Antipsychotics, Antidepressants, Anticonvulsants, Melatonin, and Benzodiazepines for Behavioral and Psychological Symptoms of Dementia: a Systematic Review of Meta-analyses

A proposal for a novel approach to reduce burdens of care for people with dementia: A hypothesis

Cognitive impairment of dementia patients affects their ability to communicate and cooperate with care. Dementia patients need a specialized communication to increase their cooperation during daily care and a scale to measure cooperation with care. To improve communication, we created and applied a digital communication platform (DCP) in an observational study. To measure cooperation with care, we created and tested psychometric properties of the Cooperation with Care Scale-Revised (CWCS-R) in an institutional review board-approved 6-week prospective study. DCP intervention was associated with decreased agitation and use of psychotropic medications for nursing home (NH) dementia patients. CWCS-R is both a reliable and valid tool to measure cooperation with care in NH dementia patients. Innovations in communication with dementia patients and a scale to measure cooperation with care could reduce burdens of care and improve quality of life for patients, their family members, and staff. It may potentially help decrease cost of dementia care.

Feasibility of 3-month melatonin supplementation for brain oxidative stress and sleep in mild cognitive impairment: protocol for a randomised, placebo-controlled study

INTRODUCTION

Melatonin has multiple proposed therapeutic benefits including antioxidant properties, synchronisation of the circadian system and lowering of blood pressure. In this protocol, we outline a randomised controlled trial to assess the feasibility, acceptability and tolerability of higher dose (25 mg) melatonin to target brain oxidative stress and sleep disturbance in older adults with mild cognitive impairment (MCI).

METHODS AND ANALYSIS

The study design is a randomised double-blind, placebo-controlled, parallel group trial. Forty individuals with MCI will be recruited from the Healthy Brain Ageing Clinic, University of Sydney and from the community, and randomised to receive either 25 mg oral melatonin or placebo nightly for 12 weeks. The primary outcomes are feasibility of recruitment, acceptability of intervention and adherence to trial medication at 12 weeks. Secondary outcomes will include the effect of melatonin on brain oxidative stress as measured by magnetic resonance spectroscopy, blood pressure, blood biomarkers, mood, cognition and sleep. Outcomes will be collected at 6 and 12 weeks. The results of this feasibility trial will inform a future conclusive randomised controlled trial to specifically test the efficacy of melatonin on modifiable risk factors of dementia, as well as cognition and brain function. This will be the first trial to investigate the effect of melatonin in the population with MCI in this way, with the future aim of using this approach to reduce progression to dementia.

ETHICS AND DISSEMINATION

This protocol has been approved by the Sydney Local Health District Ethics Committee (X18-0077). This randomised controlled trial will be conducted in compliance with the protocol published in the registry, the International Conference for Harmonisation on Good Clinical Practice and all other applicable regulatory requirements. The findings of the trial will be disseminated via conferences, publications and media, as applicable. Participants will be informed of results of the study at the conclusion of the trial. Eligible authors will include investigators who are involved in the conception and design of the study, the conduct of the trial, the analysis of the results, and reporting and presentation of study findings.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ANZCTRN 12619000876190).

PROTOCOL VERSION

V.8 15 October 2020.

Weekly, Seasonal, and Geographic Patterns in Health Contemplations About Sundown Syndrome: An Ecological Correlational Study

Background

Sundown syndrome (ie, agitation later in the day) is common in older adults with dementia. The underlying etiology for these behaviors is unclear. Possibilities include increased caregiver fatigue at the end of the day and disruption of circadian rhythms by both age and neurodegenerative illness.

Objective

This study sought to examine circumseptan (weekly) patterns in search volumes related to sundown syndrome, in order to determine if such searches peaked at the end of the weekend, a time when caregiver supports are least available. We also sought to examine both seasonal differences and associations of state-by-state search activity with both state latitude and yearly sun exposure.

Methods

Daily Internet search query data was obtained from Google Trends (2005-2017 inclusive). Circumseptan patterns were determined by wavelet analysis, and seasonality was determined by the difference in search volumes between winter (December, January, and February) and summer (June, July, and August) months. Geographic associations between percent sunny days and latitude were done on a state-by-state basis.

Results

“Sundowning” searches showed a significant increase at the end of the weekend with activity being 10.9% (SD 4.0) higher on Sunday as compared to the rest of the week. Search activity showed a seasonal pattern with search activity significantly highest in the winter months (36.6 [SD 0.6] vs 13.7 [SD 0.2], P<.001). State-by-state variations in “sundowning” searches showed a significant negative association with increasing mean daily sunlight (R²=.16, β=-.429 [SD .149], P=.006) and showed a positive association with increasing latitude (R²=.38, β=.648 [SD .122], P<.001).

Conclusions

Interest in “sundowning” is highest after a weekend, which is a time when external caregiver support is reduced. Searches related to sundown syndrome also were highest in winter, in states with less sun, and in states at more northerly latitudes, supporting disrupted circadian rhythms as another contributing factor to these behaviors.

Aggressive Behaviors in Alzheimer Disease and Mild Cognitive Impairment: Systematic Review and Meta-Analysis

OBJECTIVE

We aim to estimate the risk of perpetrating aggression in Alzheimer disease (AD) and mild cognitive impairment (MCI) by conducting a systematic review and meta-analysis of primary studies.

METHODS

A systematic search was conducted in six bibliographic databases according to a preregistered protocol. Studies that reported aggressive behaviors in individuals with AD and MCI compared with healthy individuals or those with other dementia etiologies were identified. Risks of aggressive behaviors were assessed using random effects models to calculate pooled odds ratios (ORs). Publication bias was examined.

RESULTS

In total, 17 studies involving 6,399 individuals with AD and 2,582 with MCI were identified. Compared with healthy individuals, significantly increased risks of aggressive behaviors were found in AD (OR, 4.9, 95% CI, 1.8-13.2) but not in MCI (OR, 1.8, 95% CI, 0.7-4.3). When comparing AD with MCI, the risk in AD was higher (OR, 2.6, 95% CI, 1.7-4.0). We found no differences in risk of aggressive behaviors between AD and other dementia subtypes or between amnestic and nonamnestic MCI.

CONCLUSION

Individuals with AD are at higher risk of manifesting aggressive behaviors than healthy individuals or those with MCI. Our findings not only underscore the necessity of treatment of aggressive behaviors in AD but also highlight the importance of preventing the transition from MCI to AD.

Diagnosis and Management of Neuropsychiatric Symptoms in Alzheimer's Disease

PURPOSE OF REVIEW

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

RECENT FINDINGS

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