Personality traits and behavioral and psychological symptoms in patients at an early stage of Alzheimer's disease

The role of maladaptive personality in behavioural and psychological symptoms in dementia

BACKGROUND

Although research demonstrated a significant link between premorbid normative personality traits and the severity of behavioural and psychological symptoms in dementia (BPSD) and associated emotional distress of the caregiver, little is known about the relationship of BPSD symptoms and associated distress with maladaptive traits.

METHOD

Informants (N = 182) of Dutch nursing home residents with dementia aged 65+, completed the Neuropsychiatric Inventory Questionnaire to assess the severity of BPSD and associated emotional distress. Premorbid maladaptive personality traits were evaluated using informant versions of a brief version of the Personality Inventory for Diagnostic and Statistical manual of Mental Disorders-5 (PID-5-BF), and two age-specific personality measures, the Informant Personality Questionnaire (HAP), and Gerontological Personality disorder Scale. Relationships between premorbid personality and BPSD were investigated with correlational and ordinal regression analyses.

RESULTS

BPSD severity and distress were associated with medium sized correlations to Negative Affectivity, Antagonism and indications of personality disorder presence. The emotional distress also correlated with a medium effect with Detachment. Higher scores on maladaptive personality traits increased the odds of higher BPSD severity and distress.

CONCLUSION

Results found with age-specific personality measures were in line with results found with other measures of (mal)adaptive traits. Several maladaptive personality traits had a significant relationship with the BPSD severity and associated emotional distress. We therefore encourage to implement personality assessment within BPSD treatment strategies. This way care becomes more person-focused and more tailored to the specific needs of patients and caregivers.

Risk factors for apathy in Alzheimer's disease: A systematic review of longitudinal evidence

BACKGROUND

Apathy is frequent and persistent in Alzheimer's disease (AD), associated with poor prognosis and carer distress; yet our knowledge of risk factors remains limited.

AIMS

To identify risk factors associated with apathy incidence and progression in AD over time.

METHODS

We systematically reviewed evidence based on longitudinal studies assessing risk factors for apathy in AD up to June 2021. Two authors independently assessed article eligibility and rated quality.

RESULTS

13,280 articles were screened, of which 13 met inclusion criteria. Studies had a mean follow-up of 2.7 years reporting on a total of 2012 participants. Most findings were based on single studies of moderate quality evidence. Risk factors increasing apathy onset were: being a carrier of the T allele of the PRND gene polymorphism, and having high levels of the IL-6 and TNFα cytokines at baseline. Risk factors for apathy worsening were: reduced inferior-temporal cortical thickness, taking antidepressants, being an ApoE ε4 carrier, living longer with AD, lower cognitive test scores, higher baseline apathy, premorbid personality traits (lower agreeableness, higher neuroticism), and higher midlife motivational abilities.

CONCLUSIONS

Although results are limited by the small number of studies, this review identified specific genetic, neurobiological, AD specific, and dispositional factors that may increase risk of apathy onset and worsening in AD.

Assessing the Effects of Healthy and Neuropathological Aging on Personality with the Iowa Scales of Personality Change

Personality changes in older adults with brain disease may be confounded by effects of normal aging. In this cross-sectional study, ratings with the Iowa Scales of Personality Change for 62 healthy older adults (OA-H, aged 60+) were compared to matched older adults with brain diseases (OA-BD). OA-H did not show any significant personality changes from middle age to older adulthood. However, between 10% and 20% of OA-H developed a disturbance in Lack of Stamina, Inflexibility, Lability, and Lack of Insight. Otherwise, the pattern of findings suggesting normal aging effects on personality disturbances in clinical groups are generally minimal.

The Relationship Between Anxiety and Alzheimer's Disease

Although Alzheimer’s disease (AD) is primarily a neurocognitive disorder, it also results in prominent neuropsychiatric symptoms (NPS). Much literature has investigated the NPS of apathy and depression in association with AD, but relatively less is known regarding anxiety, the third most common NPS in this disorder. The prevalence of anxiety symptoms in AD is about 40%, and it can be a prelude of AD. Anxiety can be especially present among patients with mild cognitive impairment, mild dementia, or early-onset forms of the disease, and can promote progression or conversion to Alzheimer’s clinical syndrome. A number of studies have established that anxiety is associated with positive amyloid scans, mesial temporal changes with atrophy and hypometabolism in the entorhinal region, and neurofibrillary tangles present on pathological examination of this region. In addition to psychosocial factors, proposed neurobiological mechanisms for increased anxiety in AD include decreased sensorimotor gating, relatively increased activation of amygdalae or the Salience Network, and the presence of comorbid pathology, particularly Lewy bodies. Having management strategies for anxiety in patients with AD is important as anxiety can worsen cognitive deficits. Interventions involve psychological support, behavioral management, and the judicious use of the psychiatric armamentarium of medications.

Interactions between Personality, Depression, Anxiety and Cognition to Understand Early Stage of Alzheimer's Disease

The multifaceted nature of Alzheimer's disease (AD) and Mild cognitive impairment (MCI) can lead to wide inter-individual differences in disease manifestation in terms of brain pathology and cognition. The lack of understanding of phenotypic diversity in AD arises from a difficulty in understanding the integration of different levels of network organization (i.e. genes, neurons, synapses, anatomical regions, functions) and in inclusion of other information such as neuropsychiatric characteristics, personal history, information regarding general health or subjective cognitive complaints in a coherent model. Non-cognitive factors, such as personality traits and behavioral and psychiatric symptoms, can be informative markers of early disease stage. It is known that personality can affect cognition and behavioral symptoms. The aim of the paper is to review the different types of interactions existing between personality, depression/anxiety, and cognition and cognitive disorders at behavioral and brain/genetic levels.

Degenerative dementias: Alterations of emotions and mood disorders

Degenerative dementias such as Alzheimer's disease and frontotemporal dementia result in distinct alterations in emotional processing, emotional experiences, and mood. The neuropathology of these dementias extends to structures involved in emotional processing, including the basolateral limbic network (orbitofrontal cortex, anterior temporal lobe, amygdala, and thalamus), the insula, and ventromedial frontal lobe. Depression is the most common emotion and mood disorder affecting patients with Alzheimer's disease. The onset of depression can be a prodromal sign of this dementia. Anxiety can also be present early in the course of Alzheimer's disease and especially among patients with early-onset forms of the disease. In contrast, patients with behavioral variant frontotemporal dementia demonstrate hypoemotionality, deficits in the recognition of emotion, and decreased psychophysiological reactivity to emotional stimuli. They typically have a disproportionate impairment in emotional and cognitive empathy. One other unique feature of behavioral variant frontotemporal dementia is the frequent occurrence of bipolar disorder. The management strategies for these alterations of emotion and mood in degenerative dementias primarily involve the judicious use of the psychiatric armamentarium of medications.

Differences in Clinical Presentation of Behavioral and Psychological Symptoms of Dementia in Alzheimer's Disease According to Sex and Education Level

BACKGROUND

The behavioral and psychological symptoms of dementia (BPSD) seriously affect the quality of life of patients with Alzheimer's disease (AD) and their caregivers.

OBJECTIVE

We aimed to identify associations between demographic/genetic factors and clinical presentations of BPSD.

METHODS

In a cohort of 463 AD patients with BPSD, we retrospectively analyzed sex, education level, AD severity (assessed using the Clinical Dementia Rating and Mini-Mental Status Examination), and BPSD severity (assessed using the Neuropsychiatry Inventory, NPI). Severe BPSD was defined as NPI ≥10 for 3 consecutive years.

RESULTS

Among patients with severe BPSD (NPI ≥10), we observed more female patients (62.96%) and a lower level of education (6.03±4.77 years) as compared to those with mild BPSD (NPI <10) (female: 51.09%, p = 0.007; education years: 7.91±4.93, p < 0.001). Females had a lower level of education (5.72±4.50 years) and higher scores for depression/dysphoria (1.22±2.05) compared with males (education: 8.96±4.89 years, p < 0.001; depression/dysphoria: 0.78±1.42, p = 0.047). Patients with a high level of education (defined as ≥12 years) had higher scores for appetite/eating (0.90±2.02) than did those without (0.69±1.79; p = 0.001). Genetic analysis showed similar total and subscale NPI scores between patients with and without APOE4 and with and without the GRN rs5848 genotype.

CONCLUSION

Our findings indicate potential contributions of sex and education to the presentation of BPSD. Further study is warranted to provide models for tailoring therapeutic programs to individual AD patients according to these factors.

Does Personality Predict Behavioral and Psychological Symptoms of Dementia? Results from PACO Prospective Study

BACKGROUND

Premorbid personality could play a role in the onset of behavioral and psychological symptoms (BPS) in Alzheimer's disease (AD) but prospective studies are lacking.

OBJECTIVE

The present study aimed at prospectively assessing the influence of premorbid personality traits on BPS evolution in a population of patients with prodromal or mild AD.

METHODS

We used a multicenter prospective cohort study of 237 patients followed-up for 18 months. The influence of personality traits on BPS evolution, measured with Neuropsychiatric Inventory (NPI), was assessed using linear mixed-effect models.

RESULTS

A principal components analysis of the 12 NPI behavioral domains yielded five factors labelled as psychotic symptoms, affective symptoms, behavioral dyscontrol, apathy/appetite symptoms, and sleep disorders. During the follow-up, higher neuroticism was significantly associated with a higher progression of affective symptoms (p < 0.0001), apathy/appetite symptoms (p = 0.002), sleep disorders (p = 0.001) as well as global NPI scores (p < 0.0001). Greater conscientiousness was related to a lower evolution of psychotic (p = 0.002), affective (p = 0.02) and apathy/appetite symptoms (p = 0.02), and global NPI score (p < 0.0001). Higher openness was associated with lower affective symptoms evolution (p = 0.01). A significant relationship was found between higher extraversion, lower affective symptoms (p = 0.02), and higher behavioral dyscontrol (p = 0.04).

CONCLUSION

The present analysis suggests that premorbid personality may influence the evolution of BPS in prodromal or mild AD. Given these results, it seems important to give more importance to personality assessment in early AD, in order to better identify and manage patients at risk of adverse behavioral changes.

Relationships between big-five personality factors and Alzheimer's disease pathology in autosomal dominant Alzheimer's disease

INTRODUCTION

Changes in personality characteristics are associated with the onset of symptoms in Alzheimer's disease (AD) and may even precede clinical diagnosis. However, personality changes caused by disease progression can be difficult to separate from changes that occur with normal aging. The Dominantly Inherited Alzheimer Network (DIAN) provides a unique cohort in which to relate measures of personality traits to in vivo markers of disease in a much younger sample than in typical late onset AD.

METHODS

Personality traits measured with the International Personality Item Pool at baseline from DIAN participants were analyzed as a function of estimated years to onset of clinical symptoms and well-established AD biomarkers.

RESULTS

Both neuroticism and conscientiousness were correlated with years to symptom onset and markers of tau pathology in the cerebrospinal fluid. Self-reported conscientiousness and both neuroticism and conscientiousness ratings from a collateral source were correlated with longitudinal rates of cognitive decline such that participants who were rated as higher on neuroticism and lower on conscientiousness exhibited accelerated rates of cognitive decline.

DISCUSSION

Personality traits are correlated with the accumulation of AD pathology and time to symptom onset, suggesting that AD progression can influence an individual's personality characteristics. Together these findings suggest that measuring neuroticism and conscientiousness may hold utility in tracking disease progression in AD.

Baseline demographic, clinical, and cognitive characteristics of the Alzheimer's Prevention Initiative (API) Autosomal-Dominant Alzheimer's Disease Colombia Trial

INTRODUCTION

The API AutosomalDominant AD (ADAD) Colombia Trial is a placebo-controlled clinical trial of crenezumab in 252 cognitively unimpaired 30 to 60-year-old Presenilin 1 (PSEN1) E280A kindred members, including mutation carriers randomized to active treatment or placebo and non-carriers who receive placebo.

METHODS

Of the 252 enrolled, we present data on a total of 242 mutation carriers and non-carriers matched by age range, excluding data on 10 participants to protect participant confidentiality, genetic status, and trial integrity.

RESULTS

We summarize demographic, clinical, cognitive, and behavioral data from 167 mutation carriers and 75 non-carriers, 30 to 53 years of age. Carriers were significantly younger than non-carriers ((mean age ± SD) 37 ± 5 vs 42 ± 6), had significantly lower Mini Mental Status Exam (MMSE) scores (28.8 ± 1.4 vs 29.2 ± 1.0), and had consistently lower memory scores.

DISCUSSION

Although PSEN1 E280A mutation carriers in the Trial are cognitively unimpaired, they have slightly lower MMSE and memory scores than non-carriers. Their demographic characteristics are representative of the local population.

Personality of late- and early-onset elderly suicide attempters

OBJECTIVES

While suicidal behavior often manifests in adolescence and early adulthood, some people first attempt suicide in late life, often with remarkable lethal intent and determination. Given these individuals' more adaptive functioning earlier in life, they may possess traits that hinder adjustment to aging, such as high conscientiousness, rather than impulsive-aggressive traits associated with suicidal behavior in younger adults.

METHODS

A cross-sectional case-control study was conducted in older adults aged ≥50 (mean: 65), divided into early- and late-onset attempters (age at first attempt ≤ or >50, mean: 31 vs 61), suicide ideators as well as non-suicidal depressed and healthy controls. Personality was assessed in terms of the five-factor model (FFM, n = 200) and five DSM personality disorders analyzed on the trait level as continuous scores (PDs, n = 160). Given our starting hypothesis about late-onset attempters, the FFM dimension conscientiousness was further tested on the subcomponent level.

RESULTS

All clinical groups displayed more maladaptive profiles than healthy subjects. Compared to depressed controls, higher neuroticism, and borderline traits characterized both suicide ideators and early-onset attempters, while only early-onset attempters further displayed lower extraversion and higher antisocial traits. Late-onset attempters were similar to depressed controls on most measures, but scored higher than them on orderliness, a conscientiousness subcomponent.

CONCLUSIONS

While neuroticism, introversion, and cluster B traits are prominent in early-onset suicidal behavior, late-onset cases generally lack these features. In contrast, higher levels of orderliness in late-onset suicidal behavior are compatible with the age-selective maladjustment hypothesis. Key points Personality of elderly attempters differed between those with early- and late-onset first attempts. Early-onset attempters possessed personality traits generally found in younger suicidal populations (high neuroticism, low extraversion, antisocial, and borderline PD traits), supporting that constitutional suicide risk factors persist into late life in some individuals. Late-onset suicide attempters had higher levels of orderliness than non-suicidal depressed participants, suggesting that this generally adaptive trait may facilitate suicidal behavior in a subset of depressed elderly.

Neuroticism-Withdrawal and Neuroticism-Volatility Differently Influence the Risk of Neuropsychiatric Symptoms in Alzheimer's Disease

BACKGROUND

Neuroticism is recognized as the personality domain that is most strongly associated with behavioral and psychological symptoms (BPS) of Alzheimer's disease (AD). Two sub-components of neuroticism have been recently isolated. Neuroticism-withdrawal (N-withdrawal) refers to the tendency to internalize negative emotion, whereas neuroticism-volatility (N-volatility) reflect the predisposition to externalize negative emotions.

OBJECTIVE

The objective of the current study was to investigate the specific influence of these two sub-components of neuroticism on BPS.

METHODS

One hundred eighty-seven patients with prodromal or mild AD were drawn from the PACO study (Personalité Alzheimer COmportement). Neuroticism and its facets were assessed at baseline using the NEO-PI-R inventory. N-withdrawal and N-volatility were isolated using a principal component analysis led on the six facets composing neuroticism. BPS were measured with the short version of Neuropsychiatric Inventory (NPI-Q) and collected at baseline, then every 6 months over an 18-month follow-up. Linear mixed-effect analyses were conducted to investigate the association between N-withdrawal, N-volatility, and the severity of BPS over the follow-up.

RESULTS

Mean age of the participant was 79.2±6.5; 59% were female; mean MMSE was 24.5±2.5. Both N-volatility and N-withdrawal were related with the NPI-Q (p < 0.001; p = 0,004). N-withdrawal was positively associated with anxiety (p = 0.001) and depression (p = 0.002), while N-volatility was positively related to delusions (p = 0.004), agitation/aggression (p < 0.001), irritability/volatility (p = 0.037), and apathy (p = 0.021).

CONCLUSION

The present study demonstrates that N-volatility and N-withdrawal influence the risk of developing BPS in a different way. These results highlight the relevance of considering sub-components of neuroticism when studying links between personality and BPS.

Personality Traits are Related to Selective Cognitive Impairment in Early Alzheimer's Disease

BACKGROUND

A link between personality traits and cognitive performance has been shown in normal adults and elderly individuals. Very few studies have evaluated this link in Alzheimer's disease (AD).

OBJECTIVE

To better understand cognitive performance as regards to personality traits, our study was aimed to evaluate the role of premorbid personality on cognitive functioning in a population of patients presenting prodromal or mild AD.

METHODS

181 elderly with prodromal or mild AD participated in a cross-sectional, prospective cohort study. The participants completed a personality inventory and a neuropsychological battery exploring memory, attention, executive function, language, and praxis. Cognitive performance were compared according to the level of each personality trait, using multivariate MANOVA models.

RESULTS

A higher level of neuroticism was associated with lower performance at similarities test (D = 9.49, p = 0.003), delayed Free and Cued Selective Reminding test (D = 5.22, p = 0.02), and digit span score (D = 7.99, p = 0.006). A higher level of openness was related to better performance at similarities (D = 4.33, p = 0.04), letter fluency (D = 11.45, p = 0.001), and category fluency test (D = 5.85, p = 0.02). Neuroticism interfered negatively with cognitive functioning at the prodromal stage; the association between openness and cognitive function was observed at both prodromal and mild AD stage.

CONCLUSION

These results suggest that personality traits, in particular neuroticism and openness, modulate cognitive abilities in patients with early AD. These results encourage the development of stress management programs to prevent its negative effects on cognitive aging.

Mental Disorders in Young Adults from Families with the Presenilin-1 Gene Mutation E280A in the Preclinical Stage of Alzheimer's Disease

Background

There are forms of Alzheimer's disease (AD) that have an autosomal dominant inheritance pattern; one of them is caused by the E280A mutation in the gene that codes for Presenilin-1 (PSEN1). Studying families of people with this mutation allows the evaluation of characteristics of the subjects before cognitive decline begins.

Objective

To determine whether having the mutation E280A in PSEN1 increases the risk of presenting mental disorders in adults under 30 years old who are in the preclinical stage of AD and may be eligible for primary prevention studies of AD.

Methods

A psychiatric evaluation was made to 120 people belonging to families with a history of early onset AD. Of these, 62 carried the E280A mutation in PSEN1. The occurrence of mental disorders between carriers and non-carriers of the mutation was compared.

Results

No statistically significant differences were found in the frequency of any mental disorder between the group of carriers and non-carriers of the mutation (Hazard Ratio: 0.80, 95% CI 0.49 to 1.31); nor were differences observed when evaluating specific disorders.

Conclusion

The E280A mutation does not increase the risk of mental disorders before the age of 30 in the relatives of people affected by familial AD. Studies with larger sample sizes are required to assess the risk of low incidence mental disorders.

WITHDRAWN: Mental Disorders in Young Adults from Families with the Presenilin-1 Gene Mutation E280A in the Preclinical Stage of Alzheimer's Disease

Ahead of Print article withdrawn by publisher.

The activated newborn neurons participate in enriched environment induced improvement of locomotor function in APP/PS1 mice

INTRODUCTION

Alzheimer's disease (AD) is an age-related neurodegenerative disorder. One of the pathological features of AD is neuronal loss in brain regions associated with cognition, particularly the hippocampus. An enriched environment (EE) can facilitate neuronal plasticity and improve behaviors such as emotion, motor function, and cognition in AD.

METHODS

After APP/PS1 mice were exposed to EE at an early stage (2 months of age), elevated plus maze performance and contextual fear conditioning were tested, and neurogenesis and the extent of activation in the hippocampus were observed.

RESULTS

The results showed that, compared with that in the mice that experienced a standard environment, the cognition of the mice exposed to EE, as measured by contextual fear conditioning, was not statistically significant. However, based on their performance in the elevated plus maze, the index was increased in the mice, especially the APP/PS1 mice, exposed to EE. Consistent with the behavioral changes, the APP/PS1 mice exposed to EE showed an increased number of c-Fos-positive neurons and elevated neurogenesis in the dentate gyrus (DG) area. In addition, the activation of newborn neurons did not occur in the other three groups.

CONCLUSIONS

These results indicate that the activation of newborn neurons may participate in the improvement of behavioral performance in APP/PS1 mice after EE.

Personality and the risk factors for developing behavioral and psychological symptoms of dementia: a narrative review

Premorbid personality traits have been implicated as risk factors for the development of behavioral and psychological symptoms of dementia (BPSD), although there is a paucity of studies investigating this relationship. In this narrative review, a number of studies found that premorbid neuroticism has consistently been observed to have a significant association with the development of BPSD symptoms while premorbid conscientiousness, extraversion, openness and agreeableness may be protective factors against future BPSD symptoms. In conclusion, premorbid personality traits appear to affect the risk of BPSD symptoms among individuals with dementia.

Meta-Analysis of Personality Traits in Alzheimer's Disease: A Comparison with Healthy Subjects

BACKGROUND

The role of specific personality traits as factor risks of Alzheimer's disease (AD) has been consistently found, whereas personality traits specifically related to AD (after the diagnosis) have not been outlined yet.

OBJECTIVE

A meta-analysis of published studies was performed to determine whether AD patients have a distinctive personality trait profile compared to healthy subjects (HC), similar to or different from a premorbid personality profile consistently reported in previous studies.

METHODS

A systematic literature search was performed using PsycInfo (PROQUEST), PubMed, and Scopus. The meta-analysis pooled results from primary studies using Hedges' g unbiased approach.

RESULTS

The meta-analysis included 10 primary studies and revealed that, when the personality was evaluated by informant-rated measures, AD patients had significantly higher levels of Neuroticism, lower levels of Openness, Agreeableness, Conscientiousness, and Extraversion than HCs. When the personality was evaluated by self-rated measures, the results obtained from informants were confirmed for Neuroticism, Openness, and Extraversion but not for Agreeableness and Conscientiousness where AD patients and HCs achieved similar scores.

CONCLUSIONS

The meta-analysis revealed that high Neuroticism and low Openness and Extraversion are distinctive personality traits significantly associated with a diagnosis of AD when evaluated both self-rated and informant-rated measures. This personality trait profile is similar to premorbid one, which contributes to development of AD over time. Therefore, our findings indirectly support the idea of specific premorbid personality traits as harbingers of AD.

Personality Changes With Dementia From the Informant Perspective: New Data and Meta-Analysis

OBJECTIVE

To examine changes in personality in individuals with mild cognitive impairment (MCI) or dementia as observed by family members using both new data and a meta-analysis with the published literature.

DESIGN

Current and retrospective personality assessments of individuals with dementia by family informants. PubMed was searched for studies with a similar design and a forward citation tracking was conducted using Google Scholar in June 2018. Results from a new sample and from published studies were combined in a random effect meta-analysis.

SETTING AND PARTICIPANTS

Family members of older adults with MCI or dementia.

MEASURES

The 5 major dimensions (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and facets of personality were assessed with NEO Personality Inventory questionnaires.

RESULTS

The new sample (n = 50) and meta-analysis (18 samples; n = 542) found consistent shifts in personality from the premorbid to current state in patients with cognitive impairment. The largest changes (>1 standard deviation) were declines in conscientiousness (particularly for the facets of self-discipline and competence) and extraversion (decreased energy and assertiveness), as well as increases in neuroticism (increased vulnerability to stress). The new sample suggested that personality changes were larger in individuals taking cognition-enhancing medications (cholinesterase inhibitors or memantine). More recent studies and those that examined individuals with MCI found smaller effects.

CONCLUSIONS AND IMPLICATIONS

Consistent with the clinical criteria for the diagnosis of dementia, the new study and meta-analysis found replicable evidence for large changes in personality among individuals with dementia. Future research should examine whether there are different patterns of personality changes across etiologies of dementia to inform differential diagnosis and treatments. Prospective, repeated assessments of personality using both self- and informant-reports are essential to clarify the temporal evolution of personality change across the preclinical, prodromal, and clinical phases of dementia.

[Premorbid personality as a risk factor in the appearance of psychological and behavioural symptoms of dementia: Systematic review]

The aetiology of behavioural and psychological symptoms of dementia (BPSD) is defined by a diversity of factors, and recent studies suggest that premorbid personality could be a risk factor for BPSD. This study aimed to review studies on the relationship between premorbid personality and BPSD. Studies were identified using PsycInfo, MedLine, and PubMed. The searches combined terms for premorbid personality, dementia and BPSD. Ten studies have been included in this review. Eight out of ten studies show a relationship between premorbid personality and BPSD. Neuroticism is associated with behavioural disturbances and anxiety. Extraversion is associated with wandering. Low agreeableness is associated with affective disturbance and aggression-related behaviours and high agreeableness is associated with wandering. The studies found no congruent results for openness and conscientiousness. In conclusion, premorbid personality may increase the risk of developing BPSD during the course of the disease. Even so, the relationship between personality and BPSD is complex due to multifactorial aetiology.

Self-reported personality traits are prospectively associated with proxy-reported behavioral and psychological symptoms of dementia at the end of life

OBJECTIVE

Behavioral and psychological symptoms of dementia (BPSD) are among the most challenging aspects of Alzheimer disease for patients and their families. Previous studies have found associations between informant-reported retrospective personality and BPSD; we test whether prospective, self-reported personality predicts who will experience these symptoms.

METHODS

Deceased participants from the Health and Retirement Study who had evidence of cognitive impairment at the end of life (N = 1988) were selected to examine whether self-reported five-factor model personality traits, measured up to 8 years before death, were associated with proxy-reported BPSD.

RESULTS

Neuroticism was associated with increased risk of the 7 BPSD: got lost in familiar places, wandered off, were not able to be left alone, experienced hallucinations, suffered from depression, had periodic confusion, and an uncontrolled temper. These associations were not moderated by age, gender, race, or education. Conscientiousness was associated with fewer symptoms overall and especially with lower risk of getting lost in familiar places and not being able to be left alone.

CONCLUSIONS

The present research indicates that self-reported personality, particularly Neuroticism, is associated prospectively with risk for a wide range of behavioral symptoms for individuals who had cognitive impairment at the end of life. The use of self-reported personality traits can help aid in identifying who is most at risk for behavioral symptoms. Such information may be useful for nonpharmacological interventions tailored to the individual's personality to reduce the prevalence and burden of these BPSD.

Personality Changes During the Transition from Cognitive Health to Mild Cognitive Impairment

BACKGROUND/OBJECTIVES

Behavioral problems in individuals with Alzheimer's disease (AD) impose major management challenges. Current prevention strategies are anchored to cognitive outcomes, but behavioral outcomes may provide another, clinically relevant opportunity for preemptive therapy. We sought to determine whether personality changes that predispose to behavioral disorders arise during the transition from preclinical AD to mild cognitive impairment (MCI).

DESIGN

Longitudinal observational cohort study.

SETTING

Academic medical center.

PARTICIPANTS

Members of an apolipoprotein E (APOE) ɛ4 genetically enriched cohort of Maricopa County residents who were neuropsychiatrically healthy at entry (N = 277). Over a mean interval of 7 years, 25 who developed MCI and had the Neuroticism, Extraversion, and Openness Personality Inventory-Revised (NEO-PI-R) before and during the MCI transition epoch were compared with 252 nontransitioners also with serial NEO-PI-R administrations.

INTERVENTION

Longitudinal administration of the NEO-PI-R and neuropsychological test battery.

MEASUREMENTS

Change in NEO-PI-R factor scores (neuroticism, extraversion, openness, agreeableness, conscientiousness) from entry to the epoch of MCI diagnosis or an equivalent follow-up duration in nontransitioners.

RESULTS

NEO-PI-R neuroticism T-scores increased significantly more in MCI transitioners than in nontransitioners (mean 2.9, 95% confidence interval (CI) = 0.9-4.9 vs 0, 95% CI = -0.7-0.7, P = .02), and openness decreased more in MCI transitioners than in nontransitioners (-4.8, 95% CI = -7.3 to -2.4 vs -1.0, 95% CI = -1.6 to -0.4, P < .001). Concurrent subclinical but statistically significant changes in behavioral scores worsened more in MCI transitioners than nontransitioners for measures of depression, somatization, irritability, anxiety, and aggressive attitude.

CONCLUSION

Personality and subclinical behavioral changes begin during the transition from preclinical AD to incident MCI and qualitatively resemble the clinically manifest behavioral disorders that subsequently arise in individuals with frank dementia.

Skin Conduction Levels Differentiate Frontotemporal Dementia From Alzheimer's Disease

Patients with behavioral variant frontotemporal dementia (bvFTD) and Alzheimer's disease (AD) differ in basic emotional tone. Skin conduction levels (SCLs), a measure of sympathetic tone, may be a sensitive test for discriminating these two dementias early in their course. Previous research has shown differences in resting SCLs between patients with bvFTD and AD, but no study has evaluated the discriminability of SCLs during different environmental conditions. The authors compared bvFTD patients (N=8), AD patients (N=10), and healthy control subjects (N=9) on SCL measures pertaining to real-life vignettes or scenarios differing in valence and emotional intensity. The SCLs among the bvFTD patients were decreased across all conditions, whereas the SCLs among the AD patients were increased compared with control participants. On analysis, the SCLs in response to emotional stimuli differentiated bvFTD from AD with an area under the receiver operator characteristic curve of 95.3%. At a cutoff ≤0.77 μS, emotional vignettes distinguished bvFTD from AD with a sensitivity of 86% and a specificity of 96%. These preliminary results indicate the potential utility of SCLs for differentiating bvFTD from AD early in their course, regardless of environmental condition.

Best practice in the management of behavioural and psychological symptoms of dementia

Behavioural and psychological symptoms of dementia (BPSD) occur in most patients with dementia. They cause great suffering in patients and caregivers, sometimes more so than the cognitive and functional decline inherent to dementia. The clinical features of BPSD include a wide variety of affective, psychotic and behavioural symptoms and signs. The causes and risk factors for BPSD are multiple and include biological, psychological and environmental variables. Frequently, their combination, rather than any specific factor, explains the occurrence of BPSD in an individual patient. Thus, a sound etiopathogenetic investigation including the patient and the family or care team is essential. The aim is to develop an individualized treatment plan using a therapeutic decision tree modified by the individual and environmental risk profile. Still, treatment may be difficult and challenging. Clinical empiricism often steps in where evidence from controlled studies is lacking. Psychosocial treatment approaches are pivotal for successful treatment of BPSD. Often a combination of different non-pharmacological approaches precedes drug treatment (most of which is off-label). Regular assessments of the treatment plan and any prescriptions must be carried out to detect signs of relapse and to stop any medicines that may have become inappropriate. Even with optimal management, BPSD will not disappear completely in some cases and will remain challenging for all involved parties. This article is a narrative review based closely on the interprofessional Swiss recommendations for the treatment of BPSD. To establish the recommendations, a thorough research of the literature has been carried out. Evidence-based data were provided through searches of Medline, Embase, ISI and Cochrane-Database research. Evidence categories of the World Federation of Biological Societies were used. Additionally, the clinical experience of Swiss medical experts was considered.

Initial Heart Rate Reactivity to Socioemotional Pictures in Early-Onset Alzheimer's Disease

Patients with Alzheimer's disease (AD) often have generalized anxiety, particularly in early-onset AD (EOAD) or the first stages of their disease. This increased anxiety could be associated with decreased sensorimotor gating with increased attention to significant stimuli from AD pathology in the entorhinal cortex. We investigated whether widening initial attention to socioemotional stimuli was association with anxiety among 16 patients with first stage EOAD compared to 19 normal controls (NCs). The participants underwent assessment of their initial heart rate deceleration ("orienting response"; OR), a measure of attentional refocusing, to pictures (International Affective Picture Stimuli) varying in pleasant-unpleasant valence and social-nonsocial content. The results showed group differences; the EOAD patients had significantly larger ORs than the NCs across conditions, with larger ORs in each valence and social condition. In addition, the EOAD patients, but not the NCs, showed ORs to normally less threatening stimuli, particularly pleasant, but also less significantly, social stimuli. On the Neuropsychiatric Inventory, the ORs among the EOAD patients significantly correlated with anxiety scores. Together, these findings suggest that anxiety in mild EOAD may be associated with widening attentional refocusing to socioemotional stimuli, possibly reflecting decreased sensorimotor gating in the entorhinal cortex. This finding could be a potential biomarker for the first stages of AD.

The importance of behavioural and pyschological symptoms in Alzheimer's disease

INTRODUCTION

Behavioral and psychological symptoms of dementia (BPSD), present in the vast majority of patients with Alzheimer's disease (AD), cause extensive impairment in all areas, including functionality. Early diagnosis and management are critical, especially since these symptoms are not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) as a diagnostic criterion of AD, but only as specific features of some patients. The main purpose of this review is to highlight the importance of these behavioural and psychological symptoms of dementia, particularly in AD. In addition, we discuss why these symptoms have not been included in the latest DSM-V.

DEVELOPMENT

We conducted a literature search through various databases to gather data about BPSD in AD, and found a total of 12 articles.

CONCLUSIONS

BPSD are present in almost all patients and result in cognitive and functional impairment. The prevalence of these symptoms varies depending on the study and the symptom in question. In our view, BPSD should be included among the DSM diagnostic criteria for AD.

Behavioral and psychological symptoms and cognitive decline in patients with amnestic MCI and mild AD: a two-year follow-up study

BACKGROUND

Mild cognitive impairment (MCI) has been defined as a transitional state between normal aging and dementia. In many cases, MCI represents an early stage of developing cognitive impairment. Patients diagnosed with MCI do not meet the criteria for dementia as their general intellect and everyday activities are preserved, although minor changes in instrumental activities of daily living (ADL) may occur. However, they may exhibit significant behavioral and psychological signs and symptoms (BPS), also frequently observed in patients with Alzheimer's disease (AD). Hence, we wondered to what extent specific BPS are associated with cognitive decline in participants with MCI or AD.

METHODS

Our sample consisted of 164 participants, including 46 patients with amnestic (single or multi-domain) MCI and 54 patients with AD, as well as 64 control participants without cognitive disorders. Global cognitive performance, BPS, and ADL were assessed using validated clinical methods at baseline and at two-year follow-up.

RESULTS

The BPS variability over the follow-up period was more pronounced in the MCI group than in patients with AD: some BPS improve, others occur newly or worsen, while others still remain unchanged. Moreover, specific changes in BPS were associated with a rapid deterioration of the global cognitive level in MCI patients. In particular, an increase of euphoria, eating disorders, and aberrant motor behavior, as well as worsened sleep quality, predicted a decline in cognitive functioning.

CONCLUSIONS

Our findings confirm a higher variability of BPS over time in the MCI group than in AD patients. Moreover, our results provide evidence of associations between specific BPS and cognitive decline in the MCI group that might suggest a risk of conversion of individuals with amnestic MCI to AD.

Social influence on associative learning: double dissociation in high-functioning autism, early-stage behavioural variant frontotemporal dementia and Alzheimer's disease

INTRODUCTION

Most of our learning activity takes place in a social context. I examined how social interactions influence associative learning in neurodegenerative diseases and atypical neurodevelopmental conditions primarily characterised by social cognitive and memory dysfunctions.

METHODS

Participants were individuals with high-functioning autism (HFA, n = 18), early-stage behavioural variant frontotemporal dementia (bvFTD, n = 16) and Alzheimer's disease (AD, n = 20). The leading symptoms in HFA and bvFTD were social and behavioural dysfunctions, whereas AD was characterised by memory deficits. Participants received three versions of a paired associates learning task. In the game with boxes test, objects were hidden in six candy boxes placed in different locations on the computer screen. In the game with faces, each box was labelled by a photo of a person. In the real-life version of the game, participants played with real persons.

RESULTS

Individuals with HFA and bvFTD performed well in the computer games, but failed on the task including real persons. In contrast, in patients with early-stage AD, social interactions boosted paired associates learning up to the level of healthy control volunteers. Worse performance in the real life game was associated with less successful recognition of complex emotions and mental states in the Reading the Mind in the Eyes Test. Spatial span did not affect the results.

CONCLUSIONS

When social cognition is impaired, but memory systems are less compromised (HFA and bvFTD), real-life interactions disrupt associative learning; when disease process impairs memory systems but social cognition is relatively intact (early-stage AD), social interactions have a beneficial effect on learning and memory.

When one loses empathy: its effect on carers of patients with dementia

The effects of empathy loss in frontotemporal dementia (FTD) and Alzheimer disease (AD) on carer symptomatology were investigated. Carers of patients with 2 clinical subtypes of FTD (behavioral-variant FTD [bvFTD] = 18; semantic dementia [SD] = 14) and AD (n = 18) completed the Interpersonal Reactivity Index (IRI), a standardized questionnaire of empathy as well as a measure of perceived burden (Zarit Burden Interview) and the quality of the marital relationship (Intimate Bond Measure). Patient ratings were also obtained on the IRI. Loss of empathy was most striking in the bvFTD group with a marked discrepancy observed between carer and patient ratings for change in emotional warmth and the ability to take the perspective of others. Empathy loss in bvFTD was associated with a loss of a caring marital relationship. Empathic deficits in SD were milder by comparison to bvFTD and correlated with disease severity and increased perceived carer burden. The behavioral pattern observed in AD differed from the FTD syndromes; deficits were observed only for measures of personal distress with carers reporting that patients were less able to handle emotionally evocative situations. Results highlight that changes in aspects of empathy differ across dementia syndromes and are associated with differing carer and clinical variables. These findings might be explained by the progression of atrophy in regions that are known to be critical for empathy and social behavior and has implications for the delivery and planning of services in dementia.