarchy model of human needs.

CONCLUSION

Although the data were gathered from the caregivers, and the views of the patients were thus not included in the analysis, the findings provide information for health providers that can enable them to better understand the underlying needs of common disruptive behaviours in patients with Alzheimer's disease and thus help develop better patient-centred care plans.

Motivational assessment of mice using the touchscreen operant testing system: effects of dopaminergic drugs

RATIONALE

Touchscreens are widely used to examine rodent cognition. Current paradigms require animals to view stimuli and nose poke at an appropriate touchscreen location. After responding, there is little screen interaction and, as infra-red touchscreens eliminate the need for physical contact, minimal somatosensory feedback. It is therefore unclear if touchscreens can support the vigorous, repetitive responding required in paradigms like progressive ratio (PR) for assessing motivation and effort-related choice (ERC) for assessing decision-making.

OBJECTIVES

This study aims to adapt and validate PR and ERC for the rodent touchscreen.

METHODS

Male C57Bl/6 mice were trained until responding on PR stabilised. Amphetamine, sulpiride and raclopride were administered via the intraperitoneal route to modify performance. Mice were transferred to ERC and paradigm parameters adjusted to demonstrate behavioural modification. ERC reward preference was assessed by home cage choice analysis.

RESULTS

PR performance stabilised within seven sessions. Amphetamine (1 mg/kg) increased and raclopride (0.3 mg/kg) decreased performance by 63 and 28 %, respectively, with a 20-min injection-test interval. Sulpiride (50 mg/kg) decreased performance by 19 % following a 40-min injection-test interval. Increasing ERC operant requirements shifted responding from the operant response-dependent preferred reward towards the freely available alternative.

CONCLUSIONS

Vigorous, repetitive responding is sustainable in touchscreen PR and ERC and task validation mirrors non-touchscreen versions. Thus, motivation and reward-related decision-making can be measured directly with touchscreens and can be evaluated prior to cognitive testing in the same apparatus to avoid confounding by motivational factors.

Impact of dual sensory impairment on onset of behavioral symptoms in European nursing homes: results from the Services and Health for Elderly in Long-Term Care study

OBJECTIVES

To investigate if dual sensory impairment (DSI) in the form of a combined visual and hearing impairment is associated with the onset of behavioral symptoms in nursing homes.

METHODS

A total of 1524 nursing home residents without behavioral symptoms at baseline followed for 12 months in 59 nursing homes from the Czech Republic, England, Finland, France, Germany, Israel, Italy, and The Netherlands. The interRAI instrument for long-term care facilities was assessed by trained staff at baseline and 12 months later.

RESULTS

Altogether, 11% of residents had a new onset of behavioral symptoms (wandering, verbal abuse, physical abuse, socially inappropriate behavior, public disrobing, and resisting care) at 12-month follow-up. In multivariate analyses adjusted for potential confounders, DSI residents had significantly higher incidence of new behavioral symptoms at 12-month follow-up, irrespective of the severity of vision and hearing impairments [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.3:3.4 for mild DSI, OR = 2.5, 95% CI = 1.6:4.0 for moderate DSI, and OR = 2.1, 95% CI = 1.2:3.7 for severe DSI] compared with residents without sensory impairment. Among the different types of symptoms, only abusive behaviors were less likely to be associated with DSI.

CONCLUSIONS

This study provides evidence that DSI could play a significant role in the development of behavioral symptoms in nursing home residents. More attention should be paid to DSI even when each of vision and hearing function is only minimally impaired.

The prevalence and clinical manifestations of delirium in sub-Saharan Africa: a systematic review with inferences

BACKGROUND

In high-income countries with ageing populations, delirium is most prevalent in older adults and in palliative and intensive care settings. The prevalence and aetiology of delirium are likely to differ in low income countries, including sub-Saharan Africa (SSA), due to different population demographics, disease burden and exposure to pathogens. We reviewed published literature relating to the prevalence, clinical features and underlying causes of delirium in SSA and compare this with that published in high-income countries in order to identify knowledge and clinical service gaps, and priorities for further research.

METHODS

We performed a narrative review by comprehensively searching the following databases: Medline, PsychInfo, Embase and PubMed. Studies published between January 1 1975 and December 31 2013 in all languages, including the terms 'delirium', 'acute brain syndrome', 'organic brain syndrome', or 'acute confusion' originating from SSA were included. In addition, reference lists of included articles and online databases of African medical literature were hand-searched. We also included case series and case reports due to paucity of published studies.

RESULTS

We identified a total of 46 relevant studies. Delirium was the main focus of only one cross-sectional study, whereas most included delirium in studies on neuropsychiatric conditions. Only two studies reported prevalence in older adults. Most studies reported very low (<2%) delirium prevalence, whereas delirium in psychiatric inpatient and outpatient settings was higher than expected (18.2%-29.9%). Descriptive studies of 'bouffee delirante' from psychiatry settings were often describing delirium. Infection and HIV seropositivity were common associations of delirium throughout these studies. There were no studies of intensive, critical or surgical care settings or of management strategies.

CONCLUSIONS

We currently know very little about the prevalence, presentation and aetiology of delirium in developing countries. This knowledge gap should be tackled with some urgency, in order to address questions of screening, diagnosis, prevention and management in this setting.

Validity and reliability of the European portuguese version of neuropsychiatric inventory in an institutionalized sample

Background

Neuropsychiatric symptoms are very common in dementia and have been associated with patient and caregiver distress, increased risk of institutionalization and higher costs of care. In this context, the neuropsychiatric inventory (NPI) is the most widely used comprehensive tool designed to measure neuropsychiatric Symptoms in geriatric patients with dementia. The aim of this study was to present the validity and reliability of the European Portuguese version of NPI.

Methods

A cross-sectional study was carried out with a convenience sample of institutionalized patients (≥ 50 years old) in three nursing homes in Portugal. All patients were also assessed with mini-mental state examination (MMSE) (cognition), geriatric depression scale (GDS) (depression) and adults and older adults functional assessment inventory (IAFAI) (functionality). NPI was administered to a formal caregiver, usually from the clinical staff. Inter-rater and test-retest reliability were assessed in a subsample of 25 randomly selected subjects.

Results

The sample included 166 elderly, with a mean age of 80.9 (standard deviation: 10.2) years. Three out of the NPI behavioral items had negative correlations with MMSE: delusions (r_s = -0.177, P = 0.024), disinhibition (r_s = -0.174, P = 0.026) and aberrant motor activity (r_s = -0.182, P = 0.020). The NPI subsection of depression/dysphoria correlated positively with GDS total score (r_s = 0.166, P = 0.038). NPI showed good internal consistency (overall α = 0.766; frequency α = 0.737; severity α = 0.734). The inter-rater reliability was excellent (intraclass correlation coefficient (ICC): 1.00, 95% confidence interval (CI) 1.00 - 1.00), as well as test-retest reliability (ICC: 0.91, 95% CI 0.80 - 0.96).

Conclusion

The results found for convergent validity, inter-rater and test-retest reliability, showed that this version appears to be a valid and reliable instrument for evaluation of neuropsychiatric symptoms in institutionalized elderly.

Impact of a cognitive rehabilitation intervention on neuropsychiatric symptoms in mild to moderate Alzheimer's disease

The main goal of this study was to evaluate the impact of a cognitive rehabilitation programme on 12 behavioural and psychological symptoms of dementia (BPSD) in patients with mild to moderate Alzheimer's disease (AD). This six-month single-blind block-randomised cross-over controlled study was conducted with 15 mild to moderate AD participants and their caregivers. All participants received a four-week home-based cognitive rehabilitation programme to learn/re-learn an instrumental activity of daily living. They were assessed up until three months following the end of the intervention. The Neuropsychiatric Inventory (NPI-12) was employed to evaluate patients' BPSD at seven assessment points during the course of the study. A general linear mixed model analysis performed on the NPI data revealed that aberrant motor behaviours (AMB) increased significantly more in the treatment condition than in the control condition. In addition, both groups registered a significant reduction of delusional symptoms during the second half of the study. Employing a multi-symptom approach to assess participants' BPSD, this cross-over randomised controlled study showed that an individualised cognitive rehabilitation intervention was generally well-tolerated by mild to moderate AD patients. Future cognitive rehabilitation studies conducted with this population should pay attention to AMB symptom changes.

Methodological approaches and magnitude of the clinical unmet need associated with amotivation in mood disorders

BACKGROUND

There is growing research interest in studying motivational deficits in different neuropsychiatric disorders because these symptoms appear to be more common than originally reported and negatively impact long-term functional outcomes. However, there is considerable ambiguity in the terminology used to describe motivational deficits in the scientific literature. For the purposes of this manuscript, the term "amotivation" will be utilised in the context of mood disorders, since this is considered a more inclusive/appropriate term for this patient population. Other challenges impacting the study of amotivation in mood disorders, include: appropriate patient population selection; managing or controlling for potential confounding factors; the lack of gold-standard diagnostic criteria and assessment scales; and determination of the most appropriate study duration.

METHODS

This paper summarises the search for a consensus by a group of experts in the optimal approach to studying amotivation in mood disorders.

RESULTS

The consensus of this group is that amotivation in mood disorders is a legitimate therapeutic target, given the magnitude of the associated unmet needs, and that proof-of-concept studies should be conducted in order to facilitate subsequent larger investigations. The focus of this manuscript is to consider the study of amotivation, as a residual symptom of major depressive disorder (MDD) or bipolar depression (BD), following adequate treatment with a typical antidepressant or mood stabiliser/antipsychotic, respectively.

DISCUSSION

There is a paucity of data studying amotivation in mood disorders. This manuscript provides general guidance on the most appropriate study design(s) and methodology to assess potential therapeutic options for the management of residual amotivation in mood disorders.

Agitation in dementia: relation to core cerebrospinal fluid biomarker levels

Background

The objective of this study was to examine the associations of agitation with the cerebrospinal fluid dementia biomarkers total-tau (T-tau), phosphorylated-tau (P-tau) and Aβ_1-42.

Methods

One hundred patients (mean age ± SD, 78.6 ± 7.5 years) with dementia and neuropsychiatric symptoms, of whom 67% were female, were included. Agitation was measured using the Cohen-Mansfield Agitation Inventory (CMAI; 46.5 ± 11.8 points).

Results

Total CMAI correlated with T-tau [r_s (31) = 0.36, p = 0.04] and P-tau [r_s (31) = 0.35, p = 0.05] in patients with Alzheimer's disease (AD; n = 33) but not in the total dementia population (n = 95).

Conclusions

Our results suggest that tau-mediated pathology including neurofibrillary tangles and the intensity of the disease process might be associated with agitation in AD.

Neuropsychiatric symptoms and rehabilitation outcomes in patients with hip fracture

OBJECTIVE

The aim of this study was to determine the association between functional recovery and neuropsychiatric symptoms in hip fracture patients undergoing in-hospital rehabilitation. Very few studies have extensively evaluated neuropsychiatric symptoms in hip fracture patients, and the relationship between these symptoms and rehabilitation outcome is not yet clearly defined.

DESIGN

This study was conducted on 200 patients with hip fracture who underwent a rehabilitation program. The Neuropsychiatric Inventory was used to identify neuropsychiatric symptoms. Efficiency and effectiveness in terms of the motor-Functional Independence Measure and length of stay were considered as outcome measures.

RESULTS

At admission, 74% of the patients had neuropsychiatric symptoms. At the end of rehabilitation, the patients with neuropsychiatric symptoms had a lower motor-Functional Independence Measure effectiveness (P = 0.015) and efficiency (P = 0.002) and a longer length of stay (P = 0.008) than those without neuropsychiatric symptoms. However, after adjustment for the Mini-Mental State Examination, the patients with neuropsychiatric symptoms differed from those without symptoms only in terms of longer length of stay (P = 0.006) and lower motor-Functional Independence Measure efficiency (P = 0.008).

CONCLUSIONS

Neuropsychiatric symptoms make the rehabilitation process slower and less efficient in hip fracture patients. Understanding the relationship between neuropsychiatric symptoms and outcome may be useful to physicians for the management of hip fracture patients.

Spouse caregivers and behavioral and psychological symptoms of dementia

BACKGROUND

Only a few studies have specifically considered the role of caregiver characteristics in the presence of behavioral and psychological symptoms of dementia (BPSD). The aim of this study was to determine whether there were differences in the presence of individual BPSD between community-dwelling dementia care recipients with spouse caregivers and those with non-spouse caregivers.

METHODS

Care recipients (n = 109) and their primary caregivers were recruited from memory clinic outpatients at the public psychiatric hospital in Sapporo City, Japan. Data were collected by questionnaire. Relationship with the care recipient was categorized as either 'spouse' or 'non-spouse.' The frequency of BPSD occurrence observed by the caregiver was assessed using the Troublesome Behavior Scale (TBS). Logistic regression analyses were performed to examine whether there were differences with regard to each of the 14 TBS items between spouse and non-spouse caregivers.

RESULTS

The number of spouse caregivers was 47 (43.1%). TBS items presented by >50% care recipients were 'repetition and/or clinging' and 'ill-natured denial and/or distortion.' After adjustment for the characteristics of caregivers and care recipients, non-spouse caregivers were found to be significantly associated with the presence of 'hiding and/or losing things,' 'rummaging,' 'crying and/or screaming,' and 'interfering with a happy home circle,' compared with spouse caregivers.

CONCLUSIONS

Our results suggest that non-spouse caregivers need more support with regard to certain symptoms of individual BPSD compared with spouse caregivers. Identifying caregiver characteristics that are independently associated with each individual BPSD may help customize interventions for caregivers with specific characteristics.

Anxiety and stigma in dementia: a threat to aging in place

The number of Americans with dementia is expected to increase as the population ages. Developing dementia is feared by many older adults and may result in anxiety in persons with dementia. This article focuses on anxiety, one of the least understood symptoms associated with dementia in community-dwelling older adults, the stigma of dementia, and the relationship between anxiety and stigma in dementia. When undetected and untreated, anxiety and associated stigma can adversely affect quality of life and the ability to age in place.

Shen-zhi-ling oral liquid improves behavioral and psychological symptoms of dementia in Alzheimer's disease

We evaluated the effects of the traditional Chinese medicine (TCM) Shen-Zhi-Ling oral liquid (SZL) on the behavioral and psychological symptoms of dementia (BPSD) in patients with Alzheimer's disease (AD). Among 98 patients with AD and BPSD enrolled (mean age, 57.2 ± 8.9 years old), 91 (M = 55, F = 36; mean age, 57.2 ± 9.7 years old) completed the study. Patients took either SZL (n = 45) or placebo granules (n = 46) in a double-blind manner for 20 weeks while maintaining other anticognitive medications unchanged. Changes in BPSD between week 0, week 10, week 20, and week 25 were assessed using the behavioral pathology in Alzheimer's disease (BEHAVE-AD) rating scale and the neuropsychiatric inventory (NPI), detrended fluctuation analysis (DFA) represented by diurnal activity (DA), evening activity (EA), and nocturnal activity (NA) according to actigraphic recordings. SZL but not placebo oral liquid delayed the development of BPSD significantly according to the changes in some of the clinical scores and the EA and NA parameters of DFA at week 20 compared with week 0. No side effects were observed in laboratory tests. The results indicate that SZL might delay the development of BPSD in AD patients and thus is a potentially suitable drug for long-term use.

Use of the Tailored Activities Program to reduce neuropsychiatric behaviors in dementia: an Australian protocol for a randomized trial to evaluate its effectiveness

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are often considered to be the greatest challenge in dementia care, leading to increased healthcare costs, caregiver burden, and placement into care facilities. With potential for pharmacological intervention to exacerbate behaviors or even lead to mortality, the development and rigorous testing of non-pharmacological interventions is vital. A pilot of the Tailored Activities Program (TAP) for reducing problem behaviors in people with dementia was conducted in the United States with promising results. This randomized trial will investigate the effectiveness of TAP for reducing the burden of BPSD on persons with dementia and family caregivers within an Australian population. This trial will also examine the cost-effectiveness and willingness to pay for TAP compared with a control group.

METHODS

This randomized trial aims to recruit 180 participant dyads of a person with dementia and their caregivers. Participants will have a diagnosis of dementia, exhibit behaviors as scored by the Neuropsychiatric Inventory, and the caregiver must have at least 7 h per week contact. Participants will be randomly allocated to intervention (TAP) or control (phone-based education sessions) groups, both provided by a trained occupational therapist. Primary outcome measure will be the revised Neuropsychiatric Inventory - Clinician rating scale (NPI-C) to measure BPSD exhibited by the person with dementia.

CONCLUSIONS

This trial investigates the effectiveness and cost-effectiveness of TAP within an Australian population. Results will address a significant gap in the current Australian community-support base for people living with dementia and their caregivers.

Vocalization in dementia: a case report and review of the literature

BACKGROUND

Vocalizations are part of the spectrum of the 'negative' behavioral and psychological symptoms of dementia (BPSD). We describe a patient with moderate-stage mixed dementia of Alzheimer's disease and cerebrovascular disease and a left orbitofrontal lesion exhibiting vocalization. The use of 'redirection' has been demonstrated to be an effective nonpharmacological means of controlling BPSD, while reducing caregiver distress.

CASE REPORT

A 78-year-old right-handed African-American female presented with complaints of worsening memory and BPSD, causing significant caregiver distress. Throughout the evaluation, she constantly vocalized her son's name and made a continuous grunting noise, correlating with increased anxiety/agitation. We utilized a redirection technique, which achieved the immediate reduction of the vocalization symptoms. Caregiver psychoeducation was provided allowing them to use the redirection technique at home.

CONCLUSIONS

In patients with dementia exhibiting negative symptoms of BPSD, using nonpharmacologic techniques (i.e. redirection) may be indicated. Psychotropic medications rarely address negative BPSD symptoms, while simultaneously decreasing patient's quality of life. Nonpharmacologic approaches are beneficial as first-line therapy for negative BPSD.

Neuropsychiatric aspects of dementia

Dementia affects approximately 6.5% of people over the age of 65. Whilst cognitive impairment is central to the dementia concept, neuropsychiatric symptoms are invariably present at some stage of the illness. Neuropsychiatric symptoms result in a number of negative outcomes for the individual and their caregivers and are associated with higher rates of institutionalization and mortality. A number of factors have been associated with neuropsychiatric symptoms including neurobiological changes, dementia type, and illness severity and duration. Specific patient, caregiver and environmental factors are also important. Neuropsychiatric symptoms can be broadly divided into four clusters: psychotic symptoms, mood/affective symptoms, apathy, and agitation/aggression. Neuropsychiatric symptoms tend to persist over time although differing symptom profiles exist at various stages of the illness. Assessment should take into account the presenting symptoms together with an appreciation of the myriad of likely underlying causes for the symptoms. A structured assessment/rating tool can be helpful. Management should focus on non-pharmacological measures initially with pharmacological approaches reserved for more troubling symptoms. Pharmacological approaches should target specific symptoms although the evidence-base for pharmacological management is quite modest. Any medication trial should include an adequate appreciation of the risk-benefit profile in individual patients and discussion of these with both the individual and their caregiver.

Relation between caffeine and behavioral symptoms in elderly patients with dementia: an observational study

OBJECTIVES

Caffeine is known to improve concentration and reduce fatigue in healthy adults, but high doses may induce anxiety and agitation. Because the effects of caffeine in elderly people with dementia are unknown, this study explores the relation between caffeine and behavioral symptoms in a group of elderly patients with dementia.

DESIGN

An observational pilot study.

SETTING

A dementia special care unit of a Dutch nursing home.

PARTICIPANTS

A total of 29 elderly patients with dementia.

MEASUREMENTS

Behavioral symptoms were measured with the NPI-NH, and sleep and caffeine consumption were measured using questionnaires.

RESULTS

A significant relation was found between the total amount of caffeine consumed during the day and apathy [Kendall's tau (KT) -0.287 p=0.03], and the number of times that participants got up at night (KT 0.462; p <0.01). The amount of caffeine consumed after 6 p.m. was also significantly related to the number of times participants got up at night (KT 0.436; p <0.01). Multilevel analysis showed caffeine to be negatively correlated with aberrant motor behavior [b = -0.47 (0.22), Wald (461) = -2.12, p=0.03] and apathy [b = -0.88 (0.45), Wald (461)= -1.96, p=0.05], and showed a significant relation between caffeine consumption after 6 p.m. and the number of times participants got up at night [b=0.48 (0.22), Wald (461)= 2.20, p=0.03].

CONCLUSION

This study established an association between caffeine consumption and behavioral symptoms in elderly patients with moderately severe dementia. Therefore, adjusting caffeine consumption could be part of an interdisciplinary approach to behavioral symptoms, particularly when aberrant motor behavior, apathy or sleeping difficulties are involved. These results indicate that further research on the effects of caffeine on behavioral symptoms in dementia is warranted.

Feasibility study of the BrightBrainer™ integrative cognitive rehabilitation system for elderly with dementia

PURPOSE

To describe the development of BrightBrainer™ integrative cognitive rehabilitation system and determine clinical feasibility with nursing home-bound dementia patients.

METHOD

BrightBrainer cognitive rehabilitation simulations were first played uni-manually, then bimanually. Participants sat in front of a laptop and interacted through a game controller that measured hand movements in 3D, as well as flexion of both index fingers. Interactive serious games were designed to improve basic and complex attention (concentration, short-term memory, dual tasking), memory recall, executive functioning and emotional well-being. Individual simulations adapted automatically to each participant's level of motor functioning. The system underwent feasibility trials spanning 16 sessions over 8 weeks. Participants were evaluated pre- and post-intervention, using standardized neuropsychological measures. Computerized measures of movement repetitions and task performance were stored on a remote server.

RESULTS

Group analysis for 10 participants showed statistically significant improvement in decision making (p < 0.01), with trend improvements in depression (p < 0.056). Improvements were also seen in processing speed (p < 0.13) and auditory attention (p < 0.17); however, these were not statistically significant (partly attributable to the modest sample size). Eight of nine neuropsychological tests showed changes in the improvement direction indicating an effective rehabilitation (p < 0.01). BrightBrainer technology was well tolerated with mean satisfaction ratings of 4.9/5.0 across participants.

CONCLUSIONS

Preliminary findings demonstrate utility within an advanced dementia population, suggesting that it will be beneficial to evaluate BrightBrainer through controlled clinical trials and to investigate its application in other clinical populations. Implications for Rehabilitation It is possible to improve cognitive function in older low-functioning patients. Integrative rehabilitation through games combining cognitive (memory, focusing, executive function) and physical (bimanual whole arm movement, grasping, task sequencing) elements is enjoyable for this population. The severity of depression in these elderly can be reduced through virtual reality bimanual games. The number of upper extremity active repetitions performed in the process of solving cognitive problems with the BrightBrainer™ system is 600. This number is 18 times (1875%) larger than those observed by other researchers in conventional physical or occupational rehabilitation sessions.

Recommendations for the use of Serious Games in people with Alzheimer's Disease, related disorders and frailty

Alzheimer's disease and other related disorders (ADRD) represent a major challenge for health care systems within the aging population. It is therefore important to develop better instruments to assess the disease severity and progression, as well as to improve its treatment, stimulation, and rehabilitation. This is the underlying idea for the development of Serious Games (SG). These are digital applications specially adapted for purposes other than entertaining; such as rehabilitation, training and education. Recently, there has been an increase of interest in the use of SG targeting patients with ADRD. However, this field is completely uncharted, and the clinical, ethical, economic and research impact of the employment of SG in these target populations has never been systematically addressed. The aim of this paper is to systematically analyze the Strengths, Weaknesses, Opportunities, and Threats (SWOT) of employing SG with patients with ADRD in order to provide practical recommendations for the development and use of SG in these populations. These analyses and recommendations were gathered, commented on and validated during a 2-round workshop in the context of the 2013 Clinical Trial of Alzheimer's Disease (CTAD) conference, and endorsed by stakeholders in the field. The results revealed that SG may offer very useful tools for professionals involved in the care of patients suffering from ADRD. However, more interdisciplinary work should be done in order to create SG specifically targeting these populations. Furthermore, in order to acquire more academic and professional credibility and acceptance, it will be necessary to invest more in research targeting efficacy and feasibility. Finally, the emerging ethical challenges should be considered a priority.

Influence of Aquariums on Resident Behavior and Staff Satisfaction in Dementia Units

The influence of an aquarium on resident behavior and staff job satisfaction in three dementia units was examined. The sample consisted of 71 individuals with dementia and 71 professional staff. A pretest–posttest design was utilized. Baseline resident behavior and staff satisfaction were obtained, and an aquarium was introduced into the setting. Post-behavioral assessment and job satisfaction surveys were completed. Residents’ behaviors improved along four domains: uncooperative, irrational, sleep, and inappropriate behaviors. The overall residents’ behavior score was significantly improved after an aquarium was introduced, F = 15.60, p < .001. Their mean disruptive behavior score decreased from 67.2 to 58.2. The staff’s satisfaction score significantly improved, F = 35.34, p < .001. Pretest to posttest mean scores improved from 149.4 to 157.9. Aquariums are an innovative way for animal-assisted therapy and nature to be introduced to specialized dementia units in long-term care.

Self-rated driving habits among older adults with clinically-defined mild cognitive impairment, clinically-defined dementia, and normal cognition

Older adults with clinically-defined dementia may report reducing their driving more than cognitively normal controls. However, it is unclear how these groups compare to individuals with clinically-defined mild cognitive impairment (MCI) in terms of driving behaviors. The current study investigated self-reported driving habits among adults age 60 and older with clinical MCI (n=41), clinical mild dementia (n=40), and normal cognition (n=43). Participants reported their driving status, driving frequency (days per week), and how often they avoided accessing the community, making left turns, driving at night, driving in unfamiliar areas, driving on high-traffic roads, and driving in bad weather. After adjusting for education, a MANCOVA revealed that participants with MCI and dementia avoided unfamiliar areas and high-traffic roads significantly more than normal participants. Participants with dementia also avoided left turns and accessing the community more than those with normal cognition and MCI (p<0.05 for all). The other driving variables did not significantly differ between groups. Thus, older adults with clinically-defined MCI, as well as those with dementia, avoided some complex driving situations more than cognitively intact adults. However, all diagnostic groups had similar rates of driving cessation and frequency. Future research should examine the safety implications of such findings.

The impact of neuropsychiatric symptoms on caregiver distress and quality of life in persons with dementia in an Asian tertiary hospital memory clinic

BACKGROUND

This study aims to determine the prevalence, profile, and severity of neuropsychiatric symptoms (NPS) across the dementia continuum and their relative impact on caregiver distress and quality of life (QoL) in persons with dementia (PWD).

METHOD

Six hundred and sixty-seven PWD and their family caregivers presented to a memory clinic in a tertiary hospital across a 60-month period. Clinicians determined the dementia diagnosis and severity using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition and the Clinical Dementia Rating scale, respectively. The Neuropsychiatric Inventory Questionnaire was administered to assess NPS in PWD and the corresponding distress experienced by the caregiver. QoL for PWD (PWD-QoL) was assessed by the Quality of Life-Alzheimer's Disease scale.

RESULTS

Ninety-six percent of PWD presented with at least one NPS, 18% experiencing mild, 31% moderate, and 47% severe symptoms, respectively. While agitation (63.1%), apathy (61.8%), depression (55.5%), and irritability (55.5%) were the most common NPS; disinhibition (35.2%), hallucination (25.5%), and elation (14.2%) were the least common. NPS increased generally but differentially as dementia progressed and significantly predicted caregiver distress (ηp 2 = 0.732, p < 0.0001) and PWD-QoL (ηp 2 = 0.066, p < 0.0001). Factor analysis revealed two NPS clusters, disruptive and affective; the former exerting greater impact on caregiver distress and the latter on PWD-QoL.

CONCLUSION

The results show a high prevalence of NPS which increase caregiver distress and negatively impact PWD-QoL. The differential profile of NPS across the dementia stages warrants stage-specific interventions and due consideration in resource planning and service design for PWD and their caregivers.

Psychotropic drug use among people with dementia--a six-month follow-up study

Background

Psychotropic drugs are widely used among old people with dementia but few studies have described long-term treatment in this group of patients. The purpose of this study was to explore the long-term use of psychotropic drugs in old people with dementia.

Methods

Data on psychotropic drug use, functioning in the activities of daily living (ADL), cognitive function and behavioral and psychological symptoms were collected at baseline and six months later, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). The data were collected in 2005–2006. Detailed data about the prescribing of psychotropic drugs were collected from prescription records. This study was conducted in 40 specialized care units in northern Sweden, with a study population of 278 people with dementia.

Results

At the start of the study, 229 of the participants (82%) were prescribed at least one psychotropic drug; 150 (54%) used antidepressants, 43 (16%) used anxiolytics, 107 (38%) used hypnotics and sedatives, and 111 (40%) used antipsychotics. Among the baseline users of antidepressants, anxiolytics, hypnotics and sedatives and antipsychotics, 67%, 44%, 57% and 57% respectively, still used the same dose of the same psychotropic drug after six months. Associations were found between behavioral and psychological symptoms and different psychotropic drugs.

Conclusion

Psychotropic drug use was high among people with dementia living in specialized care units and in many cases the drugs were used for extended periods. It is very important to monitor the effects and adverse effects of the prescribed drug in this frail group of people.

Foot massage versus quiet presence on agitation and mood in people with dementia: a randomised controlled trial

BACKGROUND

There is increasing interest in using complementary and alternative treatments to manage behavioural and psychological symptoms of dementia such as agitation, aggression and depressed mood.

OBJECTIVE

To compare the effect of foot massage (intervention) and quiet presence (control) on agitation and mood in people with dementia.

DESIGN

A randomised controlled trial using a within-subjects, crossover design.

SETTINGS

Five long-term care facilities in Brisbane, Australia. The primary outcome was the Cohen-Mansfield Agitation Inventory (CMAI) and the secondary outcome was the Observed Emotion Rating Scale (OERS). The screening and data collection research assistants, families, and care staff were blinded to participant allocation.

PARTICIPANTS

Participants of the study were 55 long-term care residents aged 74-103 years (mean age 86.5), with moderate to severe dementia and a history of agitated behaviour according to the Pittsburgh Agitation Scale. A computer-program randomised participants to 10-min foot massage (intervention) or quiet presence (control), every weekday for 3 weeks.

RESULTS

A carry-over effect was identified in the data, and so the data was treated as a parallel groups RCT. The mean total CMAI increased in both groups (reflecting an increase in agitation) with this increase greater in the quiet presence group than the foot massage group (p=0.03). There was a trend towards a difference on OERS General Alertness, with a positive change in alertness for participants in the foot massage group (indicating reduced alertness) and a negative change for participants in the quiet presence group (indicating increased alertness) (F(1,51)=3.88, p=0.05, partial ή(2)=0.07).

CONCLUSIONS

The findings highlight the need for further research on the specific conditions under which massage might promote relaxation and improve mood for people with dementia. The unfamiliar research assistants and variations in usual activity may have contributed to the increase in agitation and this needs further research.

TRIAL REGISTRATION

ACTRN12612000658819.

Special care units and traditional care in dementia: relationship with behavior, cognition, functional status and quality of life - a review

Background

Special care facilities for patients with dementia gain increasing attention. However, an overview of studies examining the differences between care facilities with respect to their effects on behavior, cognition, functional status and quality of life is lacking.

Results

Our literature search resulted in 32 studies published until October 2012. Overall, patients with dementia who lived at special care units (SCUs) showed a significantly more challenging behavior, more agitation/aggression, more depression and anxiety, more cases of global cognitive impairment and a better psychosocial functioning. There was a tendency towards a better functional status in specialized care facilities, and a better quality of life was found in favor of the SCU group compared to the traditional nursing home (n-SCU) group. Longitudinal studies showed an increased number of neuropsychiatric cases, more patients displaying deteriorating behavior and resistance to care as well as less decline in activities of daily living (ADL) in the SCU group compared to the n-SCU group. Patients in small-scale, homelike SCUs showed more agitation and less ADL decline compared to SCU patients.

Conclusion

This review shows that the patient characteristics in SCU and n-SCU settings and, to a minor extent, in SCU and small-scale, homelike SCU settings are different. Over time, there are differences between n-SCU, SCU and small-scale, homelike SCU facilities for some variables.

Behavioral symptoms related to cognitive impairment

Neuropsychiatric symptoms (NPS) are core features of Alzheimer's disease and related dementias. On one hand, behavioral symptoms in patients with mild cognitive impairment (MCI) can indicate an increased risk of progressing to dementia. On the other hand, mild behavioral impairment (MBI) in patients who usually have normal cognition indicates an increased risk of developing dementia. Whatever the cause, all dementias carry a high rate of NPI. These symptoms can be observed at any stage of the disease, may fluctuate over its course, are a leading cause of stress and overload for caregivers, and increase rates of hospitalization and early institutionalization for patients with dementia. The clinician should be able to promptly recognize NPI through the use of instruments capable of measuring their frequency and severity to support diagnosis, and to help monitor the treatment of behavioral symptoms. The aims of this review are to describe and update the construct 'MBI' and to revise the reported NPS related to prodromal stages of dementia (MCI and MBI) and dementia stages of Alzheimer's disease and frontotemporal lobar degeneration.

Impact of safety warnings on antipsychotic prescriptions in dementia: nothing has changed but the years and the substances

Dementia patients suffering from behavioral and psychological symptoms (BPSD) are often treated with antipsychotics. Trial results document an increased risk for serious adverse events and mortality in dementia patients taking these agents. Furthermore, the efficacy of treating BPSD with antipsychotics seems to be only modest. Using data of a German statutory health insurance company, we examined prescription trends of antipsychotics in prevalent dementia patients in the context of official warnings. The study period is 2004-2009. We studied trends in demographics, age and sex, as well as need of care and the intake of typical and atypical antipsychotics. Seeking for linear trends adjusted for age, sex and level of care between 2004 and 2009, we obtained p-values from a multivariate logistic regression. Prescription volumes were calculated by number of packages as well as defined daily doses (DDDs) using multiple linear regressions for trends in prescriptions amount. We included 3460-8042 patients per year (mean age 80 years). The prescription prevalence of antipsychotics decreased from 35.5% in 2004 to 32.5% in 2009 (multivariate analysis for linear trend: p=0.1645). Overall prescriptions for typical antipsychotics decreased (from 27.2% in 2004 to 23.0% in 2009, p<0.0001) and prescriptions for atypical antipsychotics increased from 17.1% to 18.9% (p<0.0001). The mean DDD per treated patient increased from 80.5 to 91.2 (2004-2009; p=0.0047). Our findings imply that warnings of international drug authorities and manufacturers against adverse drug events in dementia patients receiving antipsychotics did not impact overall prescription behavior.

Association between behavioral and psychological symptoms and psychotropic drug use among old people with cognitive impairment living in geriatric care settings

BACKGROUND

Behavioral and psychological symptoms are common among cognitively impaired individuals and psychotropic drugs are widely used for their treatment. The aim of this study was to describe the prevalence and associated factors of psychotropic and anti-dementia drug use among old people with cognitive impairment living in geriatric care settings.

METHODS

The study comprised 2,019 cognitively impaired people living in geriatric care units in the county of Västerbotten, Sweden. Data concerning psychotropic and anti-dementia drug use, function in activities of daily living, cognitive function, and prevalence of behavioral and psychological symptoms were collected, using the Multi-Dimensional Dementia Assessment Scale.

RESULTS

Of the study population, 1,442 individuals (71%) were prescribed at least one psychotropic drug (antidepressants (49%), anxiolytics, hypnotics, and sedatives (36%), antipsychotics (25%)). Furthermore, 363 individuals (18%) received anti-dementia drugs. Associations between various behavioral and psychological symptoms were found for all psychotropic drug classes and anti-dementia drugs. Verbally disruptive/attention-seeking behavior was associated with all psychotropic drugs. Use of antipsychotics was associated with several behavioral and psychological symptoms, including aggressive behavior.

CONCLUSION

The associations between behavioral and psychological symptoms and psychotropic drug use found in this study indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals despite limited evidence of their efficacy. Given the significant risk of adverse effects among old people with cognitive impairment, it is important to ensure that any medication used is both appropriate and safe.

Neuropsychiatric symptoms, apolipoprotein E gene, and risk of progression to cognitive impairment, no dementia and dementia: the Aging, Demographics, and Memory Study (ADAMS)

OBJECTIVE

To examine the relationship of neuropsychiatric symptoms and apolipoprotein E (APOE) ε4 allele status to dementia at baseline and progression to dementia in older adults with and without cognitive impairment, no dementia (CIND).

METHODS

Adults (n = 856) 71 years and older (mean age = 79.15 years), 12.8% ethnic minority and 60.6% women, completed neuropsychological tests and APOE genotyping, and a proxy informant completed the Neuropsychiatric Inventory.

RESULTS

After adjusting for age and education, neuropsychiatric symptoms and APOE ε4 were independently associated with CIND and dementia status at baseline (compared with cognitively normal). Further, neuropsychiatric symptoms predicted progression to dementia at 16- to 18-month follow-up among participants with CIND at baseline; the presence of these symptoms decreased the risk of progression from normal to CIND or dementia at 36 to 48 months.

CONCLUSION

Findings provide cross-sectional and longitudinal support for the role of neuropsychiatric symptoms in the prediction of cognitive impairment, particularly dementia. APOE ε4, although important, may be a less robust predictor. This investigation highlights the importance of behavioral symptoms, such as neuropsychiatric symptom status or frequency/severity, as predictors of future cognitive decline.

Neuropsychiatric Symptoms (NPS) in patients with pure Vascular Dementia (VaD) and Mixed Dementia (MD) from a memory outpatient clinic in southeast Brazil

Vascular Dementia (VaD) and Vascular Cognitive Impairment (VCI) are increasingly common worldwide. Nevertheless, the clinical-neuropsychiatric profile of these patients at presentation is still poorly characterized in developing countries.

OBJECTIVE

We aimed to characterize the prevalence of neuropsychiatric symptoms, as well as the clinical and cognitive profile of patients with VaD and VCI in our tertiary University outpatient cognitive clinic.

METHODS

We reviewed data on 253 patients diagnosed with VaD or VCI at our center between January 1996 and December 2005, located in an industrial region of the state of Sao Paulo, southeast Brazil. We excluded 19 patients who did not complete the medical investigation or who did not meet the clinical or neuroimaging criteria for vascular dementia. We collected socio-demographic data, educational level, vascular risk factors, behavioral and neuropsychological symptoms and cognitive complaints at presentation.

RESULTS

Two hundred and thirty-four cases were included in this analysis. The mean age was 67.77±10.35 years; 72% were males and 82% had less than four years of education (average 2.84±2.96 years). The initial Clinical Dementia Rating score was 2 & 3 in 68%. A total of 185 patients had neuropsychiatric symptoms distributed in main categories as follows: psychosis (52.6%), hallucinations (23.5%), psychomotor agitation (22.5%), depression (17.5%) and apathy (17.5%). Hypertension and previous stroke were the most prevalent risk factors.

CONCLUSION

We found a high prevalence of neuropsychiatric symptoms. The clinical-neuropsychiatric profile of patients presenting to cognitive clinics in developing countries may differ greatly to that of more developed nations. These characteristics may have implications for public health strategies.

Comparing the effects of different individualized music interventions for elderly individuals with severe dementia

BACKGROUND

Individuals with dementia often experience poor quality of life (QOL) due to behavioral and psychological symptoms of dementia (BPSD). Music therapy can reduce BPSD, but most studies have focused on patients with mild to moderate dementia. We hypothesized that music intervention would have beneficial effects compared with a no-music control condition, and that interactive music intervention would have stronger effects than passive music intervention.

METHODS

Thirty-nine individuals with severe Alzheimer's disease were randomly and blindly assigned to two music intervention groups (passive or interactive) and a no-music Control group. Music intervention involved individualized music. Short-term effects were evaluated via emotional response and stress levels measured with the autonomic nerve index and the Faces Scale. Long-term effects were evaluated by BPSD changes using the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) Rating Scale.

RESULTS

Passive and interactive music interventions caused short-term parasympathetic dominance. Interactive intervention caused the greatest improvement in emotional state. Greater long-term reduction in BPSD was observed following interactive intervention, compared with passive music intervention and a no-music control condition.

CONCLUSION

Music intervention can reduce stress in individuals with severe dementia, with interactive interventions exhibiting the strongest beneficial effects. Since interactive music intervention can restore residual cognitive and emotional function, this approach may be useful for aiding severe dementia patients' relationships with others and improving QOL. The registration number of the trial and the name of the trial registry are UMIN000008801 and "Examination of Effective Nursing Intervention for Music Therapy for Severe Dementia Elderly Person" respectively.

Prevalence and associations of potentially inappropriate prescriptions in Austrian nursing home residents: secondary analysis of a cross-sectional study

BACKGROUND

Potentially inappropriate prescriptions (PIP) are an important cause of adverse medication-related events and increases morbidity, hospitalization, and health care costs, especially in nursing home residents. However, little is known about the associations between PIP and residents' characteristics.

OBJECTIVE

The aim of our study was to analyse the prevalence and associations of PIP with residents' and facilities' characteristics.

METHODS

We performed a secondary analysis of a cross-sectional study with 48 out of 50 eligible nursing homes and 1,844 out of 2,005 eligible residents in a defined rural-urban area in Austria. The Austrian list of potentially inappropriate medications was applied for the evaluation of inappropriate prescribing. Cluster-adjusted multiple regression analysis was used to investigate institutional and residents' characteristics associated with PIP.

RESULTS

Mean cluster-adjusted prevalence of residents with at least one PIP was 70.3 % (95 % CI 67.2-73.4). The number of residents with at least one psychotropic PIP was 1.014 (55 %). The most often prescribed PIP were Prothipendyl (25.9 % residents), Lorazepam (14.5 %) and Diclofenac (6.1 %). Multiple regression analysis showed an inverse association of PIP with cognitive impairment and significant positive associations with permanent restlessness and permanent negative attitude. The associations of PIP with age and male gender were inconsistent. No significant associations were found for PIP and the ratio of staff nurses to residents.

CONCLUSIONS

Our study results confirm that PIP is highly prevalent in the nursing home population. These results urgently call for effective interventions. Initiatives and successful interventions performed in other countries could serve as examples for safer prescribing in residents in Austria.