The Neuropsychiatric Inventory: Development and Applications

Optimizing detection of Alzheimer's disease in mild cognitive impairment: a 4-year biomarker study of mild behavioral impairment in ADNI and MEMENTO

BACKGROUND

Disease-modifying drug use necessitates better Alzheimer disease (AD) detection. Mild cognitive impairment (MCI) leverages cognitive decline to identify the risk group; similarly, mild behavioral impairment (MBI) leverages behavioral change. Adding MBI to MCI improves dementia prognostication over conventional approaches of incorporating neuropsychiatric symptoms (NPS). Here, to determine if adding MBI would better identify AD, we interrogated associations between MBI in MCI, and cerebrospinal fluid biomarkers [β-amyloid (Aβ), phosphorylated-tau (p-tau), and total-tau (tau)-ATN], cross-sectionally and longitudinally.

METHODS

Data were from two independent referral-based cohorts, ADNI (mean[SD] follow-up 3.14[1.07] years) and MEMENTO (4.25[1.40] years), collected 2003-2021. Exposure was based on three-group stratification: 1) NPS meeting MBI criteria; 2) conventionally measured NPS (NPSnotMBI); and 3) noNPS. Cohorts were analyzed separately for: 1) cross-sectional associations between NPS status and ATN biomarkers (linear regressions); 2) 4-year longitudinal repeated-measures associations of MBI and NPSnotMBI with ATN biomarkers (hierarchical linear mixed-effects models-LMEs); and 3) rates of incident dementia (Cox proportional hazards regressions).

RESULTS

Of 510 MCI participants, 352 were from ADNI (43.5% females; mean [SD] age, 71.68 [7.40] years), and 158 from MEMENTO (46.2% females; 68.98 [8.18] years). In ADNI, MBI was associated with lower Aβ42 (standardized β [95%CI], -5.52% [-10.48-(-0.29)%]; p = 0.039), and Aβ42/40 (p = 0.01); higher p-tau (9.67% [3.96-15.70%]; p = 0.001), t-tau (7.71% [2.70-12.97%]; p = 0.002), p-tau/Aβ42 (p < 0.001), and t-tau/Aβ42 (p = 0.001). NPSnotMBI was associated only with lower Aβ42/40 (p = 0.045). LMEs revealed a similar 4-year AD-specific biomarker profile for MBI, with NPSnotMBI associated only with higher t-tau. MBI had a greater rate of incident dementia (HR [95%CI], 3.50 [1.99-6.17; p < 0.001). NPSnotMBI did not differ from noNPS (HR 0.96 [0.49-1.89]; p = 0.916). In MEMENTO, MBI demonstrated a similar magnitude and direction of effect for all biomarkers, but with a greater reduction in Aβ40. HR for incident dementia was 3.93 (p = 0.004) in MBI, and 1.83 (p = 0.266) in NPSnotMBI. Of MBI progressors to dementia, 81% developed AD dementia.

CONCLUSIONS

These findings support a biological basis for NPS that meet MBI criteria, the continued inclusion of MBI in NIA-AA ATN clinical staging, and the utility of MBI criteria to improve identification of patients for enrollment in disease-modifying drug trials or for clinical care.

The neural correlates of apathy in the context of aging and brain disorders: a meta-analysis of neuroimaging studies

Introduction

Apathy is a prevalent mood disturbance that occurs in a wide range of populations, including those with normal cognitive aging, mental disorders, neurodegenerative disorders and traumatic brain injuries. Recently, neuroimaging technologies have been employed to elucidate the neural substrates underlying brain disorders accompanying apathy. However, the consistent neural correlates of apathy across normal aging and brain disorders are still unclear.

Methods

This paper first provides a brief review of the neural mechanism of apathy in healthy elderly individuals, those with mental disorders, neurodegenerative disorders, and traumatic brain injuries. Further, following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, the structural and functional neuroimaging meta-analysis using activation likelihood estimation method is performed on the apathy group with brain disorders and the healthy elderly, aiming at exploring the neural correlates of apathy.

Results

The structural neuroimaging meta-analysis showed that gray matter atrophy is associated with apathy in the bilateral precentral gyrus (BA 13/6), bilateral insula (BA 47), bilateral medial frontal gyrus (BA 11), bilateral inferior frontal gyrus, left caudate (putamen) and right anterior cingulate, while the functional neuroimaging meta-analysis suggested that the functional connectivity in putamen and lateral globus pallidus is correlated with apathy.

Discussion

Through the neuroimaging meta-analysis, this study has identified the potential neural locations of apathy in terms of brain structure and function, which may offer valuable pathophysiological insights for developing more effective therapeutic interventions for affected patients.

Comparing behavioral and psychological symptom structures on the Neuropsychiatric Inventory Questionnaire

The Neuropsychiatric Inventory Questionnaire (NPI-Q) is a collateral-rated measure of behavioral and psychological symptoms commonly found in dementia (BPSD). Several factor structures have been published, but they have not been systematically compared. Furthermore, the possibility of hierarchical models or presence of measurement invariance around cognitive stage or dementia syndrome has not been previously evaluated. This study addressed these gaps with confirmatory factor analyses using a multicenter sample (n = 41,801; Mage = 71.4; 57% women; 79% White, 13% Black, 8% Hispanic; Meducation = 15.1) that was divided into exploratory, derivation, and holdover subsets for cross-validation. We found that a four-factor model had the best fit, with adequate reliability estimates, adequate τ-equivalence, and the least amount of measurement variance. Strict invariance across stage and syndrome was not supported, although there was adequate support for weaker restrictions (e.g., equal forms). Furthermore, all bifactor models had a significant increase in fit. In sum, the present study provides practical guidance on using NPI-Q factor-derived subscales and theoretical elaboration of BPSD's hierarchical and syndrome-variant structure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Behavioral and Psychiatric Symptoms in Patients with Severe Traumatic Brain Injury: A Comprehensive Overview

Traumatic brain injury (TBI) is defined as an altered brain structure or function produced by an external force. Adults surviving moderate and severe TBI often experience long-lasting neuropsychological and neuropsychiatric disorders (NPS). NPS can occur as primary psychiatric complications or could be an exacerbation of pre-existing compensated conditions. It has been shown that changes in behavior following moderate to severe TBI have a prevalence rate of 25-88%, depending on the methodology used by the different studies. Most of current literature has found that cognitive behavioral and emotional deficit following TBI occurs within the first six months whereas after 1-2 years the condition becomes stable. Identifying the risk factors for poor outcome is the first step to reduce the sequelae. Patients with TBI have an adjusted relative risk of developing any NPS several-fold higher than in the general population after six months of moderate-severe TBI. All NPS features of an individual's life, including social, working, and familiar relationships, may be affected by the injury, with negative consequences on quality of life. This overview aims to investigate the most frequent psychiatric, behavioral, and emotional symptoms in patients suffering from TBI as to improve the clinical practice and tailor a more specific rehabilitation training.

Investigating the relationship between sleep disturbances and white matter hyperintensities in older adults on the Alzheimer's disease spectrum

Background

While studies report that sleep disturbance can have negative effects on brain vasculature, its impact on cerebrovascular disease such as white matter hyperintensities (WMHs) in beta-amyloid positive older adults remains unexplored.

Methods

Linear regressions, mixed effects models, and mediation analysis examined the crosssectional and longitudinal associations between sleep disturbance, cognition, and WMH burden, and cognition in normal controls (NCs), mild cognitive impairment (MCI), and Alzheimer's disease (AD) at baseline and longitudinally.

Results

People with AD reported more sleep disturbance than NC and MCI. AD with sleep disturbance had more WMHs than AD without sleep disturbances. Mediation analysis revealed an effect of regional WMH burden on the relationship between sleep disturbance and future cognition.

Conclusion

These results suggest that WMH burden and sleep disturbance increases from aging to AD. Sleep disturbance decreases cognition through increases in WMH burden. Improved sleep could mitigate the impact of WMH accumulation and cognitive decline.

Relationship between APOE, PER2, PER3 and OX2R Genetic Variants and Neuropsychiatric Symptoms in Patients with Alzheimer's Disease

Alzheimer's disease (AD) is characterized by the presence of neuropsychiatric or behavioral and psychological symptoms of dementia (BPSD). BPSD have been associated with the APOE_ε4 allele, which is also the major genetic AD risk factor. Although the involvement of some circadian genes and orexin receptors in sleep and behavioral disorders has been studied in some psychiatric pathologies, including AD, there are no studies considering gene-gene interactions. The associations of one variant in PER2, two in PER3, two in OX2R and two in APOE were evaluated in 31 AD patients and 31 cognitively healthy subjects. Genotyping was performed using real-time PCR and capillary electrophoresis from blood samples. The allelic-genotypic frequencies of variants were calculated for the sample study. We explored associations between allelic variants with BPSD in AD patients based on the NPI, PHQ-9 and sleeping disorders questionnaires. Our results showed that the APOE_ε4 allele is an AD risk variant (p = 0.03). The remaining genetic variants did not reveal significant differences between patients and controls. The PER3_rs228697 variant showed a nine-fold increased risk for circadian rhythm sleep-wake disorders in Mexican AD patients, and our gene-gene interaction analysis identified a novel interaction between PERIOD and APOE gene variants. These findings need to be further confirmed in larger samples.

Addition of the FTD Module to the Neuropsychiatric Inventory improves classification of frontotemporal dementia spectrum disorders

Most neuropsychiatric symptoms (NPS) common in frontotemporal dementia (FTD) are currently not part of the Neuropsychiatric Inventory (NPI). We piloted an FTD Module that included eight extra items to be used in conjunction with the NPI. Caregivers of patients with behavioural variant FTD (n = 49), primary progressive aphasia (PPA; n = 52), Alzheimer's dementia (AD; n = 41), psychiatric disorders (n = 18), presymptomatic mutation carriers (n = 58) and controls (n = 58) completed the NPI and FTD Module. We investigated (concurrent and construct) validity, factor structure and internal consistency of the NPI and FTD Module. We performed group comparisons on item prevalence, mean item and total NPI and NPI with FTD Module scores, and multinomial logistic regression to determine its classification abilities. We extracted four components, together explaining 64.1% of the total variance, of which the largest indicated the underlying dimension 'frontal-behavioural symptoms'. Whilst apathy (original NPI) occurred most frequently in AD, logopenic and non-fluent variant PPA, the most common NPS in behavioural variant FTD and semantic variant PPA were loss of sympathy/empathy and poor response to social/emotional cues (part of FTD Module). Patients with primary psychiatric disorders and behavioural variant FTD showed the most severe behavioural problems on both the NPI as well as the NPI with FTD Module. The NPI with FTD Module correctly classified more FTD patients than the NPI alone. By quantifying common NPS in FTD the NPI with FTD Module has large diagnostic potential. Future studies should investigate whether it can also prove a useful addition to the NPI in therapeutic trials.

Distinguishing apathy from depression: A review differentiating the behavioral, neuroanatomic, and treatment-related aspects of apathy from depression in neurocognitive disorders

OBJECTIVES

This narrative review describes the clinical features of apathy and depression in individuals with neurocognitive disorders (NCDs), with the goal of differentiating the two syndromes on the basis of clinical presentation, diagnostic criteria, neuropathological features, and contrasting responses to treatments.

METHODS

Literature was identified using PubMed, with search terms to capture medical conditions of interest; additional references were also included based on our collective experience and knowledge of the literature.

RESULTS

Evidence from current literature supports the distinction between the two disorders; apathy and depression occur with varying prevalence in individuals with NCDs, pose different risks of progression to dementia, and have distinct, if overlapping, neurobiological underpinnings. Although apathy is a distinct neuropsychiatric syndrome, distinguishing apathy from depression can be challenging, as both conditions may occur concurrently and share several overlapping features. Apathy is associated with unfavorable outcomes, especially those with neurodegenerative etiologies (e.g., Alzheimer's disease) and is associated with an increased burden for both patients and caregivers. Diagnosing apathy is important not only to serve as the basis for appropriate treatment, but also for the development of novel targeted interventions for this condition. Although there are currently no approved pharmacologic treatments for apathy, the research described in this review supports apathy as a distinct neuropsychiatric condition that warrants specific treatments aimed at alleviating patient disability.

CONCLUSIONS

Despite differences between these disorders, both apathy and depression pose significant challenges to patients, their families, and caregivers; better diagnostics are needed to develop more tailored treatment and support.

Ensemble feature selection with data-driven thresholding for Alzheimer's disease biomarker discovery

BACKGROUND

Feature selection is often used to identify the important features in a dataset but can produce unstable results when applied to high-dimensional data. The stability of feature selection can be improved with the use of feature selection ensembles, which aggregate the results of multiple base feature selectors. However, a threshold must be applied to the final aggregated feature set to separate the relevant features from the redundant ones. A fixed threshold, which is typically used, offers no guarantee that the final set of selected features contains only relevant features. This work examines a selection of data-driven thresholds to automatically identify the relevant features in an ensemble feature selector and evaluates their predictive accuracy and stability. Ensemble feature selection with data-driven thresholding is applied to two real-world studies of Alzheimer's disease. Alzheimer's disease is a progressive neurodegenerative disease with no known cure, that begins at least 2-3 decades before overt symptoms appear, presenting an opportunity for researchers to identify early biomarkers that might identify patients at risk of developing Alzheimer's disease.

RESULTS

The ensemble feature selectors, combined with data-driven thresholds, produced more stable results, on the whole, than the equivalent individual feature selectors, showing an improvement in stability of up to 34%. The most successful data-driven thresholds were the robust rank aggregation threshold and the threshold algorithm threshold from the field of information retrieval. The features identified by applying these methods to datasets from Alzheimer's disease studies reflect current findings in the AD literature.

CONCLUSIONS

Data-driven thresholds applied to ensemble feature selectors provide more stable, and therefore more reproducible, selections of features than individual feature selectors, without loss of performance. The use of a data-driven threshold eliminates the need to choose a fixed threshold a-priori and can select a more meaningful set of features. A reliable and compact set of features can produce more interpretable models by identifying the factors that are important in understanding a disease.

Feasibility, Acceptability, and Efficacy of Home-Based Transcranial Direct Current Stimulation on Pain in Older Adults with Alzheimer's Disease and Related Dementias: A Randomized Sham-Controlled Pilot Clinical Trial

Although transcranial direct current stimulation (tDCS) is emerging as a convenient pain relief modality for several chronic pain conditions, its feasibility, acceptability, and preliminary efficacy on pain in patients with Alzheimer's disease and related dementias (ADRD) have not been investigated. The purpose of this pilot study was to assess the feasibility, acceptability, and preliminary efficacy of 5, 20-min home-based tDCS sessions on chronic pain in older adults with ADRD. We randomly assigned 40 participants to active (n = 20) or sham (n = 20) tDCS. Clinical pain intensity was assessed using a numeric rating scale (NRS) with patients and a proxy measure (MOBID-2) with caregivers. We observed significant reductions of pain intensity for patients in the active tDCS group as reflected by both pain measures (NRS: Cohen's d = 0.69, p-value = 0.02); MOBID-2: Cohen's d = 1.12, p-value = 0.001). Moreover, we found home-based tDCS was feasible and acceptable intervention approach for pain in ADRD. These findings suggest the need for large-scale randomized controlled studies with larger samples and extended versions of tDCS to relieve chronic pain on the long-term for individuals with ADRD.

A data-driven examination of apathy and depressive symptoms in dementia with independent replication

Apathy is one of the most common neuropsychiatric symptoms (NPS) and is associated with poor clinical outcomes. Research that helps define the apathy phenotype is urgently needed, particularly for clinical and biomarker studies. We used latent class analysis (LCA) with two independent cohorts to understand how apathy and depression symptoms co-occur statistically. We further explored the relationship between latent class membership, demographics, and the presence of other NPS. The LCA identified a four-class solution (no symptoms, apathy, depression, and combined apathy/depression), reproducible over both cohorts, providing robust support for an apathy syndrome distinct from depression and confirming that an apathy/depression syndrome exists, supported by the model fit test with the four-class solution scores evidencing better fitting (Bayesian information criterion adjusted and entropy R 2). Using a data-driven method, we show distinct and statistically meaningful co-occurrence of apathy and depressive symptoms. There was evidence that these classes have different clinical associations, which may help inform diagnostic categories for research studies and clinical practice.

Highlights

We found four classes: no symptoms, apathy, depression and apathy/depression.Apathy conferred a higher probability for agitation.Apathy diagnostic criteria should include accompanying neuropsychiatric symptoms.

Health literacy of informal caregivers of older adults with dementia: results from a cross-sectional study conducted in Florence (Italy)

AIM

The aim of this study was to measure the prevalence of inadequate health literacy (HL) in a sample of family caregivers of older adults with dementia, and to assess the relationship of HL with characteristics of caregiver and persons with dementia.

METHODS

The study followed a cross-sectional design. Persons with dementia and their family caregivers were enrolled in an outpatients' geriatric memory clinic. For the caregivers, the following information was collected: socio-demographic data, level of HL, cognitive impairment (using the Mini-Cog). For persons with dementia, the following data were collected: socio-demographic data, functional status (using the Basic and Instrumental Activities of Daily Living), cognitive impairment (using the Mini Mental State Evaluation, and the Global Deterioration Scale) behavioral and psychological symptoms associated with dementia (assessed using the Neuropsychiatric Inventory).

RESULTS

A total of 174 person with dementia/caregiver dyads were enrolled. About 45% of the caregivers presented a possibility or a high likelihood of inadequate HL. The percentage of caregivers with inadequate HL was higher among spousal caregivers than in offspring. Female gender, higher age and lower education were independent predictors of low HL. On multiple logistic regression analysis, persons with dementia assisted by caregivers with a high likelihood of limited HL presented higher risk of a more severe disease.

CONCLUSION

The results of this study suggest that the HL of dementia caregivers has to be included in the comprehensive geriatric assessment, to develop an appropriate individualized care plan. Moreover, public health interventions are needed to increase the HL of dementia caregivers.

Neuropsychiatric outcomes and caregiver distress in primary progressive aphasia

BACKGROUND

In this study, we aimed to outline the neuropsychiatric consequences of primary progressive aphasia (PPA) and to understand how neuropsychiatric symptomatology affects distress in caregivers.

METHODS

The Neuropsychiatric Inventory (NPI) including the distress index (NPI-Distress) was used. Additional information about the caregiver burden was obtained using Zarit Burden Interview (ZBI). NPI, NPI-Distress, and ZBI data from 17 patients with a clinical diagnosis of PPA were compared with 10 stroke aphasia patients. Neuropsychiatric symptomatology was investigated based on three clusters; Mood, Frontal/Comportmental, and Psychotic/Disruptive. Additionally, the Activities of Daily Living Questionnaire (ADLQ) was used to outline the functional impairment. Twelve healthy controls were included to compare the neurocognitive test scores with PPA and stroke aphasia groups.

RESULTS

A greater number of neuropsychiatric symptoms were observed in the PPA group compared to the stroke aphasia group. The number of symptoms in Mood, and Frontal/Comportmental clusters were greater than the number of symptoms in Psychotic/Disruptive clusters in the PPA group, whereas no significant relationship between the number of symptoms and symptom clusters was found in the stroke aphasia group. In the PPA group, a strong correlation was found between the NPI-Frequency × Severity scores and the NPI-Distress scores. Moreover, the NPI-Distress scores in the PPA group strongly correlated with the ZBI scores. Scores for anxiety, irritability/lability, and apathy had a stronger correlation with the NPI-Distress scores compared to the other NPI symptoms. The Communication subscale was the most impaired domain in the PPA group. Travel, and Employment and Recreation subscales showed greater functional impairment in the stroke aphasia group compared to the PPA group.

CONCLUSIONS

Neuropsychiatric symptoms in PPA in our study were more frequent than previously reported. Furthermore, the distress index of the NPI was not only correlated with the severity of the neuropsychiatric symptoms but also reflected the overall burden on the caregivers in the PPA group.

Apathy and APOE in mild behavioral impairment, and risk for incident dementia

Introduction

Mild behavioral impairment (MBI) is a high-risk state for incident dementia and comprises five core domains including affective dysregulation, impulse dyscontrol, social inappropriateness, psychotic symptoms, and apathy. Apathy is among the most common neuropsychiatric symptoms (NPS) in dementia but can also develop in persons with normal cognition (NC) or mild cognitive impairment (MCI). The later-life emergence and persistence of apathy as part of the MBI syndrome may be a driving factor for dementia risk. Therefore, we investigated MBI-apathy-associated progression to dementia, and effect modification by sex, race, cognitive diagnosis, and apolipoprotein E (APOE) genotype.

Methods

Dementia-free National Alzheimer's Coordinating Center participants were stratified by persistent apathy status, based on Neuropsychiatric Inventory (NPI)-Questionnaire scores at two consecutive visits. Hazard ratios (HRs) for incident dementia for MBI-apathy and NPI-apathy relative to no NPS, and MBI-apathy relative to no apathy, were determined using Cox proportional hazards regressions, adjusted for baseline age, sex, years of education, race, cognitive diagnosis, and APOE genotype. Interactions with relevant model covariates were explored.

Results

Of the 3932 participants (3247 with NC), 354 had MBI-apathy. Of all analytic groups, MBI-apathy had the greatest dementia incidence (HR = 2.69, 95% confidence interval [CI]: 2.15-3.36, P < 0.001). Interaction effects were observed between cognitive diagnosis and APOE genotype with the NPS group. The contribution of apathy to dementia risk was greater in NC (HR = 5.91, 95% CI: 3.91-8.93) than in MCI (HR = 2.16, 95% CI: 1.69-2.77, interaction P < 0.001) and in all APOE genotypes, was greatest in APOE ɛ3 (HR = 4.25, 95% CI: 3.1-5.82, interaction P < 0.001).

Discussion

Individuals with MBI-apathy have a markedly elevated risk for future dementia, especially when symptoms emerge in those with NC. Both cognitive status and APOE genotype are important moderators in the relationship between MBI-apathy and incident dementia. MBI-apathy may represent a group in whom apathy is a preclinical or prodromal manifestation of dementia and identify a precision medicine target for preventative interventions.

Neuropsychiatric symptoms influence differently cognitive decline in older women and men

OBJECTIVE

The potential impact of sex on cognitive performance in normal aging and participants with Alzheimer's disease (AD) has been outlined previously. Nevertheless, differences in neuropsychiatric symptoms (NPS) have been also outlined. We aimed to study a potential association between NPS and cognitive performances according to sex, in older individuals with and without cognitive impairment.

METHODS

Demographic, neuropsychiatric and neuropsychological data from the ADNI and NACC databases were merged into a dataset of 506 participants with healthy cognitive performance, 467 patients with mild cognitive impairment, and 238 patients with AD. Cognitive performance in each group was evaluated according to sex and the presence of NPS.

RESULTS

Based on sex, cognitive performance differed according to clinical stage: in the healthy controls and AD groups, women had better fluency performance, while in the mild cognitive impairment group, women had better working memory and men better oral naming. Regardless of sex, depression showed a negative effect on processing speed in AD. Finally, there was an interaction between sex and NPS in mild cognitive impairment, where women with apathy had better working memory performance, and in AD, women with depression had better fluency performance. The opposite pattern being was observed in men, where men with depression have worse focused attention.

CONCLUSION

Cognitive performance is influenced by sex, yet this influence has different manifestations at normal cognition, MCI or AD. Furthermore, apathy and depression seem to influence differently women and men at different types of cognitive decline.

Well-Being Benefits of Horticulture-Based Activities for Community Dwelling People with Dementia: A Systematic Review

Most people living with dementia in the early-to-middle stages live in the community or in their own homes and engagement in enjoyable activities is fundamental to maintaining quality of life and autonomy. Horticulture-based activities are beneficial for the health and well-being for people living with dementia ("PLWD") in residential care settings, yet evidence within community settings, where the majority live, has not been comprehensively synthesized. A mixed studies systematic review protocol was registered and a systematic search conducted to June 2022 across MEDLINE, COCHRANE, Web of Science, Embase, Psycnet, CINAHL, PsycINFO databases, using terms relating to dementia and horticulture. Original studies examining group or individual horticulture-based programs for community-dwelling PLWD were included. Forty-five articles were selected for full review, eight met inclusion criteria and were retained for data extraction. Evidence from three mixed methods, two quantitative, two qualitative, and one case study design, involving a total of 178 community dwelling PLWD, was narratively summarized. Findings revealed that involvement in horticulture-based activities led to positive impacts on engagement, social interactions, and mental and physical well-being in PLWD. No conclusive evidence was found from included studies for improvement in cognitive function. As most studies to date have concentrated on PLWD in long-term care settings, future research should evaluate the effect of these types of activities in a more rigorous intervention design in community settings.

Management of Neuropsychiatric Symptoms for Chronic Traumatic Encephalopathy

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repeated head injury. The common presenting neuropsychiatric manifestations and diagnostic strategies for early diagnosis and subsequent treatment will be reviewed. This article discusses methods for injury prevention, risk assessment, and methods for supportive symptom management including lifestyle modifications, physical, occupational, and neurorehabilitation, and pharmaceutical management. Lastly, we propose the use of assessment tools validated for other neurodegenerative disorders in CTE to establish a baseline, track outcomes, and measure improvement in this population.

Application of the Older Adult Self-Report and Older Adult Behavior Checklist to Chinese Older Adults: Syndrome Structure and Inter-Informant Agreement

Despite the rapid aging of the world's population, comprehensive assessment tools to meet the mental health needs of older adults are lacking. The aim of the current study was to assess the multidimensionality of Chinese versions of U.S.-derived instruments designed to evaluate a broad spectrum of emotional, behavioral, social, and thought problems in older adults. The Older Adult Self-Report (OASR) and Older Adult Behavior Checklist (OABCL) were completed by 686 and 639 older adults, respectively, aged 60 to 99 years, from a sample of 755 older adults. Confirmatory factor analyses (CFAs) on the 97 OASR/OABCL problem items found that the models showed good fit according to our primary and secondary fit indices. None of the seven syndromes showed informant effects, whereas four showed small sex effects, and three showed small age effects. Overall, findings demonstrate the applicability of the seven syndrome OASR/OABCL model to Chinese older adults and support the use of these instruments to assess older adult mental health in Chinese clinical and research settings. These standardized tools can help health care professionals more comprehensively assess cognitive, behavioral, and mental health problems among Chinese-speaking older adult populations. [Journal of Gerontological Nursing, 48(8), 26-32.].

Latest Trends in Outcome Measures in Dementia and Mild Cognitive Impairment Trials

Disease modification trials in dementia and mild cognitive impairment (MCI) have not met with success. One potential criticism of these trials is the lack of sensitive outcome measures. A large number of outcome measures have been employed in dementia and MCI trials. This review aims to describe and analyze the utility of cognitive/clinical outcome measures in Alzheimer's disease (AD) and MCI trials. Methods: A PubMed search was conducted using relevant MeSH terms and exploded keywords. The search was confined to English language publications of human studies from the last five years which describe the latest trends in the use of outcome measures. Results: Despite broad use, the outcome measures employed are heterogeneous, with little data on correlations between scales. Another problem is that most studies are over-reliant on clinician/researcher assessment and cognitive outcomes, and there is a definite lack of stakeholder input. Finetuning of the paradigm is also required for people with early-stage disease, mild to moderate disease, and advanced dementia, as the outcome measures in these subgroups have varying relevance. Disease modification/prevention is an appropriate goal in early disease, whereas palliation and freedom from discomfort are paramount in later stages. The outcome measures selected must be suitable for and sensitive to these particular care goals. Although there is a shift to enrich MCI cohorts using a biomarker-based approach, the clinical relevance of such outcome measures remains uncertain. Conclusions: Outcome measures in dementia/MCI trials remain inhomogeneous and diverse, despite extensive use. Outcome measures fall within several paradigms, including cognitive, functional, quality-of-life, biomarker-based, and patient-reported outcome measures. The success of future disease-modifying trials is reliant to a large extent on the selection of outcome measures which combine all outcomes of clinical relevance as well as clinical meaning. Outcome measures should be tied to the type and stage of dementia and to the specific interventions employed.

Psychosis as a Treatment Target in Dementia: A Roadmap for Designing Interventions

Psychotic phenomena are among the most severe and disruptive symptoms of dementias and appear in 30% to 50% of patients. They are associated with a worse evolution and great suffering to patients and caregivers. Their current treatments obtain limited results and are not free of adverse effects, which are sometimes serious. It is therefore crucial to develop new treatments that can improve this situation. We review available data that could enlighten the future design of clinical trials with psychosis in dementia as main target. Along with an explanation of its prevalence in the common diseases that cause dementia, we present proposals aimed at improving the definition of symptoms and what should be included and excluded in clinical trials. A review of the available information regarding the neurobiological basis of symptoms, in terms of pathology, neuroimaging, and genomics, is provided as a guide towards new therapeutic targets. The correct evaluation of symptoms is transcendental in any therapeutic trial and these aspects are extensively addressed. Finally, a critical overview of existing pharmacological and non-pharmacological treatments is made, revealing the unmet needs, in terms of efficacy and safety. Our work emphasizes the need for better definition and measurement of psychotic symptoms in dementias in order to highlight their differences with symptoms that appear in non-dementing diseases such as schizophrenia. Advances in neurobiology should illuminate the development of new, more effective and safer molecules for which this review can serve as a roadmap in the design of future clinical trials.

The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

BACKGROUND

There is limited knowledge regarding the process of deprescribing psychotropic drugs to people with dementia (PwD) conducted by general practitioners (GP). We investigated the impact of a multicomponent intervention, emphasizing medication reviews, on psychotropic drugs and behavioral and psychological symptoms (BPSD) in home-dwelling PwD and quantified change in patient-GP communication evaluated by their informal caregivers.

METHODS

LIVE@Home.Path is a stepped-wedge closed-cohort cluster randomized controlled trial for people with mild to moderate dementia aged ≥65 and their informal caregivers (dyads) in Norway. Complementary to health care as usual (control condition), municipal coordinators implemented the multicomponent LIVE intervention: Learning, Innovation, Volunteer support, and Empowerment (including medication review by the PwD's regular GPs). Block-randomization was used to allocate dyads in three groups receiving the intervention sequentially in periods of 6 months duration. Prepandemic data from the first period is reported, resulting in a 1:2 intervention-to-control ratio. Primary outcome was change in psychotropic drug use. Secondary outcomes were changes in BPSD by Neuropsychiatric Inventory and Cornell Scale of Depression in Dementia and patient-GP communication by an adaption of the Clinical Global Impression of Change.

RESULTS

Four hundred thirty-eight dyads were screened, 280 included, and 237 participated at 6 months (intervention group n=67; control condition n=170). At baseline, 63% used psychotropic medication regularly: antidementia drugs (47%), antidepressants (13%), hypnotics/sedatives (13%), antipsychotics (5%), and anxiolytics (2%). At 6 months, medication reviews were more frequently conducted in the intervention group compared to control (66% vs 42%, P=0.001). We found no differences regarding a change in drug use and BPSD. Patient-GP communication enhanced in the intervention group (mean score 0.95 [standard deviation 1.68] vs 0.41 [1.34], P=0.022). In the intervention group, control group, and overall sample, the informal caregivers of those who had their medications reviewed reported improved patient-GP communication compared to those who did not.

CONCLUSIONS

Change in psychotropic drug use and BPSD did not differ, even though patient-GP communication improved with medication reviews. Restricted psychotropic drug use among PwD likely reflects more judicious prescribing practices in recent years. Nevertheless, medication reviews could be cultivated to optimize pharmacologic treatment for this complex population.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT04043364 ; registered 15/03/2019.

Neuropsychiatric Symptoms Assessment: Cross-cultural Adaptation and Validation of the Portuguese Abe's BPSD Score (ABS)

OBJECTIVES

This study aims to report on the development and psychometric properties of the Portuguese-language Abe's BPSD score (ABS) to screen for neuropsychiatric symptoms (NPS).

METHODS

ISPOR and COSMIN recommendations were followed to translate and culturally adapt the ABS. A validation study was conducted to assess the psychometric properties of the newly-translated instrument. Outpatients attending a psychogeriatric consultation were included by consecutive referrals and were assessed with the ABS, the Neuropsychiatric Inventory (NPI) and NPI Caregiver Distress scale (NPI-D), and the Mini-Mental State Examination (MMSE). The ABS reliability (internal consistency, item-total correlations, inter-rater and test-retest reliability), validity (concurrent and convergent), feasibility and diagnostic accuracy were examined.

RESULTS

Overall, 107 participants were included. The ABS Cronbach alpha was 0.672, and item-total correlations ranged from -0.056 to 0.546. Strong inter-rater (ICC 0.997; 95%CI: 0.995-0.999) and test-retest reliability (ICC 0.976; 95%CI: 0.958-0.986) were found. Concurrent validity with NPI was high (r_s = 0.847, p < .001), and correlations with MMSE and NPI-D were also significant. An exploratory threshold score ≥2 is proposed to identify clinically relevant NPS.

CONCLUSIONS

Data provide satisfactory proof of ABS psychometric characteristics. Nevertheless, some items exhibited less optimal properties.

CLINICAL IMPLICATIONS

The newly-translated instrument proved to be relevant, valid and easy to use in a real geriatric clinical setting.

Diminished preparatory physiological responses in frontotemporal lobar degeneration syndromes

Researchers typically study physiological responses either after stimulus onset or when the emotional valence of an upcoming stimulus is revealed. Yet, participants may also respond when they are told that an emotional stimulus is about to be presented even without knowing its valence. Increased physiological responding during this time may reflect a 'preparation for action'. The generation of such physiological responses may be supported by frontotemporal regions of the brain that are vulnerable to damage in frontotemporal lobar degeneration. We examined preparatory physiological responses and their structural and functional neural correlate in five frontotemporal lobar degeneration clinical subtypes (behavioural variant frontotemporal dementia, n = 67; semantic variant primary progressive aphasia, n = 35; non-fluent variant primary progressive aphasia, n = 30; corticobasal syndrome, n = 32; progressive supranuclear palsy, n = 30). Comparison groups included patients with Alzheimer's disease (n = 56) and healthy controls (n = 35). Preparatory responses were quantified as cardiac interbeat interval decreases (i.e. heart rate increases) from baseline to an 'instruction period', during which participants were told to watch the upcoming emotional film but not provided the film's valence. Patients' behavioural symptoms (apathy and disinhibition) were also evaluated via a caregiver-reported measure. Compared to healthy controls and Alzheimer's disease, the frontotemporal lobar degeneration group showed significantly smaller preparatory responses. When comparing each frontotemporal lobar degeneration clinical subtype with healthy controls and Alzheimer's disease, significant group differences emerged for behavioural variant frontotemporal dementia and progressive supranuclear palsy. Behavioural analyses revealed that frontotemporal lobar degeneration patients showed greater disinhibition and apathy compared to Alzheimer's disease patients. Further, these group differences in disinhibition (but not apathy) were mediated by patients' smaller preparatory responses. Voxel-based morphometry and resting-state functional MRI analyses revealed that across patients and healthy controls, smaller preparatory responses were associated with smaller volume and lower functional connectivity in a circuit that included the ventromedial prefrontal cortex and cortical and subcortical regions of the salience network. Diminished preparatory physiological responding in frontotemporal lobar degeneration may reflect a lack of preparation for actions that are appropriate for an upcoming situation, such as approaching or withdrawing from emotional stimuli. The ventromedial prefrontal cortex and salience network are critical for evaluating stimuli, thinking about the future, triggering peripheral physiological responses, and processing and interpreting interoceptive signals. Damage to these circuits in frontotemporal lobar degeneration may impair preparatory responses and help explain often-observed clinical symptoms such as disinhibition in these patients.

The ATENción Plena en Enfermedad de Alzheimer (ATENEA—Mindfulness in Alzheimer’s Disease) Program for Caregivers: Study Protocol for a Randomized Controlled Trial

A person affected by Alzheimer’s disease (AD) gradually loses the ability to perform activities of daily living and becomes dependent on caregivers, thereby having a negative impact on the caregivers’ quality of life. There is evidence that suggests that interventions aimed at caregivers, such as mindfulness, may be effective at reducing this burden and emotional issues, such as depression and anxiety, and improving their quality of life. However, there is a lack of consistency in the findings and conclusions remain tentative. In addition, as neuropsychiatric symptoms (NPSs) of AD are major determinants of the caregiver’s burden, these interventions should examine the relationship between these symptoms and caregiver outcomes. Importantly, to improve the design of therapeutic interventions for caregivers and complement the treatment of AD, aspects related to occupational performance and the participation of people with AD and their caregivers should also be considered. Therefore, this study will aim to examine first, the effects of a mindfulness-based program designed for caregivers on NPSs of AD and caregivers’ anxiety and depression; second, the effects of this program on patients’ functional capacity, cognitive performance, executive functions, and quality of life, and on caregivers’ burden, quality of life, occupational balance, executive functions, psychological wellbeing, and self-compassion. We believe that the findings of this study will have significant implications for future healthcare strategies focused on improving the quality of life and wellbeing of caregivers.

Impact of COVID-19 restrictions on behavioural and psychological symptoms in home-dwelling people with dementia: a prospective cohort study (PAN.DEM)

OBJECTIVES

To investigate the impact of the COVID-19 restrictions on behavioural and psychological symptoms of dementia (BPSD).

DESIGN

Prospective cohort study (PAN.DEM) nested within the halted parent trial (LIVE@Home.Path).

SETTING

Households in Norway immediate before and 6-9 weeks into the COVID-19 restrictions.

PARTICIPANTS

104 dyads (persons with mild to moderate dementia aged ≥65 and their informal carers) completed both prepandemic and pandemic assessments, among 237 in the parent trial. Mini-Mental Status Examination score 15-26 or Functional Assessment Staging score 3-7 covered dementia severity.

MAIN OUTCOME MEASURES

Neuropsychiatric Inventory (NPI-12) total (range 0-144), psychosis (range 0-24), hyperactive behaviour (range 0-60) and mood subsyndrome (range 0-48) scores; Cornell Scale for Depression in Dementia (CSDD) total score (range 0-38).

RESULTS

We found an overall increase in BPSD by NPI-12 total score comparing prepandemic to pandemic levels (median 16 IQR (4.5-29) to 20 (7-32.5), p=0.03) over a mean of 86 days (SD 19). NPI-12 total score worsened in 57 (55%) of people with dementia and was associated with postponed or averted contacts with healthcare professionals (logistic regression, OR 3.96, 95% CI 1.05 to 14.95). Psychosis subsyndrome levels increased (0 (0-3) to 0.5 (0-6), p=0.01) in 37 (36%) persons; this worsening was associated with partial insight (9.57, 1.14 to 80.71) and reduced informal carer contact (4.45, 1.01 to 19.71). Moreover, depressive symptoms increased as assessed by CSDD total score (5 (3-9) to 7 (4-12), p=0.01) and worsened for 56 (54%), which was inversely associated with psychotropic drugs on-demand (0.16, 0.03 to 0.75).

CONCLUSIONS

BPSD worsened during the first months of the COVID-19 restrictions, most pronounced for psychosis and depression. These BPSD exacerbations have implications for pandemic policies, emphasising that restrictions must balance COVID-19 morbidity and mortality against dementia deterioration.

TRIAL REGISTRATION NUMBER

NCT04043364; Results.

Neuropsychiatric symptoms as a sign of small vessel disease progression in cognitive impairment

Background

Neuropsychiatric symptoms associate cross-sectionally with cerebral small vessel disease but it is not clear whether these symptoms could act as early clinical markers of small vessel disease progression. We investigated whether longitudinal change in Neuropsychiatric Inventory (NPI) scores associated with white matter hyperintensity (WMH) progression in a memory clinic population.

Material and methods

We included participants from the prospective Sunnybrook Dementia Study with Alzheimer's disease and vascular subtypes of mild cognitive impairment and dementia with two MRI and ≥ 1 NPI. We conducted linear mixed-effects analyses, adjusting for age, atrophy, vascular risk factors, cognition, function, and interscan interval.

Results

At baseline (n=124), greater atrophy, age, vascular risk factors and total NPI score were associated with higher baseline WMH volume, while longitudinally, all but vascular risk factors were associated. Change in total NPI score was associated with change in WMH volume, χ2 = 7.18, p = 0.007, whereby a one-point change in NPI score from baseline to follow-up was associated with a 0.0017 change in normalized WMH volume [expressed as cube root of (WMH volume cm³ as % intracranial volume)], after adjusting for age, atrophy, vascular risk factors and interscan interval.

Conclusions

In memory clinic patients, WMH progression over 1-2 years associated with worsening neuropsychiatric symptoms, while WMH volume remained unchanged in those with stable NPI scores in this population with low background WMH burden.

Relationship Between Home Caregivers and Caregivers Employed at Selected Institutions Providing Assistance to Seniors with Their Care Recipients Suffering from Dementia

Introduction: There are many difficulties connected with caring for an elderly person sufferring dementia. Symptoms such as aggression or apathy, as well as the progressive nature of the disorder, affect the attitude of both home and institutional caregivers towards the people for whom they care. An important element related to the provision of care is the relationship between a senior with dementia and those who provide the care (home and institutional caregivers). The aim of the article is to characterise and compare these relations. Material and methods: The study comprised 124 participants, 57 professional caregivers and 67 home carers. Two standardised questionnaires were used: the Neuropsychiatric Inventory Questionnaire (NPI-Q) and the Quality of Carer-Patient Relationship - QCPR Questionnaire. Additionally, the respondents provided socio-demographic data. The study was conducted via electronic media in the first quarter of 2021. Results: It was found that there is a significant difference in the relationship between home and institutional caregivers, with their charges in the dimension of "warmth and attachment" (measured by QCPR). People providing professional care have significantly higher scores in this area. There was also a significant difference between scores in the 'no conflict and criticism' dimension (measured by QCPR) for home and professional caregivers. Institutional caregivers, in relation to their care recipients, have a higher level of this indicator than home caregivers. Conclusions: Relationships between seniors with dementia and institutional or home carers differ with regard to some issues. The differences in relationships with seniors suffering dementia may be due to the time spent caring for this person and the caregiver's response to symptoms of dementia.

Psychometric Properties of the Neuropsychiatric Inventory: A Review

Neuropsychiatric symptoms cause a significant burden to individuals with neurocognitive disorders and their families. Insights into the clinical associations, neurobiology, and treatment of these symptoms depend on informant questionnaires, such as the commonly used Neuropsychiatric Inventory (NPI). As with any scale, the utility of the NPI relies on its psychometric properties, but the NPI faces unique challenges related to its skip-question and scoring formats. In this narrative review, we examined the psychometric properties of the NPI in a framework including properties pertinent to construct validation, and health-related outcome measurement in general. We found that aspects such as test-retest and inter-rater reliability are major strengths of the NPI in addition to its flexible and relatively quick administration. These properties are desired in clinical trials. However, the reported properties appear to cover only some of the generally examined psychometric properties, representing perhaps necessary but insufficient reliability and validity evidence for the NPI. The psychometric data seem to have significant gaps, in part because small sample sizes in the relevant studies have precluded more comprehensive analyses. Regarding construct validity, only one study has examined structural validity with the NPI subquestions. Measurement error was not assessed in the reviewed studies. For future validation, we recommend using data from all subquestions, collecting larger samples, paying specific attention to construct validity and formulating hypotheses a priori. Because the NPI is an outcome measure of interest in clinical trials, examining measurement error could be of practical importance.

The acceptability, adoption, and feasibility of a music application developed using participatory design for home-dwelling persons with dementia and their caregivers. The "Alight" app in the LIVE@Home.Path trial

BACKGROUND

Music interventions for persons with dementia can improve health and interaction with caregivers, yet the reach is often restricted to institutions. We describe the participatory design process of a prototype music application for patients affiliated with a gerontopsychiatric hospital and evaluate the acceptability, adoption, and feasibility of use for dyads of home-dwelling persons with dementia and their informal caregivers.

METHODS

The application "Alight" was developed following an iterative, expert-driven participatory design approach, which includes a requirement elicitation phase and two rounds of prototyping and testing in real-world settings. End users and stakeholders were involved in all steps, that is, workshops, interviews, field observation, ethnographic inquiries, and beta testing sessions with music therapists, patients, and caregivers in collaboration with a commercial music and technology company. The last prototyping and testing took place in the LIVE@Home.Path trial, a stepped-wedge multicomponent randomized controlled trial to improve resource utilization and caregiver burden in municipal dementia care during 2019-2021.

RESULTS

Mean age of the person with dementia in the LIVE@Home.Path trial was 82 years, 62% were female, and the majority had Alzheimer's dementia (44%) of mild severity (71%). Sixty-three dyads were offered Alight in the multicomponent intervention, of which 13% (n = 8) accepted use. The dyads accepting Alight did not differ in demographic and clinical characteristics compared to those not interested. The feasibility was high among those accepting Alight, 75% (n = 6) reported a positive impact on mood, 50% (n = 4) experienced a positive impact on activity, and 50% (n = 4) gooduser-friendliness. The adoption was high with daily use or use several times a week reported by 63% (n = 5). Obstacles emerged when updating the application in homes without wireless Wi-Fi, and some participants were unfamiliar with using touchscreens.

CONCLUSION

The feasibility and adoption of the application were high and accepting dyads did not differ on demographic and clinical variables from those not reached. This suggests a high potential for utilization in dementia care. This study contributes methodologically to the field of participatory design and mHealth interventions by demonstrating a specific design approach that throughout the process successfully involved researchers, industry partners, health care practitioners, and end users.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04043364.

Wrist accelerometry for monitoring dementia agitation behaviour in clinical settings: A scoping review

Agitated behaviour among elderly people with dementia is a challenge in clinical management. Wrist accelerometry could be a versatile tool for making objective, quantitative, and long-term assessments. The objective of this review was to summarise the clinical application of wrist accelerometry to agitation assessments and ways of analysing the data. Two authors independently searched the electronic databases CINAHL, PubMed, PsycInfo, EMBASE, and Web of Science. Nine (n = 9) articles were eligible for a review. Our review found a significant association between the activity levels (frequency and entropy) measured by accelerometers and the benchmark instrument of agitated behaviour. However, the performance of wrist accelerometry in identifying the occurrence of agitation episodes was unsatisfactory. Elderly people with dementia have also been monitored in existing studies by investigating the at-risk time for their agitation episodes (daytime and evening). Consideration may be given in future studies on wrist accelerometry to unifying the parameters of interest and the cut-off and measurement periods, and to using a sampling window to standardise the protocol for assessing agitated behaviour through wrist accelerometry.

Research Criteria for the Behavioral Variant of Alzheimer Disease: A Systematic Review and Meta-analysis

Importance

The behavioral variant of Alzheimer disease (bvAD) is characterized by early and predominant behavioral deficits caused by AD pathology. This AD phenotype is insufficiently understood and lacks standardized clinical criteria, limiting reliability and reproducibility of diagnosis and scientific reporting.

Objective

To perform a systematic review and meta-analysis of the bvAD literature and use the outcomes to propose research criteria for this syndrome.

Data Sources

A systematic literature search in PubMed/MEDLINE and Web of Science databases (from inception through April 7, 2021) was performed in duplicate.

Study Selection

Studies reporting on behavioral, neuropsychological, or neuroimaging features in bvAD and, when available, providing comparisons with typical amnestic-predominant AD (tAD) or behavioral variant frontotemporal dementia (bvFTD).

Data Extraction and Synthesis

This analysis involved random-effects meta-analyses on group-level study results of clinical data and systematic review of the neuroimaging literature. The study was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Main Outcomes and Measures

Behavioral symptoms (neuropsychiatric symptoms and bvFTD core clinical criteria), cognitive function (global cognition, episodic memory, and executive functioning), and neuroimaging features (structural magnetic resonance imaging, [18F]fluorodeoxyglucose-positron emission tomography, perfusion single-photon emission computed tomography, amyloid positron emission tomography, and tau positron emission tomography).

Results

The search led to the assessment of 83 studies, including 13 suitable for meta-analysis. Data were collected for 591 patients with bvAD. There was moderate to substantial heterogeneity and moderate risk of bias across studies. Cases with bvAD showed more severe behavioral symptoms than tAD (standardized mean difference [SMD], 1.16 [95% CI, 0.74-1.59]; P < .001) and a trend toward less severe behavioral symptoms compared with bvFTD (SMD, -0.22 [95% CI, -0.47 to 0.04]; P = .10). Meta-analyses of cognitive data indicated worse executive performance in bvAD vs tAD (SMD, -1.03 [95% CI, -1.74 to -0.32]; P = .008) but not compared with bvFTD (SMD, -0.61 [95% CI, -1.75 to 0.53]; P = .29). Cases with bvAD showed a nonsignificant difference of worse memory performance compared with bvFTD (SMD, -1.31 [95% CI, -2.75 to 0.14]; P = .08) but did not differ from tAD (SMD, 0.43 [95% CI, -0.46 to 1.33]; P = .34). The neuroimaging literature revealed 2 distinct bvAD neuroimaging phenotypes: an AD-like pattern with relative frontal sparing and a relatively more bvFTD-like pattern characterized by additional anterior involvement, with the AD-like pattern being more prevalent.

Conclusions and Relevance

These data indicate that bvAD is clinically most similar to bvFTD, while it shares most pathophysiological features with tAD. Based on these insights, we propose research criteria for bvAD aimed at improving the consistency and reliability of future research and aiding the clinical assessment of this AD phenotype.

A Comparison of Behavioral and Psychological Symptoms of Dementia (BPSD) and BPSD Sub-Syndromes in Early-Onset and Late-Onset Alzheimer's Disease

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) have a large impact on the quality of life of patients with Alzheimer's disease (AD). Few studies have compared BPSD between early-onset (EOAD) and late-onset (LOAD) patients, finding conflicting results.

OBJECTIVE

The aims of this study were to: 1) characterize the presence, overall prevalence, and time of occurrence of BPSD in EOAD versus LOAD; 2) estimate the prevalence over time and severity of each BPSD in EOAD versus LOAD in three stages: pre-T0 (before the onset of the disease), T0 (from onset to 5 years), and T1 (from 5 years onwards); 3) track the manifestation of BPSD sub-syndromes (i.e., hyperactivity, psychosis, affective, and apathy) in EOAD versus LOAD at T0 and T1.

METHODS

The sample includes 1,538 LOAD and 387 EOAD diagnosed from 1996 to 2018. Comprehensive assessment batteries, including the Neuropsychiatric Inventory (NPI), were administered at the first medical assessment and at different follow-up period.

RESULTS

The overall prevalence for the most of BPSD was significantly higher in EOAD compared to LOAD whereas most BPSD appeared significantly later in EOAD patients. Between the two groups, from pre-T0 to T1 we recorded a different pattern of BPSD prevalence over time as well as for BPSD sub-syndromes at T0 and T1. Results on severity of BPSD did not show significant differences.

CONCLUSION

EOAD and LOAD represent two different forms of a single entity not only from a neuropathological, cognitive, and functional level but also from a psychiatric point of view.

How Singing can Help People With Dementia and Their Family Care-Partners: A Mixed Studies Systematic Review With Narrative Synthesis, Thematic Synthesis, and Meta-Integration

Background: Recent research on the efficacy of music-based interventions for people with dementia have focused on specific outcomes and methods, and singing has been noted as a particularly beneficial activity. However, due to heterogeneity of research methods, there is a need to synthesise the findings of both quantitative and qualitative research in order to better understand both the impact and potential mechanisms of singing for people in this population. Method: This systematic review included quantitative, qualitative and mixed-methods studies, and analysed these using a systematic mixed-studies synthesis (with a results-based convergent approach). Quantitative and qualitative data were initially synthesised using a narrative synthesis and thematic synthesis method, respectively, before a final meta-integration method was used to synthesise common themes across the two data forms. Results: Electronic and hand search strategies revealed 1,815 relevant studies, 40 of which met the full eligibility criteria. Narrative synthesis of quantitative data revealed six key outcome areas (quality of life; psychological well-being; cognition; engagement; activities of daily living; care-partner well-being), and thematic synthesis of qualitative data generated seven themes relating to the impact and mechanisms of singing (pragmatic elements; social benefits; mood; identity; memory; flow-on effects; and relationships). Meta-integration identified four key areas relating to the impact and mechanisms of singing for people with dementia and care-partners: psychological well-being, quality of life, cognition, and care-partner well-being. Conclusion: Results from the syntheses suggest that singing can positively impact the lives of people with dementia and their care-partners, although due to heterogeneity of study design and outcome measures, it is difficult to draw conclusions based on quantitative data alone. Qualitative data provides further context and insights from participant perspectives, and when integrated with quantitative data, contextual factors that may influence the benefits that participants experience from singing are revealed.

Gender Differences in Neuropsychiatric Symptoms Among Community-Dwelling Mexican Americans Aged 80 and Older

Background and ObjectivesTo assess gender differences in prevalence of neuropsychiatric symptoms (NPS) among community-dwelling Mexican Americans ≥80 years. Research Design and Methods: Using data from Wave 7 (2010-2011) of the Hispanic Established Population for the Epidemiological Study of the Elderly, we analyzed the NPS of 914 participants as determined by the Neuropsychiatric Inventory (NPI) with assessments conducted by their caregivers. Multivariate logistic regression models were used to test the association of individual NPS with gender, adjusting for relevant characteristics. Results: The average age of our sample was 86.1 years, and 65.3% were women. Over 60% of participants had at least one informant/caregiver reported NPS. After adjustment, women had lower odds than men of agitation/aggression but higher odds of dysphoria/depression and anxiety. Discussion: Recognizing gender differences in NPS phenotype could help guide development of culturally appropriate NPS screening and treatment programs.

Social Behavior Observer Checklist: Patterns of Spontaneous Behaviors Differentiate Patients With Neurodegenerative Disease From Healthy Older Adults

Neurodegenerative disease syndromes often affect personality and interpersonal behavior in addition to cognition, but there are few structured observational measures of altered social demeanor validated for this population. We developed the Social Behavior Observer Checklist (SBOCL), a 3-min checklist tool, to facilitate identification of patterns of interpersonal behavior that are diagnostically relevant to different neurodegenerative syndromes. Research assistants without formal clinical training in dementia used the SBOCL to describe participants' behavior, including 125 healthy older adults and 357 patients diagnosed with one of five neurodegenerative disease syndromes: 135 behavioral variant frontotemporal dementia (bvFTD), 57 semantic variant primary progressive aphasia (svPPA), 51 non-fluent variant PPA (nfvPPA), 65 progressive supranuclear palsy (PSP), and 49 amyloid-positive Alzheimer's disease syndrome (AD), all of whom had concurrent 3D T1 MRI scans available for voxel-based morphometry analysis. SBOCL item interrater reliability ranged from moderate to very high, and score elevations showed syndrome-specific patterns. Subscale scores derived from a degree*frequency product of the items had excellent positive predictive value for identifying patients. Specifically, scores above 2 on the Disorganized subscale, and above 3 on the Reactive and Insensitive subscales, were not seen in any healthy controls but were found in many patients with bvFTD, svPPA, nfvPPA, PSP, and AD syndromes. Both the Disorganized and Reactive subscale scores showed significant linear relationships with frontal and temporal gray matter volume that generalized across syndromes. With these initial psychometric characteristics, the SBOCL may be a useful measure to help non-experts identify patients who are appropriate for additional specialized dementia evaluation, without adding time to patient encounters or requiring the presence of an informant.

Access to and interest in assistive technology for home-dwelling people with dementia during the COVID-19 pandemic (PAN.DEM)

The COVID-19 restrictions affect daily living in Norway, including home-dwelling people with dementia, and researchers conducting clinical trials in dementia care. In this paper, we 1) describe the development of a pandemic cohort (PAN.DEM) incorporated in the LIVE@Home.Path, an ongoing clinical intervention trial on resource utilisation including home-dwelling people with dementia and their caregivers (N = 438 dyads), 2) describe pre-pandemic use of assistive technology and 3) explore the extent to which COVID-19 restrictions increase caregivers interest in innovation in the PAN.DEM cohort (N = 126). Our main finding is that assistive technology is available to 71% pre-pandemic; the vast majority utilise traditional stove guards and safety alarms, only a few operate sensor technology, including GPS, fall detectors or communication aids. In response to COVID-19, 17% show increased interest in technology; being less familiar with operating a telephone and having higher cognitive functioning are both associated with increased interest. We conclude that wearable and sensor technology has not yet been fully implemented among people with dementia in Norway, and few caregivers show increased interest under the restrictions. Clinicaltrials.gov (NCT0404336).

Contribution of neuropsychiatric symptoms in Parkinson's disease to different domains of caregiver burden

Introduction

Caregiver burden is high among caregivers of PD patients (CPD). Neuropsychiatric symptoms are leading contributors to CPD burden, but whether different symptoms differentially impact domains of caregiver burden is not known. Our objective was to examine which neuropsychiatric symptoms and demographic factors contribute to different domains of caregiver burden in PD.

Methods

This was a cross-sectional online survey study. Participants were recruited from the Fox Insight (FI) study and were eligible if they identified themselves as a CPD. The primary outcome was the Caregiver Burden Inventory (CBI) total score and its 5 sub-domain scores. The Neuropsychiatric Inventory Questionnaire (NPI-Q) assessed caregiver-reported neuropsychiatric symptoms in the care recipient. Multivariable linear regression models were used to characterize the associations between NPI-Q symptom severity scores and CBI scores. Covariates were caregiver age, sex, education, and caregiving duration.

Results

The sample consisted of 450 CPD, mean age 65.87 (SD 10.39) years, 74% females. After adjusting for covariates, CBI total score was predicted by NPI-Q total score (β = 1.96, p < 0.001); model adjusted R² = 39.2%. Anxiety severity had the largest effect size [standardized β (sβ) = 0.224] on the time-dependency domain, which was also associated with female sex (sβ = − 0.133) and age (sβ = 0.088). Severity of disinhibition (sβ = 0.218), agitation (sβ = 0.199), and female sex (sβ = 0.104) were associated with greater emotional burden.

Conclusion

Our findings indicate that demographic characteristics and specific neuropsychiatric symptoms contribute differentially to domains of caregiver burden. Tailored interventions to support CPD are needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10443-7.

New approaches to symptomatic treatments for Alzheimer's disease

BACKGROUND

Successful development of agents that improve cognition and behavior in Alzheimer's disease (AD) is critical to improving the lives of patients manifesting the symptoms of this progressive disorder.

DISCUSSION

There have been no recent approvals of cognitive enhancing agents for AD. There are currently 6 cognitive enhancers in Phase 2 trials and 4 in phase 3. They represent a variety of novel mechanisms. There has been progress in developing new treatments for neuropsychiatric symptoms in AD with advances in treatment of insomnia, psychosis, apathy, and agitation in AD. There are currently 4 AD-related psychotropic agents in Phase 2 trials and 7 in Phase 3 trials. Many novel mechanisms are being explored for the treatment of cognitive and behavioral targets. Progress in trial designs, outcomes measures, and population definitions are improving trial conduct for symptomatic treatment of AD.

CONCLUSIONS

Advances in developing new agents for cognitive and behavioral symptoms of AD combined with enhanced trial methods promise to address the unmet needs of patients with AD for improved cognition and amelioration of neuropsychiatric symptoms.

Neuropsychiatric Symptoms by Cognitive Status for Mexican-Americans Aged 85 and Older

Few studies have investigated the relationship between neuropsychiatric symptoms (NPS) and cognitive status among older Mexican-American adults. Our objective was to describe the NPS of Mexican-Americans 85 years and older according to cognitive status. Data came from Wave 9 (conducted in 2016) of the Hispanic Established Populations for the Epidemiological Study of the Elderly. The final sample consisted of 381 care recipients ≥85 years. The 12-item Neuropsychiatric Inventory was administered to measure NPS among care recipients. Cognitive impairment was defined as a score of ≤18 on the Mini Mental State Exam or by clinical diagnosis of dementia as reported by the caregiver. Logistic regression models were used to estimate the average marginal effect (range = -1 to 1) of cognitive impairment on NPS, controlling for care-recipient characteristics. Overall, 259 (68.0%) participants had one or more NPS. Approximately 87% of care recipients with cognitive impairment had at least one NPS compared to 55.8% of those without cognitive impairment (p < .01). The predicted probability of having one or more NPS was 0.25% points (95% CI = 0.14-0.35) higher for participants with cognitive impairment than those without. NPS are present in the majority of very old Mexican American adults, particularly in those with cognitive impairment.

A 5-min Cognitive Task With Deep Learning Accurately Detects Early Alzheimer's Disease

Introduction: The goal of this study was to investigate and compare the classification performance of machine learning with behavioral data from standard neuropsychological tests, a cognitive task, or both.

Methods: A neuropsychological battery and a simple 5-min cognitive task were administered to eight individuals with mild cognitive impairment (MCI), eight individuals with mild Alzheimer's disease (AD), and 41 demographically match controls (CN). A fully connected multilayer perceptron (MLP) network and four supervised traditional machine learning algorithms were used.

Results: Traditional machine learning algorithms achieved similar classification performances with neuropsychological or cognitive data. MLP outperformed traditional algorithms with the cognitive data (either alone or together with neuropsychological data), but not neuropsychological data. In particularly, MLP with a combination of summarized scores from neuropsychological tests and the cognitive task achieved ~90% sensitivity and ~90% specificity. Applying the models to an independent dataset, in which the participants were demographically different from the ones in the main dataset, a high specificity was maintained (100%), but the sensitivity was dropped to 66.67%.

Discussion: Deep learning with data from specific cognitive task(s) holds promise for assisting in the early diagnosis of Alzheimer's disease, but future work with a large and diverse sample is necessary to validate and to improve this approach.

Benfotiamine and Cognitive Decline in Alzheimer's Disease: Results of a Randomized Placebo-Controlled Phase IIa Clinical Trial

BACKGROUND

In preclinical models, benfotiamine efficiently ameliorates the clinical and biological pathologies that define Alzheimer's disease (AD) including impaired cognition, amyloid-β plaques, neurofibrillary tangles, diminished glucose metabolism, oxidative stress, increased advanced glycation end products (AGE), and inflammation.

OBJECTIVE

To collect preliminary data on feasibility, safety, and efficacy in individuals with amnestic mild cognitive impairment (aMCI) or mild dementia due to AD in a placebo-controlled trial of benfotiamine.

METHODS

A twelve-month treatment with benfotiamine tested whether clinical decline would be delayed in the benfotiamine group compared to the placebo group. The primary clinical outcome was the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog). Secondary outcomes were the clinical dementia rating (CDR) score and fluorodeoxyglucose (FDG) uptake, measured with brain positron emission tomography (PET). Blood AGE were examined as an exploratory outcome.

RESULTS

Participants were treated with benfotiamine (34) or placebo (36). Benfotiamine treatment was safe. The increase in ADAS-Cog was 43% lower in the benfotiamine group than in the placebo group, indicating less cognitive decline, and this effect was nearly statistically significant (p = 0.125). Worsening in CDR was 77% lower (p = 0.034) in the benfotiamine group compared to the placebo group, and this effect was stronger in the APOEɛ4 non-carriers. Benfotiamine significantly reduced increases in AGE (p = 0.044), and this effect was stronger in the APOEɛ4 non-carriers. Exploratory analysis derivation of an FDG PET pattern score showed a treatment effect at one year (p = 0.002).

CONCLUSION

Oral benfotiamine is safe and potentially efficacious in improving cognitive outcomes among persons with MCI and mild AD.