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

Association between prescription of conventional or atypical antipsychotic drugs and mortality in older persons with Alzheimer's disease

BACKGROUND/AIMS

To evaluate whether dementia patients prescribed antipsychotic drugs have a higher mortality compared to unexposed patients, and to investigate whether there are differences in mortality associated with exposure to conventional versus atypical antipsychotic drugs.

METHODS

Retrospective population cohort study with information gathered from the Italian Health Information System. All 4,369 residents of Milan (Italy) aged 60 years or older who were newly prescribed an antidementia drug (donepezil, rivastigmine or galantamine) from January 2002 to June 2008 were included. All new users of antipsychotic drugs in this cohort were categorized according to conventional (n = 156) or atypical (n = 806) drug exposure. The mortality risks of users of conventional or atypical antipsychotics compared to nonusers were evaluated with survival analysis, considering exposure to antipsychotic drugs as a time-dependent variable.

RESULTS

Mortality was increased two- and fivefold in users of atypical and conventional antipsychotics, respectively, with respect to nonusers.

CONCLUSIONS

Dementia patients prescribed antipsychotic drugs had a higher risk of death. This risk was highest for those prescribed conventional antipsychotics. At least part of the excess mortality may be due to the underlying neuropsychiatric symptoms that prompted the use of antipsychotics rather than a direct medication effect.

A 6-month, randomized, double-blind, placebo-controlled pilot discontinuation trial following response to haloperidol treatment of psychosis and agitation in Alzheimer's disease

OBJECTIVE

In patients with Alzheimer's disease (AD) with psychosis or agitation that respond to haloperidol treatment, to evaluate the risk of relapse following discontinuation.

METHODS

In outpatients with AD with symptoms of psychosis or agitation, responders to 20 weeks of haloperidol (0.5-5 mg daily) were randomized to a 24-week, double-blind pilot trial of discontinuation on placebo versus continuation haloperidol. Phase A response criteria were minimum 50% reduction in three target symptoms, and improvement on the Clinical Global Impression-Change (CGI-C) score for psychosis/agitation. Phase B relapse criteria required 50% worsening in target symptoms and on the CGI-C. α = 0.1 was the significance criterion in this pilot study.

RESULTS

Of 44 patients, 22 patients responded in Phase A. The sum score of target symptoms, and Brief Psychiatric Rating Scale (BPRS) psychosis and hostile suspiciousness factor scores, decreased in Phase A (p's < 0.001). Extrapyramidal signs increased in Phase A (p < 0.01). Of 22 responders, 21 patients entered Phase B, and 20 had at least one follow-up visit. Four of 10 patients (40%) on continuation haloperidol relapsed compared to eight of 10 patients on placebo (80%, χ(2)  = 3.3, p = 0.07). In survival analyses, time to relapse was shorter on placebo than haloperidol (χ(2)  = 4.1, p = 0.04).

CONCLUSIONS

Haloperidol open treatment was efficacious, and relapse was greater on placebo than with haloperidol continuation. In patients with AD who have psychosis or agitation and respond to antipsychotic medication, the increased risk of relapse after discontinuation needs to be weighed against the side effects associated with continuing the medication.

An approach to and the rationale for the pharmacological management of behavioral and psychological symptoms of dementia

The behavioral and psychological symptoms of dementia (BPSD) have been a difficult management area for neurologists and psychiatrists alike. The correct identification of each symptom and the underlying precipitating cause is the key to proper management-nonpharmacological as well as pharmacological. BPSD has been well documented in all types of dementia in various stages of the disease and in all dementias at an advanced stage. The proper management is not only rewarding in terms of responsiveness in an otherwise "incurable" and progressive disease, but also improves the quality of life of the patients and the caregivers alike. The caregiver burden is greatly decreased by an efficient management of BPSD. This review discusses the implications and boundaries of the term BPSD and unravels each symptom and its identification. Manifestations of psychological symptoms such as delusion, hallucination, misidentification, psychosis, depression, apathy, and anxiety are briefly described. Correct identification of behavior symptoms such as wandering, agitation, catastrophic reaction, disinhibition, and delirium has been outlined. While the subtle differences in each entity make the precise identification difficult, the different therapeutics of each make the exercise necessary. Pharmacological recommendations and side effects of medications have been mentioned thereafter. The review will help in the identification and correct pharmacological management of BPSD.

Physically violent behaviour in dementia care: Characteristics of residents and management of violent situations

OBJECTIVE

Physically violent behaviour (PVB) is common among residents with dementia and often complicates nursing care. This study aims to explore types of caring situations, resident characteristics related to PVB and professional caregivers' management of PVB.

METHODS

The study included 40 group homes for 309 residents with dementia. Data was gathered by means of structured interviews, the Multi-Dimensional Dementia Assessment Scale and the Geriatric Rating Scale.

RESULTS

Ninety-eight of the residents (31.7%) were assessed as showing PVB during the preceding week. Three factors were independently associated with PVB: male gender, antipsychotic treatment and decline in orientation. Violent residents were more likely to have impaired speech, difficulties understanding verbal communication and prescribed analgesics and antipsychotics than were non-violent residents. PVB occurred mainly in intimate helping situations and was managed by symptom-oriented approaches, such as distraction, medication and isolation. The working team also held frequent discussions about the residents with PVB.

CONCLUSION

This study shows that PVB is frequently displayed among residents in group homes for persons with dementia and the caregivers mainly manage PVB in a symptom-oriented way. To enhance the quality of care for patients with dementia, there is a need for interventions that aim to understand and manage the residents' physical violent behaviour.

Behavioral symptoms of dementia: a dyadic effect of caregivers' stress process?

This study used multilevel modeling to evaluate a newly revised model in which dementia caregivers' stress process variables-perceived stress and emotional-behavioral responses-were posited as predictors of behavioral symptoms of dementia (BSD) within community-based dyads. Secondary analyses were conducted on data from a primary two-group (experimental and control) trial, in which experimental participants received a home monitoring system for managing nighttime activity in individuals with dementia. Models indicated that caregivers' trajectories did not differ significantly between groups over time; however, the time-by-group interaction of BSD approached significance. Because BSD were not targeted, this indicated that the system may have indirectly lowered BSD. In addition, caregivers' perceived stress and emotional-behavioral responses predicted BSD, on average (across all occasions) and from occasion to occasion, with higher levels associated with worse BSD. These limited results provide support for further research to investigate the nature of these relationships.

Neuropsychiatric Symptoms, Endophenotypes, and Syndromes in Late-Onset Alzheimer's Disease: Focus on APOE Gene

Neuropsychiatric symptoms, previously denominated as behavioural and psychological symptoms of dementia, are common features of Alzheimer's disease (AD) and are one of the major risk factors for institutionalization. At present, the role of the apolipoprotein E (APOE) gene in the development of neuropsychiatric symptoms in AD patients is unclear. In this paper, we summarized the findings of the studies of neuropsychiatric symptoms and neuropsychiatric syndromes/endophenotypes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between APOE and neuropsychiatric symptoms in late-onset AD, other studies reported a significant association between the APOE ε4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. Furthermore, some negative studies that focused on the distribution of APOE genotypes between AD patients with or without neuropsychiatric symptoms further emphasized the importance of subgrouping neuropsychiatric symptoms in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, and possible lack of statistical power to detect associations in the negative studies.

Physical activity attenuates neuropsychiatric disturbances and caregiver burden in patients with dementia

INTRODUCTION

A significant benefit from physical activity has recently been described in some patients who suffer from neurodegenerative diseases.

OBJECTIVE

To assess the effects of physical activity on neuropsychiatric disturbances in demented patients and on the mental burden of their caregivers.

METHODS

Assisted by a public geriatric psychiatry clinical unit, we studied 59 patients with dementia. Patients were divided into three groups according to their diagnosis and level of physical activity. Data were assessed through a semi-structured interview. Patients were evaluated with the Neuropsychiatric Inventory, the Mini-Sleep Questionnaire and the Baecke Questionnaire. The data were statistically analyzed using the Mann-Whitney U test and linear regression, with the level of significance set at 5%.

RESULTS

Patients with Alzheimer's or vascular dementia who engaged in physical activity had fewer neuropsychiatric symptoms than those who did not. When compared to the control group, the caregivers of patients with vascular dementia who engaged in physical activity had a reduced burden.

CONCLUSION

The regular practice of physical activity seems to contribute to a reduction in neuropsychiatric symptoms in dementia patients and to attenuate the burden of the caregivers of those patients.

Reasons to prescribe antipsychotics for the behavioral symptoms of dementia: a survey in Dutch nursing homes among physicians, nurses, and family caregivers

OBJECTIVES

Despite serious safety concerns, prescription rates of antipsychotics for the treatment of the behavioral and psychological symptoms of dementia remain high, especially in nursing homes. This high prevalence of antipsychotic use cannot be explained by the modest success rate reported in the literature. In this study, we aim at clarifying the reasons for prescribing an antipsychotic drug in behavioral and psychological symptoms of dementia and look at the role of nurses and family caregivers in the decision-making process that precedes the prescription of an antipsychotic drug.

DESIGN

Questionnaire used in a one-on-one interview with elderly care physicians, nurses, and family caregivers.

SETTING

We conducted a survey in 23 nursing homes in the Netherlands.

METHOD

On each dementia ward, the physician selected 1 or 2 patients who started antipsychotics most recently. An interviewer then held a structured questionnaire with the physician, the nurse, and the first relative of the patient. The first part of the interview consisted of questions about the general ideas of the physicians and the second part consisted of case-related questions to physicians, nurses, and family caregivers.

RESULTS

Physicians, nurses, and family caregivers generally consider the possible benefits of antipsychotics to outweigh the risk of side effects. The main reasons to start therapy are agitation and aggression. Physicians felt pressured by nurses to prescribe in 17% of cases. Physicians felt supported by the guideline of the Dutch Association of Elderly Care Physicians. The estimated average success rate in the discussed cases (the patient is expected to improve on the target behavior) among physicians was 50%, nurses reported 53%, and relatives 55%. The most frequently expected adverse reactions were increased fall risk, sedation, and parkinsonism. Nurses expected cognitive decline. The family felt insufficiently informed about the side effects in 44% of the cases.

CONCLUSION

The interviewed nursing home physicians and nurses expect almost half of their patients with dementia and behavioral disturbances to benefit from antipsychotic therapy. Serious side effects were expected to occur only sporadically. These expectations may contribute to the high rate of antipsychotic use among these patients.

Clinical progression of moderate-to-severe Alzheimer's disease and caregiver burden: a 12-month multicenter prospective observational study

BACKGROUND

Prospective studies on the clinical progression of Alzheimer's disease (AD) and its relationship to caregiver burden are needed to improve illness management and use of resources.

METHODS

This national, multicenter, observational study evaluated 1235 moderate to severe AD patients under routine care in Spain. Baseline cross-sectional sociodemographic and clinical data, and changes from baseline to month 12 of various neuropsychological tests and clinical ratings, including Blessed Dementia Scale, Mini-mental State Examination (MMSE), Hughes Clinical Dementia Rating sum-of-boxes (CDR-SB), Clinical Global Impression of Change (CGIC) and Zarit Caregiver Burden scales, were recorded and comprehensively analyzed.

RESULTS

Baseline data were in accordance with characteristics consistently reported to influence AD risk regarding anthropometrics, sociocultural features and comorbidities. Significant progressive functional impairments (i.e. in routine activities and essential daily tasks) and cognitive (i.e. MMSE and CDR-SB) impairments were found at month 12. However, patients' behavior and caregivers' burden improved slightly, but significantly, corroborating the major influence of behavioral symptoms on caregivers' distress. Caregivers showed significantly lower burden with patients with higher levels of education and, to a lesser extent, when patients received AD-specific medication. Physicians accurately detected AD clinical evolution as their CGIC ratings significantly correlated with all tests.

CONCLUSIONS

These findings reinforce previous AD knowledge and add data on the clinical course of advanced stages of AD. Caregiver burden depended more on patients' behavioral alterations than on their functional or cognitive declines; and it was diminished by their patients having higher levels of education and being treated with AD-specific medications. Research into unexplored factors that might reduce caregiver burden, ultimately benefiting both patients and caregivers, is encouraged.

Behavioural symptoms in patients with Alzheimer's disease and their association with cognitive impairment

Background

Behavioural and psychological symptoms of dementia (BPSD) are non-cognitive symptoms commonly associated to Alzheimer's disease (AD). The characterization of the clinical profile of AD patients might help to better understand disease evolution and to improve diagnosis and treatment. Thus, the aim of the present study is to describe the clinical profile of AD patients, and to correlate the presence of BPSD with the severity of the disease.

Methods

A cross-sectional, observational and multicenter study was conducted at 115 centres in Spain. Patients suffering from AD with higher and lower BPSD scores (ADAS-Noncog score 26-50 and ≤25, respectively) were included. Demographic and clinical data were collected, and dementia severity was assessed by the Mini Mental State Examination (MMSE) [mild 27-21, moderate 20-11, severe ≤10]. The use of ADAS-Noncog in clinical practice was also explored.

Results

A total of 1014 patients (463 with higher and 551 with lower BPSD scores) were included (mean age 77 ± 7 years, 65% women). Almost all patients (90%) had BPSD at inclusion, 17% of which reported psychotic outbreaks. The most prevalent symptoms were lack of concentration (56%), tremors (56%), depression (44%), lack of cooperation (36%), and delusions (32%). Patients with higher BPSD scores showed a significantly higher prevalence of psychotic symptoms (delusions, hallucinations, and delirium) and tremors, while emotional symptoms (tearfulness and apathy) predominated in patients with lower BPSD scores. MMSE and ADAS-Noncog scores were negatively associated (p = 0.0284), suggesting a correlation between cognitive impairment and BPSD. Lack of concentration and appetite change significantly correlated with MMSE (p = 0.0472 and p = 0.0346, respectively). Rivastigmine and donepezil were the first choice therapies in mild to moderate dementia. ADAS-Noncog was generally considered better or similar to other scales (82%), and 68% of the investigators were willing to use it in the future.

Conclusions

Our study shows that patients with AD have a high prevalence of noncognitive symptoms, and that cognitive impairment and BPSD are correlated. Therefore, ADAS-Noncog is a useful evaluation tool.

Envelhecimento e demência: o que sabem os Agentes Comunitários de Saúde?

Trata-se de um estudo qualitativo cujo objetivo foi identificar o conhecimento que os Agentes Comunitários de Saúde (ACS) apresentam sobre envelhecimento e demência, com a finalidade de subsidiar a implantação de uma linha de cuidado à demência em um município paulista. Todos os cuidados éticos foram observados. Os sujeitos foram 51 ACS. O instrumento de coleta foi a entrevista semiestruturada. A análise foi fundamentada na técnica de conteúdo. Com relação à questão o que é idoso para você, a maioria dos agentes associam aspectos negativos do envelhecimento à idade cronológica, como dependência física e social. Com relação à concepção de demência, a maioria dos entrevistados a define como um problema biológico que afeta o cérebro, compromete a memória e causa dependência. Os resultados apontam para a necessidade de um programa de capaci-tação dos agentes em gerontologia.

The relationship between pre-morbid personality and challenging behaviour in people with dementia: A systematic review

It has been suggested that challenging behaviour in people with dementia reflects a person's pre-morbid personality traits and a number of studies have explored this hypothesis. However, inconsistencies in outcome between studies suggest a need to review the available evidence systematically. As a result, major bibliographic databases were searched for studies examining the relationship between pre-morbid personality and challenging behaviour in order to conduct a systematic review. We included all English language studies published in referenced journals that assessed pre-morbid personality via a valid comprehensive personality measure, and also explored a relationship with challenging behaviour in people with dementia. A total of 18 studies were identified that covered a wide range of challenging behaviours including 'wandering', affective states, aggression, anxiety and delusions/hallucinations. Studies were assessed for their methodological quality and statistical findings. Studies lacked representative samples, were affected by confounding variables and suffered from small sample sizes. However, 72% of the studies reported significant relationships between pre-morbid personality and behaviour. In terms of specific relationships, the strongest evidence was found for a positive relationship between pre-morbid neuroticism and mood, and aggression and overall behavioural acts, thus supporting the inclusion of personality as one factor in the formulation of behaviour (Ballard, C., O'Brien, J., James, I., & Swann, A. (2001). Dementia: Management of Behavioural and Psychological Symptoms. Oxford: Oxford University Press; Kitwood, T. (1993). Person and process in dementia: Editorial. International Journal of Geriatric Psychiatry, 1, 541-545).

Evaluation of exercise on individuals with dementia and their carers: a randomised controlled trial

Background

Almost all of the 820,000 people in the UK with dementia will experience Behavioural and Psychological Symptoms of Dementia (BPSD). However, research has traditionally focused on treating cognitive symptoms, thus neglecting core clinical symptoms that often have a more profound impact on living with dementia. Recent evidence (Kales et al, 2007; Ballard et al, 2009) indicates that the popular approach to managing BPSD - prescription of anti-psychotic medication - can increase mortality and the risk of stroke in people with dementia as well as impair quality of life and accelerate cognitive decline. Consequently, there is a need to evaluate the impact that non-pharmacological interventions have on BPSD; we believe physical exercise is a particularly promising approach.

Methods/Design

We will carry out a pragmatic, randomised, single-blind controlled trial to evaluate the effectiveness of exercise (planned walking) on the behavioural and psychological symptoms of individuals with dementia. We aim to recruit 146 people with dementia and their carers to be randomized into two groups; one will be trained in a structured, tailored walking programme, while the other will continue with treatment as usual. The primary outcome (BPSD) will be assessed with the Neuropsychiatric Inventory (NPI) along with relevant secondary outcomes at baseline, 6 and 12 weeks.

Discussion

Designing this study has been challenging both ethically and methodologically. In particular to design an intervention that is simple, measurable, safe, non-invasive and enjoyable has been testing and has required a lot of thought. Throughout the design, we have attempted to balance methodological rigour with study feasibility. We will discuss the challenges that were faced and overcome in this paper.

Trial Registration

ISRCTN01423159

[Nursing care for the aged with dementia and with behavioral symptoms]

In the course of dementia, behavioral disorders are highly prevalent and are frequently associated with the stress of caregivers. This study aims to identify in scientific literature the types of dementia associated with behavioral and psychological symptoms (BPSD); describe the non-pharmacological management of these alterations, and describe the nursing interventions in this context. The literature in the field of geriatrics and nursing was searched. It became evident that the nursing care provided to the demented elderly goes farther beyond the basic care and depends on the active participation of the family. The identification of strategies to minimize and manage the behavioral symptoms is an important contribution that nursing can give to geriatrics.

Follow-up for Alzheimer patients: European Alzheimer Disease Consortium position paper

BACKGROUND AND PURPOSE

Alzheimer disease (AD) is one of the leading causes of dependence in the elderly. Providing care for patients with AD is complex and the type of care required depends on the stage of the disease and varies over time. The aim of this article is to discuss available care strategies once the AD diagnosis has been made and to propose a follow-up plan as standard of care at a European level.

METHODS

The proposals developed in this article stem from the collaborative work of a panel of multidisciplinary experts involved in the care of AD patients (European Alzheimer Disease Consortium) based on the results of published scientific studies and on their experience from clinical practice.

CONCLUSION

Suggestions for follow-up frequency and easily administered and scored assessment tools are provided, thereby increasing efficiency and quality of care for patients with Alzheimer disease.

Effects of yokukansan, a traditional Japanese medicine, on aggressiveness induced by intracerebroventricular injection of amyloid beta protein into mice

The effects of yokukansan, a traditional Japanese medicine, on aggressiveness and motor activities were examined in mice after injection of amyloid beta protein (Abeta) into the lateral ventricle of the brain. The results were compared with those of conventional (haloperidol) and atypical (risperidone) antipsychotic medicines. A significant increase in aggressiveness was observed on day 7 after injection of Abeta, and it lasted until day 28. A single oral administration of yokukansan (1.0 g/kg) did not ameliorate the aggressiveness observed on day 7. However, a tendency toward amelioration of the aggressiveness was observed after the administration of yokukansan (0.5 and 1.0 g/kg) for 1 week (days 7-14). The 3 week administration (days 7-28) of yokukansan significantly ameliorated the aggressiveness in a dose-dependent manner without inhibition of motor activity. In contrast, a single administration of intraperitoneal haloperidol (0.03-0.1 mg/kg) or oral risperidone (0.1-0.3 mg/kg) on day 28 significantly reduced aggressiveness in a dose-dependent manner. However, motor activities were significantly suppressed. These results suggest yokukansan reduces aggressiveness without suppressing physical activity.

Investigating the mechanisms of hoarding from an experimental perspective

BACKGROUND

Acquiring and discarding objects are routine decision processes for most people. Despite the ubiquitous need to make such decisions, little is known about how they are made and what goes wrong when individuals acquire and fail to discard so many items that many areas of their home become unlivable (i.e., clinical hoarding). We hypothesize that clinical hoarding reflects a normal variation in the tendency to acquire and retain objects, only just at a more extreme level.

METHODS

To test this hypothesis, we examined 89 nonclinical, undergraduate students' performance on a novel experimental paradigm that measures decisions about acquiring and discarding everyday objects. To test our hypothesis, and validate our task as a possible research tool for studying hoarding, we related decisions on the task to a variety of measures known to correlate with clinical hoarding. The paradigm was sensitive to individual differences, as subjects varied widely in the quantity of objects they chose to acquire and retain under an increasing pressure to discard. In addition, we replicated expected relationships from the clinical hoarding literature between acquisition and retention tendencies and self-report measures of hoarding, indecisiveness, and obsessive-compulsive behavior.

RESULTS

Our data suggest that decisions about objects, even in a nonclinical undergraduate population, vary widely and are influenced by the same variables that influence clinical hoarding, but to a less extreme degree.

CONCLUSIONS

Future research with this experimental task can separately investigate the role of acquisition, retention, impulsivity, and sensitivity to constraints in clinical hoarding to inform our understanding of this disorder.

Psychologische Interventionen bei demenziellen Erkrankungen

Hintergrund: In verschiedenen Krankheitsstadien einer Demenz nehmen psychologische Interventionen einen zentralen Stellenwert bei der günstigen Beeinflussung kognitiver, behavioraler und psychopathologischer Symptome ein. Die Wirksamkeit dieser Ansätze wurde bisher nicht hinreichend systematisch in randomisierten kontrollierten Studien untersucht. Methode: Zur Erfassung des Forschungsstands über evidenzbasierte psychologische Therapien bei Demenz wurde eine Recherche in MEDLINE, PsycInfo, Psyndex und der Cochrane-Database durchgeführt. Eingeschlossen in die Evaluation wurden systematische Reviews, randomisierte kontrollierte Studien und kontrollierte Studien. Ergebnisse: Innerhalb der Vielzahl von Therapiemethoden zeigen sich hohe Evidenzlevels für (a) kognitive Verhaltenstherapie zur Behandlung behavioraler und psychopathologischer Symptome, insbesondere von Depressivität und (b) Psychoedukation und kognitiv-behaviorale Psychotherapie für Angehörige bei der Reduktion psychischer Belastung und psychopathologischer Symptome bei Angehörigen und Patienten. Moderate Evidenz besteht für die Anwendung von (a) kognitiver Stimulation zur Stabilisierung kognitiver Funktionen bei leichter bis mittelschwerer Alzheimer-Demenz und (b) Musiktherapie bei der kurzfristigen Reduktion von Agitation und anderer behavioraler und psychopathologischer Symptome bei mittelschwerer bis schwerer Demenz. Nur bedingt wirksam zur Reduktion behavioraler und psychopathologischer Symptome sind verschiedene Ansätze sensorischer Therapie. Zunehmende Evidenz zeigt sich für die Bedeutung einer milieutherapeutischen Umweltgestaltung. Diskussion: Weitere randomisierte kontrollierte Studien zu psychologischen Interventionen bei verschiedenen Demenzformen und -stadien mit größeren Fallzahlen sind dringend erforderlich.

A pilot study of differences in behavioral and psychological symptoms of dementia in nursing home residents in Sydney and Shanghai

BACKGROUND

There are limited cross-cultural studies of behavioral and psychological symptoms of dementia (BPSD). The aim of the present study was to increase understanding of the effects of culture on BPSD by comparing the rates of BPSD in nursing home residents across three residential facility types: (1) mainstream nursing homes in Sydney, (2) ethno-specific Chinese nursing homes in Sydney, and (3) a long-term high care facility in Shanghai known as a dementia hospital.

METHODS

149 residents and their caregivers voluntarily participated in this study. The rates and levels of BPSD were assessed by interviewing staff with the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). Clinical interviews using the Mini-mental State Examination (MMSE) and Global Deterioration Scale (GDS) were conducted with residents to assess dementia severity.

RESULTS

The mean NPI-NH total score for the sample was 28.5 (SD = 17.2) with no significant differences across the three facility types. Comparison of NPI-NH subscales showed residents from the ethno-specific Chinese facilities had lower rates of hallucinations than Shanghai residents (p = 0.003), but no differences from those in mainstream facilities. Shanghai residents had lower frequencies of disinhibition and irritability than ethno-specific Chinese residents (p = 0.003, p = 0.004 respectively), but no differences with mainstream residents.

CONCLUSION

The prevalence of BPSD does not differ among nursing home populations of different cultural backgrounds. Longitudinal community studies among different cultural groups would better elucidate the effects of culture on BPSD at different stages of dementia.

An itemized approach to assessing behavioral and psychological symptoms in dementia

In an effort to obtain more detailed clinical information regarding behavioral and psychology symptoms in dementia, we submitted an existing, comprehensive measure of behavioral and psychology symptoms in dementia (Neuropsychiatric Inventory) to an alternate itemized scoring system. One hundred twenty-four caregivers of patients with dementia (mean Mini-Mental State Examination=22.6) rated the frequency of individual symptoms across all domains of the measure. Internal reliability and factor structures for all domains were analyzed to assess the stability of this scoring approach. Internal consistency alphas for each domain ranged from .57 to .91. Alpha reliability for the total inventory was .96. Results indicate an itemized approach to assessing behavioral and psychological symptoms in dementia among patients with mild-to-moderate dementia can be reliable, has the power to capture multiple features of neuropsychiatric symptoms, and can produce a rich neurobehavioral profile adding valuable information to the diagnosis and treatment of these patients.

Non-cognitive psychopathological symptoms associated with incident mild cognitive impairment and dementia, Alzheimer's type

OBJECTIVE

To test the hypothesis that specific psychopathological non-cognitive symptoms are associated with incident mild cognitive impairment (MCI), while different symptoms are associated with incident dementia of Alzheimer's type (DAT).

METHODS

A representative community sample of 4,803 individuals aged 55+ years was interviewed in a two-phase screening, in Wave I or ZARADEMP I. This is the baseline, cross-sectional study of the ZARADEMP Project, a longitudinal study to document incidence and risk factors of dementia. The main instrument for assessment of participants was the ZARADEMP Interview, which includes standardized Spanish versions of instruments such as the Mini-Mental Status Examination and the Geriatric Mental State GMS-AGECAT. Two years later, in Wave II or ZARADEMP II, the cognitively non-deteriorated elderly were reassessed in a similar, two-phase procedure. "Incident cases" of both dementia and DAT (DSM-IV-TR criteria), as well as MCI (operationally defined Petersen's criteria) were diagnosed by a panel of psychiatrists. Statistical, logistic regression models, adjusted by age, sex and education were used to test the hypothesized association.

RESULTS

"Irritability", "neurovegetative symptoms", "sleep problems", "concentration difficulties", "loneliness" and "subjective slowing" documented at baseline were associated with incident MCI (odds ratio, OR range 1.71-2.67). A different profile of non-cognitive symptoms was associated with incident DAT, specifically "tension" (OR= 2.45), "sleep problems" (OR= 2.81), and "observed slowing" (OR= 4.35). On the contrary, "subjective restriction of activities" seemed to be negatively associated with DAT (OR= 0.12).

CONCLUSIONS

To our knowledge, this is the first report about some specific psychopathological, non-cognitive symptoms associated with incident MCI and/ or incident DAT, when controlling by each other. The psychopathological profile associated with MCI is different from the profile preceding DAT.

Behavioral symptoms and caregiver burden in dementia

BACKGROUND

Dementia care in developing countries will continue to be provided by co-resident caregivers at home. Behavioral and Psychological Symptoms of Dementia (BPSD) are difficult to manage at home. Interventions leading to reduction or remission of reduction or remission of BPSD will be of immense help in the management of these patients.

MATERIALS AND METHODS

The nature and prevalence of BPSD in a community sample of patients with dementia was assessed by a clinician. The impact of these symptoms on the caregiver was assessed by measures of burden of care and the psychological well being of the caregiver. Another rater carried out these assessments independently.

RESULTS

Prevalence of BPSD was very high and they were more common in patients with Alzheimer's Disease than patients with Vascular Dementia. They were rated as troubling to most caregivers. Caregiver burden was associated with adverse effects on the mental health of the carer.

CONCLUSIONS

To be effective, dementia care services in developing countries need to focus on management of BPSD at home. Development of a low cost, effective and sustainable dementia care service should be given due importance by the policy makers in the developing world.

Demanding behaviours and workload in elderly care in Sweden: occurrence at two time points within a decade

The aim of this study was to investigate the occurrence of demanding behaviours in persons >or=65 years receiving home care or living in sheltered accommodation at two points in time, 1993 and 2002. Another aim was to investigate whether the perceived workload in staff had changed during this period. All persons >or=65 years living at home and utilizing home care services or those who lived in some form of sheltered housing were included and assessed by staff using a three-part questionnaire, in two cross-sectional studies. The study group comprised 1187 and 1017 participants which equals 77% and 99% respectively. Symptoms and degree of behavioural and psychiatric symptoms common in dementia that were assessed with a subscale in The Gottfries-Bråne-Steen Scale, demonstrated an all over increase from 1993 to 2002. Items from The Multi Dimensional Dementia Assessment Scale (MDDAS) measured a decrease in 'daily' occurrences of dementia symptoms but an increase in 'sometimes per week'. A mixed pattern was seen concerning behaviours where increases as well as decreases were found. The behaviours 'constantly seeking attention' and 'shrieking continuously' increased significantly. The number of individuals showing restless, aggressive or shrieking behaviours increased significantly over the decade. Two items from the MDDAS were used to measure the workload. The physical workload increased significantly over the decade whereas the rising tendencies of the psychological workload were not statistically significant. The mean age over the decade had increased from 83 to 86 years, which together with the findings make the recipients of home care and sheltered housing a very vulnerable group. The demanding problems place considerable pressure on staff.

Effectiveness of simulated presence therapy for individuals with dementia: a systematic review and meta-analysis

OBJECTIVES

To formally assess the strength of evidence for the efficacy of simulated presence therapy for challenging behaviours in dementia (playing an audio or videotape to an individual, personalized by a carer and containing positive experiences from the client's life and shared memories involving family and friends) using meta-analytic techniques.

METHOD

Systematic review and meta-analysis of k = 4 studies of simulated presence therapy for challenging behaviours in dementia.

RESULTS

Meta-analysis indicated a significance effect (d = 0.70, 95% CI = 0.38-1.02), although this was reduced when the first published study was removed from the analysis.

CONCLUSION

These findings provide limited support for the use of simulated presence therapy with this population and stress the importance of assessing participants' suitability for such an approach and monitoring their responses closely. Future adequately powered studies are necessary to confirm the efficacy of simulated presence therapy.

Mild behavioral impairment: A prodromal stage of dementia

Mild cognitive impairment (MCI) was defined by Petersen et al. (1999) as progressive memory loss, a prodrome of Alzheimer's disease. MCI is a well-established entity that can be both a diagnosis in medical practice and a valid target of Alzheimer's prevention therapy. More recently MCI has expanded to include other cognitive domains with other potential causes: amnestic MCI, multiple domains MCI, and single domain non-amnestic MCI. Behavioral symptoms in MCI are associated with a higher risk of dementia, but their association with dementia risk in patients without MCI is unknown. The objective of our paper was to address the question of whether aging patients with behavioral symptoms with or without cognitive impairment represent a population at risk for dementia. Mild Behavioral Impairment (MBI) defines a late life syndrome with prominent psychiatric and related behavioral symptoms in the absence of major cognitive symptoms. MBI also appears to be a transitional state between normal aging and dementia. MBI may carry a higher risk for dementia than MCI. A subgroup of MBI patients is likely to exhibit symptoms of a frontotemporal dementia (FTD) prodrome. We proposed 4 subtypes of patients at risk for dementia: amnestic MCI (which is said to progress preferentially to Alzheimer's disease), multiple domain MCI (which may represent normal aging or may progress to vascular cognitive impairment or a neurodegenerative disorder), single domain non-amnestic MCI, and MBI (which may progress to frontotemporal dementia, Lewy Body dementia or Alzheimer's disease). We concluded that MBI is a counterpart of MCI as a transitional state between normal aging and dementia. These findings have implications for early detection, prevention, and treatment of patients with late-life dementia.

Behavioral and psychological symptoms of dementia and bipolar spectrum disorders: review of the evidence of a relationship and treatment implications

Dementia is a neuropsychiatric disorder characterized by cognitive impairment and behavioral disturbances. The behavioral and psychological symptoms of dementia (BPSD) are common, contributing to caregiver burden and premature institutionalization. Management of BPSD is complex and often needs recourse to psychotropic drugs. Though widely prescribed, there is a lack of consensus concerning their use, and serious side effects are frequent. This is particularly the case with antidepressant treatment based on the assumption that BPSD is depressive in nature. A better understanding of BPSD etiology could lead to better management strategies. We submit that some BPSD could be the consequence of both dementia and an undiagnosed comorbid bipolar spectrum disorder, or a pre-existing bipolar diathesis pathoplastically altering the clinical expression of dementia. The existence of such a relationship is based on clinical observation, as far as the high frequency of bipolar spectrum disorders in the general population, with a prevalence estimated to be between 5.4% and 8.3%, and the psychopathological similarities between BPSD and mood disorder episodes in bipolar illness. We will review the concept of the bipolar spectrum and explain BPSD before proposing clinical pointers of a possible bipolar spectrum contaminating the phenomenology of dementia, which could lead to the targeted prescription of mood-stabilizing agents in lieu of antidepressant monotherapy. These considerations are of heuristic interest in reconceptualizing the origin of the behavioral manifestations of dementia, with important implications for geriatric practice.

Behavioral and psychological symptoms, neurocognitive performance, and functional independence in mild dementia

This research investigated the interrelationships between behavioral and psychological symptoms in dementia (BPSD; i.e. disturbance of perception, thought content, mood, or behavior), cognition, and functional independence among mildly demented outpatients (MMSE = 23). A comprehensive neuropsychological evaluation was administered to 48 outpatients diagnosed with Alzheimer's disease ( n = 32) and vascular dementia ( n = 16) in order to assess cognitive function. A neuropsychiatric symptom inventory assessed BPSD and an instrumental activities of daily living questionnaire assessed functional independence. Pearson correlational analyses found that BPSD were associated with dementia severity, but not with performance on tests of specific neurocognitive domains. In addition, functional independence was associated with BPSD, dementia severity, and executive control, but not with language or memory. Multiple regression analyses revealed that dementia severity alone best predicted BPSD, and that BPSD more so than dementia severity best predicted functional independence. None of the specific neurocognitive domains predicted either BPSD or functional independence.

Associations between the working characteristics of nursing staff and the prevalence of behavioral symptoms in people with dementia in residential care

BACKGROUND

Clinical experience suggests that the work characteristics of staff in residential care may influence the well-being of residents with dementia. However, few studies have explored those anecdotal experiences. The aim of this study was to investigate associations between work characteristics of nursing staff and prevalence of behavioral symptoms among people with dementia in residential care settings.

METHODS

The self-report job strain assessment scale was used to measure staff perceptions of their working environment, and the Multi Dimensional Dementia Assessment Scale to measure the occurrence of behavioral symptoms among residents in 40 residential care units for people with dementia.

RESULTS

The findings show that in settings where staff reported high job strain, the prevalence of behavioral symptoms was significantly higher compared to settings where staff reported low job strain. Furthermore, settings characterized by staff having a more positive caring climate had significantly less prevalence of escape, restless and wandering behaviors compared to settings having a less positive caring climate. There was no statistically significant association between staff members' self-reported knowledge in caring for people with dementia and prevalence of behavioral symptoms.

CONCLUSIONS

This study provides evidence for the oft-cited clinical experience that the well-being of nursing staff is associated with the well-being of people with dementia in residential care settings.

Management of the behavioral and psychological symptoms of dementia

More than 50% of people with dementia experience behavioral and psychological symptoms of dementia (BPSD). BPSD are distressing for patients and their caregivers, and are often the reason for placement into residential care. The development of BPSD is associated with a more rapid rate of cognitive decline, greater impairment in activities of daily living, and diminished quality of life (QOL). Evaluation of BPSD includes a thorough diagnostic investigation, consideration of the etiology of the dementia, and the exclusion of other causes, such as drug-induced delirium, pain, or infection. Care of patients with BPSD involves psychosocial treatments for both the patient and family. BPSD may respond to those environmental and psychosocial interventions, however, drug therapy is often required for more severe presentations. There are multiple classes of drugs used for BPSD, including antipsychotics, anticonvulsants, antidepressants, anxiolytics, cholinesterase inhibitors and NMDA modulators, but the evidence base for pharmacological management is poor, there is no clear standard of care, and treatment is often based on local pharmacotherapy customs. Clinicians should discuss the potential risks and benefits of treatment with patients and their surrogate decision makers, and must ensure a balance between side effects and tolerability compared with clinical benefit and QOL.

Omega-3 supplementation in mild to moderate Alzheimer's disease: effects on neuropsychiatric symptoms

BACKGROUND

Epidemiological and animal studies have suggested that dietary fish or fish oil rich in omega-3 fatty acids (omega3), docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), may have effects in psychiatric and behavioral symptoms in Alzheimer's disease (AD). An association with APOEomega4 carriers and neuropsychiatric symptoms in AD has also been suggested.

OBJECTIVE

To determine effects of dietary omega3 supplementation to AD patients with mild to moderate disease on psychiatric and behavioral symptoms, daily functions and a possible relation to APOEgenotype.

METHODS

Randomized, double-blind, placebo-controlled clinical trial where 204 AD patients (74+/-9 years) with acetylcholine esterase inhibitor treatment and a MMSE>15 points were randomized to daily intake of 1.7 g DHA and 0.6 g EPA (omega3 group) or placebo for 6 months. Then, all received the omega3 supplementation for 6 more months. Neuropsychiatric symptoms were measured with Neuropsychiatric Inventory (NPI) and Montgomery Asberg Depression Scale (MADRS). Caregivers burden and activities of daily living (Disability Assessment for Dementia, DAD) were also assessed.

RESULTS

One hundred and seventy-four patients fulfilled the trial. 72% were APOEomega4 carriers. No significant overall treatment effects on neuropsychiatric symptoms, on activities of daily living or on caregiver's burden were found. However, significant positive treatment effects on the scores in the NPI agitation domain in APOEomega4 carriers (p=0.006) and in MADRS scores in non-APOEomega4 carriers (p=0.005) were found.

CONCLUSIONS

Supplementation with omega3 in patients with mild to moderate AD did not result in marked effects on neuropsychiatric symptoms except for possible positive effects on depressive symptoms (assessed by MADRS) in non-APOEomega4 carriers and agitation symptoms (assessed by NPI) in APOEomega4 carriers. ClinicalTrials.gov identifier: NCT00211159

Managing the wandering behaviour of people living in a residential aged care facility

Background  Wandering behaviour is frequently seen in older people with cognitive impairment. The prevalence of patients exhibiting wandering behaviour has been estimated to be 11.6% on traditional units and 52.7% on Alzheimer's units. Wandering is one of the core behavioural characteristics that impact on familial carers and is likely to influence the decision to place a family member in an aged care environment. Considering the possible risks associated with wandering behaviour, the successful identification and management of wandering is essential. Wandering is also a problem for caregivers in the institutionalised setting, in terms of containment, usually being addressed by securing the environment. There has been some research conducted to assist in the understanding and management of wandering behaviour; however, the findings have been diverse resulting in a level of confusion about the best approaches to take. Objectives  This review aims to present the best available evidence on the management of wandering in older adults who reside in an aged care facility (both high and low care). Search strategy  An extensive search of keywords contained in the title and abstract, and relevant MeSH headings and descriptor terms was performed on the following databases: MEDLINE, CINAHL, PsychINFO, AGELINE, Cochrane Library, Embase, APAIS Health, Current Contents, Dare, Dissertation Abstracts, Personal Communication, Social Science Index. Selection criteria  Papers were selected if they focused on the treatment of wandering in an institutional setting. Some studies were not specifically examining wanderers over the age of 65 years as per the protocol requirements, but were included as it was felt that their findings could be applied to this age group. Data collection and analysis  Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary. Results  Searches identified one care protocol, two systematic reviews and 24 other studies that satisfied the inclusion criteria. The following recommendations are divided into four categories of interventions (environmental, technology and safety, physical/psychosocial, and caregiving support and education) with only Level 1, 2 or 3 evidence presented. Environmental modifications  Gridlines placed in front of doors or covering exit door doorknobs or panic bars may be effective at reducing exit-seeking behaviour (Level 3b). Technology and safety  Mobile locator devices may be effective at enabling quick location of wandering residents (Level 3c). Physical/psychosocial interventions  Implementation of a walking group or an exercise program may reduce the incidence of disruptive wandering behaviour (Level 3b). Use of air mat therapy may reduce wandering behaviour for at least 15 min post therapy (Level 2). Providing music sessions (and reading sessions) may keep residents from wandering during the period of the session (Level 3b). Caregiving support and education  There is no evidence to support any interventions. Conclusions  The majority of the available research for which the guidelines are based upon was derived from observational studies or expert opinion (Level of evidence 3 or 4). More rigorous research is required to demonstrate the efficacy of these recommendations.

Discomfort and agitation in older adults with dementia

Background

A majority of patients with dementia present behavioral and psychological symptoms, such as agitation, which may increase their suffering, be difficult to manage by caregivers, and precipitate institutionalization. Although internal factors, such as discomfort, may be associated with agitation in patients with dementia, little research has examined this question. The goal of this study is to document the relationship between discomfort and agitation (including agitation subtypes) in older adults suffering from dementia.

Methods

This correlational study used a cross-sectional design. Registered nurses (RNs) provided data on forty-nine residents from three long-term facilities. Discomfort, agitation, level of disability in performing activities of daily living (ADL), and severity of dementia were measured by RNs who were well acquainted with the residents, using the Discomfort Scale for patients with Dementia of the Alzheimer Type, the Cohen-Mansfield Agitation Inventory, the ADL subscale of the Functional Autonomy Measurement System, and the Functional Assessment Staging, respectively. RNs were given two weeks to complete and return all scales (i.e., the Cohen-Mansfield Agitation Inventory was completed at the end of the two weeks and all other scales were answered during this period). Other descriptive variables were obtained from the residents' medical file or care plan.

Results

Hierarchical multiple regression analyses controlling for residents' characteristics (sex, severity of dementia, and disability) show that discomfort explains a significant share of the variance in overall agitation (28%, p < 0.001), non aggressive physical behavior (18%, p < 0.01) and verbally agitated behavior (30%, p < 0.001). No significant relationship is observed between discomfort and aggressive behavior but the power to detect this specific relationship was low.

Conclusion

Our findings provide further evidence of the association between discomfort and agitation in persons with dementia and reveal that this association is particularly strong for verbally agitated behavior and non aggressive physical behavior.

Neuropsychiatric symptoms in nursing home patients: factor structure invariance of the Dutch nursing home version of the neuropsychiatric inventory in different stages of dementia

BACKGROUND/AIMS

To examine the influence of dementia stage and psychoactive medication use on the factor structure of the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) in Dutch nursing home patients.

METHODS

The NPI-NH was administered to a large sample of 1,437 patients with mild to severe dementia receiving nursing home care. Exploratory factor analysis was used to examine behavioural dimensions underlying neuropsychiatric symptoms indicated by the NPI-NH across dementia stages (as assessed with the Global Deterioration Scale - GDS) and in patients with or without psychoactive medication prescribed.

RESULTS

In GDS stages 4/5, 6 and 7, a 4- or 5-factor solution was found, with factors referred to as agitation/aggression, depression, psychosis, psychomotor agitation and apathy. These symptom clusters were replicated in the group of drug-naive patients, but only partially in the group of patients on psychoactive medication.

CONCLUSION

The factor structure of the NPI-NH in nursing home patients is consistent with the clinical taxonomy of symptoms, is relatively stable across dementia stages, and is only moderately influenced by psychoactive medication use. The division of depression and apathy into separate behavioural dimensions - also in patients with severe dementia - may have important therapeutic consequences.

Pharmacologic management of neuropsychiatric symptoms of Alzheimer disease

OBJECTIVE

To systematically review published clinical trials of the pharmacotherapy of neuropsychiatric symptoms of Alzheimer disease (AD).

METHOD

We searched MEDLINE and EMBASE for published English-language medical literature. Our review focused on randomized controlled trials (RCTs) and corresponding metaanalyses.

RESULTS

The pharmacotherapy of neuropsychiatric symptoms of AD has been studied with numerous RCTs. The largest number of studies has focused on antipsychotics. Data are of reasonably high quality and indicate that risperidone and olanzapine are more effective than placebo for institutionalized patients with severe agitation, aggression, and psychosis. The efficacy of antipsychotics is counterbalanced by safety concerns that include cerebrovascular adverse events and mortality. Cholinesterase inhibitors and memantine appear to have modest benefits for patients with mildly to moderately severe symptoms. Antidepressants are effective for treating depression in AD, but more data are required to determine the efficacy of trazodone and citalopram for agitation and aggression. Carbamazepine appears to be efficacious, although side effects and concerns about drug-drug interactions limit its use. The data do not support the use of valproate. Benzodiazepines should only be used for short-term, as-needed use. There are insufficient data on other pharmacologic interventions, such as beta blockers, buspirone, and estrogen preparations.

CONCLUSIONS

Although there have been numerous well-designed studies of the pharmacotherapy of neuropsychiatric symptoms in AD, safer and more effective treatments are urgently needed.

Behavioral and psychological symptoms assessed with the BEHAVE-AD-FW are differentially associated with cognitive dysfunction in Alzheimer’s disease

To assess the possible neurological basis of behavioral and psychological symptoms of dementia (BPSD), the relationships between BPSD and cognitive function were evaluated in 40 patients with Alzheimer's disease (AD). BPSD was assessed using the Behavioral Pathology in Alzheimer's Disease Frequency Weighted Severity Scale (BEHAVE-AD-FW) for behavioral symptoms and psychological symptoms separately, and cognitive function was also assessed using the Cognitive Abilities Screening Instrument (CASI). We found that only behavioral symptoms were associated with cognitive function based on the CASI total score and the score for the CASI attention domain. Administration of risperidone, an atypical anti-psychotic drug, for one month, improved the behavioral symptoms and the scores for the CASI attention and orientation domains. Our data suggest that BPSD in AD may reflect two largely independent pathophysiological processes: one associated with behavioral symptoms partly overlapping with attention, and the other associated with psychological symptoms predominantly unrelated to cognitive function.

Managing the wandering behaviour of people living in a residential aged care facility

BACKGROUND

Wandering behaviour is frequently seen in older people with cognitive impairment. The prevalence of patients exhibiting wandering behaviour has been estimated to be 11.6% on traditional units and 52.7% on Alzheimer's units. Wandering is one of the core behavioural characteristics that impact on familial carers and is likely to influence the decision to place a family member in an aged care environment. Considering the possible risks associated with wandering behaviour, the successful identification and management of wandering is essential. Wandering is also a problem for caregivers in the institutionalised setting, in terms of containment, usually being addressed by securing the environment. There has been some research conducted to assist in the understanding and management of wandering behaviour; however, the findings have been diverse resulting in a level of confusion about the best approaches to take.

OBJECTIVES

This review aims to present the best available evidence on the management of wandering in older adults who reside in an aged care facility (both high and low care).

SEARCH STRATEGY

An extensive search of keywords contained in the title and abstract, and relevant MeSH headings and descriptor terms was performed on the following databases: MEDLINE, CINAHL, PsychINFO, AGELINE, Cochrane Library, Embase, APAIS Health, Current Contents, Dare, Dissertation Abstracts, Personal Communication, Social Science Index.

SELECTION CRITERIA

Papers were selected if they focused on the treatment of wandering in an institutional setting. Some studies were not specifically examining wanderers over the age of 65 years as per the protocol requirements, but were included as it was felt that their findings could be applied to this age group.

DATA COLLECTION AND ANALYSIS

Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary.

RESULTS

Searches identified one care protocol, two systematic reviews and 24 other studies that satisfied the inclusion criteria. The following recommendations are divided into four categories of interventions (environmental, technology and safety, physical/psychosocial, and caregiving support and education) with only Level 1, 2 or 3 evidence presented.

ENVIRONMENTAL MODIFICATIONS

Gridlines placed in front of doors or covering exit door doorknobs or panic bars may be effective at reducing exit-seeking behaviour (Level 3b).

TECHNOLOGY AND SAFETY

Mobile locator devices may be effective at enabling quick location of wandering residents (Level 3c).

PHYSICAL/PSYCHOSOCIAL INTERVENTIONS

Implementation of a walking group or an exercise program may reduce the incidence of disruptive wandering behaviour (Level 3b). Use of air mat therapy may reduce wandering behaviour for at least 15 min post therapy (Level 2). Providing music sessions (and reading sessions) may keep residents from wandering during the period of the session (Level 3b).

CAREGIVING SUPPORT AND EDUCATION

There is no evidence to support any interventions.

CONCLUSIONS

The majority of the available research for which the guidelines are based upon was derived from observational studies or expert opinion (Level of evidence 3 or 4). More rigorous research is required to demonstrate the efficacy of these recommendations.

Tratando os sintomas comportamentais e psicológicos da demência (SCPD)

Os transtornos neuropsiquiátricos na demência, também denominados de sintomas comportamentais e psicológicos da demência (SCPD), têm prevalência elevada no curso clínico da doença de Alzheimer e de outras desordens relacionadas. A relevância dessas manifestações é bem reconhecida, estando relacionada a evolução clínica mais desfavorável, maior sobrecarga do cuidador e maior incidência de institucionalização, entre outros fatores. O objetivo desta conferência clínica é procurar responder a algumas questões relacionadas a este tema, com o intuito de oferecer aos leitores uma breve atualização sobre o assunto. Os seguintes tópicos foram selecionados para discussão: se a nomenclatura SCPD é adequada para denominar essas manifestações clínicas; se há uma forma de classificar e como diagnosticar esses sintomas; qual a sua prevalência, seu impacto no curso clínico das demências e quais os fatores de risco associados ao seu aparecimento; quais as bases fisiopatológicas conhecidas; e, finalmente, como abordar esses pacientes e também suas famílias e cuidadores, do ponto de vista terapêutico, tanto em relação a intervenções farmacológicas quanto não farmacológicas.

Risperidone for the treatment of neuropsychiatric features in dementia

Neuropsychiatric features of dementia are a common and significant burden on patients and their carers. Management usually involves a combination of pharmacological and non-pharmacological approaches. Antipsychotics are the cornerstone of treatment; among the atypical antipsychotics, risperidone is the most studied. Several trials have confirmed the efficacy of risperidone in the treatment of neuropsychiatric features in dementia, especially for agitation and psychosis. Recent concerns over an increased cerebrovascular adverse event profile and overall mortality with use of antipsychotics have emphasised the need for a risk-benefit analysis for individual demented patients being treated for neuropsychiatric features of their disease.

Efficacy and safety of donepezil in patients with dementia with Lewy bodies: preliminary findings from an open-label study

The objectives of the present study were first to determine the feasibility of conducting a randomized clinical trial of 5 mg/day donepezil in patients with mild to moderate dementia with Lewy bodies (DLB) and second, to obtain preliminary data of possible intervention effects. Twelve patients with probable DLB were evaluated at weeks 4, 8, and 12 using modified Neuropsychiatric Inventory (NPI) with an extra domain to additionally evaluate fluctuation in cognitive functions (NPI-11); the Japanese version of Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-J cog); and the Unified Parkinson's Disease Rating Scale (UPDRS). The NPI-11 scores were significantly improved at weeks 8 and 12 compared with baseline. Despite a significant improvement in ADAS-J-cog at week 4, no more improvement was noted thereafter. Deterioration was not noted in UPDRS scores. Donepezil is expected to be therapeutically useful and safe in treating DLB patients, indicating marked improvements in behavioral and psychological symptoms of dementia (BPSD) rather than in cognitive deficit, without deteriorating parkinsonism.

The management of inappropriate vocalisation in dementia: a hierarchical approach

BACKGROUND

Patients with dementia can demonstrate noisy behaviours such as screaming, repetitive speech, moaning and singing. Such behaviours can be grouped under the title of "Inappropriate Vocalisation" which is used in this article to describe any noise making which impacts detrimentally upon patients, families or those in a caring role. Inappropriate vocalisation is notoriously difficult to treat and clinicians may have to rely on a "trial and error" approach when attempting to limit the distress it causes.

OBJECTIVES

This paper applies a hierarchical approach to Behavioural and Psychological Symptoms of Dementia (BPSD) in attempting to tackle inappropriate vocalisation systematically. Nine steps are ranked within three stages, with evidence for each intervention being considered sequentially in terms of the likelihood for success as the authors attempt to review the relevant literature.

METHODS

The authors performed a search of the medline database using the key words "screaming," "shouting," "persistent vocalisation" and "inappropriate vocalisation" combined with the key word "dementia". Further searches of the references of medline generated articles revealed a second group of articles of use in this review.

RESULTS

The search generated 53 reviews, research papers, case studies or letters, 36 of which are referenced in this article and the remaining references drawn from reading by the authors around the subject and related problems.

CONCLUSION

Interventions for inappropriate vocalisation in dementia are not limited to medication. Environmental factors and behavioural approaches are considered ahead of pharmacotherapy as the concepts of Underlying Illness, Hidden Meaning and Empirical Treatments are used to structure consideration of important, and sometimes overlooked, issues including pain, depression and overall level of stimulation.

Evaluation of risperidone in the treatment of behavioral and psychological symptoms and sleep disturbances associated with dementia

BACKGROUND

Dementia is associated with progressive cognitive impairment and behavioral and psychological symptoms. Sleep-wake cycle disturbances are common in patients with dementia. This study evaluated the efficacy and safety of risperidone in the treatment of the behavioral and psychological symptoms of dementia (BPSD) and associated sleep-wake cycle disturbances.

METHODS

In this open-label, 12-week, observational, prospective study, the effects of risperidone were assessed using the Neuropsychiatric Inventory (NPI) total and subscale scores. Sleep-wake cycle disturbances were rated by patients/caregivers using a newly developed sleep behavior questionnaire that included assessment of sleep duration, quality, awakenings, and effects on daily activities. Tolerability assessments included the Udvalg for Kliniske Undersogelser (UKU) subscale for extrapyramidal symptoms (EPS) and the recording of adverse events.

RESULTS

A total of 338 patients entered the study, with 321 patients completing. Following 12 weeks of risperidone treatment (mean dose 1.49 mg/day at end-point), the mean NPI score was reduced to 10.6 from a baseline score of 28.7. Compared with baseline, patients/caregivers reported significant improvements following 12 weeks of risperidone in total sleep hours at night (5.5 vs. 7.1 hours), hours awake in bed at night (2.3 vs. 1.2 hours), insomnia (40.1% vs. 8.4%), and other sleep-related variables. Six patients reported a total of 10 adverse events, including somnolence (n = 3) and sialorrhea (n = 2). Scores on the UKU subscale of EPS improved significantly (mean 4.0 at baseline vs. 1.7 at week 12).

CONCLUSIONS

Risperidone is effective and well tolerated in the treatment of BPSD and associated sleep disturbances.