The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia

Clinical and metabolic profiles in behavioural frontotemporal dementia: Impact of age at onset

AIM

Frontotemporal dementia (FTD) is a heterogeneous neurodegenerative disorder, with considerable variability of age-at-onset. We explored clinical and metabolic differences between early- and late-onset behavioural FTD (bvFTD), assuming that they might represent different disease phenotypes.

MATERIALS AND METHODS

We retrospectively studied consecutive patients diagnosed with prodromal or overt bvFTD with [18F]FDG PET scan, neuropsychological assessment (NPS), and Neuropsychiatric Inventory (NPI) available at baseline. Patients were divided into three groups based on age-at-onset: early onset-bvFTD (EO-bvFTD, age<70), late onset-bvFTD (LO-bvFTD, age 70-75) and very late onset-bvFTD (vLO-bvFTD, age>75). NPS and NPI were compared between groups and in the subset of prodromal patients, to study different syndromic phenotypes. Voxel-based analysis compared brain [18F]FDG PET of EO-bvFTD, LO-bvFTD and vLO-bvFTD independently, with respect to healthy controls, to explore metabolic differences. An inter-regional metabolic covariance analysis was performed in frontal lobe subregions, to explore differences in brain connectivity. Moreover, we supported our result using a correlation-based approach on clinical and metabolic variables.

RESULTS

101 bvFTD (62 prodromal bvFTD) were enrolled (EO-bvFTD: n = 36, prodromal n = 21; LO-bvFTD: n = 36, prodromal: n = 22; vLO-bvFTD: n = 29, prodromal: n = 19). Greater verbal memory deficit was evident in LO-bvFTD and vLO-bvFTD compared to EO-bvFTD (immediate recall: p = .018; p = .024; delayed recall: both p = .001, respectively), with similar results in the subset of prodromal patients. EO-bvFTD and LO-bvFTD had a higher behavioural severity than vLO-bvFTD. LO-bvFTD and vLO-bvFTD showed more widespread relative hypometabolism, with a greater involvement of posterior, subcortical and temporo-limbic regions compared with EO-bvFTD. Moreover, vLO-bvFTD showed a different pattern of intrafrontal metabolic covariance compared to EO-bvFTD and LO-bvFTD.

DISCUSSION

The cognitive-behavioural profile of bvFTD differs between early- and late-onset, already from the prodromal stage of the disease. Both metabolic pattern and functional connectivity vary based on age-at-onset. Understanding these differences could contribute to improve diagnostic accuracy and understanding the underling pathological heterogeneity.

Characterization of subclinical depressive and anxiety symptoms in older adults with subjective cognitive decline progressing to objective cognitive impairment: A prospective 4-year follow-up study

BackgroundSubjective cognitive decline (SCD) is linked to a more rapid progression to the development of mild cognitive impairment (MCI) or Alzheimer's disease (AD). SCD has been correlated with affective symptoms such as depression and anxiety. Recent research aimed to shed light on the relationship between these affective symptoms and how they might correlate to a more rapid progression to objective cognitive impairment. No studies have assessed the presence, type, and intensity of depressive and anxiety symptoms between SCD individuals who progressed versus those who did not.ObjectiveThis study aimed to establish whether there are differences between subclinical depressive and anxiety symptoms in terms of presence, type, and intensity of symptoms presented by individuals with SCD who progressed to an objective cognitive decline.MethodsThe recruited participants originated from the Consortium for the Early Identification of Alzheimer's Disease - Québec (CIMA-Q) cohort. They were assessed twice, with an interval of 4 years separating the evaluations. Anxiety symptoms were assessed using the Geriatric Anxiety Inventory (GAI) and depression symptoms using the Geriatric Depression Scale (GDS-30).ResultsThe presence, type and intensity of anxiety symptoms did not significantly distinguish the two groups. Only one type of hopelessness-related depressive symptom was significantly higher in SCD participants who had progressed to objective cognitive decline compared with those who had not.ConclusionsOur results suggest that it may be beneficial to target hopelessness in non-pharmacological interventions aimed at preventing the progression of people with SCD to MCI or AD.

Exploring the association between mild behavioral impairment and plasma p-tau217: Implications for early detection of Alzheimer's disease

INTRODUCTION

Mild behavioral impairment (MBI), marked by late-onset persistent neuropsychiatric symptoms (NPS), may signal early dementia risk. While MBI is linked to previously established amyloid-beta (Aβ) and tau biomarkers, its association with plasma p-tau217, a promising blood-based biomarker for Alzheimer's disease (AD), remains unexplored. Here, we investigated the association between MBI and plasma p-tau217 in dementia-free individuals from the Alzheimer's Disease Neuroimaging Initiative.

METHODS

MBI was defined using the Neuropsychiatric Inventory (NPI) data. Linear regression assessed the association between NPS status and continuous p-tau217 levels, while logistic regression modeled the association between NPS status and p-tau217 positivity, using a study-specific cutoff. Models adjusted for age, sex, education, and cognitive diagnosis.

RESULTS

Among 101 participants (mean age = 72.0 ± 6.5; 44.6% female), those with MBI had higher plasma p-tau217 levels (β = 36.4%; 95% confidence interval [CI]: 2.2-82.0, p = 0.04) and higher odds of being p-tau217 positive (odds ratio [OR] = 3.06, 95% CI: 1.14-8.70, p = 0.03) than MBI- participants.

DISCUSSION

Findings support the role of MBI in AD risk stratification.

Highlights

Mild behavioral impairment (MBI) is linked to elevated plasma p-tau217, a specific Alzheimer's disease biomarker.MBI increases the odds of plasma p-tau217 positivity in dementia-free individuals.Findings support MBI as an early indicator for Alzheimer's disease risk.MBI assessment can improve biomarker-based screening and clinical trial efficiency.

Three approaches to determining clinically meaningful benefit on the Cohen-Mansfield Agitation Inventory in dementia clinical trials for agitation

INTRODUCTION

There is a need to understand the clinical meaningfulness of symptom score changes in treatment trials of dementia-related agitation. We estimated minimal clinically important differences (MCIDs) for commonly employed agitation scales and contextualized their clinical application.

METHODS

We employed anchor- and distribution-based approaches to determine changes in scores corresponding to minimal symptom improvement. An opinion-based approach assessed expert clinicians' agreement on the meaningfulness of score changes through three clinical vignettes.

RESULTS

Minimal symptom improvement for Cohen-Mansfield Agitation Inventory total score ranged from -4 (over <1 month) to -11 (over 1 to 3 months) points. Greater symptom severity correlated with higher MCID estimates. The clinical importance of score changes was influenced by treatment duration, pharmacological side effects, and impacts on caregiver distress/time resources.

DISCUSSION

The clinical meaningfulness of agitation scale MCIDs is influenced by trial-specific and clinical factors. Shorter trial durations and measuring caregiver distress/time resources enhance the clinical interpretation of agitation treatment outcomes.

Highlights

For the CMAI total score, the MCID was -4 points over shorter time scales and -11 points for longer time scales.Worse agitation severity was associated with higher MCID estimates.There was high expert consensus that a noticeable treatment benefit was not worthwhile if it occurred after 12 weeks or had no impact on caregiver/staff distress/time resources.

Physical Activity and Acute Care Utilization Among Older Adults With Mild Cognitive Impairment and Dementia

People living with dementia have high rates of hospitalizations. Identifying factors that influence hospitalization is important. This study examines the influence of physical activity levels on risk of hospitalization and emergency department (ED) use among older people living with mild cognitive impairment (MCI) or dementia followed in our primary care practice in Rochester, Minnesota, United States. We included those age 55 years and older, who had a clinic visit between June 1, 2019 and June 30, 2021 and completed a social determinants of health questionnaire about physical activity levels (n = 3090). Physical activity was classified as sufficiently active, insufficiently active, or physically inactive. Risk of hospitalization and ED visits by physical activity levels were examined. People who were physically inactive were at higher risk of hospitalization and ED visits (p < .001) compared with those who were sufficiently active. This highlights an area for health promotion in people living with MCI and dementia.

Comprehensive Clinical and Behavioral Characteristics of Mild Cognitive Impairment According to Amyloid Positivity: A Large Multi-Center Korean Cohort

Background and Purpose

Mild cognitive impairment (MCI) is a transitional stage to dementia, Alzheimer's disease being a major cause. Although amyloid beta-positive (Aβ+) MCI has been well-characterized, Aβ-negative (Aβ-) MCI has not. This study compared the comprehensive clinical and behavioral characteristics of Aβ+ and Aβ- MCI in a large multi-center cohort to better understand the heterogeneity of MCI, and to identify contributing factors to cognitive impairment.

Methods

A total of 686 MCI participants were included. Aβ positivity was determined using Aβ positron emission tomography imaging with a direct conversion Centiloid cutoff value of 25.5. Standardized assessment and questionnaires were used to collect a wide range of clinical information, including vascular risk factors, cognition, daily living function, neuropsychiatric symptoms, and lifestyle behavior. Groups were compared using independent t-tests and χ2 tests.

Results

Aβ+ participants (n=406) were older, predominantly female, and more likely to be ApoE4 carriers. In contrast, Aβ- participants (n=280) showed higher vascular risk factors, including diabetes, elevated body mass index, and higher C-reactive protein levels. Aβ+ participants exhibited worse global cognition and functional decline, with a higher prevalence of delusions and appetite disturbances. Meanwhile, Aβ- participants reported greater social engagement, but poorer sleep quality.

Conclusions

This study highlights the distinct clinical and lifestyle profiles of Aβ+ and Aβ- MCI, illuminating the heterogeneity of MCI and its underlying factors in the Korean population.

Comparing patterns of impairment in social cognition between young-onset and late-onset Alzheimer's disease

BackgroundYoung-onset Alzheimer's disease (YOAD) is defined as when the disease starts before 65 years old. Compared with late-onset AD (LOAD), the progression is faster and more aggressive. However, the impact on social cognition deficits may not follow the same clear pattern.ObjectiveThe present study aims to investigate the relationship between social cognition, global cognition, and other clinical variables in people with YOAD and LOAD and their caregivers.MethodsUsing a cross-sectional design, we included 48 people with YOAD and 118 with LOAD, and their caregivers. We assessed social cognition, global cognition, quality of life, dementia severity, mood, functionality, neuropsychiatric symptoms, and caregiver burden.ResultsThe YOAD group was more impaired in general cognition (p = 0.002, d = 0.06), had a worse quality of life (p = 0.036, d = 0.36), and presented more neuropsychiatric symptoms (p = 0.044, d = 0.35). However, social cognition did not exhibit the same disease progression and showed no difference when compared with the reports of their caregivers or with individuals with LOAD. The multifactorial regression analyses showed that functionality was related to social cognition impairment in YOAD (p = 0.035), and LOAD (p = 0.001).ConclusionsOur study found that people diagnosed with YOAD showed more global cognitive impairment but maintained social and emotional functioning.

Associations between neuropsychiatric symptoms and pathology in clinicopathologically defined Alzheimer's disease, Alzheimer's disease with Lewy bodies, and dementia with Lewy bodies

BackgroundNeuropsychiatric symptoms (NPS) are frequent in Alzheimer's disease (AD) dementia, but a higher NPS burden is found in dementia with Lewy bodies (DLB). Lewy body (LB) pathology frequently co-occurs with AD pathology and may not meet neuropathological criteria for DLB (ADLB). NPS trajectories over disease course in these subgroups is not well understood.ObjectiveWe investigated changes in NPS severity over time, at two time points, comparing clinicopathologically defined cohorts of AD (without LB), ADLB, DLB, and controls.MethodsCases with two available Neuropsychiatric Inventory-Questionnaire (NPIQ), at the time of enrollment and within 2.5 years of death, were selected from the Arizona Study of Aging and Neurodegenerative Disorders. Differences and rate of change in NPIQ scores were compared between AD (n = 75), ADLB (n = 48) DLB (n = 65), and controls (n = 32) with covariates for age, sex, and cognition.ResultsFirst NPIQ scores were highest in ADLB when compared to AD (p = 0.04) and controls (p = 0.01) but not different from DLB. A significant increase in NPS severity was observed in DLB and AD (p < 0.001) over a mean follow up time of 4.9 ± 3.0 years, and the rate of change was significantly greater in DLB when compared to other groups. Final NPIQ scores were highest in DLB when compared to AD (p = 0.03) but not ADLB, and in DLB, ADLB, and AD than controls (all p < 0.001).ConclusionsEarly NPS burden as well as NPS severity progression rate, independently of cognitive status, might be useful clinical metrics and may help predict underlying pathological diagnoses.

Associations among diurnal cortisol, melatonin, and agitation in people living with cognitive impairment

BackgroundWhile the underlying mechanisms of agitation are not fully understood in people with Alzheimer's disease and related disorders, research suggests that dysregulated neuroendocrine processes, including the hypothalamic-pituitary-adrenal axis, may play a role.ObjectiveThis study aimed to explore the associations between salivary cortisol, melatonin at baseline, and agitation both at baseline and at post-intervention.MethodsThis study was a secondary analysis of a two-group, randomized, parallel designed clinical trial of 210 people living with cognitive impairment. Agitation, salivary cortisol, and salivary melatonin were measured at baseline and four weeks. Salivary cortisol and melatonin indicators were generated through three timepoints of cortisol and melatonin collection across the two consecutive days. Presence of agitation was measured using the Neuropsychiatric Inventory. Logistic regressions were conducted to achieve the aim.ResultsA significant association was found at baseline between diurnal cortisol slope and agitation (OR = 0.03, p = 0.029), there were no relationships between all other cortisol or melatonin indicators with agitation. Cortisol awaking response (OR = 0.16, p = 0.048), its percentage (OR = 0.27, p = 0.021) and its increase higher than 50% (OR = 0.09, p = 0.009), were significant with agitation at four weeks.ConclusionsGiven the potential link between cortisol and agitation, exploring cortisol-lowering interventions like minimizing environmental stressors, smoothing transitions to different situations, stress-reduction techniques, and behavioral therapies may aid in managing agitation in older adults with cognitive impairment.

Validation of the neuropathological criteria of the fourth Consortium on dementia with Lewy Bodies in autopsy cases from psychiatric hospitals

AIM

The pathological criteria from the fourth Consortium on Dementia With Lewy bodies (DLB) in psychiatric cohorts has not been validated. Also, the pathological differences in prodromal DLB subtypes remain unclear. This study aimed to elucidate the clinicopathological features of patients with DLB in psychiatric hospitals.

METHODS

Of 165 autopsied cases, patients who developed psychiatric symptoms at 50 years or older were investigated based on the current criteria of DLB. Clinicopathological findings were compared among prodromal DLB subtypes.

RESULTS

Sixteen of 30 cases with DLB pathology had no parkinsonism, which represented diverse nigral neurodegeneration. Regarding the scheme to estimate the likelihood of DLB syndrome, the prevalence of core clinical features excluding rapid eye movement sleep behavior disorder and probable DLB diagnosis were significantly higher in the high-likelihood group than in the low-likelihood group. Regarding the prodromal DLB subtypes, mild cognitive impairment (MCI) onset was identified in 60%, psychiatric onset in 20%, delirium onset in 10%, and motor onset in 10% of cases, and the proportion of psychiatric onset or delirium onset was significantly higher compared with those without DLB pathology. Coexistence of MCI and psychiatric symptoms was observed in 41.6% of the MCI-onset cases. Patients with psychiatric-onset cases were significantly younger at the onset, with a longer disease duration than those with MCI-onset cases. No differences were observed in other clinicopathological variables among the subtypes.

CONCLUSION

The fourth Consortium pathological criteria for DLB were applicable in a psychiatric cohort. MCI-onset cases in conjunction with core clinical features is the main prodromal DLB subtype, and four cases exhibited isolated psychiatric symptoms for long-term duration.

A hospital-based special care unit for dementia decreased hospital readmission rates for behaviour while reducing rates of falls and occupational violence across medical wards

BACKGROUND

Hospital-based Special Care Units (SCU) for dementia show promise as effective models of care. However, limited research describes hospital-wide benefits.

OBJECTIVE

To describe patient-level outcomes and hospital service-level outcomes of a SCU.

DESIGN

Pre-post analyses of SCU-patient data and hospital service-unit incident report data.

SETTING, PARTICIPANTS

2-years of SCU-patient admissions and 4-years of hospital incident-reports from four medical wards (2-years pre-post SCU).

METHODS

Admission and discharge severity of SCU-patients' behaviour was prospectively measured by specialist SCU nurses. One-year hospitalisation rates, length-of-stay, diagnosis and patient demographics were retrospectively obtained from medical records. Hospital service-unit data included 4 years of monthly incident report rates for falls, pressure injury and occupational violence (OV) across four medical wards. Analysis of count data used Poisson and Negative Binomial Regression models.

RESULTS

121 SCU admissions involved 107 unique patients. Median SCU LoS was 23 days (interquartile range [IQR], 13-50), and stabilisation of behaviour severity took 11 days (IQR 6-12). Barriers to discharge related to substitute decision-making and care facility availability. After SCU discharge, yearly hospitalisation rates for 'all-reasons' decreased by 68% (Incident Rate Ratio [IRR], 0.32, 95% CI, 0.23-0.43), and 83% for behaviour-related admissions (IRR 0.17, 95% CI, 0.11-0.28). For hospital service-unit outcomes, falls-per-month decreased by 21% (IRR 0.79, 95% CI 0.64-0.99) after SCU implementation and OV by 26% (IRR, 0.74, 95% CI 0.59-0.94).

CONCLUSIONS

A hospital-based SCU reduced hospital health service demand through decreased SCU-patient readmissions and was associated with decreased falls and OV rates across hospital medical wards.

Development of a Mindfulness and Self-compassion (MASC) Stress Reduction Program for Caregivers of Persons With Dementia With Behavioral Symptoms

BACKGROUND AND OBJECTIVES

Caregivers of persons living with dementia experience high stress triggered by the behavioral symptoms of care-recipients. Current stress management interventions exist but are primarily focused on providing support or education targeting general caregiving stress. We need caregiver interventions that also address stress triggered by the behavioral symptoms of persons living with dementia. Here, we showcase the development of the Mindfulness and Self Compassionate Care program (MASC), a new program that integrates emotional regulation skills (mindfulness, compassion, and self-compassion), with practical strategies to manage behavioral symptoms in persons living with dementia.

RESEARCH DESIGN AND METHODS

In this mixed-methods study, we conducted 5 focus groups (N = 28) with a racially and socioeconomically diverse sample of stressed caregivers of persons living with dementia who endorse behavioral symptoms. We aimed to understand their needs, preferences, and perceptions of the proposed MASC skills. Twenty-four of these caregivers completed an optional quantitative survey. We used a hybrid inductive-deductive approach for qualitative analyses and descriptive statistics to analyze quantitative data.

RESULTS

Qualitative analyses showed high stress in caregivers stemming from their care-recipients behavioral symptoms. Caregivers reported interest in a program like MASC, liked the proposed skills, and provided recommendations to enhance the program's format and content. Quantitative analyses supported the need of the program and the interrelation between program mechanisms and outcomes.

DISCUSSION AND IMPLICATIONS

Caregivers provided valuable information for adapting the program content and methodology. Current work includes an open pilot with exit interviews to refine the program with the goal of efficacy testing and implementation.

Genetic and clinical analysis of OPTN in amyotrophic lateral sclerosis

BACKGROUND

Considerable heterogeneity in genotypes and phenotypes has been observed among patients with amyotrophic lateral sclerosis (ALS) harbouring optineurin gene (OPTN) mutations, as reported in prior studies. The study aimed to elucidate the correlation between OPTN genotypes and phenotypes.

METHODS

OPTN gene variants were screened within a substantial Chinese cohort of patients with ALS, encompassing LoF and rare missense variants. Additionally, a systematic literature review was conducted to compile the spectrum of OPTN mutations and explore the relationship between the genotype and phenotype of patients with ALS with OPTN.

RESULTS

A total of 33 unrelated patients with ALS with 24 rare OPTN variants, including 17 novel variants, were identified in 2279 patients with ALS. Among 24 variants in our cohort and 106 variants in previous studies, only 33.3% and 35.8% were pathogenic/likely pathogenic variants. Moreover, the frequency of OPTN variants in the Asian ALS population was higher (1.08%) than that of the Caucasian population (0.55%). For the phenotype of patients with ALS carrying OPTN variants, we found that patients with pathogenic/likely pathogenic variants had the highest baseline progression rate and the shortest survival time among groups in our cohort.

CONCLUSION

Our study contributed to a broader understanding of the genotype and phenotype spectrum of patients with ALS carrying OPTN variants. Further investigations are warranted to definitively establish the genotype-phenotype associations.

Evaluating ChatGPT for neurocognitive disorder diagnosis: a multicenter study

Objective: To evaluate the accuracy and reliability of ChatGPT 4 Omni in diagnosing neurocognitive disorders using comprehensive clinical data and compare its performance to previous versions of ChatGPT. Method: This project utilized a two-part design: Study 1 examined diagnostic agreement between ChatGPT 4 Omni and clinicians using a few-shot prompt approach, and Study 2 compared the diagnostic performance of ChatGPT models using a zero-shot prompt approach using data from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set 3. Study 1 included 12,922 older adults (Mage = 69.13, SD = 9.87), predominantly female (57%) and White (80%). Study 2 involved 537 older adults (Mage = 67.88, SD = 9.52), majority female (57%) and White (81%). Diagnoses included no cognitive impairment, amnestic mild cognitive impairment (MCI), nonamnestic MCI, and dementia. Results: In Study 1, ChatGPT 4 Omni showed fair association with clinician diagnoses (χ2 (9) = 6021.96, p < .001; κ = .33). Notable predictive measures of agreement included the MoCA and memory recall tests. ChatGPT 4 Omni demonstrated high internal reliability (α = .96). In Study 2, no significant diagnostic agreement was found between ChatGPT versions and clinicians. Conclusions: Although ChatGPT 4 Omni shows potential in aligning with clinician diagnoses, its diagnostic accuracy is insufficient for clinical application without human oversight. Continued refinement and comprehensive training of AI models are essential to enhance their utility in neuropsychological assessment. With rapidly developing technological innovations, integrating AI tools in clinical practice could soon improve diagnostic efficiency and accessibility to neuropsychological services.

Sense of coherence, subjective burden, and anxiety and depression symptoms in caregivers of people with dementia: Causal dynamics unveiled by a longitudinal cohort study in Europe

BACKGROUND

Sense of coherence (SOC) is a disposition to perceive things as comprehensible, manageable and meaningful. Lower SOC is associated with subjective burden and psychological morbidity in family caregivers, including in dementia. However, the evidence-base mainly comprises small-scale or cross-sectional studies. More should be known about SOC stability, causal relationships, and international contexts. We aimed to study longitudinal links between dementia caregivers' SOC, subjective burden, and anxiety and depression symptoms in a multinational sample.

METHODS

We analyzed the EU-Actifcare cohort (451 dyads of community-dwelling people with mild-moderate dementia and their caregivers). Caregivers' assessments included: SOC scale, Relatives' Stress Scale, Hospital Anxiety and Depression Scale. A cross-lagged panel model was used to investigate associations between these measures at baseline, 6 and 12-month follow-ups, controlling for covariates.

RESULTS

Caregivers' subjective burden, anxiety and depression symptoms increased over time, SOC remaining overall stable. Considering the first six-month follow-up, we found bidirectional relationships between SOC and subjective burden, and SOC and anxiety symptoms, while lower SOC predicted depression symptoms but not vice versa. For the remaining follow-up period, both anxiety and depression symptoms predicted lower SOC but not vice versa.

LIMITATIONS

Convenience sampling precludes full generalizability.

CONCLUSIONS

This large longitudinal study shed more light on interplays between SOC, subjective burden and mental health outcomes in dementia caregivers. Findings were consistent with SOC potential protective role against burden and psychological morbidity. However, they also supported reverse causality regarding part of the associations. Caregivers' SOC levels may be directly influenced by subjective burden and psychological morbidity.

Key motor and non-motor features in early dementia with Lewy bodies

Objective

The objective of our study was to characterize early-stage dementia with Lewy bodies (DLB) focusing on motor and non-motor symptoms.

Methods

This cross-sectional study prospectively included newly diagnosed DLB patients within 3 years of cognitive symptom onset. Comparisons were made with individuals with Parkinson's disease (PD), Alzheimer's disease (AD), and controls. Demographic and clinical data were collected, and motor and non-motor symptoms were assessed using structured interviews and validated scales and questionnaires.

Results

A total of 107 participants were included (23 DLB, 27 PD, 26 AD, and 31 controls). DLB patients (median age 75 years, median disease duration since diagnosis 2 months) commonly reported motor symptoms, including gait disturbances (91.3%), tremor (73.9%), and bradykinesia (87%), with tremor being predominantly unilateral (76.5%) and action-type (52.9%). The most frequent motor subtype was akinetic-rigid (52.2%). Motor symptoms were similar to PD, except for more frequent falls (34.8% vs. 11.1%, p = 0.044) and gait disturbances in DLB patients (91.3% vs. 63%, p = 0.019). Non-motor symptoms, particularly visual hallucinations and neuropsychiatric symptoms were more prevalent in DLB than in PD, while sleep and autonomic symptoms were similar. An abnormal orthostatic test was more frequent in DLB than in PD (45.5% vs. 11.5%, p < 0.008). Compared to AD, all non-motor symptoms were significantly more frequent in DLB. Finally, DLB patients had lower functional independence and quality of life than both PD and AD (p < 0.0001).

Conclusion

Early-stage DLB closely resembles PD in motor symptoms but has more neuropsychiatric non-motor symptoms compared to PD and overall non-motor symptoms than AD.

Music-based therapeutic interventions for people with dementia

BACKGROUND

Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music-based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music-based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music-based interventions for people with dementia.

OBJECTIVES

To assess the effects of music-based therapeutic interventions for people with dementia on emotional well-being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta-register-the International Clinical Trials Registry Platform on 30 November 2023.

SELECTION CRITERIA

We included randomised controlled trials of music-based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music.

DATA COLLECTION AND ANALYSIS

Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random-effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE.

MAIN RESULTS

We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty-eight studies with 1366 participants contributed data to meta-analyses. Ten studies contributed data to long-term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music-based therapeutic interventions compared to usual care, we found moderate-certainty evidence that, at the end of treatment, music-based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) -0.23, 95% confidence interval (CI) -0.42 to -0.04; 9 studies, 441 participants), and we found low-certainty evidence that it may have improved overall behavioural problems (SMD -0.31, 95% CI -0.60 to -0.02; 10 studies, 385 participants). We found moderate-certainty evidence that music-based therapeutic interventions likely did not improve agitation or aggression (SMD -0.05, 95% CI -0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well-being (SMD 0.14, 95% CI -0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD -0.15, 95% CI -0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI -0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI -0.02 to 0.41; 7 studies, 353 participants). Low or very-low -certainty evidence showed that music-based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music-based therapeutic interventions compared to other interventions, we found low-certainty evidence that, at the end of treatment, music-based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low-certainty evidence of a positive effect on anxiety (SMD -0.75, 95% CI -1.27 to -0.24; 10 studies, 291 participants). For all other outcomes, low-certainty evidence showed no evidence of an effect: emotional well-being (SMD 0.20, 95% CI -0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD -0.14, 95% CI -0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI -0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD -0.08, 95% CI -0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI -0.21 to 0.45; 5 studies; 147 participants). We found low or very-low certainty evidence that music-based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported.

AUTHORS' CONCLUSIONS

When compared to usual care, providing people with dementia with at least five sessions of a music-based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music-based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long-term effects from music-based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions.

Annual societal cost of Alzheimer's disease in Malaysia: a micro-costing approach

BACKGROUND

Alzheimer's disease (AD) is expected to have a significant impact on resource use and economic consequences along with population aging. This study aims to investigate the annual economic burden of Alzheimer's disease along with underlying cost drivers.

METHODOLOGY

Patients with AD aged 65 and above accompanied with primary caregivers were recruited in 6 tertiary care hospitals. A structured interview was conducted to collect sociodemographic, clinical and resource use information using an adapted questionnaire. Direct medical cost, direct non-medical cost and indirect cost were annualised and categorised by severity level. Generalised linear models were applied to investigate predictors of costs.

RESULTS

Among 135 patient-caregiver dyads, the annual economic burden of AD from a societal perspective was USD 8618.83 ± USD 6740.79 per capita. The societal cost of severe AD patients (USD11943.19 ± USD6954.17) almost doubled those in mild AD (USD6281.10 ± USD6879.83). IDC was the primary cost driver (77.7%) which represented the impact of productivity loss due to informal care. Besides disease severity, time spent in informal care, caregivers' employment and use of special accommodation were predictors of AD cost. This neurodegenerative disorder is estimated to impose a burden of USD1.9 billion in 2022, which represents 0.47% of Malaysia's GDP.

CONCLUSION

This study provided real-world empirical cost estimates of AD burden in Malaysia. Informal care is a significant contributor to the societal cost of AD. Optimal healthcare resource allocation is essential in the decision making of healthcare stakeholders to address rising demands.

Building Consensus on the Relevant Criteria to Screen for Depressive Symptoms Among Near-Centenarians and Centenarians: Modified e-Delphi Study

BACKGROUND

The number of centenarians worldwide is expected to increase dramatically, reaching 3.4 million by 2050 and >25 million by 2100. Despite these projections, depression remains a prevalent yet underdiagnosed and undertreated condition among this population that carries significant health risks.

OBJECTIVE

This study aimed to identify and achieve consensus on the most representative signs and symptoms of depression in near-centenarians and centenarians (aged ≥95 years) through an e-Delphi study with an international and interdisciplinary panel of experts. Ultimately, the outcomes of this study might help create a screening instrument that is specifically designed for this unique population.

METHODS

A modified e-Delphi study was carried out to achieve expert consensus on depressive symptoms in near-centenarians and centenarians. A panel of 28 international experts was recruited. Consensus was defined as 70% agreement on the relevance of each item. Data were collected through a web-based questionnaire over 3 rounds. Experts rated 104 items that were divided into 24 dimensions and 80 criteria to identify the most representative signs and symptoms of depression in this age group.

RESULTS

The panel consisted of experts from various countries, including physicians with experience in old age psychiatry or geriatrics as well as nurses and psychologists. The response rate remained consistent over the rounds (20/28, 71% to 21/28, 75%). In total, 4 new dimensions and 8 new criteria were proposed by the experts, and consensus was reached on 86% (24/28) of the dimensions and 80% (70/88) of the criteria. The most consensual potentially relevant dimensions were lack of hope (21/21, 100%), loss of interest (27/28, 96%), lack of reactivity to pleasant events (27/28, 96%), depressed mood (26/28, 93%), and previous episodes of depression or diagnosed depression (19/21, 90%). In addition, the most consensual potentially relevant criteria were despondency, gloom, and despair (25/25, 100%); depressed (27/27, 100%); lack of reactivity to pleasant events or circumstances (28/28, 100%); suicidal ideation (28/28, 100%); suicide attempt(s) (28/28, 100%); ruminations (27/28, 96%); recurrent thoughts of death or suicide (27/28, 96%); feelings of worthlessness (25/26, 96%); critical life events (20/21, 95%); anhedonia (20/21, 95%); loss of interest in activities (26/28, 93%); loss of pleasure in activities (26/28, 93%); and sadness (24/26, 92%). Moreover, when assessing depression in very old age, the duration, number, frequency, and severity of signs and symptoms should also be considered, as evidenced by the high expert agreement.

CONCLUSIONS

The classification of most elements as relevant highlights the importance of a multidimensional approach for optimal depression screening among individuals of very old age. This study offers a first step toward improving depression assessment in near-centenarians and centenarians. The development of a more adapted screening tool could improve early detection and intervention, enhancing the quality of mental health care for this population.

Adapting the Hopkins Verbal Learning Test-Revised with Semantic Cues: Assessing diagnostic utility in a Spanish clinical population

Background: The Hopkins Verbal Learning Test-Revised (HVLT-R) is widely used for assessing episodic memory. In this study, we evaluated the HVLT-R with Semantic Cues (HVLT-R-SC), an adapted version incorporating semantic cues to improve diagnostic utility. The assessment was conducted in a Spanish cohort comprising cognitively unimpaired controls, individuals with multi-domain amnestic mild cognitive impairment (md-aMCI), and early Alzheimer's disease (AD). Methods: 684 participants (333 controls, 141 md-aMCI, and 210 early AD) completed the HVLT-R-SC. Effect sizes were calculated to quantify group differences, while Cronbach's alpha was used to assess the test's reliability. Receiver Operating Characteristic curve analysis was performed to assess discriminatory power, with the Area Under the Curve (AUC) summarizing classification accuracy. Sensitivity, specificity, and efficacy percentages were reported, with optimized cutoff points determined. Odds ratios quantified the association between HVLT-R-SC performance and diagnostic group classifications. Results: Significant differences were observed across all HVLT-R-SC indices among the groups. Total Delayed Recall with and without Semantic Cues exhibited the largest effect size (η2 = 0.69), with Total Delayed Recall with Semantic Cues demonstrating the highest diagnostic accuracy (AUC = 0.90 for differentiating md-aMCI from controls and 0.99 for distinguishing early AD from controls). Optimal cutoffs for Total Delayed Recall with Semantic Cues were 5 words for md-aMCI (sensitivity = 74%, specificity = 90%, efficacy = 85.44%) and 4 words for early AD (sensitivity = 93%, specificity = 97%, efficacy = 95.21%). Significant associations were observed between HVLT-R-SC performance and diagnostic classification, with an odds ratio of 26.04 for md-aMCI and 362.50 for early AD. Internal consistency was excellent (Cronbach's alpha = 0.95), indicating strong reliability of the HVLT-R-SC. Conclusions: The HVLT-R-SC demonstrated strong reliability and excellent diagnostic performance in identifying memory impairments. The inclusion of semantic cues improved diagnostic accuracy, provided clinically actionable cutoff points, and enhanced the test's utility, particularly for detecting md-aMCI and early AD.

The Cerebellar Neuropsychiatric Rating Scale

The triad of cerebellar ataxiology is the cerebellar motor, vestibular, and cerebellar cognitive affective / Schmahmann syndrome (CCAS). The CCAS affective component comprises 5 domains: Attentional control, Emotional control, Autism spectrum, Psychosis spectrum, and Social Skill Set, each with hypermetric / overshoot and hypometric / undershoot poles reflecting the dysmetria of thought and universal cerebellar transform theories. There is no validated screening instrument to assess neuropsychiatric impairments in patients with cerebellar disorders. To examine the psychometric properties of our Cerebellar Neuropsychiatric Rating Scale (CNRS) that explores these symptoms and behaviors in patients with cerebellar disorders, 21 adults with ataxia completed the CNRS and other validation measures: the Behavior Rating Inventory of Executive Function-Adult Version Informant Report, Adult Behavior Checklist, Older Adult Behavior Checklist, Neuropsychiatric Inventory Questionnaire. We examined CNRS internal consistency using Cronbach's alpha, assessed item to subscale correlations, studied ceiling and floor effects, and convergent construct validity between CNRS and validity measure subscales. Internal consistency was α > 0.70 for each of the five domains. Subscale structure was generally confirmed: 86% of correlations between CNRS and validity subscales were significant. There were no ceiling effects. Item to subscale correlations indicated adequate reliability for total scale and subdomains. NPI-Q and CNRS scores were correlated, and 86.4% (19/22) of conceptually related subscales were significant. The CNRS is a reliable and valid measure of cerebellar neuropsychiatry. Further development can refine the instrument and shed light on the patient experience of their affective dysregulation and its clinical meaningfulness.

Neuropsychiatric symptom-related role and activity restrictions by relatives: focusing on the gender of older adults with suspected dementia

BACKGROUND

As cognitive function declines, relatives may restrict the roles and activities they consider older adults unable to continue independently performing. We examined the characteristics of these role and activity restrictions by relatives among older adults prior to their first visit to a memory clinic for an official diagnosis, focusing on gender and the diagnosis of dementia. Additionally, we examined the relationship between role and activity restrictions by relatives and the presence of neuropsychiatric symptoms (NPS) controlling for older adults' gender.

METHODS

We retrospectively reviewed the medical charts of 213 older adults. First, we calculated descriptive statistics for the characteristics of role and activity restrictions by relatives. Second, we examined the association between these roles and activity restrictions and NPS using multivariate logistic regression analysis controlling for older adults' gender, diagnosis, and presence of a cohabitant.

RESULTS

The rate of role and activity restrictions by relatives was 21.6%. Of the older adults experiencing these restrictions, 78.3% were women, and 34.8% had mild cognitive impairment. The most common role and activity restriction was money-related. Role and activity restrictions were associated with the NPS of hyperactivity, psychosis. Hyperactivity was related to men.

CONCLUSIONS

Hyperactivity psychosis may be more strongly related to family involvement than other NPS. These findings highlight the importance of avoiding premature role and activity restrictions among older adults with suspected dementia.

Validation study of the Persian version of behavioral pathology in Alzheimer's Disease Rating scale (BEHAVE-AD) and the empirical BHAVE-AD (E-BEHAVE-AD)

INTRODUCTION

Behavioral and psychological symptoms of dementia (BPSD) are observed in more than 90% of patients with Alzheimer's disease (AD). BPSDs are remediable if detected early and managed appropriately. Behavioral Pathology in Alzheimer's disease Rating Scale (BEHAVE-AD) and Empirical BEHAVE-AD (E-BEHAVE-AD) were designed to identify BPSD. The aim of this study is to validate and prepare BEHAVE-AD and E-BEHAVE-AD in Persian language for clinical and research applications.

METHOD

120 patients were selected through a combination of intentional and convenience sampling. All participants should fulfill the NINCDS-ADRDA Work Group criteria for a clinical diagnosis of Alzheimer's disease. Functional Assessment Staging Tool (FAST) was used to determine the rate of AD progression. All patients were evaluated using the BEHAVE-AD and E-BEHAVE-AD questionnaires, as well as the Persian version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Mini-Mental State Examination (MMSE). The Content Validity Index (CVI) is determined based on the compatibility of the Persian and the original version of the two scales according to the opinion of expert panels. Correlation of MMSE with BEHAVE-AD and E-BEHAVE-AD as well as the BPSD pattern on AD progression continuum by FAST were considered as indices of construct validity. Concurrent validity was estimated by correlating NPI-Q scores with BEHAVE-AD and E-BEHAVE-AD scores. For both scales, interrater reliability was extracted as a reliability index.

RESULTS

Pearson correlation coefficients for the BEHAVE-AD scale were as follows: with NPI-Q (r = 0.77, p-value <0.01), with MMSE (r = -0.34, p-value <0.01), indicating concurrent and construct validity, respectively. The result for E-BEHAVE-AD was as follows: with NPI-Q-total (r = 0.59, p-value <0.01), and with MMSE (r = 0.31, p-value <0. 01). BEHAVE-AD and E-BEHAVE-AD scores increased in parallel with AD severity according to FAST, but not on the most severe AD stage. The area under the curve was estimated to be 0.84 (p-value <0.001) for BEHAVE-AD and 0.78 (p-value <0.001) for E-BEHAVE-AD. Correlation between BEHAVE-AD and E-BEHAVE-AD scores ranged from 0.45 to 0.63. The inter-rater reliability index ranged from 0.88 to 0.99 for BEHAVE-AD and from 0.74 to 0.95 for E-BEHAVE-AD.

CONCLUSIONS

The Persian version of BEHAVE-AD and E-BEHAVE-AD is valid and reliable for the assessment of BPSD in patients with AD.

Comparison of cerebral technetium-99m-ethyl cysteinate dimer perfusion in patients with dementia with Lewy bodies and Parkinson's disease dementia

OBJECTIVE

Dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) are closely related neurodegenerative conditions within the Lewy body spectrum. The relationship between DLB and PDD remains debated, with ongoing discussion about whether they are distinct diseases or different manifestations of the same disorder. This study aimed to identify differences in cerebral perfusion patterns between DLB and PDD patients.

METHODS

Single-photon emission computed tomography (SPECT) ethyl cysteinate dimer (ECD) imaging was performed on patients diagnosed with DLB ( n  = 46) and PDD ( n  = 30). The data were acquired by two SPECT/computed tomography systems from two affiliated centers and were retrospectively recruited under the local ethics approval. Relative tracer uptake levels were calculated across 47 automatically determined regions of interest and 240 subregions. A two-sided Welch's t -test was employed to evaluate mean perfusion differences, with results further confirmed through a voxel-wise t -test mapping. The Benjamini-Hochberg procedure was used to adjust P -values for multiple comparisons.

RESULTS

The greatest difference in perfusion was in the left associative visual cortex in planes 34 and 36 and the right primary visual cortex in plane 34, with lower mean perfusion observed in PDD patients than those with DLB ( P  = 0.005).

CONCLUSION

No statistically significant differences in ECD perfusion were found between DLB and PDD patients. The greatest difference was in the visual cortices, where PDD patients suffered a greater loss of perfusion.

Mild Behavioral Impairment and cognitive functions: A systematic review and meta-analysis

Mild behavioral impairment (MBI) represents a recently introduced diagnostic concept that focuses on behavioral and personality changes occurring in late life and associated with cognitive decline. Nevertheless, the relationship between these dimensions remains unclear. This systematic review and meta-analysis aim to analyze the relationship between MBI and cognitive functioning. The review process was conducted according to the PRISMA-Statement. Restrictions were made, selecting the studies published in peer-review journals, including at least one cognitive measure and presenting the measurement of MBI. Studies that included participants with neurological disorders, dementia, or psychiatric disorders or that only did a neuroimaging or genetic study were excluded. Twenty-two studies were included in the systematic review, while in the meta-analysis seventeen studies featured data to be included in the analyses. The results were classified according to the following cognitive domains: global cognitive functioning, memory, language, attention executive functions, visuospatial skills, and processing speed. In the quantitative analysis, only global cognitive functioning, executive function, attention, and memory were evaluated. The results of both qualitative and quantitative analysis indicate that individuals with MBI exhibited diminished performance on cognitive tasks when compared to those without MBI symptoms. These results are stronger when evaluating the various domains individually (particularly memory and executive functions) than when a global assessment was made. These findings highlight the potential role of MBI symptoms as early indicators of neurodegenerative processes, reinforcing the necessity for comprehensive assessments that encompass both behavioral and cognitive evaluations. The early detection of these symptoms in prodromal phases can be very useful for the development of non-pharmacological interventions and may provide relevant guidelines for clinicians in the management and diagnosis of neurodegenerative disorders.

Validation of the Cognitive-Emotional Perspective Taking test in patients with neurodegeneration

BackgroundTheory of mind (ToM) is crucial for socioemotional interaction. ToM deficits may explain behavioral changes in dementia, especially Alzheimer's disease (AD) and frontotemporal dementia (FTD).ObjectiveThis study examined the psychometrics of a new ToM test in healthy adults, identified ToM differences in dementia syndromes, and assessed if ToM scores predict neuropsychiatric function and real-life behavior.MethodsThe UCSF Cognitive and Emotional Perspective Taking Test (CEPT) was evaluated in 195 healthy adults (age: 42.69 ± 16.20) and in a clinic cohort of 304 participants (age: 64.07 ± 9.2). Participants included healthy controls, AD, behavioral-variant frontotemporal dementia (bvFTD), semantic variant primary progressive aphasia (svPPA), non-fluent PPA (nfvPPA), and progressive supranuclear palsy (PSP) patients. CEPT's psychometrics were assessed, and ToM differences and predictions of neuropsychiatric symptoms were analyzed using regression models.ResultsIn controls, CEPT showed good validity and reliability. In patients, CEPT scores correlated with executive and emotional measures, but not language measures, showing good construct validity. Cognitive ToM was most impaired in AD and bvFTD, with less impairment in svPPA and PSP, and all patient groups showed impaired emotional ToM. ToM performance predicted real-life neuropsychiatric behavior, including anxiety, apathy, disinhibition, and aberrant motor behaviors.ConclusionsToM deficits appear early in dementia syndromes and predict neuropsychiatric behavior. Assessing ToM and social cognition with ecologically valid tasks may help identify altered social cognition in early neurodegeneration.

Resting-state electroencephalographic rhythms depend on sex in patients with dementia due to Parkinson's and Lewy Body diseases: An exploratory study

Parkinson's disease with dementia (PDD) and dementia with Lewy bodies (DLB) are more prevalent in males than females. Furthermore, they typically showed abnormally high delta (< 4 Hz) and low alpha (8-10 Hz) rhythms from resting-state electroencephalographic (rsEEG) activity. Here, we hypothesized that those abnormalities may depend on the patient's sex. An international database provided clinical-demographic-rsEEG datasets for cognitively unimpaired older (Healthy; N = 49; 24 females), PDD (N = 39; 13 females), and DLB (N = 38; 15 females) participants. Each group was stratified into matched female and male subgroups. The rsEEG rhythms were investigated across the individual rsEEG delta, theta, and alpha frequency bands based on the individual alpha frequency peak. The eLORETA freeware was used to estimate cortical rsEEG sources. In the Healthy group, widespread rsEEG alpha source activities were greater in the females than in the males. In the PDD group, widespread rsEEG delta source activities were lower and widespread rsEEG alpha source activities were greater in the females than in the males. In the DLB group, central-parietal rsEEG delta source activities were lower, and posterior rsEEG alpha source activities were greater in the females than in the males. These results suggest sex-dependent hormonal modulation of neuroprotective-compensatory neurophysiological mechanisms in PDD and DLB patients underlying the generation of rsEEG delta and alpha rhythms, which should be considered in the treatment of vigilance dysregulation in those patients.

Specific cognitive impairment predicts the neuropsychiatric symptoms in patient with mild cognitive impairment

BACKGROUND

Neuropsychiatric symptoms (NPS) are common in mild cognitive impairment (MCI). However, knowledge is limited about the relationship of NPS, clinical factors, and cognition in MCI.

METHODS

A total of 1099 dementia, 1323 MCI and 377 cognitively normal (CN) were selected from the Tongji Cohort Study of Aging. All participants underwent comprehensive clinical and neuropsychological assessment. NPS were evaluated by the Neuropsychiatric Inventory Questionnaire (NPI-Q). Logistic regression analyses were conducted to investigate the relationship between clinical factors, cognition and NPS.

RESULTS

The NPS presented in 56.39% of MCI participants, and the NPI-Q scores of MCI was intermediate between CN and dementia. The most common NPS in MCI were depression (30.76%), anxiety (25.09%), apathy (19.43%), and irritability (12.02%). MCI patients with NPS showed worse performance in global, memory, language, and attention than those without NPS. Additionally, Logistic regression analyses revealed that MCI patients with ischemic heart disease (OR = 1.41; 95%CI 1.050-1.897; P = 0.022) were more likely to have NPS, but MCI patients with increased memory domain Z score (OR = 0.847, 95%CI = 0.720-0.996, p = 0.044), and language domain Z score (OR = 0.801, 95%CI = 0.682-0.941, p = 0.007) were less likely to have NPS.

CONCLUSIONS

Neuropsychiatric symptoms occur commonly in MCI participants, and are mainly related to defect of language and memory function. A better understanding of the relationship between specific cognition and NPS may alert clinicians to pay close attention to the NPS in MCI patient, which may need early intervention.

Psychometric properties and clinical correlates of the Frontal Behaviour Inventory in progressive supranuclear palsy: data from the PSP-NET

OBJECTIVES

Neuropsychiatric symptoms, such as apathy, disinhibition and irritability, are common in Progressive Supranuclear Palsy (PSP). The Frontal Behaviour Inventory (FBI) is a useful instrument for the evaluation of behavioural disorders in neurodegenerative diseases. The main goal of the present study was to explore the psychometric properties of the FBI in PSP.

DESIGN, SETTING AND PARTICIPANTS

FBI was administered to the PSP-NET cohort including Italian patients diagnosed according to the Movement Disorder Society criteria. Patients underwent a clinical interview, a motor evaluation, extensive cognitive and behavioural testing.

RESULTS

Two hundred and eight subjects were included in this study. The internal consistency was high (Cronbach's alpha = 0.868) and no improvement of this value was noted upon removal of any item. FBI showed also good acceptability, reliability and validity. The standard error of measurement (SEM) value for FBI total score was 0.169 [SEM = SD √ (1 - Cronbach's alpha)]. Factor analysis indicated a five-factor structure: Apathy, Behavioural disorders, Impulsivity, Motor and speech frontal behaviour and Executive disorders that explained the 54.92% of the total variance. Linear regression analysis showed that global cognitive impairment significantly affects both Apathy and Motor and speech frontal behaviour factors.

CONCLUSIONS

In conclusion, FBI is a reliable and valid tool for the assessment of neuropsychiatric symptoms in PSP, despite some constructs, such as euphoria and irritability, are better measured by the NPI. Two third of the cohort was represented by Richardson's syndrome, thus our data are mainly applicable to such common phenotype. Such data are useful in both clinical and research settings to plan adequate therapeutic interventions and to improve the quality of life of PSP patients and their caregivers.

What are the Correlates of Hearing Aid Use for People Living With Dementia?

OBJECTIVES

To identify correlates of hearing aid use in people with dementia and age-related hearing loss.

METHODS

Bivariate and multivariate logistic regression analyses of predictor variables from 239 participants with dementia and hearing loss in the European SENSE-Cog Randomized Controlled Trial (Cyprus, England, France, Greece, and Ireland).

RESULTS

In multivariate analysis, four variables were significantly associated with hearing aid use: greater self-perceived hearing difficulties (OR 2.61 [CI 1.04-6.55]), lower hearing acuity (OR .39 [CI .2-.56]), higher cognitive ability (OR 1.19 [CI 1.08-1.31]), and country of residence. Participants in England had significantly increased odds of use compared to Cyprus (OR .36 [CI .14-.96]), France (OR .12 [CI .04-.34]) or Ireland (OR .05 [CI .01-.56]) but not Greece (OR 1.13 [CI .42-3.00]).

CONCLUSIONS

Adapting interventions to account for cognitive ability, country of residence, self-perceived hearing difficulties, and hearing acuity may support hearing aid use in people with dementia.

The limitations and challenges in the assessment of executive dysfunction associated with real-world functioning: The opportunity of serious games

Nowadays, there is a broad range of methods for detecting and evaluating executive dysfunction ranging from clinical interview to neuropsychological evaluation. Nevertheless, a critical issue of these assessments is the lack of correspondence of the neuropsychological test's results with real-world functioning. This paper proposes serious games as a new framework to improve the neuropsychological assessment of real-world functioning. We briefly discuss the contribution and limitations of current methods of evaluation of executive dysfunction (paper-and-pencil tests, naturalistic observation methods, and Information and Communications Technologies) to inform on daily life functioning. Then, we analyze what are the limitations of these methods to predict real-world performance: (1) A lack of appropriate instruments to investigate the complexity of real-world functioning, (2) the vast majority of neuropsychological tests assess well-structured tasks, and (3) measurement of behaviors are based on simplistic data collection and statistical analysis. This work shows how serious games offer an opportunity to develop more efficient tools to detect executive dysfunction in everyday life contexts. Serious games provide meaningful narrative stories and virtual or real environments that immerse the user in natural and social environments with social interactions. In those highly interactive game environments, the player needs to adapt his/her behavioral performance to novel and ill-structured tasks which are suited for collecting user interaction evidence. Serious games offer a novel opportunity to develop better tools to improve diagnosis of the executive dysfunction in everyday life contexts. However, more research is still needed to implement serious games in everyday clinical practice.

Ginkgo biloba extract EGb 761 is safe and effective in the treatment of mild dementia - a meta-analysis of patient subgroups in randomised controlled trials

BACKGROUND

Mild dementia is distressing for patients and their relatives. Due to its chronic and progressive nature, healthcare systems are at risk of being overwhelmed by the increasing number of affected patients. Thus, there is a need for safe and well-tolerated treatments that can be initiated at the earliest stages.

OBJECTIVES

This meta-analysis of clinical trials aimed to assess the treatment effects of Ginkgo biloba extract EGb 761 in patients with mild dementia.

METHODS

Eligible randomised placebo-controlled trials were included in this meta-analysis. Data of patients with mild dementia (defined as the SKT Short Cognitive Performance Test total scores from 9 to 15) were selected.

RESULTS

The meta-analysis was performed with pooled data from four eligible trials comprising 782 patients with mild dementia. Treatment with 240 mg EGb 761 daily was significantly superior to placebo in cognition (p = 0.04), global assessment (p = 0.01), activities of daily living (p = 0.01) and quality of life (p = 0.02). Standardised effects were medium to large. The frequency of adverse events was alike in patients treated with EGb 761 and placebo (p = 0.66).

CONCLUSIONS

The meta-analysis demonstrates that patients with mild dementia benefit from EGb 761 in terms of cognition, activities of daily living, global assessment and quality of life.

Effects of single-session repetitive transcranial magnetic stimulation to identify the optimal brain target in primary progressive aphasia

BACKGROUND

Non-invasive brain stimulation has shown positive results in maximizing the effects of language therapy in primary progressive aphasia (PPA). Due to the different patterns of brain damage in each aphasia variant, we hypothesized that patients with non-fluent and semantic variants would show a differential response to transcranial magnetic stimulation (TMS).

OBJECTIVE

We aimed to compare the clinical responses after a single session of repetitive TMS in the left inferior frontal gyrus (IFG) and the left dorsolateral prefrontal cortex (DLPC).

METHODOLOGY

Twenty patients with PPA (14 with non-fluent and 6 with semantic variants) were assessed before and after repetitive TMS over the IFG, DLPC, and vertex with several language tasks, connected speech, and a subjective impression of change scale.

RESULTS

IFG stimulation was associated with an improvement in words per minute and the subjective assessment in the non-fluent variant, but no effects were found in the semantic variant. DLPC stimulation was associated with an improvement in words per minute, repetition, and naming latency in the non-fluent variant, and in naming and subjective impression of change in the semantic variant.

CONCLUSIONS

Our study showed a differential effect of one session of brain stimulation over the IFG and DLPC in patients with non-fluent and semantic PPA variants. These findings suggest that the selection of the target of stimulation may be relevant for the success of brain stimulation and favor the use of DLPC over the IFG.

Smart Digital Solutions for EARLY Treatment of COGNitive Disability (EARLY-COGN^3): A Study Protocol

Background: Healthy cognitive functioning is a primary component of well-being, independence, and successful aging. Cognitive deficits can arise from various conditions, such as brain injury, mental illness, and neurological disorders. Rehabilitation is a highly specialized service limited to patients who have access to institutional settings. In response to this unmet need, telehealth solutions are ideal for triggering the migration of care from clinics to patients' homes. Objectives: The aim of EARLY-COGN^3 will be threefold: (1) to test the efficacy of a digital health at-home intervention (tele@cognitive protocol) as compared to an unstructured cognitive at-home rehabilitation in a cohort of patients with Chronic Neurological Diseases (CNDs); (2) to investigate its effects on the biomolecular and neurophysiological marker hypothesizing that people with CNDs enrolled in this telerehabilitation program will develop changes in biological markers and cortical and subcortical patterns of connectivity; (3) to analyze potential cognitive, neurobiological, and neurophysiological predictors of response to the tele@cognitive treatment. Method: In this single-blind, randomized, and controlled pilot study, we will assess the short- and long-term efficacy of cognitive telerehabilitation protocol (tele@cognitive) as compared to an unstructured cognitive at-home rehabilitation (Active Control Group-ACG) in a cohort of 60 people with Mild Cognitive Impairment (MCI), Subjective Cognitive Complaints (SCCs), or Parkinson's Disease (PD). All participants will undergo a clinical, functional, neurocognitive, and quality of life assessment at the baseline (T0), post-treatment (5 weeks, T1), and at the 3-month (T2) follow-up. Neurophysiological markers and biomolecular data will be collected at T0 and T1. Conclusions: EARLY-COGN^3 project could lead to a complete paradigm shift from the traditional therapeutic approach, forcing a reassessment on how CNDs could take advantage of a digital solution. (clinicaltrials.gov database, ID: NCT06657274).

How do caregivers successfully cope with behavioral and psychological symptoms of dementia? A web-based, preliminary analysis using a hybrid approach

OBJECTIVES

There has been no systematic analysis of coping strategies for behavioral and psychological symptoms of dementia (BPSD) using large-scale cumulative data. We preliminarily examined the characteristics of successful and unsuccessful coping strategies for BPSD.

DESIGN

We employed a deductive and inductive analysis (hybrid approach) of the data derived from "Ninchisho Chienowa-net," a web-based system that collects caregivers' coping strategies for BPSD. Antecedent control procedure and consequence manipulation in applied behavior analysis (ABA) were used as theory-driven codes for deductive classification.

CASES

We targeted 1049 cases except "others" among BPSD's categories submitted from January 2016 to January 2019, and finally, 1027 were selected.

MEASUREMENTS

Subsequently, nine sub-codes of coping strategies were inductively generated through a trial classification in the first BPSD category, applying these to remaining categories.

RESULTS

Success frequencies varied significantly across coping strategy sub-codes: strategies "assisting the person in performing other activities," "addressing setting events," "listening to the person and accepting her/his challenges," and "multi-coping strategies" had higher success frequencies than expected. Conversely, "explaining reality" and "inhibiting BPSD" had higher failure frequencies than expected. As for the BPSD category "problems due to forgetting," "prompting the person to do an appropriate behavior" was more successful than other coping strategies.

CONCLUSIONS

This investigation systematically elucidated the efficacy of various coping strategies, delineating successful ones from those that were not. The discerned patterns across all categories of BPSD and within each individual category will provide valuable insights for caregivers.

Traditional Chinese Medicine for Alzheimer's Disease: A Systematic Review and Meta-Analysis

The treatment of Alzheimer's Disease (AD) remains a challenge for modern medicine due to its complex pathogenesis. Traditional Chinese Medicine (TCM) has demonstrated significant success in the prevention and treatment of variable medical conditions. For AD pharmacological management, TCM could provide promising approaches. This study aimed to systematically evaluate the current evidence of the effects of TCM therapies on AD. A systematic search of the literature was performed on electronic databases including PubMed, the Cochrane Library, the Chinese National Knowledge Infrastructure (CNKI), and Web of Science. Thirteen studies were included in this review, subject to inclusion and exclusion criteria. Screening, data extraction, and quality assessment were undertaken following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Our results show that TCM offered a significant improvement in cognitive functioning compared to the control group, measured on both MMSE and ADAS-CoG scales, suggesting its potential utility in slowing cognitive decline and improving cognitive function as compared to conventional drug treatments and placebos. No significant difference was found for scores of neuropsychiatric symptoms (NPI) or ability to perform daily living activities (ADCS-ADL). These findings highlight TCM as a potential adjuvant therapy, in combination with conventional medicine, to improve the effectiveness and reduce the limitations of conventional AD drug regimes. Studies with larger sample sizes, rigorous study designs, accurate long-term reporting, and correlation to neuropathological markers are needed in the future to enhance the evidence base for the use of TCM in AD patients, and to further confirm its efficacy.

Drug repurposing for Alzheimer's disease and other neurodegenerative disorders

Repurposed drugs provide a rich source of potential therapies for Alzheimer's disease (AD) and other neurodegenerative disorders (NDD). Repurposed drugs have information from non-clinical studies, phase 1 dosing, and safety and tolerability data collected with the original indication. Computational approaches, "omic" studies, drug databases, and electronic medical records help identify candidate therapies. Generic repurposed agents lack intellectual property protection and are rarely advanced to late-stage trials for AD/NDD. In this review we define repurposing, describe the advantages and challenges of repurposing, offer strategies for overcoming the obstacles, and describe the key contributions of repurposing to the drug development ecosystem.

Does an Audio Wearable Lead to Agitation Reduction in Dementia: The Memesto AWARD Proof-of-Principle Clinical Research Study

BACKGROUND

Agitation is a common behavioral symptom in persons living with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD), especially in the setting of residential care. Pharmacologic and non-pharmacologic interventions are limited. Memesto is a wearable audio device designed to provide messages and music that can be scheduled or played on demand. The objective of this proof-of-principle study was to quantify whether Memesto can reduce agitation in persons with AD/ADRD.

METHODS

Persons living with AD/ADRD with a Clinical Global Impressions-Severity (CGI-S) average score of 4 or greater, one informal caregiver, and one formal caregiver (triad) were recruited from residential care facilities in the Midwest region of the United States. After consent and a two-week training period, the triad was monitored every two weeks from Baseline to Week 10 with the Neuropsychiatric Inventory (NPI) agitation domain subscale (primary endpoint) and the CGI-S scale (secondary endpoint) with the last observation carried forward. The average score on the NPI agitation domain subscale and the CGI-S scale at Baseline and Week 10 as rated by the two caregivers were compared. A 30% drop in the NPI agitation domain subscale in 50% of the persons living with AD/ADRD was considered a clinically meaningful finding.

RESULTS

Over thirteen months of recruitment, 9 triads were identified in 6 residential care facilities in three Midwestern states. For the NPI agitation domain, 6 of 9 (67%) persons with AD/ADRD had a 30% reduction in the average caregiver ratings at Week 10. No adverse events were identified associated with the use of the device. Device usability was rated as positive based on a survey.

DISCUSSION

This study provided quantitative data on psychometrically sound agitation scales regarding a 10-week treatment course with Memesto after a two-week training period. The results were limited by the inability to recruit the desired set of 20 triads due to disruptions in care and staff at residential care facilities. Further effectiveness testing in a larger cohort with a sham control device is necessary.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov. NCT05153161. First posted December 10, 2021.

Visual cortical activity in Charles Bonnet syndrome: testing the deafferentation hypothesis

Visual hallucinations in individuals following sight loss (Charles Bonnet syndrome; CBS) have been posited to arise because of spontaneous, compensatory, neural activity in the visual cortex following sensory input loss from the eyes-known as deafferentation. However, neurophysiological investigations of CBS remain limited. We performed a multi-modal investigation comparing visual cortical activity in 19 people with eye disease who experience visual hallucinations (CBS) with 18 people with eye disease without hallucinations (ED-Controls; matched for age and visual acuity) utilising functional MRI, EEG, and transcranial magnetic stimulation (TMS). A pattern of altered visual cortical activity in people with CBS was noted across investigations. Reduced BOLD activation in ventral extrastriate and primary visual cortex, and reduced EEG alpha-reactivity in response to visual stimulation was observed in CBS compared to ED-Controls. The CBS group also demonstrated a shift towards lower frequency band oscillations in the EEG, indicative of cortical slowing, with significantly greater occipital theta power compared to ED-controls. Furthermore, a significant association between reduced activation in response to visual stimulation and increased excitability (in the form of reduced TMS phosphene thresholds) was observed in CBS, indicating persistent visual cortical activation consistent with hyperexcitability, which was found to be significantly associated with increased hallucination severity. These results provide converging lines of evidence to support the role of increased visual cortical excitability in the formation of visual hallucinations in some people following sight loss, consistent with the deafferentation hypothesis.

Telemedicine for the Management of Neuropsychiatric Symptoms in Patients With Dementia Living in Long Term Care Facilities: Secondary and Exploratory Analyses From the DETECT Interventional Pilot Study

OBJECTIVE

This study aimed to compare the effects of telemedicine use in management of neuropsychiatric symptoms (NPS) in patients with dementia in long-term care facilities (LTCFs) versus usual care.

DESIGN

DETECT is a prospective randomized controlled cluster pilot study with two arms: "usual care" and "intervention arm" utilizing telemedicine for NPS management. Our study includes secondary and exploratory analyses from the DETECT study (primary analyses were the subject of a separate publication).

SETTING

Nineteen LTCFs participated. Patient outcomes included total hospitalizations including emergency room admittance, psychotropic drug prescriptions, NPS based on NPI-NH, quality of life based on QolAD, and functional status based on Activity Daily Living (ADL).

MEASUREMENTS

Analyses were conducted on a modified intention-to-treat population. Mixed models were used for outcome measures, considering data correlation over time and intra-LTCF correlation.

RESULTS

One hundred forty-one patients were included: 65 in the control group and 76 in the intervention group, 99 women (70.2%) with a mean age of 86.8 years ± 6.6 (SD). No difference was identified regarding hospitalizations and psychotropic drug prescriptions in the intervention group. During exploratory analyses, telemedicine showed significant improvement in the intervention group for NPI frequency × severity score (p = 0.001), NPI distress score (p = 0.03), ADL (p = 0.006), and several quality-of-life items compared to usual care.

CONCLUSIONS

Secondary analyses form DETECT study show no difference in the use of telemedicine on management of NPS in patients with dementia in LTCFs, in terms of hospitalizations and psychotropic drug prescription. However, some exploratory analyses indicated a positive effect of Telemedicine, including severity, frequency, distress, and functional autonomy compared to usual care.

A longitudinal investigation of the relationship between dimensional psychopathology, gray matter structure, and dementia status in older adulthood

BACKGROUND

The structure of psychopathology can be organized hierarchically into a set of transdiagnostic dimensional phenotypes. No studies have examined whether these phenotypes are associated with brain structure or dementia in older adults.

METHODS

Data were drawn from a longitudinal study of older adults aged 70-90 years at baseline (N = 1072; 44.8% male). Confirmatory factor models were fit to baseline psychiatric symptoms, with model fit assessed via traditional fit indices, model-based reliability estimates, and evaluation of model parameters. Bayesian plausible values were generated from the best-fitting model for use in subsequent analyses. Linear mixed models examined intraindividual change in global and regional gray matter volume (GMV) and cortical thickness over 6 years. Logistic regression examined whether symptom dimensions predicted incident dementia over 12 years.

RESULTS

A higher-order model showed a good fit to the data (BIC = 28,691.85; ssaBIC = 28,396.47; CFI = 0.926; TLI = 0.92; RMSEA = 0.047), including a general factor and lower-order dimensions of internalizing, disinhibited externalizing, and substance use. Baseline symptom dimensions did not predict change over time in total cortical and subcortical GMV or average cortical thickness; regional GMV or cortical thickness in the frontal, parietal, temporal, or occipital lobes; or regional GMV in the hippocampus and cerebellum (all p-values >0.5). Finally, baseline symptom dimensions did not predict incident dementia across follow-ups (all p-values >0.5).

CONCLUSIONS

We found no evidence that transdiagnostic dimensions are associated with gray matter structure or dementia in older adults. Future research should examine these relationships using psychiatric indicators capturing past history of chronic mental illness rather than current symptoms.

Amyloid-β predominant Alzheimer's disease neuropathologic change

Different subsets of Alzheimer's disease neuropathologic change (ADNC), including the intriguing set of individuals with severe/widespread amyloid-β (Aβ) plaques but no/mild tau tangles [Aβ-predominant (AP)-ADNC], may have distinct genetic and clinical features. Analysing National Alzheimer's Coordinating Center data, we stratified 1187 participants into AP-ADNC (n = 95), low Braak primary age-related tauopathy (PART; n = 185), typical-ADNC (n = 832) and high-Braak PART (n = 75). AP-ADNC differed in some clinical features and genetic polymorphisms in the APOE, SNX1, WNT3/MAPT and IGH genes. We conclude that AP-ADNC differs from classical ADNC with implications for in vivo studies.

Neuropsychiatric Symptoms and Mortality in Cognitively Normal Older Mexican Americans

Neuropsychiatric symptoms (NPS) present in older adults with Alzheimer's disease (AD) and other dementias are related to mortality. Research on the relationship between NPS and mortality in a non-dementia population is limited. This study examines NPS as a predictor of six-year mortality among community dwelling Mexican Americans aged 80 years and older. Data included 466 cognitively normal participants from Wave 7 of the Hispanic Established Population for the Epidemiological Study of Elderly. NPS were measured using the Neuropsychiatric inventory (NPI). Cox proportional hazard models were used to estimate the hazard ratio (HR) of mortality. The HR of death at 6 years was 1.02 (95% Confidence Interval-CI [1.00, 1.04]) as a function of NPI score and 1.09 (95% CI [1.02, 1.17]) for the number of NPI conditions, controlling for demographic and health characteristics. Apathy, irritability, and aberrant motor behavior were all independently predictors of mortality. NPS may be modifiable risk factors to increase survival time or may be indicative of underlying health problems. NPS may be related to underlying health conditions among older adults with normal cognitive functioning.

Plasma phosphorylated tau and neuropsychiatric symptoms in dementia with Lewy bodies

INTRODUCTION

Neuropsychiatric symptoms (NPSs) are common in dementia with Lewy bodies (DLB) but their neurobiological mechanisms are poorly understood.

METHODS

NPSs and cognition were assessed annually in participants (DLB n = 222; Alzheimer's disease [AD] n = 125) from the European DLB (E-DLB) Consortium, and plasma phosphorylated tau-181 (p-tau181) and p-tau231 concentrations were measured at baseline.

RESULTS

Hallucinations, delusions, and depression were more common in DLB than in AD and, in a subgroup with longitudinal follow-up, persistent hallucinations and NPSs were associated with lower p-tau181 and p-tau231 in DLB. In adjusted linear mixed-effects models, hallucinations at baseline were associated with greater longitudinal cognitive impairment in DLB, with a significant interaction with p-tau231.

DISCUSSION

Higher p-tau181 and p-tau231 levels were associated with a lower longitudinal risk of NPSs and hallucinations in early-stage DLB. However, the interaction between hallucinations and p-tau231 suggests that when AD co-pathology and hallucinations do co-exist in DLB that they may synergistically exacerbate cognitive decline.

HIGHLIGHTS

Neuropsychiatric symptoms (NPSs) were more common in dementia with Lewy bodies (DLB) than in Alzheimer's disease (AD). Lower plasma phosphorylated tau-231 (p-tau231) and p-tau181 levels were associated with persistent hallucinations in DLB. Lower plasma p-tau231 and p-tau181 levels were associated with an increased risk of persistent NPSs in early DLB. Hallucinations at baseline were associated with greater cognitive dysfunction in DLB, and there was an interaction with p-tau231.

Self-reported Visual Difficulty, Age-related Eye Disease, and Neuropsychiatric Outcomes in Older Adults

PURPOSE

Self-reported visual difficulty is consistently associated with dementia and other neuropsychiatric outcomes, but studies of specific age-related eye diseases have yielded conflicting results.

METHODS

We conducted a retrospective cohort study using data from The National Health and Aging Trends Study, an ongoing nationally representative survey of older U.S. adults (n = 10,089). All subjects are screened for self-reported visual difficulty annually. Using linked Medicare claims data, we identified subjects with age-related macular degeneration (AMD), primary open-angle glaucoma (POAG), diabetic retinopathy, and cataract. For each condition, controls with complete Medicare eligibility and at least one eye care encounter were selected. We used semiparametric discrete time proportional hazards models to measure associations with incident dementia, and generalized estimating equations to examine longitudinal associations with depression, anxiety, and hallucinations, adjusting for baseline demographics and time-varying comorbidities.

RESULTS

Self-reported visual difficulty was associated with dementia (HR 1.16, 95% CI: 1.00-1.34), depression (OR 1.14, 95% CI: 1.04-1.26), anxiety (OR 1.17, 95% CI: 1.06-1.29), and hallucinations (OR 1.54, 95% CI: 1.29-1.84). Diabetic retinopathy was associated with depression (OR 1.31, 95% CI: 1.05-1.64), and cataracts were associated with a lower risk of depression (OR 0.84, 95% CI: 0.74-0.95) and anxiety (OR 0.86, 95% CI: 0.75-0.99). There were no other associations between age-related eye disease and neuropsychiatric outcomes.

CONCLUSION

Self-reported visual difficulty is associated with dementia and other neuropsychiatric outcomes to a greater degree than age-related eye disease. These findings highlight the distinction between self-reported vision and clinically diagnosed eye disease with regard to health outcomes in older adults.

Behavioral disorders in dementia with Lewy bodies: old and new knowledge

Dementia with Lewy bodies (DLB), the second most common primary degenerative neurocognitive disorder after Alzheimer disease, is frequently preceded by REM sleep behavior disorders (RBD) and other behavioral symptoms, like anxiety, irritability, agitation or apathy, as well as visual hallucinations and delusions, most of which occurring in 40-60% of DLB patients. Other frequent behavioral symptoms like attention deficits contribute to cognitive impairment, while attention-deficit/hyperactivity disorder (ADHD) is a risk factor for DLB. Behavioral problems in DLB are more frequent, more severe and appear earlier than in other neurodegenerative diseases and, together with other neuropsychiatric symptoms, contribute to impairment of quality of life of the patients, but their pathophysiology is poorly understood. Neuroimaging studies displayed deficits in cholinergic brainstem nuclei and decreased metabolism in frontal, superior parietal regions, cingulate gyrus and amygdala in DLB. Early RBD in autopsy-confirmed DLB is associated with lower Braak neuritic stages, whereas those without RBD has greater atrophy of hippocampus and increased tau burden. αSyn pathology in the amygdala, a central region in the fear circuitry, may contribute to the high prevalence of anxiety, while in attention dysfunctions the default mode and dorsal attention networks displayed diverging activity. These changes suggest that behavioral disorders in DLB are associated with marked impairment in large-scale brain structures and functional connectivity network disruptions. However, many pathobiological mechanisms involved in the development of behavioral disorders in DLB await further elucidation in order to allow an early diagnosis and adequate treatment to prevent progression of these debilitating disorders.

Caregiving in the face of empathy loss in Frontotemporal Dementia: an integrative review

OBJECTIVES

Frontotemporal Degeneration (FTD) is a common cause of early onset dementia with symptoms often presenting before 65 years of age and adding tremendous burden on caregivers. FTD caregiving research describes patient behavioral symptoms such as apathy and disinhibition as primary sources of poor caregiver psychological health; however, little attention has been paid to other common patient behaviors, such as loss of empathy. To better understand the relationship between empathy loss and FTD caregiver outcomes, this integrative review aimed to address the question: How does the loss of empathy in a person living with FTD (PLwFTD) impact the caregiver?

METHOD

Quantitative and qualitative articles were found in PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus and were assessed for quality using the Crowe Critical Appraisal Tool (CCAT). Through constant comparative analysis, articles were assessed to abstract common themes in the literature.

RESULTS

From 333 citations, 8 qualitative and 8 quantitative studies published between 2010 and 2022 were included. Three main themes were uncovered: 1) caregiver emotional reactions to the PLwFTD; 2) caregiver psychological distress; 3) changes in the relationship.

CONCLUSION

This review emphasizes the detrimental impact of empathy loss on FTD caregivers. Understanding these underexplored consequences is critical in understanding the well-being of caregivers and promoting ways to support caregivers.

Intranasal oxytocin for apathy in people with frontotemporal dementia (FOXY): a multicentre, randomised, double-blind, placebo-controlled, adaptive, crossover, phase 2a/2b superiority trial

BACKGROUND

No treatments exist for apathy in people with frontotemporal dementia. Previously, in a randomised double-blind, placebo-controlled, dose-finding study, intranasal oxytocin administration in people with frontotemporal dementia improved apathy ratings on the Neuropsychiatric Inventory over 1 week and, in a randomised, double-blind, placebo-controlled, crossover study, a single dose of 72 IU oxytocin increased blood-oxygen-level-dependent signal in limbic brain regions. We aimed to determine whether longer treatment with oxytocin improves apathy in people with frontotemporal dementia.

METHODS

We conducted a multicentre, randomised, double-blind, placebo-controlled, adaptive, crossover, phase 2a/2b trial, enrolling participants from 11 expert frontotemporal dementia outpatient clinics across Canada and the USA. People aged 30-80 years with a diagnosis of probable frontotemporal dementia, a Neuropsychiatric Inventory apathy score of 2 or higher, a study partner who interacted with them for at least 3 h per day, and stable cognitive and behavioural medications for 30 days were eligible for inclusion. In stage 1, participants were randomly assigned (1:1:1:1:1:1) to one of three dose schedules (every day, every other day, and every third day) of 72 IU intranasal oxytocin or placebo and to the order they would received the intervention in the crossover; intranasal oxytocin or placebo were administered twice daily for 6 weeks, with a 6-week washout and then crossover to the other intervention. In stage 2, new participants were randomised (1:1) to the dose that had been determined as optimal in stage 1 or to placebo, with crossover as in stage 1. Randomisation used variable block sizes and was stratified by participant sex and Clinical Dementia Rating severity score. All kits of investigational product were identical and produced centrally, and all local teams, study staff, and participants were masked to treatment allocation and order. The primary outcome was difference in the change in Neuropsychiatric Inventory apathy scores for oxytocin versus placebo periods in the per-protocol population after 6 weeks of treatment. Safety was assessed at each visit via electrocardiogram, blood work, and collection of data on adverse events. This trial is registered at ClinicalTrials.gov (NCT03260920).

FINDINGS

Between Jan 31, 2018, and Dec 11, 2020, 70 patients were screened for stage 1 and 60 (86%) were enrolled. 45 (75%) completed both treatment periods of stage 1. 72 IU oxytocin every third day was the optimal dose schedule from stage 1 based on its Bayesian posterior probability (Pr(Best)=0·478). Between June 28, 2021, and Jan 31, 2023, 42 patients were screened for stage 2, and 34 (81%) were enrolled. 28 (82%) completed both treatment periods in stage 2. 38 (40%) of 94 participants were female and 56 (60%) were male (mean age 65·9 years, SD 8·2) Treatment with oxytocin every third day resulted in an improved Neuropsychiatric Inventory apathy score, with an estimated -1·32 points (95% CI -2·43 to -0·21) relative to placebo (one sided p=0·010). Two adverse events were reported in at least 5% of participants: upper respiratory tract infection (five [6%] of 78 participants on placebo and three [5%] on every third day at all doses of oxytocin) and headache (two [3%] participants on placebo, one [7%] of 15 participants on oxytocin every day, and two [4%] of 55 participants on oxytocin every third day). No adverse events were attributed to oxytocin treatment.

INTERPRETATION

Intranasal oxytocin given every third day was well tolerated and was associated with a small reduction in apathy in patients with frontotemporal dementia. Future trials might investigate intermittent dosing of more potent formulations than in this study, to establish whether larger effects are possible.

FUNDING

Canadian Institutes of Health Research and Weston Foundation.

Behavioral disorders in Parkinson disease: current view

Patients with Parkinson disease (PD) frequently experience several behavioral symptoms, such as anxiety, apathy, irritability, agitation, impulsive control and obsessive-compulsive or REM sleep behavior disorders, which can cause severe psychosocial problems and impair quality of life. Occurring in 30-70% of PD patients, these symptoms can manifest at early stages of the disease, sometimes even before the appearance of classic motor symptoms, while others can develop later. Behavioral changes in PD show distinct patterns of brain atrophy, dopaminergic and serotonergic deterioration, altered neuronal connectivity in frontostriatal, corticolimbic, default mode and other networks due to a cascade linking molecular pathologies and deficits in multiple behavior domains. The changes suggest a multi-system neurodegenerative process in the context of a specific α-synucleinopathy inducing a variety of biochemical and functional changes, the neurobiological basis and clinical relevance of which await further elucidation. This paper is intended to review the recent literature with focus on the main behavioral disturbances in PD patients, their epidemiology, clinical features, risk factors, animal models, neuroimaging findings, pathophysiological backgrounds, and treatment options of these deleterious lesions.

Cognitive behavioural treatment for mild Alzheimer's patients and their caregivers (CBTAC): results of a randomised controlled trial

OBJECTIVES

This study aimed to evaluate the effects of a multicomponent psychotherapy programme for people with mild Alzheimer's dementia (AD) and their caregivers on depression and related neuropsychiatric symptoms.

METHOD

The cognitive behavioural therapy (CBT)-based treatment consisted of 25 weekly sessions, including behavioural activation, behaviour management, interventions for the caregiver, reminiscence, couples counselling, and cognitive restructuring. 41 participants and their caregivers were randomised to either the CBT or the control group, which received treatment-as-usual (TAU). Follow-ups took place at 6 and 12 months posttreatment. The primary outcome was depression in the patient with AD. The secondary outcomes were apathy, other neuropsychiatric symptoms, functional abilities, quality of life, and quality of the relationship with the caregiver.

RESULTS

Linear mixed models revealed a statistically significant superiority of CBT regarding clinician-rated depression at the 12-month follow-up with large effect sizes (within-subject d = 1.22, between-subject d = 1.00). Effect sizes were only moderate for self-rated depression and small for informant-rated depression. There was also a significant advantage for CBT regarding clinician-rated apathy, relationship quality, and informant-rated quality of life (QoL) but not for the other neuropsychiatric symptoms or self-rated QoL.

CONCLUSION

The results are very encouraging and support an adequately powered multicentre study.

Trial registration: ClinicalTrials.gov NCT01273272. Date of registration: 3 Jan 2011.