The Present Behavioural Examination (PBE): the development of an interview to measure current behavioural abnormalities

Predictors of institutionalization for people with dementia living at home with a carer

OBJECTIVE

This article examines the relationships between behaviour, psychological functioning, the caring environment and subsequent institutionalization in patients with dementia living at home with a carer.

DESIGN

Longitudinal study of behaviour in dementia, with a nested case-control study to investigate predictors of institutionalization.

SETTING

Subjects with dementia, known to service, living at home with a carer. All lived in Oxfordshire, UK.

PARTICIPANTS

100 people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer at the start of the study.

MEASURES

At 4-monthly intervals, the carers were interviewed and the subjects with dementia were assessed cognitively. Subjects' behaviour and psychological functioning were assessed using the Present Behavioural Examination.

RESULTS

The characteristics which best predicted institutionalization 1 year later were: excessive night-time activity; immobility or difficulty in walking; incontinence; being away from a carer for more than 16 hours a week; and being cared for by a female. Aggressive behaviour was not associated with an increased chance of entry into an institution 1 year later, although it was more prevalent 4 months before entering an institution.

CONCLUSIONS

Both behaviour and psychological functioning and the caring environment can help in predicting which patients with dementia currently living at home will enter an institution 1 year later. These predictors are not the same as those which are the immediate cause of institutionalization.

Natural history of hyperphagia and other eating changes in dementia

OBJECTIVE

To investigate the natural history of overeating (hyperphagia) and its elements during the course of dementia.

DESIGN

Prospective longitudinal study of overeating (hyperphagia) in dementia. Two studies were carried out: (1) hyperphagia and associated eating changes were investigated as part of a larger prospective 10-year study into behaviour changes, using carers' reports; (2) an observational study to investigate hyperphagia quantitatively; this took place over the course of a year by means of direct observation of test meals in a normal environment.

SETTING

Subjects with dementia living in Oxfordshire, UK.

PARTICIPANTS

(1) 99 people with dementia, living at home with a carer, with data for more than 1 year. (2) Nine people with a diagnosis of Alzheimer's disease who were hyperphagic.

MEASURES

(1) The Present Behavioural Examination was used at 4-monthly intervals to assess the subjects' behaviour and psychological functioning. (2) Food intake, macronutrient choice and the microstructure of eating were measured using a standardized test meal.

RESULTS

(1) Severe or persistent hyperphagia was reported in 23% of the sample and carers reported a clear onset to hyperphagia with a median duration of 16 months. (2) From direct observation, each person who was hyperphagic was seen to maintain a constant eating rate in test meals during the course of a year but meals ended earlier as hyperphagia decreased.

CONCLUSIONS

Hyperphagia is common in dementia, it occurs over a single restricted period, mainly during the middle stages of dementia, and is not significantly related to age, sex, diagnosis, medication or activity.

Evaluation of three aggression/agitation behaviour rating scales for use on an acute admission and assessment psychogeriatric ward

BACKGROUND

In recent years many instruments measuring aggressive and agitated behaviours among the elderly in a variety of settings have emerged. Individual instruments have only occasionally been compared with each other.

METHOD

Some psychometric properties of three aggression/agitation scales on an acute assessment and admission psychogeriatric ward were examined. The correlation between the Rating Scale for Aggressive Behaviour in the Elderly (RAGE), the Cohen-Mansfield Agitation Inventory (CMAI) and the Brief Agitation Rating Scale (BARS) and their internal consistencies and test-retest and interrater reliabilities were measured.

RESULTS

The RAGE was strongly correlated with the CMAI (rho = +0.73) and the BARS (rho = +0.72). The CMAI was strongly correlated with the CMAI (rho = +0.84). The internal consistency, as measured by Cronbach's alpha, was greater than 0.8 on all three scales. The test-retest and interrater reliability correlations were 0.75 or greater for all three scales (except the BARS interrater reliability correlation of 0.6).

CONCLUSIONS

All three scales have good psychometric properties for use in acute admission assessment psychogeriatric wards.

Behaviour changes in dementia. 1: Point of entry data of a prospective study

OBJECTIVE

This article analyses behaviour changes in dementia at the point of entry to a longitudinal study.

DESIGN

Prospective, longitudinal study of behaviour in dementia, with autopsy follow-up.

SETTING

Subjects with dementia, living at home with a carer. All lived in Oxfordshire, UK.

PARTICIPANTS

Ninety-seven people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer.

MEASURES

At 4-monthly intervals, the carers were interviewed and the subjects with dementia were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections covering many different aspects of behaviour. The 121 main questions, with 66 further 'nested' questions, have been shown to have high reliability.

RESULTS

This article analyses the types of behaviour change reported by carers at the point of entry to this long-term study. Few correlations were found between behaviour and age, gender and time since onset of dementia. Some types of behaviour were significantly more prevalent in those with greater cognitive impairment.

CONCLUSIONS

Many of these changes create problems for carers, for example increased aggressive behaviour, wandering, wakefulness at night, incontinence and persecutory ideas. In general, they are more prevalent in people with more severe dementia.

Behaviour changes in dementia. 2: Are there behavioural syndromes?

OBJECTIVE

To establish whether robust behavioural 'syndromes' can be identified from among the widely heterogeneous behavioural changes which occur in dementia.

DESIGN

Longitudinal, prospective study with follow-up at 4 and 8 months.

SETTING

Community settings in Oxfordshire, UK.

PARTICIPANTS

97 elderly people with a diagnosis of Alzheimer's disease or vascular dementia (in many cases confirmed by postmortem examination) and who were living at home with a carer.

MEASURES

Each subject's behaviour was assessed in detail at each interview using the Present Behavioural Examination to assess subject's behaviour over the preceding 4 weeks. Seventeen key behaviour items which were both common and clinically important were selected for further analysis.

RESULTS

Three syndromes were identified: (a) overactivity (walking more, walking aimlessly, trailing the carer or checking where the carer was); (b) aggressive behaviour (physical aggression, aggressive resistance, verbal aggression); (c) psychosis (anxiety, persecutory ideas and hallucinations). The same syndromes were found using data collected at three different time points and by using a variety of statistical techniques, confirming their robustness.

CONCLUSIONS

Overactivity, aggressive behaviour and psychosis form three distinct behavioural syndromes in dementia.

Hyperphagia in dementia: 1. The use of an objective and reliable method for measuring hyperphagia in people with dementia

Up to one third of dementia sufferers eat an increased quantity of food, compared with their premorbid intake, at some stage during the dementia. A proportion of these eat extraordinarily large quantities if food intake is not restricted. In order to investigate this phenomenon in detail, a reliable and standardized method of quantifying the degree of hyperphagia is required. We report the development of such a method. Twenty-six people with dementia, who were reported by their carers to be hyperphagic, were compared with 14 matched non-hyperphagic controls with dementia and 14 matched normal elderly. Subjects were offered two standardized meals, under specified conditions, ad libitum. One meal consisted of a single food, the other of a mixture of foods. The total energy intake provided a reliable measure of the degree of hyperphagia. The single food meal was more reliable but the mixed meal was a more sensitive measure of the hyperphagia.

Allelic functional variation of serotonin transporter expression is a susceptibility factor for late onset Alzheimer's disease

We examined a deletion/insertion promoter polymorphism of the serotonin transporter gene, which confers an approximately 40% reduction in expression of the protein, in 196 subjects with late onset Alzheimer's disease (AD) and 271 controls. The frequency of the 484 bp low activity allele was elevated in the subjects with AD (p = 0.004), and an excess of the low activity genotype (30%) was also found in comparison with the controls (20%) (chi 2 = 7.16; p = 0.03). This association was unrelated to the age of the subjects or controls, or to epsilon 4 alleles of the ApoE gene. The odds ratio for the effect of the homozygous low activity genotype was 1.7 (95% CI 1.08-2.67), with a population attributable risk of 33% (95% CI 5-54%). These findings indicate that the low activity allele of the serotonin transporter is a risk factor for late onset AD.

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.

Apolipoprotein E: non-cognitive symptoms and cognitive decline in late onset Alzheimer's disease

OBJECTIVES

To determine the association between the epsilon2 and epsilon4 alleles of apolipoprotein E (ApoE) and independent measures of cognitive decline and non-cognitive symptomatology in late onset Alzheimer's disease.

METHODS

The frequency of the epsilon2 and epsilon4 alleles of ApoE and their association with measures of cognitive decline and non-cognitive symptomatology were assessed in a population based case register study of 164 patients with late onset Alzheimer's disease from the east Lambeth and south Southwark districts of south London.

RESULTS

Analysis of a wide range of non-cognitive symptoms against ApoE epsilon4 genotype showed no significant association but a positive relation was found between ApoE epsilon2 genotype and depressive symptomatology (P = 0.004). No relation was found between measurements of cognitive decline and the presence of the ApoE epsilon4 allele. A trend for decreasing age at onset of 3 to 4 years in carriers of the ApoE epsilon4 allele was found, confirming earlier studies.

CONCLUSION

Presence of the epsilon4 allele of ApoE is associated with an earlier age at onset but does not seem to be related to either a more severe psychopathology or a more rapid progression of the illness. The epsilon2 allele of ApoE is associated with depressive symptomatology in late onset Alzheimer's disease.

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.

The basis for behavioural disturbances in dementia

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Prospective study of relations between cortical Lewy bodies, poor eyesight, and hallucinations in Alzheimer's disease

The presence of hallucinations is included in some, but not all, of the sets of clinical diagnostic criteria that have been proposed for dementia associated with cortical Lewy bodies. These criteria were developed from retrospective casenote analyses. This prospective, longitudinal study suggests that, in patients with Alzheimer's disease, cortical Lewy bodies are associated with more persistent and severe hallucinations, independently of any association with severity of cognitive decline. Poor eyesight contributes to the severity but not the persistence of the hallucinations.

The Ward Daily Behaviour Scale

BACKGROUND

The Ward Daily Behaviour Scale is a new rating instrument that can be used to measure all the daily noteworthy behaviour of patients of various ages and diagnoses on psychiatric wards.

METHOD

The reliability and validity of the scale were tested on 40 patients.

RESULTS

This instrument proved to be both reliable and valid for use on adult acute in-patient wards.

CONCLUSIONS

The scale will be a valuable tool in a wide range of ward-based studies.