Neuropsychiatric Symptoms in Dementia: Considerations for Pharmacotherapy in the USA

Association of Visual Impairment With Neuropsychiatric Symptoms of Dementia

BACKGROUND

Visual impairment is a risk factor for cognitive impairment and hallucinations in older adults, but associations with other neuropsychiatric symptoms (NPS) of dementia have not been examined.

METHODS

We analyzed cross-sectional data from the Aging, Demographics, and Memory Study (ADAMS), a nationally representative sample of the US population aged 70+ years. Vision was measured by self-report and using a near card. Dementia was ascertained through cognitive testing with expert consensus, and NPS were screened using the Neuropsychiatric Inventory. We used logistic regression to measure the association between visual impairment and prevalent NPS adjusting for sociodemographic factors and comorbidities. Analyses incorporated sample weights to account for the complex survey design of ADAMS.

RESULTS

Of 624 participants with dementia, 332 (53%) had self-reported visual impairment and 193 (31%) had best-corrected acuity of 20/40 or worse. In unadjusted models, self-reported visual impairment was significantly associated with hallucinations (OR 2.88; 95% CI 1.12-7.44), depression (OR 2.79; 95% CI 1.7-4.57), and agitation (OR 1.61; 95% CI 1.05-2.48). Reduced visual acuity was associated with hallucinations (OR 10.13; 95% CI 2.93-34.98), psychosis (OR 6.69, 95% CI 2.53-17.7), and mania (OR 5.92, 95% CI 1.77-19.82). However, these associations did not remain significant after covariate adjustment.

CONCLUSIONS

Visual impairment was associated with hallucinations, depression, agitation, psychosis, and mania in patients with dementia, but at least some of this relationship is explained by age, comorbidities, and other factors.

The Effects of Light Therapy on Sleep, Depression, Neuropsychiatric Behaviors, and Cognition Among People Living With Dementia: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Alterations in the suprachiasmatic nucleus due to underlying pathologies disrupt the circadian rhythms in people living with dementia (PLWD). Circadian rhythms significantly impact sleep, emotional, and cognitive functions, with its synchronization depending on light exposure. We performed a meta-analysis to evaluate the effects of light therapy on sleep, depression, neuropsychiatric behaviors, and cognition among PLWD.

METHODS

A systematic search was conducted in Cochrane, ClinicalTrials.gov, Embase, EBSCOhost, Ovid-MEDLINE, PubMed, Scopus, Web of Science, and CINAHL databases. The pooled effect size was calculated using the Hedges' g with random-effects model adopted in comprehensive meta-analysis software. The Cochrane risk of bias (RoB 2.0) tool evaluated the quality of studies, while Cochrane's Q and I² tests assessed heterogeneity.

RESULTS

A total of 24 studies with 1,074 participants were included. Light therapy demonstrated small-to-medium effects on improving sleep parameters: total sleep time (Hedges' g = 0.19), wake after sleep onset (Hedges' g = 0.24), sleep efficiency (Hedges' g = 0.31), sleep latency (Hedges' g = 0.35), circadian rhythm (acrophase: Hedges' g = 0.36; amplitude: Hedges' g = 0.43), number of night awakenings (Hedges' g = 0.37), sleep disturbance (Hedges'g = 0.45), and sleep quality (Hedges' g = 0.60). Light therapy showed small-to-medium effect on reducing depression (Hedges' g = -0.46) with medium-to-large effect on cyclical function (Hedges' g = -0.68) and mood-related signs and symptoms (Hedges' g = -0.84) subscales. Light therapy also demonstrated small effect on reducing neuropsychiatric behaviors (Hedges' g = -0.34) with medium-to-large effect on agitation (Hedges' g = -0.65), affective symptom (Hedges' g = -0.70), psychosis (Hedges' g = -0.72), and melancholic behavior (Hedges' g = -0.91) subscales. Additionally, light therapy also improved cognition (Hedges' g = 0.39).

CONCLUSION

Light therapy could be used as a supportive therapy to improve sleep, depression, cognition, and neuropsychiatric behaviors among PLWD.

North Macedonia interprofessional dementia care (NOMAD) - personalized care plans for people with dementia and caregiver psychoeducation delivered at home by interprofessional teams

Introduction

The increasing number of people living with dementia and its burden on families and systems particularly in low- and middle-income countries require comprehensive and efficient post-diagnostic management. This study aimed to explore the acceptability and efficacy of a multi-professional case management and psychoeducation model (North Macedonia Interprofessional Dementia Care, or NOMAD) delivered by mobile teams for people with dementia and their caregivers in North Macedonia.

Method

We conducted a two-arm randomized controlled trial comparing the intervention with treatment as usual. Participants were recruited from 12 general practitioner (GP) offices in the Skopje region. The NOMAD intervention included the delivery of a personalized care plan over four home visits to dyads of people with dementia and their caregivers by a team including a dementia nurse and a social worker, in collaboration with GPs and dementia experts, and the introduction of a caregiver manual. We assessed caregivers' depressive symptoms, burden, and quality of life and the neuropsychiatric symptoms, daily living activities, and service utilization of people with dementia at baseline and follow-up; we also assessed the acceptability of the intervention by analyzing case notes and attendance rates.

Results

One hundred and twenty dyads were recruited and randomized to either the control (n = 60) or the intervention group (n = 60). At follow-up, caregivers in the intervention group had, on average, scores that were 2.69 lower for depressive symptoms (95% CI [-4.75, -0.62], p = 0.012), and people with dementia had, on average, 11.32 fewer neuropsychiatric symptoms (95% CI [-19.74, -2.90], p = 0.009) and used, on average, 1.81 fewer healthcare services (95% CI [-2.61, -1.00], p < 0.001) compared to the control group. The completion of the home visits was 100%, but the intervention's acceptability was underpinned by relationship building, GP competencies, and resources to support families with dementia. There were no differences in the caregivers' quality of life and burden levels or daily living activities in people with dementia. NOMAD is the first case management, non-pharmacological, and multi-professional intervention tested in North Macedonia.

Discussion

The trial showed that it is effective in reducing caregivers' depressive symptoms and neuropsychiatric symptoms in people with dementia and the burden on health and social care services, and it is acceptable for families. Implementing NOMAD in practice will require building primary care capacity and recognizing dementia as a national priority.

Influence of care modes and social resources on psychotropic medication use in community-dwelling dementia patients

Background

Optimal use of psychotropic medications for people living with dementia is important. By finding potentially modifiable factors, dementia care teams may find solutions to achieve the appropriate use of psychotropic drugs.

Objective

This study aimed to elucidate patient and caregiver factors associated with the use of psychotropic drugs listed in the potentially inappropriate medications (PIMs) in community-dwelling people with dementia.

Methods

This cross-sectional study enrolled 808 patients newly diagnosed with dementia, and their caregivers, from a dementia clinic at Changhua Christian Hospital. Patient and caregiver characteristics, care mode, and social resource usage were recorded. Multivariate logistic regression was used to identify factors associated with prescribing psychotropic medications.

Results

Of all the participants, 39.1% used at least one of psychotropic medication categorized as PIM. Patients with frontotemporal dementia, with behavior or psychological symptoms, or cared by sole foreign care workers; caregivers with higher depression scores, employed or non-spouse caregivers carried a higher risk of prescription of psychotropic medications listed in PIMs.

Conclusion

Psychotropic drug prescriptions are associated with patient and caregiver factors. Therefore, implementing appropriate interventions, especially those targeting potentially modifiable factors, is important to reduce psychotropic medication use.

A real-world assessment of healthcare costs associated with agitation in Alzheimer's dementia

AIMS

To describe and compare clinical characteristics, healthcare costs, and institutionalization/mortality outcomes among patients with and without agitation associated with Alzheimer's dementia (AAD).

METHODS

Data from the Reliant Medical Group database (01/01/2016-03/31/2020) were used, including claims, electronic medical records, and clinical information/physician notes abstracted from medical charts. Patients aged ≥55 years with Alzheimer's dementia (AD) were observed during a randomly selected 12-month study period after AD diagnosis. Using information recorded in medical charts, patients were classified into cohorts based on experiencing (agitation cohort) and not experiencing (no agitation cohort) agitated behaviours during the study period. Entropy balancing was used to create reweighted cohorts with similar characteristics. Study outcomes (patient demographic and clinical characteristics, treatments received, healthcare costs, institutionalization and death events) were compared between cohorts; agitation characteristics were described for the agitation cohort only.

RESULTS

Among 711 patients included in the study, 240 were classified in the agitation cohort and 471 in the no agitation cohort. After reweighting, several comorbidities were more frequently observed in the agitation versus no agitation cohort, including infection, depression, and altered mental status. Use of antidepressants, anticonvulsants, antipsychotics, and antianxiety medications was more common in the agitation versus no agitation cohort. Common agitated behaviours included hitting (20.8%), pacing/aimless wandering (17.5%), and cursing/verbal aggression (15.0%). Total all-cause healthcare costs were $4287 per-patient-per-year higher in the agitation cohort versus no agitation cohort (p = 0.04), driven by higher inpatient costs. Death was more common and time to death and institutionalization were shorter in the agitation versus no agitation cohort.

LIMITATIONS

Results may not be generalizable to the US population with AD.

CONCLUSIONS

Among patients with AD, agitation was associated with shorter time to death/institutionalization and increased comorbidities, medication use, and healthcare costs, highlighting the additional clinical and economic burden that agitation poses to patients and the healthcare system.

Gait Domains May Be Used as an Auxiliary Diagnostic Index for Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disorder with cognitive dysfunction and behavioral impairment. We aimed to use principal components factor analysis to explore the association between gait domains and AD under single and dual-task gait assessments.

METHODS

A total of 41 AD participants and 41 healthy control (HC) participants were enrolled in our study. Gait parameters were measured using the JiBuEn® gait analysis system. The principal component method was used to conduct an orthogonal maximum variance rotation factor analysis of quantitative gait parameters. Multiple logistic regression was used to adjust for potential confounding or risk factors.

RESULTS

Based on the factor analysis, three domains of gait performance were identified both in the free walk and counting backward assessments: "rhythm" domain, "pace" domain and "variability" domain. Compared with HC, we found that the pace factor was independently associated with AD in two gait assessments; the variability factor was independently associated with AD only in the counting backwards assessment; and a statistical difference still remained after adjusting for age, sex and education levels.

CONCLUSIONS

Our findings indicate that gait domains may be used as an auxiliary diagnostic index for Alzheimer's disease.

VTA dopamine neurons are hyperexcitable in 3xTg-AD mice due to casein kinase 2-dependent SK channel dysfunction

Alzheimer's disease (AD) patients exhibit neuropsychiatric symptoms that extend beyond classical cognitive deficits, suggesting involvement of subcortical areas. Here, we investigated the role of midbrain dopamine (DA) neurons in AD using the amyloid + tau-driven 3xTg-AD mouse model. We found deficits in reward-based operant learning in AD mice, suggesting possible VTA DA neuron dysregulation. Physiological assessment revealed hyperexcitability and disrupted firing in DA neurons caused by reduced activity of small-conductance calcium-activated potassium (SK) channels. RNA sequencing from contents of single patch-clamped DA neurons (Patch-seq) identified up-regulation of the SK channel modulator casein kinase 2 (CK2). Pharmacological inhibition of CK2 restored SK channel activity and normal firing patterns in 3xTg-AD mice. These findings shed light on a complex interplay between neuropsychiatric symptoms and subcortical circuits in AD, paving the way for novel treatment strategies.

Effects of music therapy on cognition, quality of life, and neuropsychiatric symptoms of patients with dementia: A systematic review and meta-analysis of randomized controlled trials

Dementia is a major cause of disability and dependency. Pharmacological interventions are commonly provided to patients with dementia to delay the deterioration of cognitive functions but cannot alter the course of disease. Nonpharmacological interventions are now attracting increasing scholarly interest. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we aim to assess the effectiveness of music-based therapies on the cognition, quality of life (QoL), and neuropsychiatric symptoms of patients with dementia through a systematic review and meta-analysis of randomized controlled trials (RCTs). The PubMed, Embase, and Cochrane databases were searched for reports of RCTs examining the effectiveness of music-based therapies for dementia published as of April 2023. A total of 674 articles were screened, and 22 trials from 21 studies (1780 patients) met the eligibility criteria. In 15 trials, music-based therapies significantly improved the cognition of patients with dementia compared with non-music therapies. In 11 trials, music-based therapies also significantly improved the QoL of patients with dementia compared with non-music therapies. In six trials, music-based therapies significantly improved patients' neuropsychiatric symptoms compared with non-music therapies. In conclusion, music-based therapy is recognized as a safe and effective alternative approach for patients with dementia.

Amyloid Positron Emission Tomography and Subsequent Health Care Use Among Medicare Beneficiaries With Mild Cognitive Impairment or Dementia

Importance

Results of amyloid positron emission tomography (PET) have been shown to change the management of patients with mild cognitive impairment (MCI) or dementia who meet Appropriate Use Criteria (AUC).

Objective

To determine if amyloid PET is associated with reduced hospitalizations and emergency department (ED) visits over 12 months in patients with MCI or dementia.

Design, Setting, and Participants

This nonrandomized controlled trial analyzed participants in the Imaging Dementia-Evidence for Amyloid Scanning (IDEAS) study, an open-label, multisite, longitudinal study that enrolled participants between February 2016 and December 2017 and followed up through December 2018. These participants were recruited at 595 clinical sites that provide specialty memory care across the US. Eligible participants were Medicare beneficiaries 65 years or older with a diagnosis of MCI or dementia within the past 24 months who met published AUC for amyloid PET. Each IDEAS study participant was matched to a control Medicare beneficiary who had not undergone amyloid PET. Data analysis was conducted on December 13, 2022.

Exposure

Participants underwent amyloid PET at imaging centers.

Main Outcomes and Measures

The primary end points were the proportions of patients with 12-month inpatient hospital admissions and ED visits. One of 4 secondary end points was the rate of hospitalizations and rate of ED visits in participants with positive vs negative amyloid PET results. Health care use was ascertained from Medicare claims data.

Results

The 2 cohorts (IDEAS study participants and controls) each comprised 12 684 adults, including 6467 females (51.0%) with a median (IQR) age of 77 (73-81) years. Over 12 months, 24.0% of the IDEAS study participants were hospitalized, compared with 25.1% of the matched control cohort, for a relative reduction of -4.49% (97.5% CI, -9.09% to 0.34%). The 12-month ED visit rates were nearly identical between the 2 cohorts (44.8% in both IDEAS study and control cohorts) for a relative reduction of -0.12% (97.5% CI, -3.19% to 3.05%). Both outcomes fell short of the prespecified effect size of 10% or greater relative reduction. Overall, 1467 of 6848 participants (21.4%) with positive amyloid PET scans were hospitalized within 12 months compared with 1081 of 4209 participants (25.7%) with negative amyloid PET scans (adjusted odds ratio, 0.83; 95% CI, 0.78-0.89).

Conclusions and Relevance

Results of this nonrandomized controlled trial showed that use of amyloid PET was not associated with a significant reduction in 12-month hospitalizations or ED visits. Rates of hospitalization were lower in patients with positive vs negative amyloid PET results.

Network analysis of neuropsychiatric symptoms in Alzheimer's disease

BACKGROUND

Neuropsychiatric symptoms due to Alzheimer's disease (AD) and mild cognitive impairment (MCI) can decrease quality of life for patients and increase caregiver burden. Better characterization of neuropsychiatric symptoms and methods of analysis are needed to identify effective treatment targets. The current investigation leveraged the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS) to examine the network structure of neuropsychiatric symptoms among symptomatic older adults with cognitive impairment.

METHODS

The network relationships of behavioral symptoms were estimated from Neuropsychiatric Inventory Questionnaire (NPI-Q) data acquired from 12,494 older adults with MCI and AD during their initial visit. Network analysis provides insight into the relationships among sets of symptoms and allows calculation of the strengths of the relationships. Nodes represented individual NPI-Q symptoms and edges represented the pairwise dependency between symptoms. Node centrality was calculated to determine the relative importance of each symptom in the network.

RESULTS

The analysis showed patterns of connectivity among the symptoms of the NPI-Q. The network (M = .28) consisted of mostly positive edges. The strongest edges connected nodes within symptom domain. Disinhibition and agitation/aggression were the most central symptoms in the network. Depression/dysphoria was the most frequently endorsed symptom, but it was not central in the network.

CONCLUSIONS

Neuropsychiatric symptoms in MCI and AD are highly comorbid and mutually reinforcing. The presence of disinhibition and agitation/aggression yielded a higher probability of additional neuropsychiatric symptoms. Interventions targeting these symptoms may lead to greater neuropsychiatric symptom improvement overall. Future work will compare neuropsychiatric symptom networks across dementia etiologies, informant relationships, and ethnic/racial groups, and will explore the utility of network analysis as a means of interrogating treatment effects.

Therapeutic dilemma's: antipsychotics use for neuropsychiatric symptoms of dementia, delirium and insomnia and risk of falling in older adults, a clinical review

PURPOSE

Because of the common and increasing use of antipsychotics in older adults, we aim to summarize the current knowledge on the causes of antipsychotic-related risk of falls in older adults. We also aim to provide information on the use of antipsychotics in dementia, delirium and insomnia, their adverse effects and an overview of the pharmacokinetic and pharmacodynamic mechanisms associated with antipsychotic use and falls. Finally, we aim to provide information to clinicians for weighing the benefits and harms of (de)prescribing.

METHODS

A literature search was executed in CINAHL, PubMed and Scopus in March 2022 to identify studies focusing on fall-related adverse effects of the antipsychotic use in older adults. We focused on the antipsychotic use for neuropsychiatric symptoms of dementia, insomnia, and delirium.

RESULTS

Antipsychotics increase the risk of falls through anticholinergic, orthostatic and extrapyramidal effects, sedation, and adverse effects on cardio- and cerebrovascular system. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antipsychotics without current indication.

CONCLUSIONS

Deprescribing of antipsychotics should be considered and encouraged in older people at risk of falling, especially when prescribed for neuropsychiatric symptoms of dementia, delirium or insomnia. If antipsychotics are still needed, we recommend that the benefits and harms of antipsychotic use should be reassessed within two to four weeks of prescription. If the use of antipsychotic causes more harm than benefit, the deprescribing process should be started.

Network Analysis of Neuropsychiatric Symptoms in Alzheimer's Disease

Background: Neuropsychiatric symptoms due to Alzheimer's disease (AD) and mild cognitive impairment (MCI) can decrease quality of life for patients and increase caregiver burden. Better characterization of neuropsychiatric symptoms and methods of analysis are needed to identify effective treatment targets. The current investigation leveraged the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS) to examine the network structure of neuropsychiatric symptoms among symptomatic older adults with cognitive impairment. Methods: The network relationships of behavioral symptoms was estimated from Neuropsychiatric Inventory Questionnaire (NPI-Q) data acquired from 12,494 older adults with MCI and AD during their initial visit. Network analysis provides insight into the relationships among sets of symptoms and allows calculation of the strengths of the relationships. Nodes represented individual NPI-Q symptoms and edges represented the pairwise dependency between symptoms. Node centrality was calculated to determine the relative importance of each symptom in the network. Results: The analysis showed patterns of connectivity among the symptoms of the NPI-Q. The network ( M =.28) consisted of mostly positive edges. The strongest edges connected nodes within symptom domain. Disinhibition and agitation/aggression were the most central symptoms in the network. Depression/dysphoria was the most frequently endorsed symptom, but it was not central in the network. Conclusions: Neuropsychiatric symptoms in MCI and AD are highly comorbid and mutually reinforcing. The presence of disinhibition and agitation/aggression yielded a higher probability of additional neuropsychiatric symptoms. Interventions targeting these symptoms may lead to greater neuropsychiatric symptom improvement overall. Future work will compare neuropsychiatric symptom networks across dementia etiologies, informant relationships, and ethnic/racial groups, and will explore the utility of network analysis as a means of interrogating treatment effects.

Emotional Dysregulation in Mild Behavioral Impairment Is Associated with Reduced Cortical Thickness in the Right Supramarginal Gyrus

BACKGROUND

Mild behavioral impairment (MBI) has attracted attention as a possible precursor symptom of dementia, but its neural basis has not been fully investigated.

OBJECTIVE

We aimed to investigate the relationship between MBI and surface area, cortical thickness, and volume in the temporal and parietal lobes, which are strongly associated with dementia and emotional disorders.

METHODS

This retrospective study evaluated 123 participants: 90 with mild cognitive impairment (MCI), 13 with subjective cognitive decline (SCD), and 20 cognitively healthy (CH). Using analysis of covariance (ANCOVA) with sex, age, and MMSE score as covariates, cortical thickness, surface area, and volume in 10 regions were compared between groups with and without MBI. Groups with MBI emotional dysregulation were also compared with groups without MBI.

RESULTS

ANCOVA revealed significantly smaller cortical thickness in the MBI group's right parahippocampal (p = 0.01) and supramarginal gyri (p = 0.002). After multiple comparison correction, only the right supramarginal gyrus was significantly smaller (p = 0.02). When considering only MBI emotional dysregulation, the right parahippocampal and supramarginal gyrus' cortical thicknesses were significantly smaller in this MBI group (p = 0.03, 0.01). However, multiple comparison correction identified no significant differences (p = 0.14, 0.11).

CONCLUSION

Overall MBI and the emotional dysregulation domains were associated with reduced cortical thickness in the right parahippocampal and supramarginal gyri. Since neurodegeneration in the medial temporal and parietal lobe precedes early Alzheimer's disease (AD), MBI, particularly emotion dysregulation, may predict early AD below the diagnostic threshold.

Treatment of Vascular and Neurodegenerative Forms of Cognitive Impairment and Dementias

Ideally, dementia care should be provided by a collaborative team. Eligible patients should be treated with the cognitive-enhancing medications, the cholinesterase inhibitors and memantine. For most of the common causes of dementia, there are no disease-modifying medications, with the exception that vascular dementia can be prevented by treating vascular risk factors to prevent stroke. There is hope that Alzheimer disease can be treated by using monoclonal antibodies that target amyloid beta, although more trials are needed. Holistic, patient-centered care can enhance quality and extend the time that the patient can live safely in the community.

Prediction of Cognitive Decline by Behavioral Symptoms in Neuropsychiatric Disorders

Background: Neuropsychiatric disorders are described by their neurological, behavioral, and cognitive symptoms. However, behavioral symptoms may often be overlooked due to the current approach in neurology. Objectives: This study investigated the relationship between behavioral symptoms and cognitive functioning in neurological disorders. The second aim was to predict neurocognitive patterns by behavioral symptoms as independent variables. Methods: Behavioral symptoms were collected based on semi-structured neuropsychiatric interviews with 211 patients admitted to the neuropsychiatry department of Ayatollah Kashani hospital in Isfahan by both a neuropsychiatry fellow and an attending neuropsychiatrist. A neuropsychiatry fellow assessed all patients using the neuropsychiatry unit cognitive (NUCog) assessment tool. We used a generalized linear model (GLM) to indicate the effect of behavioral symptoms on the risk of decline in cognitive domains. Due to the use of all available samples, this study had no age limit, and the patients were 15 to 92 years old. Results: The regression coefficient of NUCog subscale scores for behavioral symptoms using GLM revealed that education level had a positive relationship with the scores of attention (P < 0.001), visuoconstruction (P < 0.001), memory (P < 0.001), executive function (P < 0.001), language (P < 0.001), and the total score of NUCog (P < 0.001). Patients with apathy had lower scores on the memory subscale (P = 0.002) and total NUCog (P = 0.021). Similarly, patients with delusion had lower scores on memory (P = 0.006) and executive function (P = 0.026). There was a negative relationship between agitation and attention (P = 0.049), visuoconstruction (P = 0.015), memory (P = 0.018), executive function (P = 0.005), and total score of NUCog (P = 0.007). Sleep disturbances were accompanied by lower memory scores (P = 0.056) and lower mean NUCog scores (P = 0.052). Visual hallucination was associated with declined performance in attention (P = 0.057). Conclusions: Behavioral assessment can help predict cognitive patterns in patients with neurobehavioral syndromes.

Pinus halepensis Essential Oil Ameliorates Aβ1-42-Induced Brain Injury by Diminishing Anxiety, Oxidative Stress, and Neuroinflammation in Rats

The Pinus L. genus comprises around 250 species, being popular worldwide for their medicinal and aromatic properties. The present study aimed to evaluate the P. halepensis Mill. essential oil (PNO) in an Alzheimer’s disease (AD) environment as an anxiolytic and antidepressant agent. The AD-like symptoms were induced in Wistar male rats by intracerebroventricular administration of amyloid beta1-42 (Aβ1-42), and PNO (1% and 3%) was delivered to Aβ1-42 pre-treated rats via inhalation route for 21 consecutive days, 30 min before behavioral assessments. The obtained results indicate PNO’s potential to relieve anxious–depressive features and to restore redox imbalance in the rats exhibiting AD-like neuropsychiatric impairments. Moreover, PNO presented beneficial effects against neuroinflammation and neuroapoptosis in the Aβ1-42 rat AD model.

Dementia Is More Than Memory Loss: Neuropsychiatric Symptoms of Dementia and Their Nonpharmacological and Pharmacological Management

Neuropsychiatric symptoms of dementia (NPS) are a group of noncognitive symptoms that occur in over 90% of individuals with dementia. NPS seem to result from a complex interaction among various biological, psychosocial, and environmental factors, and they are associated with greater morbidity and mortality, higher caregiver burden and burnout, high risk of nursing home placement, and increased cost of care for patients with dementia. Use of standardized assessment tools like the Neuropsychiatric Inventory can assist with qualifying and quantifying NPS. In this review, the authors evaluate the evidence for efficacy and safety of nonpharmacological and pharmacological interventions for treating NPS, mostly based on published meta-analyses. Commonly prescribed medications include atypical antipsychotics, acetylcholinesterase inhibitors, memantine, antidepressants, and mood stabilizers. There are also limited data on cannabinoids, repetitive transcranial magnetic stimulation, and ECT in individuals with NPS. Available evidence indicates that several nonpharmacological interventions are beneficial in the management of NPS and are recommended as first-line treatments. Pharmacotherapy should be reserved for the treatment of more severe or refractory NPS or where nonpharmacological management is not feasible. Atypical antipsychotics have shown mostly modest benefit in reducing NPS, and their use is limited by their adverse effect profiles. Recent investigations suggest potential strategies for preventing or at least reducing the risk of dementia and NPS. The authors conclude with brief guidelines for clinical practice as well as future research.

Actual drug-related harms in residential aged care facilities: a narrative review

INTRODUCTION

Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods.

AREAS COVERED

The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms.

EXPERT OPINION

The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.

The association of basal cortisol levels with episodic memory in older adults is mediated by executive function

Elevated basal cortisol levels in elderly may indicate dysregulation of the internal stress-related system, as well as dysfunction and structural alterations in brain structures necessary for cognition, such as hippocampus and prefrontal cortex. Because of the close relation of executive functions and episodic memory processing, in this study we explored whether the association of elevated cortisol levels on episodic memory could be partly attributed to cortisol effects on executive functions. In this cross-sectional study we analyzed data from a sample of 236 community-dwelling older adults from the Cretan Aging Cohort aged 75.56 ± 7.21 years [53 with dementia due to probable Alzheimer's disease, 99 with Mild Cognitive Impairment (MCI) and 84 cognitively non-impaired participants (NI)]. Morning serum cortisol levels were higher in the probable AD as compared to the NI group (p = .031). Mediated regression models in the total sample supported the hypothesis that the negative association of basal cortisol levels with delayed memory was fully mediated by the relation of basal cortisol levels with executive functions and immediate memory (adjusted for age and self-reported depression symptoms). Moderated mediation regression models revealed that the direct effect of cortisol on executive function and the effect of executive function on delayed memory performance were statistically significant among participants diagnosed with MCI, while the immediate memory effect on delayed memory was more pronounced in AD patients, as compared to the NI group. The current findings corroborate neuroimaging research highlighting cortisol effects on executive functions and immediate memory and further suggest that dysregulation of systems involved in these functions may account for the purported detrimental long-term effects of high cortisol levels on delayed memory.

Characteristics associated with neuropsychiatric symptoms in persons living with dementia and caregiver distress and diminished well-being

BACKGROUND

The population of persons living with dementia (PLWDs) is increasing, although mainstream dementia care quality is suboptimal.

PURPOSE

To identify characteristics associated with: (1) PLWDs' neuropsychiatric symptoms and quality of life; and (2) distress from neuropsychiatric symptoms and well-being among their family caregivers (N = 49).

METHODOLOGY

Cross-sectional single-group examination of PLWD and caregivers when they enrolled into a nurse-led dementia-centered primary care clinic. Pearson correlations were run between characteristics of PLWD and caregiver and variables representing PLWD's neuropsychiatric symptoms and quality of life and their caregivers' well-being. Statistically significant correlations were reported via Cohen d statistics.

RESULTS

Caregivers' characteristics associated with higher distress from neuropsychiatric symptoms and diminished well-being included Black race, female gender, younger age, caring for a parent with dementia, and being employed. Characteristics of PLWD associated with caregivers' higher distress and diminished well-being included longer time since dementia onset, higher Charlson Comorbidity Index, and non-Alzheimer dementia. Caregivers' characteristics associated with higher neuropsychiatric symptom burden included Black race, female gender, younger age, caring for parent PLWD, and being employed. Characteristics of PLWDs associated with higher neuropsychiatric symptom burden included non-Alzheimer dementia, longer time since dementia onset, more comorbidities, and higher Charlson Comorbidity Index. Finally, a longer time since dementia onset was associated with PLWDs' lower quality of life.

CONCLUSIONS

Black race, caring for caring for a parent with dementia, younger age, and being employed were characteristics linked to PLWDs' higher neuropsychiatric symptom burden and caregivers' diminished well-being.

IMPLICATIONS

Clinicians must assess and intervene with unpaid caregivers who may not appear obviously distressed.

Exercise priming with transcranial direct current stimulation: a study protocol for a randomized, parallel-design, sham-controlled trial in mild cognitive impairment and Alzheimer's disease

Background

Transcranial direct current stimulation (tDCS) is a non-invasive type of brain stimulation that uses electrical currents to modulate neuronal activity. A small number of studies have investigated the effects of tDCS on cognition in patients with Mild Cognitive Impairment (MCI) and Alzheimer’s disease (AD), and have demonstrated variable effects. Emerging evidence suggests that tDCS is most effective when applied to active brain circuits. Aerobic exercise is known to increase cortical excitability and improve brain network connectivity. Exercise may therefore be an effective, yet previously unexplored primer for tDCS to improve cognition in MCI and mild AD.

Methods

Participants with MCI or AD will be randomized to receive 10 sessions over 2 weeks of either exercise primed tDCS, exercise primed sham tDCS, or tDCS alone in a blinded, parallel-design trial. Those randomized to an exercise intervention will receive individualized 30-min aerobic exercise prescriptions to achieve a moderate-intensity dosage, equivalent to the ventilatory anaerobic threshold determined by cardiopulmonary assessment, to sufficiently increase cortical excitability. The tDCS protocol consists of 20 min sessions at 2 mA, 5 times per week for 2 weeks applied through 35 cm² bitemporal electrodes. Our primary aim is to assess the efficacy of exercise primed tDCS for improving global cognition using the Montreal Cognitive Assessment (MoCA). Our secondary aims are to evaluate the efficacy of exercise primed tDCS for improving specific cognitive domains using various cognitive tests (n-back, Word Recall and Word Recognition Tasks from the Alzheimer’s Disease Assessment Scale-Cognitive subscale) and neuropsychiatric symptoms (Neuropsychiatric Inventory). We will also explore whether exercise primed tDCS is associated with an increase in markers of neurogenesis, oxidative stress and angiogenesis, and if changes in these markers are correlated with cognitive improvement.

Discussion

We describe a novel clinical trial to investigate the effects of exercise priming before tDCS in patients with MCI or mild AD. This proof-of-concept study may identify a previously unexplored, non-invasive, non-pharmacological combination intervention that improves cognitive symptoms in patients. Findings from this study may also identify potential mechanistic actions of tDCS in MCI and mild AD.

Trial registration

Clinicaltrials.gov, NCT03670615. Registered on September 13, 2018.

Impact of regional white matter hyperintensities on specific gait function in Alzheimer's disease and mild cognitive impairment

BACKGROUND

Gait disturbance and musculoskeletal changes are evident in persons living with Alzheimer's disease (AD). Because complex gait control requires the integration of neural networks, cerebral small vessel disease (SVD), which is highly prevalent in persons with AD, might have an additional impact on gait disturbance. This study investigated whether white matter hyperintensities (WMH) are more predominantly associated with gait disturbance in persons with AD than in individuals with mild cognitive impairment (MCI) and normal cognition (NC) and further identified the regional impact of WMH on specific gait changes.

METHODS

This study included 396 subjects (aged 65 to 86 years, 63.9% female) diagnosed with AD (n = 187), MCI (n = 118), or NC (n = 91). WMH, lacunes, perivascular spaces, and cerebral microbleeds were assessed as markers of SVD. The volume of WMH was quantified in each brain lobe (frontal, temporal, occipital, and parietal) and sublobar regions in the basal ganglia and thalamus. Gait function was assessed using an electronic walkway. We investigated the association between regional WMH and gait disturbance in individuals with AD, MCI, and NC, adjusted for classical and musculoskeletal confounders.

RESULTS

Among markers of SVD, WMH were most associated with gait disturbance. In AD subjects, periventricular WMH in the frontal and parietal lobes were associated with slow gait speed (r_s  = -0.21, P = 0.007 and r_s  = -0.18, P = 0.019, respectively). These lesions were also associated with changes in stride time, double-leg support time, and walking angle (all r_s  > 0.20, P < 0.01). Lesions in the basal ganglia and thalamus were associated with slow gait speed (r_s  = -0.16, P = 0.034 and r_s  = -0.18, P = 0.023, respectively) and greater gait speed variability (r_s  = 0.16, P = 0.034 and r_s  = 0.20, P = 0.010, respectively). MCI subjects showed only associations between sublobar lesions and shorter stride length (r_s  = -0.24, P = 0.016) and increased walking angle (r_s  = 0.32, P = 0.002). NC subjects did not show associations between WMH and gait parameters. MCI and NC subjects were more affected by muscle weakness than WMH for global gait function (r_s  = 0.42, P < 0.001 and r_s  = 0.23, P = 0.046, respectively).

CONCLUSIONS

Persons with AD showed a predominant association between WMH and gait disturbance compared with MCI and NC subjects, and regional WMH had a detrimental effect on specific gait changes.

Measuring neuropsychiatric symptoms in patients with early cognitive decline using speech analysis

BACKGROUND

Certain neuropsychiatric symptoms (NPS), namely apathy, depression, and anxiety demonstrated great value in predicting dementia progression, representing eventually an opportunity window for timely diagnosis and treatment. However, sensitive and objective markers of these symptoms are still missing. Therefore, the present study aims to investigate the association between automatically extracted speech features and NPS in patients with mild neurocognitive disorders.

METHODS

Speech of 141 patients aged 65 or older with neurocognitive disorder was recorded while performing two short narrative speech tasks. NPS were assessed by the neuropsychiatric inventory. Paralinguistic markers relating to prosodic, formant, source, and temporal qualities of speech were automatically extracted, correlated with NPS. Machine learning experiments were carried out to validate the diagnostic power of extracted markers.

RESULTS

Different speech variables are associated with specific NPS; apathy correlates with temporal aspects, and anxiety with voice quality-and this was mostly consistent between male and female after correction for cognitive impairment. Machine learning regressors are able to extract information from speech features and perform above baseline in predicting anxiety, apathy, and depression scores.

CONCLUSIONS

Different NPS seem to be characterized by distinct speech features, which are easily extractable automatically from short vocal tasks. These findings support the use of speech analysis for detecting subtypes of NPS in patients with cognitive impairment. This could have great implications for the design of future clinical trials as this cost-effective method could allow more continuous and even remote monitoring of symptoms.

Adjunctive Therapy to Manage Neuropsychiatric Symptoms in Moderate and Severe Dementia: Randomized Clinical Trial Using an Outpatient Version of Tailored Activity Program

BACKGROUND

Neuropsychiatric symptoms (NPS) such as aggression, apathy, agitation, and wandering may occur in up to 90%of dementia cases. International guidelines have suggested that non-pharmacological interventions are as effective as pharmacological treatments, however without the side effects and risks of medications. An occupational therapy method, called Tailored Activity Program (TAP), was developed with the objective to treat NPS in the elderly with dementia and has been shown to be effective.

OBJECTIVE

Evaluate the efficacy of the TAP method (outpatient version) in the treatment of NPS in individuals with dementia and in the burden reduction of their caregivers.

METHODS

This is a randomized, double-blind, controlled clinical trial for the treatment of NPS in dementia. Outcome measures consisted of assessing the NPS of individuals with dementia, through the Neuropsychiatric Inventory-Clinician rating scale (NPI-C), and assessing the burden on their caregivers, using the Zarit Scale. All the participants were evaluated pre-and post-intervention.

RESULTS

54 individuals with dementia and caregivers were allocated to the experimental (n = 28) and control (n = 26) groups. There was improvement of the following NPS in the experimental group: delusions, agitation, aggressiveness, depression, anxiety, euphoria, apathy, disinhibition, irritability, motor disturbance, and aberrant vocalization. No improvement was observed in hallucinations, sleep disturbances, and appetite disorders. The TAP method for outpatient settings was also clinically effective in reducing burden between caregivers of the experimental group.

CONCLUSION

The use of personalized prescribed activities, coupled with the caregiver training, may be a clinically effective approach to reduce NPS and caregiver burden of individuals with dementia.

COVID-19 y adultos mayores con deterioro cognitivo: ¿puede influir el aislamiento social en la enfermedad?

Introducción y objetivo

En Argentina, la calidad del cuidado que los adultos mayores con cuadros crónicos de deterioro cognitivo reciben, está siendo afectada por la pandemia de COVID-19. Nuestro objetivo fue estudiar en qué medida la cuarentena afectó el bienestar y los síntomas conductuales de sujetos con demencia que viven en la comunidad y sus cuidadores luego de las 8 semanas iniciales de aislamiento obligatorio.

Métodos

Familiares de 119 pacientes con demencia tipo Alzheimer (DTA) o trastornos relacionados que viven en la comunidad fueron invitados a participar de forma anónima y voluntaria de una encuesta exploratoria, de tipo transversal o sincrónica, y con formato electrónico. Se utilizó estadística descriptiva y el test de Chi-cuadrado con un valor de significación de p < 0,05 para analizar las diferencias según la severidad de la demencia.

Resultados

La edad media de los sujetos con demencia fue de 81,16 años (± 7,03), el 35% tenían > 85. El 67% tenía DTA y el 26% demencia mixta. El 34,5% tenían demencia leve, 32% moderada y 33% severa. En el 67% de los casos, el cuidador principal era familiar. Se observó un aumento de ansiedad (43%), insomnio (28%), depresión (29%), empeoramiento de la marcha (41%) y aumento del uso de psicofármacos. La frecuencia de síntomas conductuales fue mayor en sujetos con demencia leve (p < 0,05). En casi todos los casos la rehabilitación fue suspendida durante la cuarentena. Hubo un aumento significativo de la sobrecarga del cuidador durante la pandemia (t = −8,657; p < 0,001).

Conclusiones

Tanto los sujetos con demencia que viven en la comunidad como sus cuidadores mostraron un empeoramiento de su bienestar y estado de salud durante la pandemia de COVID-19, debido a una combinación multifactorial de aislamiento social, ausencia de rehabilitación, aumento del estrés del cuidador, miedo de contraer la enfermedad entre otras causas. Es necesario desarrollar un plan de acción coordinado y urgente que involucre a las familias de los pacientes, las autoridades sanitarias y el personal de salud que habitualmente atiende a estos pacientes para mitigar el impacto negativo de la cuarentena y epidemia en la salud de los sujetos con demencia que viven en la comunidad.

Correlation of Frontal Atrophy and CSF Tau Levels With Neuropsychiatric Symptoms in Patients With Cognitive Impairment: A Memory Clinic Experience

Background: Behavioral and psychological symptoms of dementia (BPSD) are a distressful condition. We aimed to investigate the BPSD distribution in subjects with cognitive impairment, and the potential correlations between BPSD and neurodegeneration in terms of cerebrospinal fluid (CSF) tau and brain atrophy.

Methods: One-hundred patients with mild cognitive impairment (MCI) or dementia (Alzheimer’s disease, AD; Lewy-body disease, LBD; frontotemporal dementia, FTD; vascular dementia, VD) underwent a complete diagnostic workup, including 3T-MRI and/or CT and CSF. Cortical atrophy was assessed with medial temporal atrophy (MTA), posterior atrophy (PA), and global cortical atrophy-frontal lobe (GCA-F) scales. BPSD were rated using the Neuropsychiatric Inventory (NPI), and BPSD clusters were defined according to the European Alzheimer Disease Consortium.

Results: Delusions, hallucinations, and psychosis cluster were differently distributed among the diagnostic groups (p < 0.05, p < 0.001, and p < 0.05), with LBD patients showing higher scores for hallucinations (vs. MCI, p < 0.001, and AD, p < 0.05) and psychosis cluster (vs. MCI, p < 0.05). In primary dementias, we found a negative correlation between NPI total score and tau levels (p = 0.08), confirmed by beta regression (p < 0.01), while a positive non-significant relationship was observed in MCI. Higher GCA-F scores were associated with delusions and apathy (p < 0.05, on both hemispheres) and hallucinations (left: p < 0.01, right: p < 0.05). GCA-F scores were positively correlated with psychosis cluster (right: p < 0.05), and agitation/aggression (left: p < 0.05). Conversely, nighttime disturbances were positively correlated with both GCA-F and MTA scores (left: p < 0.01; right: p < 0.05).

Conclusion: Our results suggest that psychotic symptoms are significantly more represented in LBD patients and that CSF tau and frontal atrophy are associated with the occurrence and severity of BPSD in clinical practice. Longitudinal studies are however required to ascertain their actual predictive value.

Group Music Intervention Using Percussion Instruments to Reduce Anxiety Among Elderly Male Veterans with Alzheimer Disease

Background

This study aimed to assess the impact of a group music intervention on anxiety and depression of elderly male veterans with dementia.

Material/Methods

In total, 50 elderly men with Alzheimer disease were randomly divided into intervention and control groups. Patients in the intervention group attended a 60-minute group music session that used percussion instruments with familiar music in the morning once a week for 12 weeks, whereas those in the control group received a rest and reading session at the same intervals and under the same conditions. The Hamilton Anxiety Rating Scale and Geriatric Depression Scale were used to assess anxiety and depression at baseline, week 6, and week 12. The Primary Measures of Music Audiation (PMMA) was used to assess musical aptitude at the baseline.

Results

A significant reduction in the anxiety level following the 12-week music sessions was observed in the intervention group (P<.001), but there was no significant change in the control group. However, the change in depressive symptoms between the 2 groups was nonsignificant. In the intervention group, when stratifying patients based on music aptitude determined through PMMA assessment, patients with high PMMA scores had significantly reduced anxiety symptoms over time compared with those with low scores.

Conclusions

For elderly male veterans with dementia, participating in a group music intervention reduced anxiety symptoms. In patients with high musical aptitude, the treatment effects on anxiety reduction were satisfactory. Measures of music aptitude may provide valuable information regarding patients’ response to music intervention.

Use of psychotropic agents to treat agitation and aggression in Brazilian patients with Alzheimer's disease: A naturalistic and multicenter study

We assessed psychotropic prescribing patterns in the clinical treatment of agitation and aggressive behavior in patients with Alzheimer's disease (AD) treated at specialist outpatient clinics in the Federal District of Brazil. This was a naturalistic, observational, multicenter study of a convenience sample of patients with AD (according to DSM-5) who had behavioral symptoms of aggression and/or agitation at outpatient visits, as assessed by the Neuropsychiatric Inventory (NPI), and required pharmacologic intervention. Participants were recruited in 2018-2019 from 11 AD treatment centers. Sociodemographic and clinical data were collected during routine visits. The sample consisted of 369 older adults with a mean age of 82.3 (SD, 7.7) years. The medications most commonly used in patients with behavioral disorders were antidepressants (79.1%), antipsychotics (70.2%), benzodiazepines (10.6%), and mood stabilizers (9.5%). Quetiapine was the most frequently prescribed antipsychotic medication (48.5%), at a mean dose of 57.4 (SD, 40.7) mg. Citalopram was the most widely used antidepressant medication (32.0%), at a mean daily dose of 24.1 (SD, 8.1) mg. In this sample, two or more pharmacologic agents were frequently used together to control aggression and agitation. Benzodiazepine was not frequently used.

Antipsychotic Drugs and Hip Fracture: Associations Before and After the Initiation of Treatment

OBJECTIVE

To study the association between antipsychotic drug treatment and hip fracture, before and after the initiation of treatment.

DESIGN

Nationwide cohort study.

SETTING AND PARTICIPANTS

In this study based on several Swedish registers, all individuals age ≥65 years who filled prescriptions for antipsychotic drugs in 2007-2017 were matched 1:1 by sex and age with controls, resulting in a cohort of 255,274 individuals.

MEASURES

Associations between antipsychotic drug treatment and hip fracture were investigated using multivariable conditional logistic regression models and flexible parametric survival models for nonproportional hazards, starting 1 year before the first prescription was filled and extending to 1 year thereafter.

RESULTS

The studied cohort had a mean age of 81.5 (standard deviation, 8.1) years; 152,890 (59.9%) individuals were women. Antipsychotic drug use was associated with an increased risk of hip fracture in all studied time frames, before and after the initiation of treatment. The risk was highest 16-30 days before the initiation of treatment (odds ratio 9.09; 95% confidence interval 7.00-11.81). The pattern was consistent in subgroup analyses of users of conventional and atypical antipsychotics, men and women, as well as in younger old and older old participants. The association with hip fracture was not influenced by antipsychotic drug dose.

CONCLUSIONS AND IMPLICATIONS

The association between antipsychotic drug use and the risk of hip fracture was observed before the initiation of antipsychotic treatment. This finding suggests that factors other than exposure to antipsychotic drugs are responsible for the increased risk of hip fracture in the treatment group.

Current Understanding of the Neurobiology of Agitation

Introduction

Managing agitation in the clinical setting is a challenge that many practitioners face regularly. Our evolving understanding of the etiological factors involved in aggressive acts has better informed our interventions through pharmacologic and behavioral strategies. This paper reviews the literature on the neurobiological underpinnings of aggressive behaviors, linking psychopathology with proposed mechanisms of action of psychiatric medications shown to be effective in mitigating agitation.

Methods

We performed a review of the extant literature using PubMed as a primary database. Investigation focused on neurobiology of agitation and its relation to the current evidence base for particular interventions.

Results

There are well-established pathways that can lead to increased autonomic response and the potential for violence. Psychopathology and substance-induced perceptual distortions may lead to magnification and overestimation of environmental threat, heightening the potential for aggression. Additional challenges have arisen with the advent of several novel drugs of abuse, many of which lead to atypical clinical presentations and which can elude standard drug screens. Our interventions still lean on the evidence base found in Project BETA (Best Practices in Evaluation and Treatment of Agitation). Although not a new drug and not included in the Project BETA guidelines, ketamine and its use are also discussed, given its unique pharmacology and potential benefits when other protocoled interventions have failed.

Conclusion

Aggression can occur due to manifold reasons in the clinical setting. Having an informed understanding of the possible determinants of agitation can help with more tailored responses to individual patients, limiting the unnecessary use of medications or of interventions that could be deemed forceful.

Changes in Psychotropic Prescribing for Patients With Dementia, 2014-2016: Potential implications for Pharmacists

OBJECTIVE

To assess changes in psychotropic pharmacotherapy for patients with dementia over a three-year period.<br/> SETTING: National Ambulatory Medical Care Survey, physician office visits from 2014 to 2016.<br/> PRACTICE DESCRIPTION: Retrospective analysis of publicly available, nationally representative data on patient characteristics; diagnoses, including comorbidities; and treatments, including medications. Included were patients with a diagnosis of Alzheimer's disease or dementia who were 18 years of age or older. No sample exclusions were applied.<br/> INTERVENTION: Time period, comparing calendar year (CY) 2014 versus the calendar years 2015 and 2016 using Pearson chi-square tests.<br/> MAIN OUTCOME MEASURE(S): Prescribing rates of psychotropic medications, grouped by therapy class.<br/> RESULTS: The sample included 647 patients (337 in 2014 and 310 in 2015-2016). A majority (69.5%) of the patients were 75 years of age or older; 62.4% were female. Prescribing rates remained relatively stable for antipsychotics (15.1% in 2014 to 12.9% in 2015-16; P = 0.607); antidepressants (35.0% to 27.7%; P = 0.263); acetylcholinesterase inhibitors (38.6% to 33.9%; P = 0.446); and memantine (19.4% to 16.8%; P = 0.551). Significant increases were noted for sedatives (11.9% to 21.7%; P = 0.037) and anticonvulsants (10.0% to 27.6%, P = 0.001).<br/> CONCLUSION: Clinically significant increases in the prescribing of anticonvulsants and sedatives suggest the possibility that these agents are used to combat behavioral and psychological symptoms of dementia in patients with dementia. Further research is required to assess the rationale, efficacy, and safety of these uses.

Pharmacologic Approaches for the Management of Apathy in Neurodegenerative Disorders

Apathy is one of the most frequent behavioral disturbances in many neurodegenerative disorders and is known to have a negative impact on the disease progression, particularly in Alzheimer’s disease. Therapeutic options are currently limited and non-pharmacological approaches should constitute first line treatments. Pharmacological agents likely to reduce apathy levels are lacking. The objective of the present article is to review recent pharmacological treatments for apathy in neurodegenerative disorders. The Pubmed database was searched with a particular focus on articles published as of January 2017. Current main levels of evidence have been reported so far with cholinergic, glutamatergic and dopaminergic agents to reduce levels of apathy, despite several conflicting results. Treatment duration and samples sizes may have however decreased the validity of previous results. Ongoing studies involving more participants/treatment duration or distinct neural pathways may provide new insights in the treatment of apathy in neurodegenerative disorders.

COVID-19 Epidemic in Argentina: Worsening of Behavioral Symptoms in Elderly Subjects With Dementia Living in the Community

In Argentina, the quality of care that elderly subjects with dementia living in the community received has been deeply affected by COVID-19 epidemic. Our objective was to study to what extend mandatory quarantine imposed due to COVID-19 had affected behavioral symptoms in subjects with dementia after the first 8 weeks of quarantine. We invited family members to participate in a questionnaire survey. The sample consisted of family caregivers (n = 119) of persons with AD or related dementia living at home. We designed a visual analog scale to test the level of the burden of care of family members. Items inquired in the survey included type and setting (home or day care center) of rehabilitation services (physical/occupational/cognitive rehabilitation) and change in psychotropic medication and in behavioral symptoms that subjects with dementia experienced before and during the epidemic. Characteristics of people with dementia and their caregivers were analyzed with descriptive statistics using the chi-square tests, p < 0.01 was considered significant. Results: The sample included older adults with dementia. Mean age: 81.16 (±7.03), 35% of the subjects had more than 85 years of age. Diagnosess were 67% Alzheimer´s dementia and 26% mixed Alzheimer´s disease (AD). Stages were 34.5% mild cases, 32% intermediate stage, and 33% severe cases as per Clinical dementia Rating score. In 67% of the sample, a family member was the main caregiver. Important findings were increased anxiety (43% of the sample), insomnia (28% of the subjects), depression (29%), worsening gait disturbance (41%), and increase use of psychotropics to control behavioral symptoms. When we compared the frequency of behavioral symptoms within each dementia group category, we found that anxiety, depression, and insomnia were more prevalent in subjects with mild dementia compared to subjects with severe dementia. We analyzed the type and pattern of use of rehabilitation services before and during the isolation period, and we observed that, as a rule, rehabilitation services had been discontinued in most subjects due to the quarantine. We concluded from our analysis that during COVID-19 epidemic there was a deterioration of behavioral symptoms in our population of elderly dementia subjects living in the community. Perhaps, our findings are related to a combination of social isolation, lack of outpatient rehabilitation services, and increased stress of family caregivers. It is necessary to develop a plan of action to help dementia subjects deal with the increased stress that this epidemic imposed on them.

Clinical drug development for dementia with Lewy bodies: past and present

Introduction: Dementia with Lewy bodies (DLB) is an under-researched area despite being the second most common type of degenerative dementia after Alzheimer's disease. It is an area of unmet need with no approved symptomatic or disease-modifying therapies. The pharmacological management of DLB is complex and challenging because early trials of drugs for DLB have resulted in no demonstrable efficacy. Randomized controlled trials (RCTs) in the DLB population have only recently been initiated. Understanding results from previous and current clinical trials in DLB can provide insights for future research and development.Areas covered: We provide an overview of the DLB drug development landscape and the current treatment strategies. We reviewed ClinicalTrials.gov to identify all clinical trials for the treatment of DLB.Expert opinion: DLB drug development has significantly improved in recent years with eight agents now in clinical trials. However, more rigorous RCTs are urgently needed. Diagnostic criteria must be optimized to accurately diagnose patients for clinical trials and care. New biomarker strategies are necessary to improve diagnostic capabilities and trial designs, and novel drug targets should be identified to develop DLB specific disease-modifying therapies. Evaluating the current drug development landscape can provide insight into how best to optimize development practices.