Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel

Management of Behavioral and Psychological Symptoms of Dementia

PURPOSE OF REVIEW

We review non-pharmacological and pharmacological approaches to managing behavioral and psychological symptoms of dementia (BPSD). We examine methods for assessment and evidence for interventions, focusing on recent findings and innovations. Finally, we recommend an algorithm for management of BPSD.

RECENT FINDINGS

Training of formal caregivers is the most effective intervention for BPSD; other non-pharmacological interventions are also beneficial. Antidepressants and antipsychotics remain a mainstay of pharmacological treatment for BPSD. There is limited evidence supporting the use of stimulants, cognitive enhancers, dextromethorphan/quinidine, benzodiazepines, anticonvulsants, and pimavanserin. The management of BPSD is highly individualized. Following thorough assessment, the initial step is addressing contributing medical problems. Non-pharmacological interventions should be tried prior to pharmacological interventions. Antipsychotics should be prescribed only when behaviors pose a significant safety risk or if the person with dementia is very distressed. New approaches will be needed to address an increasing population of people with dementia.

The Symptoms Targeted for Monitoring in a Web-Based Tracking Tool by Caregivers of People With Dementia and Agitation: Cross-Sectional Study

BACKGROUND

In people with dementia, neuropsychiatric symptoms (NPSs), especially agitation, are associated with worse quality of life and caregiver burden. As NPSs may vary with illness severity, knowledge of how people with dementia and their caregivers describe and rate the importance of agitation symptoms can improve the understanding of the clinical meaningfulness of the manifestations of agitation. The internet provides new opportunities to better understand patient experiences, as patients and caregivers increasingly look to Web-based platforms as a means of managing symptoms.

OBJECTIVE

The aim of this study was to examine Web-based reports from a dementia symptom website to better understand the symptoms of agitation and explore how they are being targeted for monitoring by caregivers of people with dementia.

METHODS

The Dementia Guide website hosts a Web-based database used by caregivers (97%) and people with dementia (3%). From its 61 dementia symptoms, users can select relevant symptoms that they deem important to monitor or track the effects of treatment. We employed a staging algorithm to determine if individuals had mild cognitive impairment (MCI) or mild, moderate, or severe dementia. Agitation was defined using terms consistent with the International Psychogeriatrics Association's provisional consensus definition. We compared the proportion of people with NPSs and agitation across stages of dementia severity and studied how many agitation-defining descriptors were selected, and how often they occurred, by stage.

RESULTS

As of March 2017, 4121 people had used the tracking tool, of whom 2577 provided sufficient data to allow disease severity staging. NPSs were tracked by 2127/2577 (82.54%) and agitation by 1898/2577 (73.65%). The proportion in whom agitation was tracked increased with increasing cognitive impairment: 68.5% (491/717) in people with MCI, and 72.50% (754/1040), 73.3% (378/516), and 90.5% (275/304) in mild, moderate, and severe dementia, respectively (χ²₃=54.9; P<.001). The number of NPS and agitation descriptors selected also increased with severity (median number of NPSs=1, 2, 2, and 3 for MCI, mild, moderate, and severe dementia, respectively, Kruskal-Wallis H Test H₃=250.47; P<.001; median number of agitation descriptors=1, 2, 3, and 4, H₃=146.11; P<.001).

CONCLUSIONS

NPSs and agitation are common targets for tracking over the course of dementia and appear more frequently with increasing disease severity. These common and distressing symptoms represent clinically meaningful targets in treating people with dementia.

TIME to reduce agitation in persons with dementia in nursing homes. A process evaluation of a complex intervention

BACKGROUND

The Targeted Intervention Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) has recently in a three-month cluster randomised controlled trial demonstrated reduction in agitation in nursing home residents with dementia. To ease replication and future implementation, and to clarify possible causal mechanisms, we performed a process evaluation of the intervention based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance).

METHODS

An exploratory and a quasi-experimental design with mixed methods were used. The RE-AIM dimensions were explored by questionnaires to 807 staff members and 46 leading ward nurses in both the intervention nursing homes (INH) and the control nursing homes (CNH), before the start of the trial (baseline), and six and 12 months later. These questionnaires assessed data regarding the reach, effectiveness (staff level) and adoption dimensions. To assess implementation, we used a checklist for performance of the main components in TIME and analysed the minutes from 84 case conferences in the INH. To explore adoption and maintenance, five focus group interviews with 32 participants from the staff in the INH were conducted three to 6 months after the end of the trial.

RESULTS

Reach: On average 61% (SD 22) of the staff in each ward in the INH attended the training sessions. Effectiveness at staff level: There were no between-group differences throughout the study period for attitudes towards dementia, perceived competence or perception of mastery and social interaction. Adoption: 16 of the 17 INH completed the intervention.

IMPLEMENTATION

75% or more of the components of TIME were performed for 91% of the included residents. Maintenance: Most of the nursing homes used TIME three to 6 months after the end of the trial. An easy to grasp model and an engaged leadership facilitated the intervention and maintenance.

CONCLUSIONS

A high degree of reach, adoption, implementation and maintenance contributed to the effectiveness of TIME at resident level. One other causal assumption of the effectiveness of TIME is the development in the staff of a new, shared and situated knowledge about each individual resident, not reflected by measurements in general knowledge and attitudes.

TRIAL REGISTRATION

The trial was registered January 6, 2016 with ClinicalTrials.gov ( NCT02655003 ).

"Would you like to join me for a walk?" The feasibility of a supervised walking programme for people with dementia who wander

AIMS AND OBJECTIVES

Five of the eight focus areas of Bowen's Feasibility Framework were utilised to assess the feasibility of implementing the Safe Walking Program (SWP) with people with severe dementia who wander in long-term care (LTC).

BACKGROUND

Dementia-related wandering in LTC is associated with adverse outcomes related to intensity (malnutrition, exhaustion and pain, injury) and type of walking (sleep deprivation, resident violence and elopement, death). There is little evidence guiding best practice for managing wandering in LTC.

DESIGN

The SWP involved a three-week trial of taking residents (n = 7) for a 30-min supervised walk, 30 min before individual peak walking activity periods (PWAP), outside the care facility. Quantitative (real-time observation and 24/7 Actigraph™ data: not reported here) and qualitative data were collected pre-, during and postintervention.

METHODS

Feasibility to implement the SWP protocol was evaluated using a protocol fidelity checklist completed at the end of each scheduled intervention. Acceptability and sustainability of the programme were evaluated through staff interviews.

RESULTS

Eighty per cent of scheduled walks commenced and were completed, with 91% of walks lasting the full 30 min. Care staff reported benefits for participants and care staff. The perceived sustainability of the SWP in the LTC setting was impacted by the strict timing of the walk to coincide with participant's individual PWAP. The use of care staff to lead some scheduled walks was seen as interfering with care routines.

CONCLUSIONS

To enhance the acceptability/sustainability of the SWP in LTC, further testing of the importance of dose and timing is required. Consideration needs to be given to suggested modifications to the protocol.

IMPLICATIONS FOR PRACTICE

The SWP is an acceptable and enjoyable activity for people with severe dementia who wander. Utilising walking tracks around the neighbourhood was perceived as being an important element of the programme.

Early recognition and treatment of neuropsychiatric symptoms to improve quality of life in early Alzheimer's disease: protocol of the BEAT-IT study

BACKGROUND

Neuropsychiatric symptoms (NPS) are very common in patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) dementia and are associated with various disadvantageous clinical outcomes including a negative impact on quality of life, caregiver burden, and accelerated disease progression. Despite growing evidence of the efficacy of (non)pharmacological interventions to reduce these symptoms, NPS remain underrecognized and undertreated in memory clinics. The BEhavioural symptoms in Alzheimer's disease Towards early Identification and Treatment (BEAT-IT) study is developed to (1) investigate the neurobiological etiology of NPS in AD and (2) study the effectiveness of the Describe, Investigate, Create, Evaluate (DICE) approach to structure and standardize the current care of NPS in AD. By means of the DICE method, we aim to improve the quality of life of AD patients with NPS and their caregivers who visit the memory clinic. This paper describes the protocol for the intervention study that incorporates the latter aim.

METHODS

We aim to enroll a total of 150 community-dwelling patients with MCI or AD and their caregivers in two waves. First, we will recruit a control group who will receive care as usual. Next, the second wave of participants will undergo the DICE method. This approach consists of the following steps: (1) describe the context in which NPS occur, (2) investigate the possible causes, (3) create and implement a treatment plan, and (4) evaluate whether these interventions are effective. Primary outcomes are the quality of life of patients and their caregivers. Secondary outcomes include NPS change, caregiver burden, caregivers' confidence managing NPS, psychotropic medication use, the experiences of patients and caregivers who underwent the DICE method, and the cost-effectiveness of the intervention.

CONCLUSIONS

This paper describes the protocol of an intervention study that is part of the BEAT-IT study and aims to improve current recognition and treatment of NPS in AD by structuring and standardizing the detection and treatment of NPS in AD using the DICE approach.

TRIAL REGISTRATION

The trial was registered on the Netherlands Trial Registry ( NTR7459 ); registered 6 September 2018.

Safety and effectiveness of cannabinoids for the treatment of neuropsychiatric symptoms in dementia: a systematic review

BACKGROUND

Neuropsychiatric symptoms (NPS) in dementia impact profoundly on the quality of life of people living with dementia and their care givers. Evidence for the effectiveness and safety of current therapeutic options is varied. Cannabinoids have been proposed as an alternative therapy, mainly due to their activity on CB1 receptors in the central nervous system. However, little is known regarding the safety and effectiveness of cannabinoid therapy in people with dementia. A literature review was undertaken to identify, describe and critically appraise studies investigating cannabinoid use in treating NPS in dementia.

METHODS

We undertook a systematic review adhering to PRISMA guidelines. Twenty-seven online resources were searched, including Medline, PsycINFO and Embase. Studies assessing the safety and or effectiveness of cannabinoids in treating NPS in dementia in people aged ⩾ 65 years were included. Study quality was assessed using the Johanna Briggs Institute and Cochrane Collaboration critical appraisal tools.

RESULTS

Twelve studies met the inclusion criteria. There was considerable variability across the studies with respect to study design (50% randomized controlled trials), intervention [dronabinol (33%), nabilone (25%) or delta-9 tetrahydrocannabinol (THC; 42%)] and outcome measures. Dronabinol (three studies) and THC (one study) were associated with significant improvements in a range of neuropsychiatric scores. The most common adverse drug event (ADE) reported was sedation. A high risk of bias was found in eight studies. The highest-quality trial found no significant improvement in symptoms or difference in ADE rate between treatment arms. Included studies used low doses of oral cannabinoids and this may have contributed to the lack of demonstrated efficacy.

CONCLUSION

While the efficacy of cannabinoids was not proven in a robust randomized control trial, observational studies showed promising results, especially for patients whose symptoms were refractory. In addition, the safety profile is favourable as most of the ADEs reported were mild. Future trials may want to consider dose escalation and formulations with improved bioavailability.

Psychosis symptoms in nursing home residents with and without dementia-Cross-sectional analyses from the COSMOS study

OBJECTIVE

To investigate the characteristics of nursing home residents with psychosis and the association with potential underlying factors, such as pain, sleep disturbances, and antipsychotic medication.

METHOD

Five hundred forty-five residents with and without dementia from 67 Norwegian nursing home units were included in the cross-sectional analyses. Psychosis was the main outcome measure in our study; other outcome measures include quality of life (QoL), activities of daily living (ADL) function, cognitive function, pain, and antipsychotic medication.

RESULTS

One hundred twelve residents had one or more symptoms of psychosis, and compared with residents without psychosis, they had lower QoL (p < 0.001), ADL function (p = 0.003), and cognitive functioning (p = 0.001). Adjusted logistic regression analyses showed that psychosis was associated with the prevalence of pain (OR: 3.19; 95% CI, 1.94-5.24), sleep disturbances (OR: 4.51; 95% CI, 2.91-6.99), and total number of medication (OR: 1.10; 95% CI, 1.03-1.17). Residents with psychosis but without antipsychotic medication had better QoL (p = 0.005) compared with residents receiving any antipsychotics.

CONCLUSION

Psychosis in NH residents is associated with pain, sleep disturbances, and number of medications. Residents with psychosis have poor QoL, although better QoL was observed among those who did not use antipsychotic medication.

Clinical and cost-effectiveness of the Managing Agitation and Raising Quality of Life (MARQUE) intervention for agitation in people with dementia in care homes: a single-blind, cluster-randomised controlled trial

BACKGROUND

Many people with dementia living in care homes have distressing and costly agitation symptoms. Interventions should be efficacious, scalable, and feasible.

METHODS

We did a parallel-group, cluster-randomised controlled trial in 20 care homes across England. Care homes were eligible if they had 17 residents or more with dementia, agreed to mandatory training for all eligible staff and the implementation of plans, and more than 60% of eligible staff agreed to participate. Staff were eligible if they worked during the day providing face-to-face care for residents with dementia. Residents were eligible if they had a known dementia diagnosis or scored positive on screening with the Noticeable Problems Checklist. A statistician independent of the study randomised care homes (1:1) to the Managing Agitation and Raising Quality of Life (MARQUE) intervention or treatment as usual (TAU) using computer-generated randomisation in blocks of two, stratified by type of home (residential or nursing). Care home staff were not masked to the intervention but were asked not to inform assessors. Residents with dementia, family carers, outcome assessors, statisticians, and health economists were masked to allocation until the data were analysed. MARQUE is an evidence-based manualised intervention, delivered by supervised graduate psychologists to staff in six interactive sessions. The primary outcome was agitation score at 8 months, measured using the Cohen-Mansfield Agitation Inventory (CMAI). Analysis of the primary outcome was done in the modified intention-to-treat population, which included all randomly assigned residents for whom CMAI data was available at 8 months. Mortality was assessed in all randomly assigned residents. This study is registered with the ISRCTN registry, number ISRCTN96745365.

FINDINGS

Between June 14, 2016, and July 4, 2017, we randomised ten care homes (189 residents) to the MARQUE intervention and ten care homes (215 residents) to TAU. At 8 months, primary outcome data were available for 155 residents in the MARQUE group and 163 residents in the TAU group. At 8 months, no significant differences in mean CMAI scores were identified between the MARQUE and TAU groups (adjusted difference -0·40 [95% CI -3·89 to 3·09; p=0·8226]). In the intervention care homes, 84% of all eligible staff completed all sessions. The mean difference in cost between the MARQUE and TAU groups was £204 (-215 to 623; p=0·320) and mean difference in quality-adjusted life-years was 0·015 (95% CI -0·004 to 0·034; p=0·127). At 8 months, 27 (14%) of 189 residents in the MARQUE group and 41 (19%) of 215 residents in the TAU group had died. The prescription of antipsychotic drugs was not significantly different between the MARQUE group and the TAU group (odds ratio 0·66; 95% CI 0·26 to 1·69, p=0·3880).

INTERPRETATION

The MARQUE intervention was not efficacious for agitation although feasible and cost-effective in terms of quality of life. Addressing agitation in care homes might require resourcing for delivery by professional staff of a more intensive intervention, implementing social and activity times, and a longer time to implement change.

FUNDING

UK Economic and Social Research Council and the National Institute of Health Research.

NonPharmacological interventions for managing wandering in the community: A narrative review of the evidence base

Dementia-related wandering is exhibited by as many as 63% of people with dementia living in the community. There is strong evidence that people with dementia who wander are at risk of life-threatening outcomes including injury from falls, exhaustion, weight loss, and becoming lost. Furthermore, carers have reported that fear of a person with dementia becoming lost contributes to them taking extreme measures in an attempt to maintain safety at home and there are few guidelines to direct care practices. Previous literature reviews of interventions to manage wandering have been inconclusive as the quality of research resulted in most studies being excluded. This narrative review aimed to report on the current state of wandering intervention science for people with dementia cared for in the community. An extensive search of articles and grey literature published between January 1999 and November 2017 was conducted and included quantitative studies that reported findings of nonpharmacological interventions for people with dementia living in the community that reported outcome measures of wandering characteristics (e.g., frequent ambulation, pacing, and boundary transgression). Eleven papers met the inclusion criteria, the majority of which were small nonrandomised studies or case studies with interventions that focused on: engaging the person with dementia in an activity, improving safety with environmental modifications, and technology to improve navigation or to monitor movement. While the strength of the evidence was low, the review has identified some promising interventions that carers of people with dementia could trial to reduce risky aspects of wandering, as well as identifying potential directions for future research.

Using electronic health records to estimate the prevalence of agitation in Alzheimer disease/dementia

BACKGROUND

Agitation is a common neuropsychiatric symptom of Alzheimer disease (AD). Data are scarce regarding agitation prevalence among community-dwelling patients with AD.

OBJECTIVE

To estimate agitation prevalence in a sample of US patients with AD/dementia overall and by AD/dementia disease severity, using data from electronic health records (EHR).

METHODS

This retrospective database study examined community-dwelling patients with ≥1 EHR record indicating AD/dementia from January 2008 to June 2015 and no evidence of non-Alzheimer dementia during the 12-month preindex and postindex periods. Agitation was identified using diagnosis codes for dementia with behavioral disturbance and EHR abstracted notes records indicating agitation symptoms compiled from the International Psychogeriatric Association provisional consensus definition.

RESULTS

Of 320 886 eligible patients (mean age, 76.4 y, 64.7% female), 143 160 (44.6%) had evidence of agitation during the observation period. Less than 5% of patients with agitation had a diagnosis code for behavioral disturbance. The most prevalent symptom categories among patients with agitation, preindex and postindex, were agitation (31.4% and 41.3%), falling (22.6% and 21.7%), and restlessness (18.3% and 23.3%). Among the 78 827 patients (24.6%) with known AD/dementia severity, agitation prevalence was 61.3%. Agitation during the observation period was most prevalent for moderate-to-severe and severe AD/dementia (74.6% and 68.3%, respectively) and lowest for mild AD/dementia (56.4%).

CONCLUSIONS

Agitation prevalence was 44.6% overall and 61.3% among patients with staged AD/dementia. Behavioral disturbance appeared to be underdiagnosed. While agitation has previously been shown to be highly prevalent in the long-term care setting, this study indicates that it is also common among community-dwelling patients.

Delirium and Antipsychotic Medications at Hospital Intake: Screening to Decrease Likelihood of Aggression in Inpatient Settings Among Unknown Patients With Dementia

For individuals with dementia, disorientation and both external and internal stimuli may trigger behaviors that are difficult to manage or dangerous to health-care providers. Identification of correlational risk factors to aggressive behavior in patients who are unknown to the hospital can allow providers to adapt patient care quickly. Records for patients aged 60+ who spent at least 24 hours at the hospital other than in the psychiatric unit were used (N = 14 080). The first 4000 records and every 10th person who met criteria (N = 5008) were searched for documentation of dementia (n = 505). Logistic regressions and χ2 tests were used to examine relationships between variables. Recognition of delirium (P = .014, Exp(B) = 2.53), coupled with an existing prescription for antipsychotic medication at intake (P < .001, Exp(B) < 4.37), may be a reliable means of screening for risk and intervening at the earliest possible contact, improving quality of care and safety in acute care for individuals with dementia.

Healthcare resource utilisation and costs of agitation in people with dementia living in care homes in England - The Managing Agitation and Raising QUality of LifE in Dementia (MARQUE) study

Background

People with dementia living in care homes often experience clinically significant agitation; however, little is known about its economic impact.

Objective

To calculate the cost of agitation in people with dementia living in care homes.

Methods

We used the baseline data from 1,424 residents with dementia living in care homes (part of Managing Agitation and Raising QUality of lifE in dementia (MARQUE) study) that had Cohen-Mansfield Agitation Inventory (CMAI) scores recorded. We investigated the relationship between residents’ health and social care costs and severity of agitation based on the CMAI total score. In addition, we assessed resource utilisation and compared costs of residents with and without clinically significant symptoms of agitation using the CMAI over and above the cost of the care home.

Results

Agitation defined by the CMAI was a significant predictor of costs. On average, a one-point increase in the CMAI will lead to a 0.5 percentage points (cost ratio 1.005, 95%CI 1.001 to 1.010) increase in the annual costs. The excess annual cost associated with agitation per resident with dementia was £1,125.35. This suggests that, on average, agitation accounts for 44% of the annual health and social care costs of dementia in people living in care homes.

Conclusion

Agitation in people with dementia living in care homes contributes significantly to the overall costs increasing as the level of agitation increases. Residents with the highest level of agitation cost nearly twice as much as those with the lowest levels of agitation, suggesting that effective strategies to reduce agitation are likely to be cost-effective in this setting.

Degenerative or Debilitative Neurologic Syndromes

Neurodegenerative disorders are progressive, debilitating impairments of neurologic function. Dementia affects cognition and function. Persons with cognitive deficits should undergo a full workup and may be treated with cholinesterase inhibitors and/or memantine. Behavioral and psychological symptoms of dementia may be assessed and treated individually. Parkinson disease is a disorder of movement. Levodopa is the standard treatment of dopamine-related movement symptoms. Associated symptoms should be assessed and treated. Other neurodegenerative syndromes are less common but highly debilitating. Currently, there are no curative or disease-modifying therapies for neurodegenerative disorders. Novel therapies or research are in the pipeline.

Characteristics of Hospice Referrals From an Inpatient Geriatric Psychiatry Unit

OBJECTIVE

Geriatric psychiatrists who treat neuropsychiatric symptoms of dementia are in the unique position of offering palliation to people with terminal illness in whom neuropsychiatric symptoms may be indicators of the illness's end stage (e.g., feeding problems). Little is known, however, about the characteristics of hospice referrals from inpatient geriatric psychiatry units.

METHODS

This was a retrospective chart review of patients with dementia admitted to an inpatient geriatric psychiatry unit and referred to hospice on discharge.

RESULTS

Patients were referred to hospice because of feeding problems, with oral intake insufficient to sustain life. Most patients (78%) died within 31 days of discharge, and all patients (100%) died within 6 months of discharge.

CONCLUSION

The results from this study support a symptom-based approach to hospice referral for people with dementia, as opposed to prognostic estimation, where certain symptom clusters may indicate a more rapidly progressing course.

Description of Process and Content of Online Dementia Coaching for Family Caregivers of Persons with Dementia

Family caregivers of persons with dementia encounter resistance to care behaviors (RCBs). The purpose of this methods paper was to describe the process and content of six weekly 60-min caregiver coaching sessions delivered synchronously through an online platform to 26 family caregivers of persons with dementia. All session notes were analyzed for process; two coaching sessions from five purposely-selected participants were transcribed and analyzed thematically for content. The six sessions followed an overall pattern. The first session included the most teaching and goal-setting; the coaches also queried the family caregiver about the premorbid personality, work history, and interpersonal attributes of the person with dementia. Sessions two through five were the most active coaching sessions; previously suggested strategies were evaluated and tailored; caregivers also role-played with the coaches and developed scripts designed to curtail RCB. The sixth session served as a review of successful caregiver strategies and concluded the coaching relationship. Four primary content themes emerged in the coaching process: (1) education; (2) caregiver communication; (3) affirmation of the caregiver; and (4) individualized strategies. These four content categories were used throughout the coaching process and were interwoven with each other so that the participant knew why the behavior was occurring, how to verbally address it, how to use a strategy effectively, and affirmation of the result. The coaching process and content demonstrated alignment with person-centered practices and relationship-centered care.

Antiepileptic Drug Use Is Associated with an Increased Risk of Pneumonia Among Community-Dwelling Persons with Alzheimer's Disease-Matched Cohort Study

BACKGROUND

Antiepileptic drugs (AEDs) have sedative properties which may lead to an increased risk of pneumonia.

OBJECTIVES

To investigate whether incident AED use is associated with an increased risk of pneumonia among community-dwelling persons with Alzheimer's disease (AD). In addition, we determined the risk according to duration of AED use and specific AEDs.

METHODS

Persons with AD were identified from the MEDALZ dataset which includes all community-dwelling persons who received a clinically verified diagnosis of AD during 2005-2011 in Finland (N=70,718). New AED users were identified with one-year washout period. A matched cohort (1 : 1, N=5,769, matching criteria age, gender, and time since AD diagnoses) of nonusers was formed. Data from nationwide registers included dispensed medications which were modelled with PRE2DUP method, hospitalizations, and causes of death. The association between AED use and hospital admission or death due to pneumonia was analyzed with Cox proportional hazard models.

RESULTS

AED use was associated with an increased risk of pneumonia (adjusted HR 1.92, 95% CI 1.63-2.26; incidence rate per 100 person-years 12.58, 95% CI 12.49-12.66 during AED use and 6.41, 95% CI 6.37-6.45 during nonuse). The highest risk was observed during the first month of use (aHR 3.59, 95% CI 2.29-5.61) and the risk remained elevated until two years of use. Of specific drug substances, phenytoin, carbamazepine, valproic acid, and pregabalin were associated with an increased risk.

CONCLUSION

Antiepileptic drug use may increase the risk of pneumonia which is concerning as persons with AD have elevated risk of pneumonia.

Management of behavioral and psychological symptoms in people with Alzheimer's disease: an international Delphi consensus

ABSTRACTObjectives:Behavioral and psychological symptoms of dementia (BPSD) are nearly universal in dementia, a condition occurring in more than 40 million people worldwide. BPSD present a considerable treatment challenge for prescribers and healthcare professionals. Our purpose was to prioritize existing and emerging treatments for BPSD in Alzheimer's disease (AD) overall, as well as specifically for agitation and psychosis.

DESIGN

International Delphi consensus process. Two rounds of feedback were conducted, followed by an in-person meeting to ratify the outcome of the electronic process.

SETTINGS

2015 International Psychogeriatric Association meeting.

PARTICIPANTS

Expert panel comprised of 11 international members with clinical and research expertise in BPSD management.

RESULTS

Consensus outcomes showed a clear preference for an escalating approach to the management of BPSD in AD commencing with the identification of underlying causes. For BPSD overall and for agitation, caregiver training, environmental adaptations, person-centered care, and tailored activities were identified as first-line approaches prior to any pharmacologic approaches. If pharmacologic strategies were needed, citalopram and analgesia were prioritized ahead of antipsychotics. In contrast, for psychosis, pharmacologic options, and in particular, risperidone, were prioritized following the assessment of underlying causes. Two tailored non-drug approaches (DICE and music therapy) were agreed upon as the most promising non-pharmacologic treatment approaches for BPSD overall and agitation, with dextromethorphan/quinidine as a promising potential pharmacologic candidate for agitation. Regarding future treatments for psychosis, the greatest priority was placed on pimavanserin.

CONCLUSIONS

This international consensus panel provided clear suggestions for potential refinement of current treatment criteria and prioritization of emerging therapies.

Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia

Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent and represent a significant burden for patients and their caregivers. Early recognition and management of these symptoms is crucial as they are associated with increased risk of institutionalization, impairments in daily functioning, reduced quality of life, and more rapid progression to severe dementia. This chapter will discuss the pathophysiology, proposed diagnostic criteria, clinical features, and management of BPSD, including apathy, depression, agitation/aggression, psychosis, and sleep disturbances. Apathy and depression are the most common overall, and apathy is associated with high symptom severity likely because of its greater persistence. Symptoms such as agitation, aggression, hallucinations, and delusions may be especially distressing and dangerous to patients and caregivers. Nonpharmacologic management should be considered first-line therapy in most cases due to the modest and inconsistent evidence base for pharmacologic agents and greater risk of harm. However, the judicious use of pharmacologic agents may be warranted when symptoms are dangerous and/or severely distressing.

Adopting a Diary to Support an Ecological Assessment of Neuropsychiatric Symptoms of Dementia

Neuropsychiatric symptoms (NPS) are one of the most challenging issues in the management and care of people with dementia. Their accurate assessment is thus crucial for properly approaching subjects with cognitive disorders in the clinical setting. In parallel, the correct evaluation of NPS is also particularly relevant in the research field where they serve as critical indicators for measuring the efficacy of interventions against cognitive disorders. However, the study of NPS is extremely challenging given their extreme inter- and intra-individual variability. Moreover, the available assessment tools are often inadequate to fully capture their complexity and phenotypic expression. Based on these considerations, novel modalities for the assessment and measurement of NPS may be important to identify and develop. In this regard, a promising alternative (or, at least, a complementary aid) to traditional scales and questionnaires might be constituted by diaries. In the present article, we discuss the potential advantages and implications that may result from the adoption of this kind of instruments for the ecological assessment of NPS in subjects with dementia.

Neuropsychiatric symptoms in dementia

The prevalence of dementia is expected to rise with the aging of our population for decades to come. Neuropsychiatric symptoms of dementia, also known as behavioral and psychologic symptoms of dementia, are extremely common. Symptoms are most prevalent in the moderate stages of the disease, often increase with advancing disease stage, and often more than one symptom is present. These symptoms can cause a great deal of distress for patients and families, and take a toll on society as well. Evaluation and management can be challenging, with nonpharmacologic strategies recommended as first-line approach. There is growing evidence for specific pharmacologic strategies, but these come with significant risk, such that informed consent with the patient and surrogate decision maker is critical. In this chapter, we focus on general principles of etiology, assessment, and management, and then turn to individual symptoms of agitation, psychosis, apathy, sleep disturbance, and feeding and eating problems more specifically. Depression and anxiety are covered elsewhere in this text.

Threshold for a Reduction in Anticholinergic Burden to Decrease Behavioral and Psychological Symptoms of Dementia

BACKGROUND

A high anticholinergic burden (AB) is associated with the occurrence of behavioral and psychological symptoms (BPSDs), which are frequent in dementia.

OBJECTIVES

Our aim was to determine the threshold for a reduction in AB that would lead to a clinically significant improvement in BPSDs (in terms of frequency, severity, and disruptiveness).

DESIGN

A single-center prospective study.

SETTINGS

Dedicated geriatric care unit specializing in the management of patients with dementia.

PARTICIPANTS

The study involved older patients with dementia, hospitalized for management of BPSDs.

METHODS

One hundred forty-seven patients were included (mean age = 84.1 ± 5.2 years). The AB was assessed using 3 scales, namely, the Anticholinergic Drug Scale (ADS), the Anticholinergic Cognitive Burden scale (ACB), and the Anticholinergic Risk Scale (ARS). A clinically significant improvement in BPSDs was defined as a reduction of 4 points in the frequency × severity (F×S) score of the Neuropsychiatric Inventory-Nursing Home (NPI-NH) questionnaire. The threshold for a reduction in AB that corresponded to a clinically significant improvement in BPSDs was determined by multiple linear regression.

RESULTS

One hundred forty-seven patients were included (mean age = 84.1 ± 5.2 years). Using the ADS, a reduction of 2 points in AB in patients with moderate-intensity BPSDs was associated with a clinically significant improvement in the F×S score of the NPI-NH [6.34, 95% confidence interval (CI) 4.54-8.14], and a reduction of 3 points was associated with a clinically significant improvement in the occupational disruptiveness score (4.26, 95% CI 3.11-5.41).

CONCLUSIONS/IMPLICATIONS

In older patients with dementia presenting BPSDs, the risk-benefit ratio of anticholinergic drugs is debatable and, where possible, drugs with a lower AB would be preferable. Because BPSDs are a frequent cause of hospitalization, a standardized approach to analysis and reduction of AB is warranted in this population. Depending on the scale used to assess anticholinergic burden (AB), a small reduction in AB is associated with a decrease in frequency, severity, and disruptiveness of moderate-intensity BPSDs. Drugs with a high AB should be avoided where possible in older patients with dementia, and drugs with a lower AB would be preferable. Heterogeneity between the assessment scales for AB precludes generalization of the impact of a reduction in AB on BPSDs.

Strategy of Cardiovascular Surgery for Patients With Dementia as Evaluated by Mini-Mental State Examination

BACKGROUND

The strategy for cardiovascular surgery in dementia patients is controversial, so we aimed to investigate whether preoperative dementia and its severity might affect the outcomes of cardiovascular surgery by evaluating with the Mini-Mental State Examination (MMSE). Methods and Results: The study group comprised 490 patients undergoing cardiovascular surgery. Their preoperative cognitive status was evaluated using the MMSE, and analysis was performed to compare the patients with MMSE score <24 (dementia group, n=51) or MMSE score 24-30 (non-dementia group, n=439). Furthermore, the effect of the severity of dementia was analyzed with a cut-off MMSE score of 19/20. Risk factors for surgical outcomes were explored using multivariate logistic regression analysis. Hospital mortality was 11.8% in the dementia group and 2.1% in the non-dementia group (P=0.002). Regarding the postoperative morbidities, the incidence of cerebrovascular disorder (P=0.001), pneumonia (P=0.039), delirium (P=0.004), and infection (P=0.006) was more frequent in dementia group. Among the patients with MMSE <20, hospital mortality was as high as 25%, and the rate of delirium was 58%. Multivariate logistic regression analysis revealed that MMSE score <24 (P=0.003), lower serum albumin (P=0.023) and aortic surgery (P=0.036) were independent risk factors for hospital death.

CONCLUSIONS

Preoperative dementia affects the outcomes of cardiovascular surgery with regard to hospital death and delirium. The surgical indication for patients with MMSE <20 might be difficult, but surgery with an appropriate strategy should be considered for patients with MMSE <24.

Pharmacologic management of behavioral and psychological symptoms of major neurocognitive disorder

Behavioral and psychological symptoms of dementia (BPSD) occur in approximately 80% of patients who receive a diagnosis of major neurocognitive disorder. Nonpharmacologic strategies are the first-line treatment for BPSD. However, psychotropic medications are often necessary when nonpharmacologic methods are not effective in treating symptoms that are distressing or are causing behaviors that are dangerous to the patient or the patient's caregivers. The article provides a review of evidence-based recommendations for the use of antipsychotics, cognitive enhancers, and serotonin reuptake inhibitors for the treatment of BPSD. Different pharmacologic approaches are demonstrated through 2 patient cases in which nonpharmacologic management was not effective. The severity of BPSD must be weighed against the risks and benefits of pharmacologic intervention in order to implement an optimal medication regimen.

Diagnosis and Management of Neuropsychiatric Symptoms in Alzheimer's Disease

PURPOSE OF REVIEW

To explore the most recent developments in the effective diagnosis and treatment of neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD).

RECENT FINDINGS

The clinical diagnosis of NPS in AD is facilitated by the use of the Neuropsychiatric Inventory (NPI). CT and MRI scans can be useful for detecting structural changes indicating AD. Other promising diagnostic methodologies that are less frequently used in the clinical setting include positron emission tomography (PET) scans for detecting amyloid and blood tests for detecting serum biomarkers. Numerous pharmaceutical agents have been studied for their use in managing NPS, with antipsychotics being popular for managing agitation but also having significant side effects. Non-pharmacological interventions, such as reminiscence therapy and the Describe, Investigate, Create, Evaluate (DICE) approach may be able to provide treatment without such adverse effects. Diagnosing AD and the comorbid NPS remains primarily a clinical endeavor with CT and MRI scans sometimes used, but evidence is amassing for the use of other imaging modalities and different lab tests for convenient and empiric diagnosis of AD to distinguish it from other psychiatric illnesses. The number of pharmacologic treatments for NPS that are safe as well as efficacious remains limited, yet non-pharmacologic interventions have clear clinical utility. In addition to searching for more successful pharmacological treatments, further research should focus on novel diagnostic tests and non-pharmacologic therapies.

Demographics, Clinical Characteristics, and Therapeutic Approaches among Older Adults Referred to Mobile Psychiatric Crisis Intervention Teams: A Retrospective Study

Background / Aims

The advent of mobile old age psychiatry intervention teams supports policies maintaining older adults in their habitual living environments, even those who are very old and suffering from acute cognitive and psychiatric impairments. Analyzing sociodemographic data, clinical and health characteristics, reasons for crisis-oriented psychiatric consultations, and other therapeutic suggestions for supporting home- or nursing home-dwelling older adult patients suffering from an onset of a psychiatric crisis.

Methods

Reviews of the medical records and discharge letters of home- or nursing home-dwelling older adults who had undergone a consultation with the Lausanne region's Mobile Old Age Psychiatry Teams (MOAPTs), between May 2016 and December 2017.

Results

Of 570 older adult patients referred for consultation with MOAPTs, 333 had medical records and discharge letters eligible for retrospective analysis (59%). The majority of these older adult patients were women aged over 80 years suffering from dementia, mood disorders with and without a risk of suicide, and delirium. Challenging behaviors related to different stages of cognitive impairment were the most important clinical reason for crisis consultations. Nonpharmacological and pharmacological treatments were delivered concurrently in 68% of crisis consultations.

Conclusion

Appropriate responses by dual nurse-psychiatrist teams using crisis-oriented nonpharmacological and pharmacological interventions decreased hospitalization.

Taking Another Look: Thoughts on Behavioral Symptoms in Dementia and Their Measurement

This article proposes taking another look at behavioral symptoms of dementia (BSDs) both from a theoretical perspective that informs research and practice and from a measurement perspective. We discuss why this rethinking of behaviors impacts current models of care and our ability to better detect outcomes from interventions. We propose that BSDs be viewed from a pattern perspective and provide some suggestions for how to identify and measure these patterns that can influence the timing and type of intervention. Evidence suggests that BSDs are complex, sequential, patterned clusters of behavior recurring repeatedly in the same individual and escalate significantly without timely intervention. However, BSDs are frequently viewed as separate behaviors rather than patterns or clusters of behaviors, a view that affects current research questions as well as the choice, timing, and outcomes of interventions. These symptoms cause immense distress to persons with the disease and their caregivers, trigger hospitalizations and nursing home placement, and are associated with increased care costs. Despite their universality and that symptoms manifest across disease etiologies and stages, behaviors tend to be underrecognized, undertreated, and overmanaged by pharmacological treatments that may pose more harm than benefit.

The course of neuropsychiatric symptoms in nursing home residents from admission to 30-month follow-up

Aim

The aim of this study was to describe the prevalence and persistence of clinically significant neuropsychiatric symptoms (NPS) in nursing home residents with dementia, and to study the association between severity of dementia and specific neuropsychiatric sub-syndromes over time.

Methods

In total, 583 residents with dementia were included at admission to a nursing home and followed with biannual assessments until death, or to 30-month follow-up. At the end of the 30-month follow-up, 305 participants had died and 57 had left the study for other reasons, leaving 221 residents in the study. We collected data on demographics, cognition, severity of dementia, NPS, personal activities of daily living (P-ADL), physical health, medication and type of nursing home unit. NPS was assessed using the Neuropsychiatric Inventory (NPI), the Nursing Home version.

Results

The prevalence and persistence at two consecutive time-points of clinically significant NPS was high during the study period. The mean NPI agitation sub-syndrome score increased during the study period, while the NPI affective and psychosis sub-syndrome scores remained unchanged. More severe dementia was associated with higher NPI agitation, psychosis and affective sub-syndrome scores. The association remained unchanged over time for agitation and psychosis. For the NPI affective sub-syndrome, the association was stronger at the beginning, and declined towards the end of the study period.

Conclusion

The findings of high prevalence and persistence at two consecutive time points of clinically significant NPS over time, and the associations between severity of dementia and NPI sub-syndromes shed light on the burden and care needs of nursing home residents with dementia after admission to nursing home care. This information is of interest to health care planners and providers to enable them to increase the quality of care for nursing home residents.

Rehabilitation to live better with dementia

The goal of dementia treatment is to improve the quality of life for both people with dementia and their families. Rehabilitation as a non-pharmacological approach, coordinated with pharmacological treatment, aims to allow patients to live better by slowing the progression, and relieving the behavioral and psychological symptoms of dementia. In dementia, the manifestation of symptoms caused by neurological impairment is modified by various factors; thus, multidimensional assessment and approaches are effective based on the concept of the International Classification of Functioning, which emphasizes the healthy components of every person's functioning. Regarding the process of rehabilitation, every person with dementia should take initiative throughout the course of rehabilitation, and shared decision-making is a fundamental requirement at every phase of intervention. The needs of rehabilitation differ depending on the stage of dementia. In the early stages, cognitive rehabilitation is needed, and interventions are carried out using preserved functions and compensatory strategies. As the disease progresses, capacities of instrumental and then basic activities of daily living deteriorate, and interventions need to be tailor-made and carried out in the context of actual living situations. In the early-to-moderate stages, prevention and management of behavioral and psychological symptoms of dementia are required. In the interventions to alleviate behavioral and psychological symptoms of dementia, it is critical to consider the individual and the meaning behind his/her behaviors from a holistic perspective. Family carers also need support, and education to learn coping strategies can be beneficial for both people with dementia and their carers. Rehabilitation can empower people with dementia and their families to live better with dementia. Geriatr Gerontol Int 2018; 18: 1529-1536.

Application of the European quality indicators for psychosocial dementia care in long-term care facilities in the Asia-Pacific region: a pilot study

OBJECTIVES

An Asia-Pacific regional collaboration group conducted its first multi-country research project to determine whether or not European quality indicators (QIs) for psychosocial care in dementia could be implemented as a valid tool in residential aged care across seven Asia-Pacific sites (Australia, Hong Kong Special Administrative Region, Mainland China, Malaysia, Singapore, South Korea, and Thailand).

METHOD

Following the European QI protocol, auditing and data extraction of medical records of consenting residents with dementia were conducted by trained auditors with relevant health care backgrounds. Detailed field notes by the auditors were also obtained to describe the characteristics of the participating care facilities, as well as key issues and challenges encountered, for each of the 12 QIs.

RESULTS

Sixteen residential care facilities in the seven Asia-Pacific sites participated in this study. Data from 275 residents' records revealed each of the 12 Qis' endorsement varied widely within and between the study sites (0%-100%). Quality of the medical records, family and cultural differences, definitions and scoring of certain indicators, and time-consuming nature of the QI administration were main concerns for implementation.

CONCLUSION

Several items in the European QIs in the current format were deemed problematic when used to measure the quality of psychosocial care in the residential aged care settings in participating Asia-Pacific countries. We propose refinements of the European QIs for the Asian-Pacific context, taking into account multiple factors identified in this study. Our findings provide crucial insights for future research and implementation of psychosocial dementia care QIs in this region.

Is music-with-movement intervention better than music listening and social activities in alleviating agitation of people with moderate dementia? A randomized controlled trial

Aim

Interactive music intervention is generally perceived as more effective on clinical outcomes than a receptive approach because it can better engage the people with dementia. The aim of this study is to compare the effects of the 6-week music-with-movement intervention on agitation of people with moderate dementia, music listening and social activity.

Methods

A multi-centre randomized controlled trial was conducted on 165 nursing home residents with moderate dementia. The participants were randomly allocated into three groups: music-with-movement, music listening or social activities groups. Participants in the music-with-movement group listened to preferred music and moved their body parts for 45 minutes, twice a week for 6 weeks. While the participants in the music listening group only listened to their preferred music and social activity group chatted with the other group members. The agitation level was examined with the Chinese Cohen-Mansfield Agitation Inventory – Nursing Home version. Total scores and sub-scores (physically aggressive, physical non-aggressive, verbal aggressive and verbal non-aggressive) were compared at baseline, at post-intervention and 6 weeks post-intervention.

Results

The results showed that there are no significant differences in agitation among three groups. Repeated measures univariate analyses revealed that all three groups yielded significant improvement in agitation from baseline to post-intervention, of which music-with-movement presented the largest effect size.

Conclusion

This study showed that interactive or receptive type of music intervention or social activities may be helpful in managing agitation although there is no statistically significant difference among them.

Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study

OBJECTIVES

Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions.

DESIGN

Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF).

SETTING AND PARTICIPANTS

A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland.

MEASURES

Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed.

RESULTS

Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants' effort to achieve "a fine balance" between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents over-sedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes ("human suffering"; "the interface between resident and nursing home"; and "power and knowledge: complex stakeholder dynamics"), which conceptualize how different nursing homes strike this "fine balance."

CONCLUSIONS

Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that "fine balance" and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.

The Long Journey of Alzheimer's Disease

The growing elderly population is creating record numbers of individuals with Alzheimer's disease (AD) and other dementias. Nursing has an unprecedented opportunity to rethink how we care for adults with dementia, reduce the burden of caregivers, and preserve the personhood of patients. This article reviews AD and dementia pathophysiology, history, screening, stigma, treatments and interventions, and caregiver support. A nurse's journey with her mother with AD imparts the meaning of patient dignity.

Behavioral Problems and Dementia

Behavioral problems decrease quality of life of people with dementia and their care providers. Three main consequences of dementia are functional impairment and in some cases also mood disorders and psychosis. These consequences, alone or in combination, result in 3 main behavioral problems: apathy, agitation, and rejection of care/aggression. Nonpharmacologic management strategies include meaningful activities and individualized comfort care, for example, Namaste Care. If needed, pharmacologic management should concentrate on treatment of main dementia consequences, especially depression, instead of treating secondary symptoms, for example, insomnia. Use of antipsychotics should be minimized but antipsychotics may be necessary for augmentation of antidepressants.

Advancing Research on Care Needs and Supportive Approaches for Persons With Dementia: Recommendations and Rationale

The first National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers was held on October 16-17, 2017, at the National Institutes of Health. In this paper, participants from the Summit Session on Research on Care Needs and Supportive Approaches for Persons with Dementia summarize the state of the science, identify gaps in knowledge, and offer recommendations to improve science and practice in long-term care. Recommendations cover 4 areas focused on persons living with dementia: (1) symptoms (behavioral and psychological symptoms of dementia, function, cognition, and sleep); (2) dementia care settings (physical and social environments, home, and residential care); (3) living with dementia (living well with dementia, living alone with dementia, and living with dementia and intellectual and developmental disabilities); and (4) technology as a cross-cutting theme. The participants identify 10 of the most pressing research issues based on the findings from their collective papers. Final Summit recommendations included those presented by session participants and will be used to advise federal agencies and other organizations that fund research.

Person-Centered Primary Care Strategies for Assessment of and Intervention for Aggressive Behaviors in Dementia

With an increase in the number of individuals affected by dementia, it is imperative for health care providers to be well versed in the most effective ways to manage neuropsychiatric symptoms, such as aggression. Aggression can be particularly hard to manage because it creates risk of harm for formal and informal caregivers, and options for medical intervention are complex and situation dependent. Although multiple guidelines for management of aggression in dementia are available in the literature, their scope is widespread and suggested treatments often vary, making decision making difficult to navigate for busy clinicians. Using a composite case as a model, the current article provides guidelines that take outpatient providers through the steps needed to provide effective treatment for aggression in individuals with dementia. Shifting the current focal point of health care for aggressive dementia patients toward a more person-centered approach will have a positive impact on patient care. [Journal of Gerontological Nursing, 43(2), 9-17.].

Neuropsychiatric Symptoms and Caregiver Burden in Individuals With Alzheimer's Disease: The TEAM-AD VA Cooperative Study

OBJECTIVES

To assess the prevalence of neuropsychiatric symptoms (NPS) in mild-to-moderate Alzheimer disease (AD) and their association with caregiver burden.

METHODS

Secondary analyses of baseline data from the Trial of Vitamin E and Memantine in Alzheimer's Disease (TEAM-AD) (N=613). Neuropsychiatric Inventory were used to measure severity of NPS and caregiver activity survey to measure caregiver burden.

RESULTS

A total of 87% of patients displayed at least 1 NPS; 70% displayed clinically meaningful NPS. The most common symptoms were apathy (47%), irritability (44%), agitation (42%), and depression (40%). Those with moderate AD had more severe NPS than those with mild AD ( P = .03). Neuropsychiatric symptoms were significantly associated with caregiver time after adjusting for age, education, cognitive function, and comorbidity ( P-value < .0001) with every point increase in NPS associated with a 10-minute increase in caregiver time.

CONCLUSION

Neuropsychiatric symptoms were prevalent in both mild and moderate AD, even in patients receiving treatment with an acetylcholinesterase inhibitors, and were more severe in moderate AD and associated with greater caregiver time.

Dementia Care at End of Life: Current Approaches

PURPOSE OF REVIEW

Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia.

RECENT FINDINGS

Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia. Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.

Effect of the WeCareAdvisor™ on family caregiver outcomes in dementia: a pilot randomized controlled trial

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are universal and associated with multiple negative outcomes. This pilot randomized controlled trial (RCT) evaluated the effect of using the WeCareAdvisor, an innovative web-based tool developed to enable family caregivers to assess, manage, and track BPSD.

METHODS

This RCT enrolled 57 dementia family caregivers from community and clinical settings in Ann Arbor, Michigan and Baltimore, Maryland. Participants were randomly assigned to immediate use of the WeCareAdvisor tool (WCA, n = 27) or a Waitlist control group (n = 30) that received the tool after a one-month waiting period. Outcomes for the caregiver and the person they were caring for were assessed at baseline (T0) and one-month followup for both the WCA (T1) and Waitlist control (T2) groups.

RESULTS

Caregiver mean age was 65.9 ± 14.0 years old. About half (49%) were spouses. Baseline characteristics were comparable between groups except for mean caregiver confidence which was higher in the control group (WCA 35.0 ± 10.0 vs. Waitlist control 39.7 ± 6.9, p = 0.04). There were no significant differences between the WCA and control groups in characteristics of the person with dementia. After their one-month of tool use (T1), WCA caregivers showed significant within group improvement in caregiver distress (- 6.08 ± 6.31 points, t = - 4.82, p < 0.0001) and behavioral frequency (- 3.60 ± 5.05, t = - 3.56, p = 0.002), severity (- 3.24 ± 3.87, t = - 4.19, p = 0.0003) and total behavioral score (- 6.80 ± 10.73, t = - 3.17, p = 004). In the same timeframe, Waitlist control caregivers showed a significant decrease in confidence (- 6.40 ± 10.30, t = - 3.40, p = 0.002). The WCA group showed greater improvement in distress compared to the Waitlist group (T0-T1; t = - 2.49, p = 0.02), which remained significant after adjusting for site and baseline distress. There were no significant between-group differences in caregiver confidence or other secondary outcomes. After their one month of tool use (T2), the Waitlist group also showed significant improvement in caregiver distress (- 3.72 ± 7.53, t = - 2.66, p = 0.013), stress (- 0.41 ± 1.02, t = - 2.19, p = 0.037), confidence (4.38 ± 5.17, t = 4.56, p < 0.0001), burden (- 2.76 ± 7.26, t = - 2.05, p = 0.05), negative communication (- 1.48 ± 2.96, t = - 2.70, p = 0.012) and behavioral frequency (- 1.86 ± 4.58, t = - 2.19, p = 0.037); distress remained significant after adjustment.

CONCLUSIONS

In this pilot RCT, WCA use resulted in a significant decrease in caregiver distress. Future research will identify whether longer use of WCA can impact other caregiver and behavioral outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02420535 (Date of registry: 4/20/2015, prior to the start of the clinical trial).

Pharmacotherapy for the treatment of depression in patients with alzheimer's disease: a treatment-resistant depressive disorder

INTRODUCTION

Pharmacotherapy for the treatment of depressive disorders in Alzheimer's Disease (AD) represents a clinical challenge. pharmacological options are often attempted after a period of watchful waiting (8-12 weeks). monoaminergic antidepressant drugs have shown only modest or null clinical benefits, maybe because the etiology of depressive symptoms in ad patients is fundamentally different from that of nondemented subjects.

AREAS COVERED

The following article looks at the selective serotonin reuptake inhibitor sertraline, which is one of the most frequently studied antidepressant medications in randomized controlled trials (RCTs). It also discusses many other pharmacological approaches that have proven to be inadequate (antipsychotics, acetylcholinesterase inhibitors, anticonvulsants, hormone replacement therapy) and new drug classes (mainly affecting glutamate transmission) that are being studied for treating depression in AD. It also gives discussion to the phase II RCT on the alternative drug S47445 and the potential effect on cognition of the multimodal antidepressant vortioxetine in older depressed patients. Finally, it discusses the N-methyl-D-aspartate antagonist ketamine.

EXPERT OPINION

The present RCT methodologies are too disparate to draw firm conclusions. Future studies are required to identify effective and multimodal pharmacological treatments that efficiently treat depression in AD. Genotyping may boost antidepressant treatment success.

Association of the Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care With the Use of Antipsychotics and Other Psychotropics in Long-term Care in the United States From 2009 to 2014

IMPORTANCE

The Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes (hereafter referred to as the partnership) was established to improve the quality of care for patients with dementia, measured by the rate of antipsychotic prescribing.

OBJECTIVE

To determine the association of the partnership with trends in prescribing of antipsychotic and other psychotropic medication among older adults in long-term care.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time-series analysis of a 20% Medicare sample from January 1, 2009, to December 31, 2014, was conducted among 637 426 fee-for-service Medicare beneficiaries in long-term care with Part D coverage. Data analysis was conducted from May 1, 2017, to January 9, 2018.

MAIN OUTCOMES AND MEASURES

Quarterly prevalence of use of antipsychotic and nonantipsychotic psychotropic medications (antidepressants, mood stabilizers [eg, valproic acid and carbamazepine], benzodiazepines, and other anxiolytics or sedative-hypnotics).

RESULTS

Among the 637 426 individuals in the study (446 538 women and 190 888 men; mean [SD] age at entering nursing home, 79.3 [12.1] years), psychotropic use was declining before initiation of the partnership with the exception of mood stabilizers. In the first quarter of 2009, a total of 31 056 of 145 841 patients (21.3%) were prescribed antipsychotics, which declined at a quarterly rate of -0.53% (95% CI, -0.63% to -0.44%; P < .001) until the start of the partnership. At that point, the quarterly rate of decline decreased to -0.29% (95% CI, -0.39% to -0.20%; P < .001), a postpartnership slowing of 0.24% per quarter (95% CI, 0.09%-0.39%; P = .003). The use of mood stabilizers was growing before initiation of the partnership and then accelerated after initiation of the partnership (rate, 0.22%; 95% CI, 0.18%-0.25%; P < .001; rate change, 0.14%; 95% CI, 0.10%-0.18%; P < .001), reaching 71 492 of 355 716 patients (20.1%) by the final quarter of 2014. Antidepressants were the most commonly prescribed medication overall: in the beginning of 2009, a total of 75 841 of 145 841 patients (52.0%) were prescribed antidepressants. As with antipsychotics, antidepressant use declined both before and after initiation of the partnership, but the decrease slowed (rate change, 0.34%; 95% CI, 0.18%-0.50%; P < .001). Findings were similar when limited to patients with dementia.

CONCLUSIONS AND RELEVANCE

Prescribing of psychotropic medications to patients in long-term care has declined, although the partnership did not accelerate this decrease. However, the use of mood stabilizers, possibly as a substitute for antipsychotics, increased and accelerated after initiation of the partnership in both long-term care residents overall and in those with dementia. Measuring use of antipsychotics alone may be an inadequate proxy for quality of care and may have contributed to a shift in prescribing to alternative medications with a poorer risk-benefit balance.

General practitioners' knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia: protocol of a mixed methods systematic review and meta-ethnography

BACKGROUND

In the context of rising dementia prevalence, the workload of general practitioners (GPs) in dementia care is set to increase. However, there are many aspects of dementia care that GPs find challenging. Behavioural and psychological symptoms of dementia (BPSD) affect the majority of people with dementia and is an aspect of dementia care that GPs find particularly difficult to manage. The aim of this mixed methods systematic review is to undertake a synthesis of qualitative and quantitative studies on GPs' knowledge, attitudes and experiences of managing BPSD.

METHODS

Seven electronic bibliographic databases will be searched from inception to present. All qualitative or quantitative studies that explore the knowledge, attitude or experiences of GPs towards the management of BPSD in community and/or residential settings will be eligible for inclusion. A meta-ethnography will be conducted to synthesise included studies. Primary outcome measures will include GPs' experiences of managing BPSD, GPs' knowledge of BPSD and their attitude to different approaches to the management of BPSD, in particular their attitude to non-pharmacological approaches. All included papers will be independently assessed for methodological validity by two reviewers using the following tools: the Joanna Briggs Institute checklist for qualitative research, the Effective Public Health Practice Project (EPHPP) tool for intervention studies and the National Institute of Health (NIH) quality assessment tool for observational and analytical cross-sectional studies. As there is no agreed quality assessment tool for descriptive cross-sectional studies, an original tool will be developed. Two independent reviewers will apply the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) tool to the review findings. The results will be reported in line with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.

DISCUSSION

This study will be the first systematic review that synthesises the existing literature of GPs' knowledge, attitudes and experiences of managing BPSD in community and residential care. This review will improve our understanding of GPs' perspectives on the management of BPSD, and the results will be used to inform the development of an intervention to improve the management of BPSD in general practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017054916 .

An Action Research to Optimize the Well-Being of Older People in Nursing Homes: Challenges and Strategies for Implementing a Complex Intervention

Few studies have been conducted on strategies to promote the implementation of complex interventions in nursing homes (NHs). This article presents a pilot study intended to assess the strategies that would enable the optimal implementation of a complex intervention approach in NHs based on the meanings of screams of older people living with Alzheimer’s disease. An action research approach was used with 19 formal and family caregivers from five NHs. Focus groups and individual interviews were held to assess different implementation strategies. A number of challenges were identified, as were strategies to overcome them. These latter included interactive training, intervention design, and external support. This study shows the feasibility of implementing a complex intervention to optimize older people’s well-being. The article shares strategies that may promote the implementation of these types of interventions in NHs.