Behavioral and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment

Clinical efficacy of lamotrigine and changes in the dosages of concomitantly used psychotropic drugs in Alzheimer's disease with behavioural and psychological symptoms of dementia: a preliminary open-label trial

AIM

We investigated the clinical efficacy and changes in the dosages of concomitantly used psychotropic drugs in lamotrigine therapy in Alzheimer's disease with behavioural and psychological symptoms of dementia (BPSD).

METHODS

This study was a 16-week, preliminary open-label trial. The subjects were 40 inpatients. The outcome measures assessed were BPSD and cognitive function. BPSD was assessed with the Neuropsychiatric Inventory (NPI) and cognitive function was assessed with the Mini-Mental State Examination. The changes in the dosages of concomitant psychotropic drugs were also assessed.

RESULTS

Although the mean changes from baseline NPI scores and the two NPI subscales (anxiety and irritability) were significantly lower within the lamotrigine therapy group, no significant differences were found when we compared the lamotrigine therapy group to the control group. The mean decrease from baseline on the NPI agitation subscale, however, was significantly greater in the lamotrigine therapy group than in the control group (P < 0.05). Furthermore, the mean decrease from baseline in the diazepam-equivalent dose was significantly greater in the lamotrigine therapy group than in the control group (P < 0.05).

CONCLUSIONS

The results of this study suggest that the administration of lamotrigine to patients with severe Alzheimer's disease with BPSD may be effective and may make it possible to avoid increasing the dosage of antipsychotic medications prescribed to elderly patients.

Development of a new assessment scale for measuring interaction during staff-assisted transfer of residents in dementia special care units

Background

Mobility problems and cognitive deficits related to transferring or moving persons suffering from dementia are associated with dependency. Physical assistance provided by staff is an important component of residents’ maintenance of mobility in dementia care facilities. Unfortunately, hands-on assistance during transfers is also a source of confusion in persons with dementia, as well as a source of strain in the caregiver. The bidirectional effect of actions in a dementia care dyad involved in transfer is complicated to evaluate. This study aimed to develop an assessment scale for measuring actions related to transferring persons with dementia by dementia care dyads.

Methods

This study was performed in four phases and guided by the framework of the biopsychosocial model and the approach presented by Social Cognitive Theory. These frameworks provided a starting point for understanding reciprocal effects in dyadic interaction. The four phases were 1) a literature review identifying existing assessment scales; 2) analyses of video-recorded transfer of persons with dementia for further generation of items, 3) computing the item content validity index of the 93 proposed items by 15 experts; and 4) expert opinion on the response scale and feasibility testing of the new assessment scale by video observation of the transfer situations.

Results

The development process resulted in a 17-item scale with a seven-point response scale. The scale consists of two sections. One section is related to transfer-related actions (e.g., capability of communication, motor skills performance, and cognitive functioning) of the person with dementia. The other section addresses the caregivers’ facilitative actions (e.g., preparedness of transfer aids, interactional skills, and means of communication and interaction). The literature review and video recordings provided ideas for the item pool. Expert opinion decreased the number of items by relevance ratings and qualitative feedback. No further development of items was performed after feasibility testing of the scale.

Conclusions

To enable assessment of transfer-related actions in dementia care dyads, our new scale shows potential for bridging the gap in this area. Results from this study could provide health care professionals working in dementia care facilities with a useful tool for assessing transfer-related actions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0003-6) contains supplementary material, which is available to authorized users.

Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition

BACKGROUND

Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome. The International Psychogeriatric Association formed an Agitation Definition Work Group (ADWG) to develop a provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies. A consensus definition will facilitate communication and cross-study comparison and may have regulatory applications in drug development programs.

METHODS

The ADWG developed a transparent process using a combination of electronic, face-to-face, and survey-based strategies to develop a consensus based on agreement of a majority of participants. Nine-hundred twenty-eight respondents participated in the different phases of the process.

RESULTS

Agitation was defined broadly as: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related). A majority of the respondents rated all surveyed elements of the definition as "strongly agree" or "somewhat agree" (68-88% across elements). A majority of the respondents agreed that the definition is appropriate for clinical and research applications.

CONCLUSIONS

A provisional consensus definition of agitation has been developed. This definition can be used to advance interventional and non-interventional research of agitation in patients with cognitive impairment.

Role of antipsychotics for treating behavioral and psychological symptoms of dementia

Over the past three decades, concerns about the high prevalence of antipsychotic use in the nursing homes (NHs) for the management of behavioral and psychological symptoms of dementia continue to be emphasized and intervened by many. However, despite the numerous side effects and the recent blackbox warning by the United States Food and Drug Administration about the increased risks for stroke and sudden death associated with the use of antipsychotics in dementia, the prevalence of antipsychotic use in NHs remains high. While the use of antipsychotics appeared to have modest efficacy in reducing symptoms of aggression and psychosis in dementia, there is insufficient evidence to routinely recommend the use of alternative psychopharmacological treatments for these symptoms. Hence, clinicians have to balance the safety warnings against the need to treat these symptoms in order to prevent harm to the resident that may result from his/her dangerous behaviors. Although the use of antipsychotics may be warranted in some cases, organizational, resource and training support should be provided to encourage and equip NH staff to participate in interventions so as to minimize inappropriate use of these medicines in NHs. This review will discuss the place in therapy, the trend and appropriateness of antipsychotic use in NHs, as well as the effectiveness of current and future strategies for reducing antipsychotic use in the NHs.

An evaluation of primary care led dementia diagnostic services in Bristol

BACKGROUND

Typically people who go to see their GP with a memory problem will be initially assessed and those patients who seem to be at risk will be referred onto a memory clinic. The demographic forces mean that memory services will need to expand to meet demand. An alternative may be to expand the role of primary care in dementia diagnosis and care. The aim of this study was to contrast patient, family member and professional experience of primary and secondary (usual) care led memory services.

METHODS

A qualitative, participatory study. A topic guide was developed by the peer and professional panels. Data were collected through peer led interviews of people with dementia, their family members and health professionals.

RESULTS

Eleven (21%) of the 53 GP practices in Bristol offered primary care led dementia services. Three professional panels were held and were attended by 9 professionals; nine carers but no patients were involved in the three peer panels. These panels identified four main themes: GPs rarely make independent dementia diagnosis; GPs and memory nurses work together; patients and carers generally experience a high quality diagnostic service; an absence of post diagnostic support. Evidence relating to these themes was collected through a total of 46 participants took part; 23 (50%) in primary care and 23 (50%) in the memory service.

CONCLUSIONS

Patients and carers were generally satisfied with either primary or secondary care led approaches to dementia diagnosis. Their major concern, shared with many health care professionals, was a lack of post diagnostic support.

Initial and long-term evaluation of patients with Alzheimer's after hospitalization in cognitive and behavioural units: the EVITAL study design

BACKGROUND

Alzheimer's disease and related disorders are characterized by cognitive impairment associated with behavioral and psychological symptoms of dementia. These symptoms have significant consequences for both the patient and his family environment. While risk factors for behavioral disorders have been identified in several studies, few studies have focused on the evolution of these disorders. Moreover, it is important to identify factors linked to the long-term evolution of behavioral disorders, as well as patients' and caregivers' quality of life. Our purpose is to present the methodology of the EVITAL study, which primary objective is to determine the factors associated with the evolution of behavioral disorders among patients with Alzheimer's disease and related disorders during the year following their hospitalization in cognitive and behavioral units. Secondary objectives were 1) to assess the factors related to the evolution of behavioral disorders during hospitalization in cognitive and behavioral units; 2) to identify the factors linked to patients' and caregivers' quality of life, as well as caregivers' burden; 3) to assess the factors associated with rehospitalization of the patients for behavioral disorders in the year following their hospitalization in cognitive and behavioral units.

METHOD/DESIGN

A multicenter, prospective cohort of patients with Alzheimer's disease and related disorders as well as behavioral disorders who are hospitalized in cognitive and behavioral units. The patients will be included in the study for a period of 24 months and followed-up for 12 months. Socio-demographic and environmental data, behavioral disorders, medications, patients and caregivers quality of life as well as caregivers burden will be assessed throughout hospitalization in cognitive and behavioral units. Follow-up will be performed at months 3, 6 and 12 after hospitalization. Socio-demographic and environmental data, behavioral disorders, medications, patients and caregivers quality of life, unplanned rehospitalization as well as caregivers burden will also be assessed at each follow-up interview.

DISCUSSION

The present study should help better identify the factors associated with reduction or stabilization of the behavioral and psychological symptoms of dementia in patients with Alzheimer's disease. It could therefore help clinicians to better manage these symptoms.

TRIAL REGISTRATION

Clinical Trials NCT01901263. Registered July 9, 2013.

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

Background

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

Methods

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

Results

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

Conclusion

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

Personality, Alzheimer's disease and behavioural and cognitive symptoms of dementia: the PACO prospective cohort study protocol

Background

Alzheimer’s disease is characterised by a loss of cognitive function and behavioural problems as set out in the term “Behavioural and Psychological Symptoms of Dementia”. These behavioural symptoms have heavy consequences for the patients and their families.

A greater understanding of behavioural symptoms risk factors would allow better detection of those patients, a better understanding of crisis situations and better management of these patients. Some retrospective studies or simple observations suggested that personality could play a role in the occurrence of behavioural symptoms. Finally, performance in social cognition like facial recognition and perspective taking could be linked to certain personality traits and the subsequent risks of behavioural symptoms.

We propose to clarify this through a prospective, multicentre, multidisciplinary study.

Main Objective:

- To assess the effect of personality and life events on the risk of developing behavioural symptoms.

Secondary Objectives:

- To evaluate, at the time of inclusion, the connection between personality and performance in social cognition tests;

- To evaluate the correlation between performance in social cognition at inclusion and the risks of occurrence of behavioural symptoms;

- To evaluate the correlation between regional cerebral atrophy, using brain Magnetic Resonance Imaging at baseline, and the risk of behavioural symptoms.

Methods/Design

Study type and Population: Prospective multicentre cohort study with 252 patients with Alzheimer’s disease at prodromal or mild dementia stage.

The inclusion period will be of 18 months and the patients will be followed during 18 months. The initial evaluation will include: a clinical and neuropsychological examination, collection of behavioural symptoms data (Neuropsychiatric-Inventory scale) and their risk factors, a personality study using both a dimensional (personality traits) and categorical approach, an inventory of life events, social cognition tests and an Magnetic Resonance Imaging. Patients will be followed every 6 months (clinical examination and collection of behavioural symptoms data and risk factors) during 18 months.

Discussion

This study aims at better identifying the patients with Alzheimer’s disease at high risk of developing behavioural symptoms, to anticipate, detect and quickly treat these disorders and so, prevent serious consequences for the patient and his caregivers.

Trial registration

ClincalTrials.gov: NCT01297140

Sleep disturbances and predictive factors in caregivers of patients with mild cognitive impairment and dementia

Background and Purpose

We examined the characteristics of sleep disturbances and sleep patterns in the caregivers of patients with amnestic mild cognitive impairment (aMCI) and dementia.

Methods

We prospectively studied 132 patients (60 with aMCI and 72 with dementia) and their caregivers, and 52 noncaregiver controls. All caregivers and controls completed several sleep questionnaires, including the Pittsburgh Sleep Quality Index (PSQI). The patients were administered neuropsychological tests and the neuropsychiatric inventory to evaluate their behavioral and neuropsychiatric symptoms of dementia (BPSD).

Results

The PSQI global score was 6.25±3.88 (mean±SD) for the dementia caregivers and 5.47±3.53 for the aMCI caregivers. The Insomnia Severity Index (ISI) and short form of the Geriatric Depression Scale (GDS-S) predicted higher PSQI global scores in aMCI caregivers, and higher scores for the ISI, Epworth Sleepiness Scale (ESS), and GDS-S in dementia caregivers. BPSD, including not only agitation, depression, and appetite change in dementia patients, but also depression, apathy, and disinhibition in aMCI patients, was related to impaired sleep quality of caregivers, but nighttime behavior was not. Age and gender were not risk factors for disturbed sleep quality.

Conclusions

Dementia and aMCI caregivers exhibit impaired quality of sleep versus non-caregivers. ISI, GDS-S, and ESS scores are strong indicators of poor sleep in dementia caregivers. In addition, some BPSD and parts of the neuropsychological tests may be predictive factors of sleep disturbance in dementia caregivers.

Neuropsychiatric profiles in patients with Alzheimer's disease and vascular dementia

Background/Aims:

The aim of the following study is to compare the behavioral and psychological symptoms of dementia (BPSD) in patients of Alzheimer disease (AD) and vascular dementia (VaD).

Materials and Methods:

We used National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for diagnosing AD and National Institute of Neurological Disorders and Stroke-Association International pour la Recherche et l’Enseignement en Neurosciences Criteria for diagnosing VaD. VaD cohort was further subcategorized into small vessel and large vessel disease. The severity of cognitive impairment and the BPSD were studied by means of the Clinical Dementia Rating Scale (CDR) and the Neuropsychiatric Inventory respectively.

Results:

We studied 50 AD and 50 VaD patients of whom 38 were small vessels and 12 were large vessels VaD. The severity of dementia was comparable in both groups. The agitation/aggression, depression/dysphoria, anxiety, apathy/indifference, irritability, aberrant motor behavior, appetite and eating behavior and night-time behaviors occurred significantly more frequently in patients with VaD than AD. We found a weak positive correlation between the CDR score and the number of neuropsychiatric symptoms per patient in both cohorts. Elation/euphoria, agitation/aggression was significantly more frequent in patients with large vessel in comparison to small vessel VaD.

Conclusions:

BPSD are common in both types of dementia and they are more severe in VaD than AD when the groups have similar levels of cognitive impairment.

Monoaminergic neurotransmitter alterations in postmortem brain regions of depressed and aggressive patients with Alzheimer's disease

Depression and aggression in Alzheimer's disease (AD) are 2 of the most severe and prominent neuropsychiatric symptoms (NPS). Altered monoaminergic neurotransmitter system functioning has been implicated in both NPS, although their neurochemical etiology remains to be elucidated. Left frozen hemispheres of 40 neuropathologically confirmed AD patients were regionally dissected. Dichotomization based on depression and aggression scores resulted in depressed/nondepressed (AD + D/AD - D) and aggressive/nonaggressive (AD + Agr/AD - Agr) groups. Concentrations of dopamine, serotonin (5-HT), (nor)epinephrine ((N)E), and respective metabolites were determined using reversed-phase high-performance liquid chromatography. Significantly lower 3-methoxy-4-hydroxyphenylglycol (MHPG) and higher homovanillic acid levels were observed in Brodmann area (BA) 9 and 10 of AD + D compared with AD - D. In AD + Agr, 5-hydroxy-3-indoleacetic acid (5-HIAA) levels in BA9, 5-HIAA to 5-HT ratios in BA11, and MHPG, NE, and 5-HIAA levels in the hippocampus were significantly decreased compared with AD - Agr. These findings indicate that brain region-specific altered monoamines and metabolites may contribute to the occurrence of depression and aggression in AD.

Grouping of behavioural and psychological symptoms of dementia

OBJECTIVE

A wide range of behavioural and psychological symptoms (BPSD) are common in dementia, and it has been suggested that groups of correlated symptoms should be studied together. Here, we describe the groups of BPSD that have been identified in the literature and how they have been used to study associations, burden, treatment and underlying biology.

METHODS

The literature database PubMed was searched for articles that identified clusters or factors of BPSD or used previously defined symptom groups.

RESULTS

Sixty-two studies were included. Generally, the following symptom groups were suggested: affective symptoms, including depression and anxiety; psychosis, including delusions and hallucinations; hyperactivity, including irritability and aggression; and euphoria. Symptoms that did not show consistent results include apathy, eating disturbances, night-time behaviour disturbances, disinhibition and aberrant motor behaviour. Symptom groups differed in their associations, treatment and biology.

CONCLUSIONS

Studies investigating symptom groups show relatively consistent results. Studying symptom groups allows similar symptoms to be studied together, which might strengthen results and may point to differences in their aetiology and treatment. However, a large amount of the individual variability of the symptoms could not be explained by the factors, and authors should carefully address their research question and hypotheses to decide if symptoms should be studied in groups or individually. Clinicians need to consider each symptom in its own right and also to be aware of the interrelations between them when assessing patients and developing strategies for treatment.

COMMUNI-CARE: Assessment tool for reactions and behaviours of patients with dementia in a multisensory stimulation environment

BACKGROUND

The 'Snoezelen' is an approach based on stimulation and sensory stimulation proposals, giving priority to the notion of caretaking. The aim of this paper is to present the creation and validation of the COMMUNI-CARE scale. This is a new tool that allows for an evaluation of the psycho-emotional well-being that the patient with dementia shows in a 'Snoezelen' multisensory stimulation environment.

METHODS

In total 429 evaluations in 143 multisensory stimulation interventions were made using the COMMUNI-CARE scale, in 16 patients between 53 and 85 years of age, diagnosed with moderate to severe dementia. The goal was to evaluate the psycho-emotional well-being the patients present.

RESULTS

The tool's internal consistency showed a Crombach alpha of 0.90. The concurrent validity between the COMMUNI-CARE scale and the Clinical Global Impression (CGI) was of r = -0.961. The Kappa index used to determine the reliability between evaluators was of K = 0.87.

CONCLUSIONS

The COMMUNI-CARE scale fulfills the basic principles of classic psychometrics of construct, and criterion validity and reliability. It does so while showing a clear idea, through its five subscales (anxiety, communication, pleasure, adaptation to the surroundings and affection), of the degree of well-being that the patient with dementia shows during such interventions. This scale embodies, through psychometrics, a very subjective human experience with a tool unavailable to date.

Managing resident-to-resident elder mistreatment in nursing homes: the SEARCH approach

This article describes an educational program to inform nursing and care staff of the management of resident-to-resident elder mistreatment (R-REM) in nursing homes, using the SEARCH (Support, Evaluate, Act, Report, Care plan, and Help to avoid) approach. Although relatively little research has been conducted on this form of abuse, there is mounting interest in R-REM because such aggression has been found to be extensive and can have both physical and psychological consequences for residents and staff. The goal of the SEARCH approach is to support staff in the identification and recognition of R-REM as well as to suggest recommendations for management. The educational program and the SEARCH approach are described. Three case studies from the research project are presented, illustrating how nurses and care staff can use the SEARCH approach to manage R-REM in nursing homes. Resident and staff safety and well-being can be enhanced by the use of the evidence-based SEARCH approach.

The influence and changes in the dosages of concomitantly used psychotropic drugs associated with the discontinuation of donepezil in severe Alzheimer's disease with behavioral and psychological symptoms on dementia: a preliminary open-label trial

OBJECTIVE

We investigated the influence on behavioral and psychological symptoms on dementia (BPSD) and the changes in the dosages of concomitant psychotropic drugs associated with the discontinuation of donepezil in patients with severe Alzheimer's disease (AD) who developed BPSD during donepezil therapy.

METHODS

The subjects were 44 inpatients who had been diagnosed with AD according to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). The outcome measures assessed were BPSD and cognitive function. BPSD was assessed using the Neuropsychiatric Inventory (NPI) and cognitive function was assessed using the Mini Mental Examination (MMSE). The changes in the dosages of concomitant psychotropic drugs were also assessed.

RESULTS

Significant decreases were found in the donepezil treatment discontinuation group in the following NPI total score and two NPI subscales (agitation and irritability), but no significant differences were seen between the donepezil treatment discontinuation group and the control group. Furthermore, the mean changes from baseline in the risperidone equivalent dose and the diazepam equivalent dose were hardly changed in the donepezil treatment discontinuation group.

CONCLUSION

The results of this study suggest that the discontinuation of donepezil treatment in patients with AD with BPSD may afford superior efficacy and may make it possible to not increase the dosage of other psychotropic drugs.

The profile of behavioral and psychological symptoms in vascular cognitive impairment with and without dementia

OBJECTIVE

The objective of this study was to compare the occurrence and severity of behavioral and psychological symptoms of dementia (BPSD) between vascular dementia (VaD) and vascular cognitive impairment-no dementia (VCI-ND).

MATERIALS AND METHODS

Consecutive patients presenting with cognitive impairment at least 3 months after an ischemic stroke and with a Hachinski Ischemic Score ≥4 were included. VaD was diagnosed as per National Institute of Neurological Disorders and Stroke - Association Internationale pour la Recherche et l'Enseignement en Neurosciences criteria for probable VaD and VCI-ND on the lines of the Canadian study of health and aging. The severity of cognitive impairment and the behavioral/psychological symptoms were studied by means of the clinical dementia rating scale and the neuropsychiatric inventory (NPI) respectively.

RESULTS

All patients with VaD and 89% of those with VCI-ND had at least one BPSD. The mean no. of symptoms per patient and the total NPI scores were higher in VaD than in VCI-ND. Apathy and night-time behavior disturbances were significantly more common and severe in VaD.

CONCLUSIONS

BPSD are very common both in VCI-ND and in VaD. The profile of BPSD is similar in both groups, albeit more severe in VaD. The net burden of BPSD is higher in VaD as compared to VCI-ND.

Parkinson disease in long term care facilities: a review of the literature

Parkinson disease (PD) is common in long term care (LTC) facilities. The number of institutionalized patients with PD will rise sharply in the coming decades because of 2 concurrent phenomena: aging of the population leads to an increased PD prevalence and improved quality of care has led to a prolonged survival in advanced disease stages. Only a few studies have investigated the prevalence and clinical characteristics of patients with PD in LTC facilities. Even fewer studies have addressed the treatment strategies used to support these institutionalized patients, who are mostly in advanced stages of the disease. The available evidence suggests that current management of patients with PD in LTC facilities is less than optimal. In the Netherlands, and we suspect in many other countries, there are no formal guidelines for treating patients with PD who have been admitted to a LTC facility. In this review, we describe the epidemiology, clinical characteristics, and clinical management of patients with PD in LTC settings. We also address potentially modifiable elements of care and provide several recommendations to improve the management of PD in these facilities. We conclude by suggesting a possible guide for future research in this area.

Responsiveness of the QUALID to Improved Neuropsychiatric Symptoms in Patients with Alzheimer's Disease

BACKGROUND

This study aimed to determine whether the Quality of Life in Late-Stage Dementia (QUALID) scale is responsive to changes in behaviour due to therapeutic intervention.

METHOD

31 long-term care residents with moderate to severe AD and agitation/aggression entered a three-month, open-label trial of memantine 10 mg BID. The relationships between the QUALID and BPSD, global improvement, and cognition at baseline and endpoint, as well as the changes in these scales as a result of treatment, were examined.

RESULTS

Despite a significant improvement in agitation and aggression (NPI agitation, F3,90 = 3.721, p =.014; CMAI total, F3,90 = 6.301, p =.001) and overall behaviour (NPI total, F3,90 = 4.035, p =.010), there was no significant change in QUALID score (t30 = -0.278, p =.783). The QUALID was correlated with NPI at baseline (τ = 0.270, p =.037) and endpoint (τ = 0.404, p =.002), but change scores were not correlated (τ = 0.107, p =.412).

CONCLUSION

While the QUALID correlates with behavioural measures at single time points, it does not appear to correlate with changes longitudinally associated with treatment.

Behavioral symptoms related to cognitive impairment

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

Correlation between neuropsychiatric symptoms and caregiver burden in a population-based sample from São Paulo, Brazil: a preliminary report

Neuropsychiatric symptoms and caregiver burden are highly prevalent in older adults with Alzheimer's disease (AD).OBJECTIVE: To evaluate the correlation between neuropsychiatric symptoms and caregiver burden in a community-based sample from São Paulo, Brazil.

METHODS

A total of 1,563 randomly-selected subjects were assessed by the Mini-Mental State Examination, Fuld Object Memory Evaluation, Informant Questionnaire on Cognitive Decline in the Elderly and Bayer - Activities of Daily Living Scale. Subjects considered screen-positives were submitted to a dementia workup and diagnosis was determined according to ICD-10 criteria. The neuropsychiatric Inventory was applied to caregivers to evaluate neuropsychiatric symptoms and the Zarit Burden Interview was also applied to assess caregivers' burden.

RESULTS

Sixty-one AD patients, 25 Cognitively Impaired Non Demented (CIND) and 79 healthy elderly subjects were evaluated. Zarit mean scores for controls, CIND and AD were 2.32, 3.92 and 20.11, respectively. There was strong positive correlation between total NPI and Zarit scores.

CONCLUSION

In conclusion, neuropsychiatric symptoms showed a significant association with higher rates of caregiver stress.

Clinical efficacy and changes in the dosages of concomitantly used psychotropic drugs in memantine therapy in Alzheimer's disease with behavioral and psychological symptoms on dementia

OBJECTIVE

We investigated the clinical efficacy and changes in the dosages of concomitantly used psychotropic drugs in memantine therapy in Alzheimer's disease (AD) with behavioral and psychological symptoms on dementia (BPSD).

METHODS

The subjects were 38 inpatients who had been diagnosed with AD according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The outcome measures assessed were BPSD and cognitive function. BPSD was assessed using the neuropsychiatric inventory (NPI) and cognitive function was assessed using the mini-mental examination (MMSE). The changes in the dosages of concomitant psychotropic drugs were also assessed.

RESULTS

SIGNIFICANT DECREASES WERE FOUND IN THE MEMANTINE THERAPY GROUP IN THE FOLLOWING NPI TOTAL SCORE AND FIVE NPI SUBSCALES: delusions, hallucinations, agitation, irritability, and aberrant motor behavior, but no significant differences were seen between the memantine therapy group and the control group. Furthermore, the memantine therapy group allowed the dosage of the psychotropic drugs to be significantly reduced compared with the control group.

CONCLUSION

The results of this study suggest that the administration of memantine to patients with AD with BPSD may afford superior efficacy and may also make it possible to reduce the risperidone equivalent dose, the diazepam equivalent dose and the dosage of the psychotropic drugs.

How do family carers respond to behavioral and psychological symptoms of dementia?

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) have been associated with increased carer burden and early institutionalization. BPSD are more responsive to treatment than are cognitive and functional decline. Little is known about how family carers understand and try to reduce these symptoms. This study aimed to explore the strategies used by carers looking after someone with high levels of BPSD.

METHODS

Twenty-five carers were interviewed using a semi-structured interview with the Neuropsychiatric Inventory (NPI). They were all caring for someone eligible for an Extended Aged Care at Home Dementia Package, which targets people with BPSD.

RESULTS

Participants reported high levels of BPSD with a mean score of 8.2 for symptoms (range 2-12, SD = 2.38) and a mean NPI score of 51.4 (range 14-111, SD = 28.74). Distress scores were also high with a mean of 18.5 (range 2-42, SD = 11.33). Carers described on average, fewer than four strategies for managing BPSD. Encouraging activity, utilizing psychotropic medications, identifying triggers, restraining or treating in a paternalistic manner, and meeting physiological needs were the most commonly used strategies.

CONCLUSION

While family carers are often at the forefront of identifying triggers and addressing unmet needs, findings from this study suggest that some carers have a limited repertoire of strategies despite experiencing a large number of symptoms. There is a clear need for ensuring evidence-based programs to educate and support carers in identifying triggers, understanding symptoms and learning to cope with these symptoms.

Assessing dementia in resource-poor regions

The numbers and proportions of elderly are increasing rapidly in developing countries, where prevalence of dementia is often high. Providing cost-effective services for dementia sufferers and their caregivers in these resource-poor regions poses numerous challenges; developing resources for diagnosis must be the first step. Capacity building for diagnosis involves training and education of healthcare providers, as well as the general public, development of infrastructure, and resolution of economic and ethical issues. Recent progress in some low-to-middle-income countries (LMICs) provides evidence that partnerships between wealthy and resource-poor countries, and between developing countries, can improve diagnostic capabilities. Without the involvement of the mental health community of developed countries in such capacity-building programs, dementia in the developing world is a disaster waiting to happen.

Relationship between delirium and behavioral symptoms of dementia

BACKGROUND

Persons with dementia frequently present behavioral and psychological symptoms as well as delirium. However, the association between these has received little attention from researchers and current knowledge in this area is limited. The purpose of this study was to examine the relation between delirium and behavioral symptoms of dementia (BSD).

METHODS

Participants were 155 persons with a diagnosis of dementia, 109 (70.3%) of whom were found delirious according to the Confusion Assessment Method. BSD were assessed using the Nursing Home Behavior Problem Scale.

RESULTS

Participants with delirium presented significantly more BSD than participants without delirium. More specifically, they presented more wandering/trying to leave, sleep problems, and irrational behavior after controlling for cognitive problems and use of antipsychotics and benzodiazepines. Most relationships between participant characteristics and BSD did not differ according to the presence or absence of delirium, but some variables, notably sleep problems, were more strongly associated to BSD in persons with delirium.

CONCLUSIONS

Although correlates of BSD in persons with delirium superimposed on dementia are generally similar to those in persons with dementia alone, delirium is associated with a higher level of BSD. Results of this study have practical implications for the detection of delirium superimposed on dementia, the management of behavioral disturbances in patients with delirium, and caregiver burden.

Behavioral correlates of cerebrospinal fluid amino acid and biogenic amine neurotransmitter alterations in dementia

BACKGROUND

Behavioral and psychological signs and symptoms of dementia (BPSD) are a heterogeneous group of behavioral and psychiatric disturbances occurring in dementia patients of any etiology. Research suggests that altered activities of dopaminergic, serotonergic, (nor)adrenergic, as well as amino acid neurotransmitter systems play a role in the etiopathogenesis of BPSD. In this study we attempted to identify cerebrospinal fluid (CSF) neurochemical correlates of BPSD to provide further insight into its underlying neurochemical pathophysiological mechanisms.

METHODS

Patients with probable Alzheimer's disease (AD; n = 202), probable AD with cerebrovascular disease (n = 37), probable frontotemporal dementia (FTD; n = 32), and probable dementia with Lewy bodies (DLB; n = 26) underwent behavioral assessment and lumbar puncture. CSF levels of six amino acids and several biogenic amines and metabolites were analyzed using ultraperformance liquid chromatography with fluorescence detection and reversed-phase high-performance liquid chromatography with fluorescence detection.

RESULTS

In the AD patients, CSF homovanillic acid/5-hydroxyindoleacetic acid (HVA/5HIAA) ratios correlated positively with anxieties/phobias, whereas CSF levels of taurine correlated negatively with depression and behavioral disturbances in general. In FTD patients, CSF levels of glutamate correlated negatively with verbally agitated behavior. In DLB patients, CSF levels of HVA correlated negatively with hallucinations.

CONCLUSIONS

Several neurotransmitter systems can be linked to one specific behavioral syndrome depending on the dementia subtype. In addition to biogenic amines and metabolites, amino acids seem to play a major role in the neurochemical etiology of BPSD as well.

The influence of 'cognitive busyness' on causal attributions of challenging behaviour in dementia: a preliminary experimental study

This study investigated the influence of 'cognitive busyness' (competing cognitive demands) on residential care staff attributions of challenging behaviour (CB) related to dementia. Following the model of attribution formation proposed by Gilbert, Pelham, and Krull (1988), it was hypothesised that care staff experiencing competing cognitive demands at the time of observing CBs linked with dementia would be more likely to make internal and controllable attributions regarding the causes of such behaviour. This study employed a cross-over experimental design. Thirty formal dementia care-workers viewed two video clips of simulated CB, one under conditions of cognitive 'busyness' and another under control conditions of no extra cognitive demands. These conditions occurred a week apart and were counterbalanced, i.e. one group of participants undertook the control condition first and then the experimental condition whilst another undertook the reverse. Self-report measures of attributions were administered after the viewing of each video clip. Competing cognitive demands significantly influenced staff attributions regarding CB, in relation to internality and controllability, and type of CB emerged as a potential moderating factor. No link was found between cognitive busyness and other attributional dimensions (stability and globality). Concurrent cognitive demands seem capable of impairing the ability to use situational information to form some causal attributions regarding CB in dementia but this might depend on the type of CB being witnessed. The results are discussed in relation to key methodological and conceptual issues.

Neuropsychiatric Inventory data in a Belgian sample of elderly persons with and without dementia

BACKGROUND/AIMS

This study assesses and compares prevalence of psychological and behavioral symptoms in a Belgian sample of people with and without dementia.

METHODS

A total of 228 persons older than 65 years with dementia and a group of 64 non-demented persons were assessed using the Neuropsychiatric Inventory (NPI) in 2004.

RESULTS

Within the group without dementia, the most frequent symptoms were depression, agitation, and irritability. Within the group with dementia, the most common symptoms were depression, irritability, apathy, and agitation. Prevalence of delusions (P < 0.05), hallucinations (P < 0.05), anxiety (P < 0.05), agitation (P < 0.05), apathy (P < 0.01), aberrant motor behavior (P < 0.01), and eating disorders (P < 0.05) were significantly higher in the group with dementia.

CONCLUSION

Depression, elation, irritability, disinhibition, and sleeping disorders are not specific to dementia. Agitation, apathy, anxiety, and delusions are more frequent in dementia but were not specific to the dementia group because their prevalence rates were close to 10% in the group without dementia. Hallucinations, aberrant motor behavior, and eating disorders are specific to dementia. The distinction between specific and nonspecific symptoms may be useful for etiological research on biological, psychological, and environmental factors.

The problem with "problem behaviors": a systematic review of the association between individual patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient-caregiver dyad

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSDs) are routinely cited as important predictors of caregiver burden and depression. Although BPSDs include a wide variety of patient behaviors, they are routinely grouped together as one construct to differentiate them from cognitive symptoms of dementia. Determining the specific BPSDs that result in increased depression and burden for caregivers may elucidate the stress process for caregivers and facilitate the development of effective interventions for caregivers.

METHODS

We conducted a systematic review of English-language articles published from 1990 to 2010 to determine whether there are known symptoms or symptom clusters which exert undue negative impact on caregiver depression and burden. Additionally, we review systems used for classifying BSPD symptom clusters and determine whether there have been any mechanisms studied by which individual BPSD symptoms negatively affect caregivers. Finally, we examine how the role of timing of symptoms has been examined within the literature.

RESULTS

Thirty-five original research articles examined the impact of an individual behavior symptom on caregiver burden or depression/depressive symptoms. The studies had no consistent system for categorizing symptoms. Although depression, aggression, and sleep disturbances were the most frequently identified patient symptoms to impact negatively on caregivers, a wide range of symptoms was associated with caregiver burden and depression.

CONCLUSIONS

The evidence is not conclusive as to whether some symptoms are more important than others. The studies reviewed were largely exploratory relative to the differential impact of individual BPSDs and did not focus on testing causal mechanisms by which specific symptoms exert more impact on caregiver mental health than others. Future research may benefit from the re-conceptualization of BPSDs from the perspective of their impact on the caregiver to examine hypothesis-driven differences among BPSD symptom clusters.

Ameliorative effect of yokukansan on vacuous chewing movement in haloperidol-induced rat tardive dyskinesia model and involvement of glutamatergic system

Effects of yokukansan (YKS) on vacuous chewing movement (VCM), which is an index for tardive dyskinesia, were investigated in haloperidol decanoate-treated rats. Haloperidol decanoate was injected to a thigh muscle once every four weeks for 18 weeks. The rats which exhibited VCM eight times or more in 3min were selected on the 12th week, and examined. A significant increase in VCM on the 12th week continued until the 18th week. Oral administration of YKS (0.1 and 0.5g/kg) once a day for three weeks (21 days) from the 12th week to 15th week ameliorated the haloperidol decanoate-induced increase in VCM in a dose-dependent manner. The significant ameliorative effect observed in 0.5g/kg YKS-treated rats was abolished by stopping administration for three weeks from the 15th week to the 18th week. The extracellular glutamate concentration and glutamate transporter mRNA expression in the striatum were evaluated by microdialysis and real-time reverse-transcription polymerase chain reaction assays at the 15th week. The striatal glutamate level increased in haloperidol-treated rats, and the increase was inhibited by treatment with YKS. The striatal GLT-1 mRNA level showed a tendency to decrease in the haloperidol-treated rats. The GLT-1 mRNA level after treatment with YKS (0.5g/kg) was greater than the control level. These results suggest the effect of YKS may be involved in the extracellular glutamate level and GLT-1 mRNA expression in the striatum.

Neuropsychiatric symptom clusters of Alzheimer's disease in Hong Kong Chinese: prevalence and confirmatory factor analysis of the Neuropsychiatric Inventory

BACKGROUND

The aim of this study was to investigate the clustering of symptoms on the Neuropsychiatric Inventory (NPI) and the relative prevalence of symptom clusters in mild and moderate Alzheimer's disease (AD).

METHODS

Confirmatory factor analysis (CFA) was performed on the polychoric correlation matrix of 12 NPI items (scored yes or no) using the weighted least squares with mean and variance adjustment (WLSMV) estimator in Mplus (N = 224 community-dwelling Chinese persons with mild/moderate AD). Severity of AD was determined by Clinical Dementia Rating scores. The relative model fit of three competing measurement models (also known as factor structures) was tested using a modified χ2 difference test. Prevalence rates across mild and moderate stages were compared using χ2 tests. Furthermore, the measurement model of choice was cross-validated in an independent sample of 181 community-dwelling persons with dementia.

RESULTS

CFA supported a four-factor model, namely behavioral problems (agitation/aggressiveness, disinhibition, irritability, and aberrant motor behavior), psychosis (delusions and hallucinations), mood disturbance (depression, anxiety, sleep, appetite, and apathy), and euphoria (a stand-alone item that is equivalent to the factor). The most prevalent symptom clusters were behavioral (72%) and mood (69%) disturbances, followed by psychosis (45%). Euphoria was rare (6%). All syndromes were more prevalent in moderate than in mild stage, except for euphoria. In addition, the four-factor model was replicated in the cross-validation sample.

CONCLUSIONS

The four syndromes provide a parsimonious conceptualization of neuropsychiatric symptoms corresponding to clinical observations and neurochemical changes of the disease. The independent replication in the second sample supports generalization of the four-factor model in Chinese persons with AD.

Antipsychotics in dementia: prevalence and quality of antipsychotic drug prescribing in UK mental health services

BACKGROUND

Up to a quarter of people in the UK with a diagnosis of dementia are prescribed an antipsychotic in any year. The potential risks of such treatment are becoming clearer, but the benefits remain uncertain. Concern about the frequency and quality of such prescribing was expressed in the National Dementia Strategy for England in 2009.

AIMS

To provide an estimate of the prevalence of antipsychotic use for dementia in secondary mental health services in the UK and to collect data relevant to quality improvement initiatives for such prescribing practice.

METHOD

In the context of a UK quality improvement programme, relevant clinical audit data were collected for patients with dementia under the care of specialist older people's mental health services.

RESULTS

Fifty-four mental health National Health Service (NHS) trusts submitted data on 10 199 patients. Of those patients without comorbid psychotic illness, 1620 (16%) were prescribed an antipsychotic; the common clinical indications for such medication were agitation, psychotic symptoms, aggression and distress. Multivariable regression found younger age, care home or in-patient setting, vascular or Parkinson's disease dementia and greater severity of dementia to be all significantly associated with being prescribed antipsychotic medication. Of the 1001 (62%) patients prescribed treatment for more than 6 months, only three-quarters had a documented review of therapeutic response in the previous 6 months.

CONCLUSIONS

The data reveal areas of relatively good current practice, including consideration of alternatives to antipsychotic medication and clear documentation of target symptoms. They also suggest areas for improvement, such as the frequency and quality of review of long-term medication. Strategies to reduce antipsychotic use should take account of the demographic and clinical variables predicting increased likelihood of antipsychotic prescription.

Review of cerebral microangiopathy and Alzheimer's disease: relation between white matter hyperintensities and microbleeds

Although Alzheimer's disease (AD) is basically considered to be a neurodegenerative disorder, cerebrovascular disease is also involved. The role of vascular risk factors and vascular disease in the progression of AD remains incompletely understood. With the development of brain MRI, it is now possible to detect small-vessel disease, whose prevalence and severity increase with age. The first types of small-vessel disease to be described were white matter hyperintensities (WMHs). More recently, small areas of signal loss on T(2)*-weighted images, also called microbleeds (MBs), have been reported. Cerebral MBs are focal deposits of hemosiderin that indicate prior microhemorrhages around small vessels, related to either ruptured atherosclerotic microvessels or amyloid angiopathy. Consequently, using brain MRI for the detection of microangiopathy may prove useful to improve our understanding of the impact of the vascular burden in AD pathology. The relationship between microangiopathy and the clinical course of AD or the conversion of mild cognitive impairment to AD remains questionable in terms of cognitive or affective symptoms, particularly if we consider MBs.

Systematic reviews on behavioural and psychological symptoms in the older or demented population

Introduction

Behavioural and psychological symptoms of dementia (BPS) include depressive symptoms, anxiety, apathy, sleep problems, irritability, psychosis, wandering, elation and agitation, and are common in the non-demented and demented population.

Methods

We have undertaken a systematic review of reviews to give a broad overview of the prevalence, course, biological and psychosocial associations, care and outcomes of BPS in the older or demented population, and highlight limitations and gaps in existing research. Embase and Medline were searched for systematic reviews using search terms for BPS, dementia and ageing.

Results

Thirty-six reviews were identified. Most investigated the prevalence or course of symptoms, while few reviewed the effects of BPS on outcomes and care. BPS were found to occur in non-demented, cognitively impaired and demented people, but reported estimates vary widely. Biological factors associated with BPS in dementia include genetic factors, homocysteine levels and vascular changes. Psychosocial factors increase risk of BPS; however, across studies and between symptoms findings are inconsistent. BPS have been associated with burden of care, caregiver's general health and caregiver depression scores, but findings are limited regarding institutionalisation, quality of life and disease outcome.

Conclusions

Limitations of reviews include a lack of high quality reviews, particularly of BPS other than depression. Limitations of original studies include heterogeneity in study design particularly related to measurement of BPS, level of cognitive impairment, population characteristics and participant recruitment. It is our recommendation that more high quality reviews, including all BPS, and longitudinal studies with larger sample sizes that use frequently cited instruments to measure BPS are undertaken. A better understanding of the risk factors and course of BPS will inform prevention, treatment and management and possibly improve quality of life for the patients and their carers.

A systematic review of the use of aromatherapy in treatment of behavioral problems in dementia

We aimed to fill the literature gap by identifying the clinical benefits of aromatherapy in older adults with dementia, and its efficacy in reducing behavioral and psychological symptoms of dementia (BPSD) based on available randomized controlled trials (RCT). A systematic review of 11 clinical trials shortlisted from electronic databases from 1995 to 2011 was carried out. The RCT showed that aromatherapy had positive effects on reduction of BPSD, improvement in cognitive functions, increasing quality of life, enhancing independence of activities of daily living and so on. However, adverse effects were noted in some studies. Limitations on methodology are discussed and suggestions on directions of further studies are made. It is recommended that aromatherapy shows the potential to be applied as a therapeutic and safe complementary and alternative therapy for the management of BPSD on more evidence collected from better designed RCT.

Staff training using STAR: a pilot study in UK care homes

BACKGROUND

Symptoms such as depression, anxiety, and behavioral problems are very common in people with dementia living in care homes. Staff training has been identified as a promising psychosocial intervention. This pilot study investigated the feasibility of implementing the Staff Training in Assisted Living Residences (STAR) program in UK care homes.

METHODS

The eight-week STAR program was delivered in two care homes. Twenty-five care staff attended the training. Thirty-two residents, with dementia and clinically significant anxiety, depression, or behavioral problems, were included in the study. Residents and staff were assessed at baseline and eight-week follow-up.

RESULTS

Residents demonstrated significantly reduced symptoms of depression and behavioral problems following the implementation of the program, although resident-rated quality of life and anxiety symptoms did not improve significantly. Staff sense of hopefulness towards people with dementia also improved significantly and staff rated themselves as significantly more competent at forming relationships with residents.

CONCLUSION

Delivering the STAR program to care staff can have an impact on the behavioral and psychological symptoms of dementia displayed by care home residents. The program was feasible to implement and was rated highly by care staff. A large-scale randomized controlled trial is now required to evaluate the effectiveness of this training intervention.

Behavioral and psychological symptoms of dementia

Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, represent a heterogeneous group of non-cognitive symptoms and behaviors occurring in subjects with dementia. BPSD constitute a major component of the dementia syndrome irrespective of its subtype. They are as clinically relevant as cognitive symptoms as they strongly correlate with the degree of functional and cognitive impairment. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. It is estimated that BPSD affect up to 90% of all dementia subjects over the course of their illness, and is independently associated with poor outcomes, including distress among patients and caregivers, long-term hospitalization, misuse of medication, and increased health care costs. Although these symptoms can be present individually it is more common that various psychopathological features co-occur simultaneously in the same patient. Thus, categorization of BPSD in clusters taking into account their natural course, prognosis, and treatment response may be useful in the clinical practice. The pathogenesis of BPSD has not been clearly delineated but it is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD. A high degree of clinical expertise is crucial to appropriately recognize and manage the neuropsychiatric symptoms in a patient with dementia. Combination of non-pharmacological and careful use of pharmacological interventions is the recommended therapeutic for managing BPSD. Given the modest efficacy of current strategies, there is an urgent need to identify novel pharmacological targets and develop new non-pharmacological approaches to improve the adverse outcomes associated with BPSD.

Cerebral correlates of psychotic syndromes in neurodegenerative diseases

Psychosis has been recognized as a common feature in neurodegenerative diseases and a core feature of dementia that worsens most clinical courses. It includes hallucinations, delusions including paranoia, aggressive behaviour, apathy and other psychotic phenomena that occur in a wide range of degenerative disorders including Alzheimer's disease, synucleinopathies (Parkinson's disease, dementia with Lewy bodies), Huntington's disease, frontotemporal degenerations, motoneuron and prion diseases. Many of these psychiatric manifestations may be early expressions of cognitive impairment, but often there is a dissociation between psychotic/behavioural symptoms and the rather linear decline in cognitive function, suggesting independent pathophysiological mechanisms. Strictly neuropathological explanations are likely to be insufficient to explain them, and a large group of heterogeneous factors (environmental, neurochemical changes, genetic factors, etc.) may influence their pathogenesis. Clinico-pathological evaluation of behavioural and psychotic symptoms (PS) in the setting of neurodegenerative and dementing disorders presents a significant challenge for modern neurosciences. Recognition and understanding of these manifestations may lead to the development of more effective preventive and therapeutic options that can serve to delay long-term progression of these devastating disorders and improve the patients' quality of life. A better understanding of the pathophysiology and distinctive pathological features underlying the development of PS in neurodegenerative diseases may provide important insights into psychotic processes in general.

CNS medications as predictors of precipitous cognitive decline in the cognitively disabled aged: a longitudinal population-based study

BACKGROUND/AIMS

Psychotropics and antiepileptics (AE) are medications commonly used among the aged with cognitive decline or dementia, although they may precipitate further cognitive decline. Our aim was to analyze the relationships between the use of (i) psychotropics (i.e. benzodiazepines or related drugs, BZD, antipsychotics, AP, or antidepressants, AD), opioids (Op), anticholinergics (ACh) or AEs or the concomitant use of two of these drugs, and (ii) the risk of precipitous cognitive decline in an older (≥65 years) cognitively disabled population.

METHODS

A longitudinal population-based study of general aged community-dwelling patients was executed in two phases (1990-1991 and 1998-1999) in Lieto, Finland. Fifty-two individuals cognitively disabled (MMSE score 0-23) at the 1990-1991 baseline form this study's sample. Cognitive abilities were assessed in each phase with the Mini-Mental State Examination (MMSE) and medication utilization data were collected in both phases. The mean follow-up time was 7.6 years. Multivariate models were used to analyze the change in MMSE total score between medication users and non-users.

RESULTS

BZD or any psychotropic use was associated with greater cognitive decline in elders aged ≥75 years compared to non-users (change in MMSE sum score: -8.6 ± 7.0 vs. -3.3 ± 5.6 and -5.9 ± 7.0 vs. -2.7 ± 6.4, respectively). A greater decline was also associated specifically with the concomitant use of BZD and AP (-16 vs. -1.4 ± 7.8); as were BZD and any drug with CNS effects (-9.6 ± 9.9 vs. -1.3 ± 7.2) compared to non-users. The concomitant use of BZD and AD (-10.7 ± 4.7 vs. -3.2 ± 5.6) or ACh (-15.0 ± 8.5 vs. -3.3 ± 5.6) or any drug with CNS effects (-13.3 ± 6.5 vs. -3.3 ± 5.6) was associated with cognitive decline in patients ≥75 years compared to non-users of any drug with CNS effects.

CONCLUSION

The use of a BZD or any psychotropic medication may be an independent risk factor for cognitive decline in the cognitively disabled aged, and patients co-prescribed psychotropic medications had greater cognitive decline. Studies with larger sample sizes and studies on possible pathophysiologic mechanisms are needed.

Female caregivers' perceptions of reasons for violent behaviour among nursing home residents

Threats and violence against professional caregivers present a growing health and safety problem in elderly care. We aimed to explore female caregivers' perceptions of reasons for violent behaviour among nursing home residents. Forty-one caregivers at three nursing homes were interviewed and their responses were subjected to qualitative content analysis, which revealed three content areas of perceived reasons for patient violence: patient characteristics, caregiver approach and environmental aspects. The caregivers' perceptions were formulated in three core statements: 'they (the residents) are not who they used to be', 'we (the caregivers) have acted inappropriately' and 'we (residents and caregivers) are all surrounded by disorder'. Our findings indicate that the reasons for violence are complex and multifactorial, so interventions should be individually tailored. Caregivers involved in a violent situation need to see the person behind the behaviour, try to interpret what the behaviour is meant to communicate and adjust the intervention according to individual need.

Citalopram for agitation in Alzheimer's disease: design and methods

BACKGROUND

Agitation is one of the most common neuropsychiatric symptoms of Alzheimer's disease (AD), and is associated with serious adverse consequences for patients and caregivers. Evidence-supported treatment options for agitation are limited. The citalopram for agitation in Alzheimer's disease (CitAD) study was designed to evaluate the potential of citalopram to ameliorate these symptoms.

METHODS

CitAD is a randomized, double-masked, placebo-controlled multicenter clinical trial, with two parallel treatment groups assigned in a 1:1 ratio and randomization stratified by clinical center. The study included eight recruiting clinical centers, a chair's office, and a coordinating center located in university settings in the United States and Canada. A total of 200 individuals having probable AD with clinically significant agitation and without major depression were recruited for this study. Patients were randomized to receive citalopram (target dose of 30 mg/d) or matching placebo. Caregivers of patients in both treatment groups received a structured psychosocial therapy. Agitation was compared between treatment groups using the NeuroBehavioral Rating Scale and the AD Cooperative Study- Clinical Global Impression of Change, which are the primary outcomes. Functional performance, cognition, caregiver distress, and rates of adverse and serious adverse events were also measured.

CONCLUSION

The authors believe the design elements in CitAD are important features to be included in trials assessing the safety and efficacy of psychotropic medications for clinically significant agitation in AD.

Criminal manifestations of dementia patients: report from the national forensic hospital

BACKGROUND/AIMS

Some dementia patients have profound behavioral and psychological symptoms which might cause legal violation. We illustrate clinical and criminal characteristics of dementia patients who had been incarcerated because of criminal activity.

METHODS

The National Forensic Hospital is the only hospital-based correctional facility in the Republic of Korea which incarcerates criminals with psychiatric or neurological disease. Between May 2008 and April 2009, those patients who had been diagnosed with dementia in the National Forensic Hospital were included in the study. We reviewed their medical and legal reports.

RESULTS

There were 7 dementia patients out of 752 patients, including 2 Alzheimer's disease (AD) patients, 1 vascular dementia patient, and 4 patients with alcohol-related dementia. Criminal behavior included simple larceny by the 2 AD patients, and multiple violent crimes in a drunken state by the other 5 patients.

CONCLUSIONS

This study reported diverse criminal behaviors among dementia patients. Inebriation may be related to violent criminal behavior among some dementia patients.

The management of behavioural and psychological symptoms of dementia in residential homes: does Tai Chi have any role for people with dementia?

Dementia is a common illness that is increasing in frequency and set to challenge the resources and expertise of health and social care services over the coming years. Increasingly, there has been interest in the management of behavioural and psychological symptoms of dementia (BPSD), as they are both common and associated with a range of negative outcomes. BPSD are associated with the admission of people with dementia to care homes. Limited resources and lack of knowledge in permanent care settings often lead to BPSD being managed with antipsychotic medications, which are associated with significant morbidity and mortality. There is evidence for the benefits of exercise within care home settings, although only a few studies include those with cognitive impairment. Tai Chi is a mind-body exercise combining relaxed physical movement and meditation, and has been suggested to have many health benefits. This article discusses the rationale and available options for treating BPSD and the current practice and reviews the literature regarding the benefits of exercise and, in particular, Tai Chi in the management of BPSD.

Resident-to-resident aggression in nursing homes: results from a qualitative event reconstruction study

PURPOSE

Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.

DESIGN AND METHODS

Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.

RESULTS

Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.

IMPLICATIONS

These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.

[Pharmacologic therapies of BPSD: messages from psychiatrists]

Behavioral and psychological symptoms of dementia (BPSD) is the term defined as symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia. As BPSD can cause remarkable distress for both the patient and the caregiver, clinicians are required to treat the symptoms effectively. Before undertaking an intervention to BPSD, patients should be assessed in a detailed clinical interview to establish symptoms causing distress to the patient and/or caregiver. Initial intervention should focus on nonpharmacologic measures. However, pharmacologic intervention is necessary in many cases. There are many classes of medications to choose from for treating BPSD, but the evidence behind treatment is varied and confusing. Clinicians should discuss the potential risks and benefits of treatment with patients, and must ensure a balance between side effects and tolerability compared with clinical benefit and QOL. To provide medical care to the patients with dementia represents the comprehensive management of them, including differential diagnosis, treatment of BPSD and education of caregivers. Almost all of the patients with dementia develop BPSD during the course of the disease. As long as dementia is a neurological disorder, both neurologists and psychiatrists should work cooperatively in the treatment of dementia.

The APOE polymorphism in Alzheimer's disease patients with neuropsychiatric symptoms and syndromes

BACKGROUND

Neuropsychiatric symptoms (NPS) are a common feature of Alzheimer's disease (AD), resulting in particular AD endophenotypes. The common AD genetic risk factor apolipoprotein E (APOE) has been suggested underlying these AD endophenotypes.

METHODS

APOE genotyping, a comprehensive geriatric assessment (CGA), and Neuropsychiatric Inventory were performed on 322 consecutive older patients. Patients were divided into three groups: AD with NPS (N = 93), AD without NPS (N = 108), and, as a control group, patients with no cognitive impairment (NoCI: N = 121). Patients with NPS were further sub-divided in four groups according to the European Alzheimer's Disease Consortium (EADC) classification of neuropsychiatric syndromes in AD: hyperactive, psychotic, affective, and apathetic.

RESULTS

AD patients with NPS showed a significantly higher grade of cognitive impairment, more severity stage of dementia, more disability in the activities of daily living (ADL), and the instrumental ADL than AD patients without NPS. As expected, an higher frequency of APOE ε3/ε4 genotype was observed in patients with AD, both with and without NPS, than patients with NoCI. No difference in the distribution of APOE genotypes was found between AD patients with vs. without NPS. However, in AD patients APOE ε4-carriers, there was an increased risk of affective [odds ratio (OR): 2.34, 95% confidence interval (CI): 1.19-4.58) and apathetic (OR: 2.24,95%CI: 1.19-4.22) syndromes.

CONCLUSIONS

These findings did not suggest a significant association between APOE polymorphism and presence of NPS in AD patients. In AD patients with NPS, however, APOE ε4-carrier status was associated with an increased risk of affective and apathetic syndromes.