Sundown syndrome in persons with dementia: an update

Sleep physiology and disorders in aging and dementia

Sleep problems occur commonly in normal and pathologic aging. Older adults typically have more difficulty falling asleep and remaining asleep, report more daytime napping, and have an increased prevalence of primary sleep disorders such as insomnia, parasomnias, sleep apnea, and sleep-related movement disorders. Medical and psychiatric disorders as well as medications used to treat them also contribute to sleep disturbances in aging. Patients with mild cognitive impairment and dementia have more severe sleep problems, and disturbed sleep and sleep disorders contribute to earlier onset and more rapid progression of neurodegenerative disorders. Approaches to diagnosing and treating sleep disorders in the elderly are discussed.

The Impact of Designated Behavioral Health Services on Resource Utilization and Quality of Care in Patients Requiring Constant Observation in a General Hospital Setting: A Quality Improvement Project

Constant observation (CO) is a common economic burden on general hospitals. A quality improvement (QI) project focusing on behavioral health (BH) management of this population was piloted using a novel BH protocol for the proactive assessment and management of all patients requiring CO. The impact on CO-cost and length of stay (LOS) was assessed. Data on demographics, diagnoses, psychopharmacologic treatment, complications and clinical setting were collected and analyzed for all CO-patients over a 6-month period. Cost and LOS data were compared with a similar sequential group prior to project implementation. Out of the 533 patients requiring CO during the study period, 491 underwent the protocol. This QI-project resulted in a significant reduction in the average monthly CO-cost by 33.06% and a 15% reduction in LOS without any increase in complications.

A time to fight: Circadian control of aggression and associated autonomic support

The central circadian clock, located in the suprachiasmatic nucleus of the mammalian hypothalamus (SCN), regulates daily behavioral rhythms including the temporal propensity for aggressive behavior. Such aggression propensity rhythms are regulated by a functional circuit from the SCN to neurons that drive attack behavior in the ventromedial hypothalamus (VMH), via a relay in the subparaventricular zone (SPZ). In addition to this pathway, the SCN also regulates sleep-wake and locomotor activity rhythms, via the SPZ, in a circuit to the dorsomedial hypothalamus (DMH), a structure that is also known to play a key role in autonomic function and the sympathetic "fight-or-flight" response (which prepares the body for action in stressful situations such as an agonistic encounter). While the autonomic nervous system is known to be under pronounced circadian control, it is less apparent how such autonomic rhythms and their underlying circuitry may support the temporal propensity for aggressive behavior. Additionally, it is unclear how circadian and autonomic dysfunction may contribute to aberrant social and emotional behavior, such as agitation and aggression. Here we review the literature concerning interactions between the circadian and autonomic systems and aggression, and we discuss the implications of these relationships for human neural and behavioral pathologies.

Aggressive behaviour risk assessment tool for long-term care (ABRAT-L): Validation study

This prospective cohort study was conducted to validate the usefulness of the Aggressive Behaviour Risk Assessment Tool for Long-Term Care (ABRAT-L) in predicting aggressive events. A total of 615 newly admitted residents at 22 long-term care homes in Canada were included. The risk of aggression was assessed using the six-item ABRAT-L within 24 hours of admission, and incident reports of aggressive events occurring within 30 days of admission were collected. Forty-seven residents out of 615 had one or more aggressive events (7.6%). The receiver operating characteristics analysis of ABRAT-L showed a good discriminant ability at the previously recommended cut-off score of 4, with satisfactory sensitivity and specificity. The usefulness of ABRAT-L in identifying potentially aggressive residents at the time of admission was confirmed. This validation study supports the adoption of a proactive risk assessment tool, ABRAT-L, as a part of routine admission assessments at long-term care homes.

Disorders of Body Weight, Sleep and Circadian Rhythm as Manifestations of Hypothalamic Dysfunction in Alzheimer's Disease

While cognitive decline and memory loss are the major clinical manifestations of Alzheimer’s disease (AD), they are now recognized as late features of the disease. Recent failures in clinical drug trials highlight the importance of evaluating and treating patients with AD as early as possible and the difficulties in developing effective therapies once the disease progresses. Since the pathological hallmarks of AD including the abnormal aggregation of amyloid-beta (Aβ) and tau can occur decades before any significant cognitive decline in the preclinical stage of AD, it is important to identify the earliest clinical manifestations of AD and elucidate their underlying cellular and molecular mechanisms. Importantly, metabolic and non-cognitive manifestations of AD such as weight loss and alterations of peripheral metabolic signals can occur before the onset of cognitive symptoms and worsen with disease progression. Accumulating evidence suggests that the major culprit behind these early metabolic and non-cognitive manifestations of AD is AD pathology causing dysfunction of the hypothalamus, a brain region critical for integrating peripheral signals with essential homeostatic physiological functions. Here, we aim to highlight recent developments that address the role of AD pathology in the development of hypothalamic dysfunction associated with metabolic and non-cognitive manifestations seen in AD. Understanding the mechanisms underlying hypothalamic dysfunction in AD could give key new insights into the development of novel biomarkers and therapeutic targets.

Effect of caffeine on sleep and behaviour in nursing home residents with dementia

BACKGROUND AND GOAL

Sleep problems and challenging behavioural symptoms are frequently reported among nursing home residents with dementia. Coffee with caffeine is consumed frequently by these residents and can have a negative effect on sleep and behaviour in older persons with dementia. In this interventional study, the effect of caffeine reduction on sleep and challenging behavioural symptoms in nursing home residents with dementia was investigated.

METHODS

In 21 nursing home residents with dementia living in 1 dementia special care unit, caffeine was gradually eliminated in the afternoon and evening. During pre-intervention and post-intervention period the care workers daily scored sleep by a specially developed sleep questionnaire. Behavioural symptoms were scored in the afternoon and evening using four items of the NPI-NH: agitation/aggression, apathy, irritability and aberrant motor behaviour.

RESULTS

A significant improvement in sleep scores (Wilcoxon signed-rank test, p = 0.015) and apathy (Wilcoxon signed-rank test, p = 0.020) was found after eliminating caffeine intake in the afternoon and evening. No significant changes occurred in agitation/aggression, irritability and aberrant motor behaviour.

DISCUSSION

This pre-post pilot study found a significant positive effect of caffeine reduction on sleep and apathy and warrants further investigation in a larger controlled study.

"A tool doesn't add anything". The importance of added value: Use of observational pain tools with patients with advanced dementia approaching the end of life-a qualitative study of physician and nurse experiences and perspectives

BACKGROUND

Observational pain tools (OPTs) are widely recommended in health care policies, clinical guidelines, and recommendations for pain assessment and management. However, it is unclear whether and how these tools are used for patients with advanced dementia approaching the end of life.

AIM

To explore hospice, secondary, and primary care physicians' and nurses' use of OPTs with patients dying with advanced dementia and their perspectives on practice development and training needs.

METHODS

Twenty-three physicians and 24 nurses with experience of caring for people dying with advanced dementia were recruited from primary care surgeries (n = 5), hospitals (n = 6), hospices (n = 4), and nursing homes (n = 10). Semistructured, face-to-face interviews were conducted. Interviews were digitally recorded, transcribed verbatim, and thematic analysis applied to identify core themes.

RESULTS

Three key themes emerged: (1) use of OPTs in this vulnerable patient population, (2) barriers to the use of OPTs and lack of perceived "added value", and (3) perspectives on practice development and training in pain assessment in advanced dementia at end of life. Just over one-quarter of participants (n = 13) routinely used OPTs. Reasons for nonuse included perceived limitations of such tools, difficulties with their use and integration with existing practice, and lack of perceived added value. Most participants strongly emphasised a need for ongoing training and development which facilitated transfer of knowledge and multidisciplinary skills across professions and specialties.

CONCLUSIONS

Health professionals require ongoing support in developing and integrating change to existing pain assessment protocols and approaches. These findings have important implications for health education, practice, and policy.

Positive Interactive Engagement (PIE): A pilot qualitative case study evaluation of a person-centred dementia care programme based on Montessori principles

Altered behaviour associated with dementia can present a number of challenges in the provision of care within both community and residential aged care settings. This paper presents a qualitative case study investigation of the implementation of the Positive Interactive Engagement programme within a residential aged care setting. The Positive Interactive Engagement programme incorporates non-pharmacological sensory techniques that have been informed by a person-centred, Montessori approach. Face-to-face semi-structured interviews with workers at a residential aged care facility in South Australia yielded seven case studies. Data were thematically analysed both within and between cases. Our data indicate the programme demonstrates underlying Montessori principles and supports participant behaviour change, with a noted reduction in ‘disruptive’ behaviours and increased social connection amongst participants. Programme staff report increased job satisfaction. The Positive Interactive Engagement programme offers a model that demonstrates encouraging outcomes, and further research would be useful in ascertaining whether these outcomes translate to quantifiable improvements in the quality of life for people with dementia in a residential aged care setting.

Early Detection of Mild Cognitive Impairment With In-Home Monitoring Sensor Technologies Using Functional Measures: A Systematic Review

The aging of the world population is accompanied by a substantial increase in neurodegenerative disorders, such as dementia. Early detection of mild cognitive impairment (MCI), a clinical diagnostic that comes with an increased chance to develop dementias, could be an essential condition for promoting quality of life and independent living, as it would provide a critical window for the implementation of early pharmacological and nonpharmacological interventions. This systematic review aims to investigate the current state of knowledge on the effectiveness of smart home sensors technologies for the early detection of MCI through the monitoring of everyday life activities. This approach offers many advantages, including the continuous measurement of functional abilities in ecological environments. A systematic search of publications in MEDLINE, EMBASE, and CINAHL, before November 2017, was conducted. Seventeen studies were included in this review. Thirteen studies were based on real-life monitoring, with several sensors installed in participants' actual homes, and four studies included scenario-based assessments, in which participants had to complete various tasks in a research lab apartment. In real-life monitoring, the most used indicators of MCI were walking speed and activity/motion in the house. In scenario-based assessment, time of completion, quality of activity completion, number of errors, amount of assistance needed, and task-irrelevant behaviors during the performance of everyday activities predicted MCI in participants. Despite technological limitations and the novelty of the field, smart home technologies represent a promising potential for the early screening of MCI and could support clinicians in geriatric care.

A hypothalamic circuit for the circadian control of aggression

“Sundowning” in dementia and Alzheimer’s disease is characterized by early evening agitation and aggression. While such periodicity suggests a circadian origin, whether the circadian clock directly regulates aggressive behavior is unknown. We demonstrate that a daily rhythm in aggression propensity in male mice is gated by GABAergic subparaventricular zone (SPZ^GABA) neurons, the major postsynaptic targets of the central circadian clock, the suprachiasmatic nucleus (SCN). Optogenetic mapping revealed that SPZ^GABA neurons receive input from vasoactive intestinal polypeptide SCN neurons and innervate neurons in the ventrolateral part of the ventromedial hypothalamus (VMHvl) known to regulate aggression. Additionally, VMH-projecting dorsal SPZ neurons are more active during early day than early night, and acute chemogenetic inhibition of SPZ^GABA transmission phase-dependently increases aggression. Finally, SPZ^GABA-recipient central VMH neurons directly innervate VMHvl neurons and activation of this intra-VMH circuit drove attack behavior. Altogether, we reveal a functional polysynaptic circuit by which the SCN clock regulates aggression.

Behavioral and SCN neurophysiological disruption in the Tg-SwDI mouse model of Alzheimer's disease

Disruption of circadian rhythms is commonly reported in individuals with Alzheimer's disease (AD). Neurons in the primary circadian pacemaker, the suprachiasmatic nucleus (SCN), exhibit daily rhythms in spontaneous neuronal activity which are important for maintaining circadian behavioral rhythms. Disruption of SCN neuronal activity has been reported in animal models of other neurodegenerative disorders; however, the effect of AD on SCN neurophysiology remains unknown. In this study we examined circadian behavioral and electrophysiological changes in a mouse model of AD, using male mice from the Tg-SwDI line which expresses human amyloid precursor protein with the familial Swedish (K670N/M671L), Dutch (E693Q), Iowa (D694N) mutations. The free-running period of wheel-running behavior was significantly shorter in Tg-SwDI mice compared to wild-type (WT) controls at all ages examined (3, 6, and 10 months). At the SCN level, the day/night difference in spike rate was significantly dampened in 6-8 month-old Tg-SwDI mice, with decreased AP firing during the day and an increase in neuronal activity at night. The dampening of SCN excitability rhythms in Tg-SwDI mice was not associated with changes in input resistance, resting membrane potential, or action potential afterhyperpolarization amplitude; however, SCN neurons from Tg-SwDI mice had significantly reduced A-type potassium current (I_A) during the day compared to WT cells. Taken together, these results provide the first evidence of SCN neurophysiological disruption in a mouse model of AD, and highlight I_A as a potential target for AD treatment strategies in the future.

Medical hypothesis: Light at night is a factor worth considering in critical care units

Exposure to light at night is not an innocuous consequence of modernization. There are compelling data linking long-term exposure to occupational and environmental light at night with serious health conditions, including heart disease, obesity, diabetes, and cancer. However, far less is known about the physiological and behavioral effects of acute exposure to light at night. Among healthy volunteers, acute night-time light exposure increases systolic blood pressure and inflammatory markers in the blood, and impairs glucose regulation. Whether critically ill patients in a hospital setting experience the same physiological shifts in response to evening light exposure is not known. This paper reviews the available data on light at night effects on health and wellbeing, and argues that the data are sufficiently compelling to warrant studies of how lighting in intensive care units may be influencing patient recovery.

Circadian wheel running behavior is altered in an APP/E4 mouse model of late onset Alzheimer's disease

Circadian rhythms are altered in several diseases associated with aging, one of which is Alzheimer's disease (AD). One example of a circadian rhythm is the rest-activity cycle, which can be measured in mice by monitoring their wheel-running. The present study sought to investigate differences in light phase/dark phase activity between a mouse model of late onset AD (APP/E4) and control (C57Bl6J) mice, in both the pre-plaque and post-plaques stages of the disease. To assess activity level, 24-h wheel running behavior was monitored at six months (pre-plaque) and twelve months (post-plaque) for a period of nine days. The following measures were analyzed: counts (wheel rotations) during the dark phase, counts during the light phase, hour of activity onset, and hour of activity offset. Key findings indicate that activity onset is delayed in APP/E4 mice at six and twelve months, and activity profiles for APP/E4 and C57Bl6J mice differ during the light and dark phase in such a way that APP/E4 mice run less in the early hours of the dark phase and more in the later hours of the dark phase compared to C57Bl6J mice. These findings imply that rest-activity cycle is altered in the pre-plaque stages of AD in APP/E4 mice, as they show impairments as early as six months of age.

'There's a Catch-22' - The complexities of pain management for people with advanced dementia nearing the end of life: A qualitative exploration of physicians' perspectives

BACKGROUND

Pain management is a cornerstone of palliative care. The clinical issues encountered by physicians when managing pain in patients dying with advanced dementia, and how these may impact on prescribing and treatment, are unknown.

AIM

To explore physicians' experiences of pain management for patients nearing the end of life, the impact of these on prescribing and treatment approaches, and the methods employed to overcome these challenges.

DESIGN

Qualitative, semi-structured interview study exploring barriers to and facilitators of pain management, prescribing and treatment decisions, and training needs. Thematic analysis was used to elicit key themes.

SETTING/PARTICIPANTS

A total of 23 physicians, responsible for treating patients with advanced dementia approaching the end of life, were recruited from primary care ( n = 9), psychiatry ( n = 7) and hospice care ( n = 7).

RESULTS

Six themes emerged: diagnosing pain, complex prescribing and treatment approaches, side effects and adverse events, route of administration, importance of sharing knowledge and training needs. Knowledge exchange was often practised through liaison with physicians from other specialities. Cross-speciality mentoring and the creation of knowledge networks were believed to improve pain management in this patient population.

CONCLUSION

Pain management in end-stage dementia is complex, requiring cross-population of knowledge between palliative care specialists and non-specialists, in addition to collateral information provided by other health professionals and patients' families. Regular, cost- and time-effective mentoring and ongoing professional development are perceived to be essential in empowering physicians to meet clinical challenges in this area.

Melatonin for Sleep Disorders in Patients with Neurodegenerative Diseases

In patients with neurodegenerative diseases, sleep disorders are common; they impair the quality of life for patients and caregivers and are associated with poorer clinical outcomes. Melatonin has circadian, hypnotic, and free radical-scavenging effects, and preclinical data suggest benefits of melatonin on neurodegeneration. However, randomized, controlled trials of melatonin in patients with neurodegenerative diseases have not shown strong effects. Trials in Alzheimer's patients demonstrate a lack of benefit on sleep quantity. Subjective measures of sleep quality are mixed, with possible symptomatic improvements seen only on some measures or at some time points. Benefits on cognition have not been observed across several studies. In Parkinson's patients, there may be minimal benefit on objective sleep measures, but a suggestion of subjective benefit in few, small studies. Effective treatments for the sleep disorders associated with neurodegenerative diseases are urgently needed, but current data are insufficient to establish melatonin as such a treatment.

Use of a Robotic Seal as a Therapeutic Tool to Improve Dementia Symptoms: A Cluster-Randomized Controlled Trial

OBJECTIVES

To test the effects of individual, nonfacilitated sessions with PARO (version 9), when compared against a look-alike plush toy and usual care, on the emotional and behavioral symptoms of dementia for people living in long-term care facilities.

DESIGN

Parallel, 3-group, cluster-randomized controlled trial conducted between June 14, 2014, and May 16, 2015.

SETTING

Twenty-eight long-term care facilities operated by 20 care organizations located in South-East Queensland, Australia.

PARTICIPANTS

Four hundred fifteen participants aged ≥60 years, with a documented diagnosis of dementia.

INTERVENTION

Stratified by private/not-for-profit status and randomized using a computer-generated sequence, 9 facilities were randomized to the PARO group (individual, nonfacilitated, 15-minute sessions 3 times per week for 10 weeks); 10 to plush toy (same, but given PARO with robotic features disabled); and 9 to usual care. Treatment allocation was masked to assessors.

MEASUREMENTS

Primary outcomes were changes in levels of engagement, mood states, and agitation after a 10-week intervention, assessed by coded video observations (baseline, weeks 1, 5, 10, and 15) and Cohen-Mansfield Agitation Inventory-Short Form (baseline, weeks 10 and 15). Analyses followed intention-to-treat, using repeated measures mixed effects models. Australian New Zealand Clinical Trials Registry (ACTRN12614000508673).

RESULTS

Video data showed that participants in the PARO group were more verbally [3.61, 95% confidence interval (CI): 6.40-0.81, P = .011] and visually engaged (13.06, 95% CI: 17.05-9.06, P < .0001) than participants in plush toy. Both PARO (-3.09, 95% CI: -0.45 to -5.72, P = .022) and plush toy (-3.58, 95% CI: -1.26 to -5.91, P = .002) had significantly greater reduced neutral affect compared with usual care, whilst PARO was more effective than usual care in improving pleasure (1.12, 95% CI: 1.94-0.29, P = .008). Videos showed that PARO was more effective than usual care in improving agitation (3.33, 95% CI: 5.79-0.86, P = .008). When measured using the CMAI-SF, there was no difference between groups.

CONCLUSIONS

Although more effective than usual care in improving mood states and agitation, PARO was only more effective than a plush toy in encouraging engagement.

Sundown syndrome and symptoms of anxiety and depression in hospitalized elderly

Sundown syndrome is characterized by the sudden appearance of neuropsychiatric symptoms such as agitation, confusion and anxiety in a chronologic fashion, usually during late afternoon or early evening.

Prevalence and factors associated with food intake difficulties among residents with dementia

Background

Few studies have examined the prevalence of food intake difficulties and their associated factors among residents with dementia in long-term care facilities in Taiwan. The purpose of the study was to identify the best cutoff point for the Chinese Feeding Difficulty Index (Ch-FDI), which evaluates the prevalence of food intake difficulties and recognizes factors associated with eating behaviors in residents with dementia.

Methods and findings

A cross-sectional design was adopted. In total, 213 residents with dementia in long-term care facilities in Taiwan were recruited and participated in this study. The prevalence rate of food intake difficulties as measured by the Chinese Feeding Difficulty Index (Ch-FDI) was 44.6%. Factors associated with food intake difficulties during lunch were the duration of institutionalization (beta = 0.176), the level of activities of daily living-feeding (ADL-Q1) (beta = -0.235), and the length of the eating time (beta = 0.416). Associated factors during dinner were the illuminance level (beta = -0.204), sound volume level (beta = 0.187), ADL-Q1 (beta = -0.177), and eating time (beta = 0.395).

Conclusions

Food intake difficulties may potentially be associated with multiple factors including physical function and the dining environment according to the 45% prevalence rate among dementia residents in long-term care facilities.

Sundown Syndrome, Sleep Quality, and Walking Among Community-Dwelling People With Alzheimer Disease

PURPOSES

Sundown syndrome and sleep disturbances cause people with Alzheimer disease (PAD) and caregivers suffering. Studies have indicated that physical exercise could have a positive impact on sundown syndrome, yet no research has ever explored the relationship between walking and sundown syndrome. The aims of this study were to examine the relationship between sundown syndrome and sleep quality, and determine whether the severity of dementia, sleep quality, and weekly duration of walking influenced sundown syndrome, and to assess differences in sundown syndrome and sleep quality in relation to the accompanying walker and weekly duration of walking among people with Alzheimer disease living in the community.

DESIGN

A cross-sectional observation study was conducted.

METHODS

A total 184 participants were recruited from dementia outpatient clinics of several hospitals and long-term care resource management centers in southern Taiwan. The Chinese version of the Cohen-Mansfield Agitation Inventory, Community form was used to assess sundown syndrome, and the Chinese version of the Pittsburgh Sleep Quality Index was used to measure sleep quality. Pearson correlation, multiple regression, and 1-way analysis of variance were performed for data analysis.

RESULTS

The results indicated that sundown syndrome was significantly correlated with sleep quality (r = 0.374), whereas severity of dementia, sleep quality, and weekly duration of walking were influencing factors of sundown syndrome and accounted for a total of 24.8% of the variance (adjusted R² = 0.222, F_6,177 = 9.709). In addition, PAD who walked with relatives showed less sundown syndrome (F_3,180 = 4.435, P = .005) and better sleep quality (F_3,180 = 3.565, P = .015) compared with those walking with nonrelatives. Also, longer walking time led to less sundown syndrome (F_4,179 = 4.351, P = .002) and better sleep quality (F_4,179 = 3.592, P = .008).

CONCLUSIONS

Advanced dementia, poor sleep quality, and shorter weekly duration of walking were the influencing factors of sundown syndrome. Walking with relatives and regular longer walking time could improve sleep quality and alleviate sundown syndrome. It is suggested that a well-designed walking intervention considering these factors could be an appropriate strategy to manage sundown syndrome and sleep quality for PAD and their caregivers.

Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches

Sundowning means the emergence or worsening of neuropsychiatric symptoms (NPS) in the late afternoon or early evening. This syndrome has been recognized since a long time in the field of dementing illnesses and is well known among most of health-care providers involved in the assistance of people with dementia. Indeed, it represents a common manifestation among persons with dementia and is associated with several adverse outcomes (such as institutionalization, faster cognitive worsening, and greater caregiver burden). Its occurrence and phenotypic characteristics may be influenced by diverse neurobiological, psychosocial, and environmental determinants. Moreover, it may pose diagnostic challenges in relation to other common causes of behavioral disruptions. Beside these considerations, this phenomenon has so far drawn limited clinical and scientific interest compared to other specific NPS occurring in dementias, as indicated by the lack of commonly agreed definitions, specific screening/assessment tools, and robust estimates on its prevalence. Accordingly, no randomized controlled trial specifically investigating the effectiveness of pharmacological and non-pharmacological strategies in managing this condition among demented patients has been yet conducted. In the present narrative review, we present and discuss available evidence concerning sundowning occurring in people with dementia. A special focus is given to its definitions, pathophysiological determinants, and clinical relevance, as well as to the clinical and therapeutic approaches required for its management in the daily practice.

Rapid eye movement sleep behavior disorder in patients with probable Alzheimer's disease

BACKGROUND AND AIMS

Rapid eye movement (REM) sleep behavior disorder (RBD) is commonly associated with neurodegenerative disorders characterized by α-synuclein deposition, including Parkinson's disease, multiple system atrophy, and Lewy body dementia. However, this tendency in tauopathy-mediated diseases is rare and only sporadically reported. We systematically illustrate the occurrence of RBD and sleep features among a cohort of patients with Alzheimer's disease (AD), a non-synucleinopathy.

METHODS

We recruited 105 clinically probable AD patients. Fifteen clinically probable AD patients with suspected RBD underwent a video-polysomnography (vPSG) examination.

RESULTS

Five patients with probable AD exhibited RBD. One of the patients performed repeated touching of the head and the face with his hands and flailed his arms. Three patients exhibited hand twisting, exploring, prominent limb kicking, and jerking. The fifth patient exhibited all of the characteristics of RBD (he recalled a dream about fighting animals), and his wife was awakened by his screaming. Of these five patients, one patient took the acetylcholinesterase inhibitor drug donepezil. The patients with AD + RBD demonstrated increases in both tonic and phasic electromyography activity during REM sleep, but sleep architecture did not differ between the AD + RBD and AD-alone groups.

CONCLUSION

RBD can occur in patients with AD. The occurrence of RBD does not change the sleep architecture of AD patients.

Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors

BACKGROUND

Inpatient geriatric falls are a frequent complication of hospital care that results in significant morbidity and mortality.

OBJECTIVE

Evaluate factors associated with falls in geriatric inpatients after implementation of the fall prevention program.

METHODS

Prospective observational study comprised of 788 consecutive patients aged 79.5±7.6 years ( [Formula: see text] ± standard deviation) (66% women and 34% men) admitted to the subacute geriatric ward. Comprehensive geriatric assessment (including Mini-Mental State Examination, Barthel Index of Activities of Daily Living, and modified Get-up and Go Test) was performed. Confusion Assessment Method was used for diagnosis of delirium. Patients were categorized into low, moderate, or high fall risk groups after clinical and functional assessment.

RESULTS

About 15.9%, 21.1%, and 63.1% of participants were classified into low, moderate, and high fall risk groups, respectively. Twenty-seven falls were recorded in 26 patients. Increased fall probability was associated with age ≥76 years (P<0.001), body mass index (BMI) <23.5 (P=0.007), Mini-Mental State Examination <20 (P=0.004), Barthel Index <65 (P=0.002), hemoglobin <7.69 mmol/L (P=0.017), serum protein <70 g/L (P=0.008), albumin <32 g/L (P=0.001), and calcium level <2.27 mmol/L. Four independent factors associated with fall risk were included in the multivariate logistic regression model: delirium (odds ratio [OR] =7.33; 95% confidence interval [95% CI] =2.76-19.49; P<0.001), history of falls (OR =2.55; 95% CI =1.05-6.19; P=0.039), age (OR =1.14; 95% CI =1.05-1.23; P=0.001), and BMI (OR =0.91; 95% CI =0.83-0.99; P=0.034).

CONCLUSION

Delirium, history of falls, and advanced age seem to be the primary risk factors for geriatric falls in the context of a hospital fall prevention program. Higher BMI appears to be associated with protection against inpatient geriatric falls.

Increasing enjoyable activities to treat depression in nursing home residents with dementia: A pilot study

This pilot study aimed to assess the feasibility and acceptability of a behavioral activities intervention (BE-ACTIV) in Australian nursing homes. BE-ACTIV was developed by researchers at the University of Louisville, USA, to improve mood and quality of life (QOL) in nursing home residents with mild to moderate dementia. An eight-week trial was conducted and 10 residents with mild to moderate dementia received the BE-ACTIV intervention while eight residents received a Walking and Talking intervention. Measures of depression (GDS-12R) and QOL (QOL-AD-NH) were administered prior to and following the interventions. Qualitative feedback indicated residents benefited from BE-ACTIV, evident by improved mood, although no statistically significant treatment effect was found. Moreover, the intervention was found to be feasible and acceptable to Australian nursing home staff and our findings highlight the importance of individualizing activities for people with dementia, of which 1:1 staff attention was a key component.

Understanding cognition in older patients with cancer

Cancer and neurocognitive disorders, such as dementia and delirium, are common and serious diseases in the elderly that are accompanied by high degree of morbidity and mortality. Furthermore, evidence supports the under-diagnosis of both dementia and delirium in older adults. Complex questions exist regarding the interaction of dementia and delirium with cancer, beginning with guidelines on how best measure disease severity, the optimal screening test for either disorder, the appropriate level of intervention in the setting of abnormal findings, and strategies aimed at preventing the development or progression of either process. Ethical concerns emerge in the research setting, pertaining to the detection of cognitive dysfunction in participants, validity of consent, disclosure of abnormal results if screening is pursued, and recommended level of intervention by investigators. Furthermore, understanding the ways in which comorbid cognitive dysfunction and cancer impact both cancer and non-cancer-related outcomes is essential in guiding treatment decisions. In the following article, we will discuss what is presently known of the interactions of pre-existing cognitive impairment and delirium with cancer. We will also discuss identified deficits in our knowledge base, and propose ways in which innovative research may address these gaps.

The Synergistic Relationship between Alzheimer's Disease and Sleep Disorders: An Update

Sleep disorders are frequently reported in Alzheimer's disease (AD), with a significant impact on patients and caregivers and a major risk factor for early institutionalization. Although changes in sleep organization are a hallmark of the normal aging processes, sleep macro- and micro-architectural alterations are more evident in patients affected by AD. Degeneration of neural pathways regulating sleep-wake patterns and sleep architecture may contribute to sleep alterations. In return, several recent studies suggested that common sleep disorders may precede clinical symptoms of dementia and represent risk factors for cognitive decline, through impairment of sleep-dependent memory consolidation processes. Thus, a close relationship between sleep disorders and AD has been largely hypothesized. Here, sleep alterations in AD and its pre-dementia stage, mild cognitive impairment, and their complex interactions are reviewed.

"Sundowning" as a biological phenomenon: current understandings and future directions: an update

The clinical phenomenon of early evening disruptive behavior also called "Sundowning" in elderly patients has been largely reported in the medical literature without a consistent diagnosis and criteria to define this phenomenon. The current understandings of sundowning are incomplete and current treatment strategies have relied heavily on use of antipsychotic medications, despite side effects and limited evidence to justify their use. A comprehensive understanding of the biogenesis of this phenomenon and mechanistic changes from oxidative pathways may provide novel information on completing the sundowning puzzle. Future studies could examine the utility of natural factors in reviving neuronal energy loss and altering the oxidative pathways might be safe and additional options in development of treatment models for this behavioral disorder.

Use of Antipsychotics for the Treatment of Behavioral Symptoms of Dementia

Antipsychotic medications are widely used in the management of behavioral and psychological symptoms of dementia. While nonpharmacological interventions should be the first-line treatment for behavioral symptoms of dementia, these are often unfeasible and/or ineffective. Conventional and atypical antipsychotic agents appear to have modest to moderate clinical efficacy in the treatment of these symptoms, though it is unclear which individual agents are most effective. No conclusive evidence exists that any available alternative medications are safer and more effective than antipsychotics. A number of studies have shown an increased risk of mortality associated with antipsychotics in patients with behavioral symptoms of dementia, though the observed risk increase may be partially confounded by illness severity and/or preexisting health determinants. The mechanisms of increased mortality risk are not fully established, but are likely to involve cardiovascular events. It is probable, though not certain, that conventional antipsychotics are associated with a greater number of poor outcomes than atypical antipsychotics. In certain patients with refractory behavioral symptoms, antipsychotics are a viable treatment option. Key considerations for antipsychotic prescribing for this population are published in regulatory guidelines, and include minimization of dosage and duration of treatment, continuous reevaluation of symptoms, and involvement of caregivers.

The impact of time of day on the gait and balance control of Alzheimer's patients

Alzheimer's patients suffer from circadian dysregulation. The aim of this study was to examine the evolution of balance control and gait at different times of the day (11:00, 14:00, 18:00) in order to identify whether Alzheimer's patients were more likely to fall at certain periods of the day. Spatio-temporal parameters of centre of foot pressure displacements were measured with a force platform and spatio-temporal parameters of walking were evaluated with a gait analysis device. The results highlighted that balance control was worse in the evening and the afternoon than in the morning. Furthermore, the walking speed was faster and support duration, swing duration and cycle duration were shorter in the evening than in the morning and afternoon. The combined analysis of balance control and gait parameters revealed that balance control and walking are concomitantly altered in the evening which increases the fall risk in the evening, in comparison with the morning, for Alzheimer's patients.

Clinical management of sleep disturbances in Alzheimer's disease: current and emerging strategies

Sleep and circadian disorders in Alzheimer's disease (AD) are more frequent than in the general population and appear early in the course of the disease. Quality of sleep and quality of life are parallel in these patients, and such disorders also represent a heavy burden for caregivers. Although alterations in melatonin and hypocretins (orexins) seem to play a key role in the origin of these disturbances, the etiology of these disorders is multifactorial, including many factors such as environment, behavior, treatments, and comorbidities, among others. A comprehensive evaluation of sleep in each patient is essential in the design of the treatment that includes nonpharmacological and pharmacological approaches. One particularly interesting point is the possibility of a role of sleep disorders in the pathogenesis of AD, raising the possibility that treating the sleep disorder may alter the course of the disease. In this review, we present an update on the role of sleep disorders in AD, the bidirectional influence of sleep problems and AD, and treatment options. Behavioral measures, bright light therapy (BLT), melatonin, and other drugs are likely well known and correctly managed by the physicians in charge of these patients. In spite of the multiple treatments used, evidence of efficacy is scarce and more randomized double-blind placebo-controlled studies are needed. Future directions for treatment are the establishment of BLT protocols and the development of drugs with new mechanisms of action, especially hypocretin receptor antagonists, melatonin receptor agonists, and molecules that modulate the circadian clock.

Sleep and agitation in nursing home residents with and without dementia

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Metabolic and Non-Cognitive Manifestations of Alzheimer's Disease: The Hypothalamus as Both Culprit and Target of Pathology

Alzheimer's disease (AD) is increasingly recognized as a complex neurodegenerative disease beginning decades prior to the cognitive decline. While cognitive deficits remain the cardinal manifestation of AD, metabolic and non-cognitive abnormalities, such as alterations in body weight and neuroendocrine functions, are also present, often preceding the cognitive decline. Furthermore, hypothalamic dysfunction can also be a driver of AD pathology. Here we offer a brief appraisal of hypothalamic dysfunction in AD and provide insight into an underappreciated dual role of the hypothalamus as both a culprit and target of AD pathology, as well as into new opportunities for therapeutic interventions and biomarker development.

Effect of an interactive therapeutic robotic animal on engagement, mood states, agitation and psychotropic drug use in people with dementia: a cluster-randomised controlled trial protocol

INTRODUCTION

Apathy, agitated behaviours, loneliness and depression are common consequences of dementia. This trial aims to evaluate the effect of a robotic animal on behavioural and psychological symptoms of dementia in people with dementia living in long-term aged care.

METHODS AND ANALYSIS

A cluster-randomised controlled trial with three treatment groups: PARO (robotic animal), Plush-Toy (non-robotic PARO) or Usual Care (Control). The nursing home sites are Australian Government approved and accredited facilities of 60 or more beds. The sites are located in South-East Queensland, Australia. A sample of 380 adults with a diagnosis of dementia, aged 60 years or older living in one of the participating facilities will be recruited. The intervention consists of three individual 15 min non-facilitated sessions with PARO or Plush-Toy per week, for a period of 10 weeks. The primary outcomes of interest are improvement in agitation, mood states and engagement. Secondary outcomes include sleep duration, step count, change in psychotropic medication use, change in treatment costs, and staff and family perceptions of PARO or Plush-Toy. Video data will be analysed using Noldus XT Pocket Observer; descriptive statistics will be used for participants' demographics and outcome measures; cluster and individual level analyses to test all hypotheses and Generalised Linear Models for cluster level and Generalised Estimation Equations and/or Multi-level Modeling for individual level data.

ETHICS AND DISSEMINATION

The study participants or their proxy will provide written informed consent. The Griffith University Human Research Ethics Committee has approved the study (NRS/03/14/HREC). The results of the study will provide evidence of the efficacy of a robotic animal as a psychosocial treatment for the behavioural and psychological symptoms of dementia. Findings will be presented at local and international conference meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry number ACTRN12614000508673 date registered 13/05/2014.

Wrist Actigraphy: A Simple Way to Record Motor Activity in Elderly Patients with Dementia and Apathy or Aberrant Motor Behavior

INTRODUCTION

In dementia, behavioral psychological symptoms are frequent and variable.

OBJECTIVE

To assess the value of wrist actigraphy as a measure of disorder in motor behavior especially apathy, aberrant motor behavior, agitation and anxiety.

METHODS

Cross sectional observational study of consecutive patients older than 75 years admitted to an intermediate care unit of a geriatric hospital ward during a two-year period. Psycho behavioral symptoms and cognitive status were assessed using the NPI scale and MMSE and diagnosis of dementia was done using DSMIV criteria. A wrist actigraph was worn for 10 days to record motor activity, sleep time and number of periods of sleep.

RESULTS

183 patients were included. Among patients with dementia, a significant decrease in motor activity was recorded in those with apathy from 9h to 12h and 18h to 21h (p <0.05) and in those with anxiety from 21h to 24h (p <0.05). Aberrant motor behavior in dementia was associated with a significant increase in motor activity from 21h to 24h (p <0.01). Agitation was not associated with a significant differences in motor activity.

CONCLUSIONS

Wrist actigraphy can be used to record motor activity in elderly patients with dementia especially in those with apathy and aberrant motor behavior.

Personalized medicine for pathological circadian dysfunctions

The recent approval of a therapeutic for a circadian disorder has increased interest in developing additional medicines for disorders characterized by circadian disruption. However, previous experience demonstrates that drug development for central nervous system (CNS) disorders has a high failure rate. Personalized medicine, or the approach to identifying the right treatment for the right patient, has recently become the standard for drug development in the oncology field. In addition to utilizing Companion Diagnostics (CDx) that identify specific genetic biomarkers to prescribe certain targeted therapies, patient profiling is regularly used to enrich for a responsive patient population during clinical trials, resulting in fewer patients required for statistical significance and a higher rate of success for demonstrating efficacy and hence receiving approval for the drug. This personalized medicine approach may be one mechanism that could reduce the high clinical trial failure rate in the development of CNS drugs. This review will discuss current circadian trials, the history of personalized medicine in oncology, lessons learned from a recently approved circadian therapeutic, and how personalized medicine can be tailored for use in future clinical trials for circadian disorders to ultimately lead to the approval of more therapeutics for patients suffering from circadian abnormalities.

Cognitive-behavioural group therapy improves a psychophysiological marker of stress in caregivers of patients with Alzheimer's disease

BACKGROUND

Family caregivers of patients with dementia frequently experience psychological stress, depression and disturbed psychophysiological activity, with increased levels of diurnal cortisol secretion.

OBJECTIVES

To compare the effects of a cognitive-behavioural group therapy (CBT) to a psychoeducation group programme (EDUC) on cortisol secretion in caregivers of patients with moderate Alzheimer's disease (AD).

METHOD

Caregivers of AD outpatients were semi-randomly allocated to one of two intervention programmes (CBT or EDUC) consisting of eight weekly sessions. Twenty-six participants completed the study. Before and after intervention, salivary cortisol was collected at four different times of the day. Effects of the interventions were evaluated with self-report psychological scales and questionnaires related to functional abilities and neuropsychiatric symptoms of the AD relative.

RESULTS

Only in the CBT group did salivary cortisol levels significantly decrease after intervention, with a large effect size and high achieved power. Both groups reported a reduction of neuropsychiatric symptoms of their AD relative after intervention.

CONCLUSION

Psychoeducation for caregivers may contribute to a reduction of neuropsychiatric symptoms of AD patients while CBT additionally attenuates psychophysiological responses to stressful situations in caregivers, by reducing diurnal cortisol levels. This may lead to a positive impact in the general health of the caregiver, eventually resulting in better care of the AD patient.

Recommendations of the Sleep Study Group of the Italian Dementia Research Association (SINDem) on clinical assessment and management of sleep disorders in individuals with mild cognitive impairment and dementia: a clinical review

Clinical assessment and management of sleep disturbances in patients with mild cognitive impairment and dementia has important clinical and social implications. Poor sleep results in an increased risk of morbidities and mortality in demented patients and is a source of stress for caregivers. Sleep disturbances show high prevalence in mild cognitive impairment and dementia patients and they are often associated one to another in the same patient. A careful clinical evaluation of sleep disorders should be performed routinely in the clinical setting of individuals with cognitive decline. The Sleep Study Group of the Italian Dementia Research Association (SINDem) reviewed evidence from original research articles, meta-analyses and systematic reviews published up to December 2013. The evidence was classified in quality levels (I, II, III) and strength of recommendations (A, B, C, D, E). Where there was a lack of evidence, but clear consensus, good practice points were provided. These recommendations may not be appropriate for all circumstances and should therefore be adopted only after a patient's individual characteristics have been carefully evaluated.

Early and progressive circadian abnormalities in Huntington's disease sheep are unmasked by social environment

Insidious changes in behaviour herald the onset of progressive neurodegenerative disorders such as Huntington's disease (HD), sometimes years before overt symptoms are seen. Sleep and circadian disturbances are particularly disruptive symptoms in patients with neurological disorders, but they are difficult to measure in humans. Here we studied circadian behaviour in transgenic HD sheep expressing the full-length human huntingtin protein with an expanded CAG repeat mutation in the juvenile range. Young HD sheep with no other symptoms exhibited circadian behavioural abnormalities that worsened with age. The most obvious change was a disturbed evening behaviour reminiscent of 'sundowning' that is seen in some patients with dementia. There were no structural abnormalities seen with magnetic resonance imaging, even in 5-year-old HD sheep. Interestingly, detection of the circadian abnormalities depended upon their social grouping. Abnormalities emerged in sheep kept in an 'HD-only' flock, whereas the behaviour of HD sheep kept mixed with normal sheep was relatively normal. Sleep-wake abnormalities in HD patients are also likely to be hidden, and may precede overt symptoms by many years. Sleep disruption has deleterious effects, even in normal people. The knock-on effects of sleep-wake disturbance may exacerbate, or even cause symptoms such as irritability and depression that are common in early stage HD patients. HD sheep will be useful models for probing the mechanisms underlying circadian behavioural disorder in HD.

The trouble with circadian clock dysfunction: multiple deleterious effects on the brain and body

This review consolidates research employing human correlational and experimental work across brain and body with experimental animal models to provide a more complete representation of how circadian rhythms influence almost all aspects of life. In doing so, we will cover the morphological and biochemical pathways responsible for rhythm generation as well as interactions between these systems and others (e.g., stress, feeding, reproduction). The effects of circadian disruption on the health of humans, including time of day effects, cognitive sequelae, dementia, Alzheimer's disease, diet, obesity, food preferences, mood disorders, and cancer will also be discussed. Subsequently, experimental support for these largely correlational human studies conducted in non-human animal models will be described.