Behavioral and psychotic symptoms of dementia (BPSD) improvements in a special care unit: a factor analysis

Behaviours and psychological symptoms of childhood dementia: two cases of psychosocial interventions

Childhood dementias are a group of rare, fatal neurodegenerative disorders, characterised by global cognitive decline, loss of previously acquired developmental skills and behaviours and psychological symptoms of dementia (BPSD). Batten disease, or neuronal ceroid lipofuscinosis, and Sanfilippo syndrome, or mucopolysaccharidosis type III, are two of the more common forms of childhood dementia disorders worldwide. While psychosocial interventions are the best available therapeutic approach for BPSD management in adult-onset dementia, there is very limited literature or clinical experience in the context of childhood dementia. To address this gap, we conducted a descriptive case analysis of BPSD profiles, associated contributing factors and targeted psychosocial interventions in two cases with childhood dementia disorders (Sanfilippo syndrome and CLN3 (juvenile onset) Batten disease) who were referred to Dementia Support Australia, a national dementia behaviour support service in Australia. Primary BPSD identified in these disorders included physical and verbal aggression and irritability/lability. In these cases, contributing factors to the development of BPSD were not monolithic, encompassing pain, caregiver's approach and over or under-stimulation. Improvement in BPSD were observed using the Neuropsychiatric Inventory-Quesionnaire and globally noted as per the qualitative feedback reported by family and caregivers. Person-centred, multimodal psychosocial interventions were recognised as effective therapies in resolving BPSD in these cases. In conclusion, the case studies described the nature and presentation of BPSD in two common forms of childhood dementia and demonstrated the potential benefits of person-centred psychosocial interventions (delivered through national dementia-specific support programs) in alleviating BPSD such as irritability and aggression in these disorders.

The Special Care Unit for People with Behavioral and Psychological Symptoms of Dementia (SCU- B) in the Context of the Project "RECage-Respectful Caring for Agitated Elderly": A Qualitative Study

BACKGROUND

Dementia is a priority for global public health. The management of behavioral and psychological symptoms of dementia (BPSD) is one of the highest ongoing challenges and needs new approaches. The special care unit for people with dementia and BPSD (SCU-B) is viewed in this context as a further medical intervention.

AIM

this study aims to explore SCU-B units in order to describe their main characteristics in relation to different implementation contexts, identify the characteristics of their replicability, and examine the social innovation elements promoted by SCU-B units.

METHOD

This qualitative study is based on focus groups (FGs) and interviews involving nine international centers. Five of the centers have a memory clinic unit and SCU-B, compared with six that only have a memory clinic unit. A total number of 18 FGs were held, which altogether involved 164 participants. All data were transcribed verbatim and analyzed by means of a content analysis and a SWOT (strengths, weaknesses, opportunities, and threats) analysis.

RESULTS

The qualitative analysis offers a vision of the SCU-B model as an innovative care unit for BPSD, promoting social innovation in the long-term care (LTC) sector. This system mainly targets people with dementia and BPSD and their informal caregivers but encourages collaboration between dementia care stakeholders at the micro and meso levels.

CONCLUSIONS

Specific characteristics of the country's LTC systems and the organization of specialized units are determinants for the success of the SCU-B experience. The replicability of the entire SCU-B model was considered low; however, the implementation of single elements composing the SCU-B model may foster innovation. This study provides relevant suggestions on how to implement the SCU-B unit and innovative solutions for dementia care.

Feasibility of the Cognitive Model for Behavioral Interventions in Older Adults with Behavioral and Psychological Symptoms of Dementia

Objectives: The purpose of this study was to develop an individually tailored, non-pharmacological treatment model, the Cognitive Model for Behavioral Interventions (CoMBI), for patients with Behavioral and Psychological Symptoms of Dementia (BPSD) and comorbid maladaptive personality traits (CMPT), and to explore its feasibility and effectiveness.Methods: CoMBI was developed and implemented in two geriatric psychiatric inpatient wards in the Netherlands. In this single-group pretest-posttest, feasibility study, 40 patients with BPSD and CMPT (M = 73.8, SD = 8.5) were treated with CoMBI. BPSD and CMPT were assessed using informant-based questionnaires. Wilcoxon signed-rank tests and effect size calculations were conducted to determine differences.Results: Wilcoxon signed-rank tests demonstrated a significant decrease of BPSD with medium (r = 0.45) to large (r = 0.56) effect sizes. CoMBI demonstrated high acceptability and compliance by health-care professionals and family members.Conclusions: CoMBI is a feasible treatment model for challenging behavior in patients with BPSD and CMPT. CoMBI is associated with a significant decrease in challenging behaviors regardless of etiology.Clinical implications: Focusing on personality and associated core needs could have a key role in the non-pharmacological treatment of the elderly with BPSD.

The Columbia Behavior Scale for Dementia (CBS-8): Validity and Reliability of a Rapidly Administered New Instrument for Dementia-Related Behaviors in Long-Term Care Settings

We developed and evaluated the psychometric properties of the Columbia Behavior Scale for Dementia (CBS-8), a rapid instrument that assesses positive symptoms, to enhance behavioral and psychological symptoms of dementia (BPSD) assessment and treatment in long-term care. Psychometric analyses were performed on CBS-8 data from residents (N = 350, age ≥50 years) in 47 Maryland long-term care facilities referred for neurocognitive and mood evaluation. The CBS-8 demonstrated acceptable internal consistency (α = 0.78) and strong interrater reliability (intraclass correlation coefficient = 1.00). CBS-8 scores were correlated with greater cognitive impairment severity (r = -0.34). The diagnosis of dementia with behavioral disturbance had higher CBS-8 scores than other dementia types (e.g., vascular, unspecified) (p < 0.001, η² = 0.40). Three CBS-8 factors-motor disinhibition, aggression, and psychosis-explained 65% of the variance in overall BPSD. The CBS-8 could enhance BPSD tracking and treatment, strengthen interdisciplinary collaboration, and aid nursing homes in meeting regulations on unnecessary medication use. [Research in Gerontological Nursing, 14(3), 160-168.].

Rationale, Design, and Methodology of a Prospective Cohort Study for Coping with Behavioral and Psychological Symptoms of Dementia: The RECage Project

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are quite challenging problems during the dementia course. Special Care Units for people with dementia (PwD) and BPSD (SCU-B) are residential medical structures, where BPSD patients are temporarily admitted, in case of unmanageable behavioral disturbances at home.

OBJECTIVE

RECage (REspectful Caring for AGitated Elderly) aspires to assess the short and long-term effectiveness of SCU-Bs toward alleviating BPSD and improving the quality of life (QoL) of PwD and their caregivers.

METHODS

RECage is a three-year, prospective study enrolling 500 PwD. Particularly, 250 community-dwelling PwDs presenting with severe BPSD will be recruited by five clinical centers across Europe, endowed with a SCU-B, for a short period of time; a second similar group of 250 PwD will be followed by six other no-SCU-B centers solely via outpatient visits. RECage's endpoints include short and long-term SCU-B clinical efficacy, QoL of patients and caregivers, cost-effectiveness of the SCU-B, psychotropic drug consumption, caregivers' attitude toward dementia, and time to nursing home placement.

RESULTS

PwD admitted in SCU-Bs are expected to have diminished rates of BPSD and better QoL and their caregivers are also expected to have better QoL and improved attitude towards dementia, compared to those followed in no-SCU-Bs. Also, the cost of care and the psychotropic drug consumption are expected to be lower. Finally, PwD followed in no-SCU-Bs are expected to have earlier admission to nursing homes.

CONCLUSION

The cohort study results will refine the SCU-B model, issuing recommendations for implementation of SCU-Bs in the countries where they are scarce or non-existent.

Course of activities of daily living in nursing home residents with dementia from admission to 36-month follow-up

Background

Dementia is affecting both the person with the disease and the family members. It is associated with nursing home admission, and a reduced ability to perform personal activities of daily living (P-ADL). The aim of this study was to examine the association between the severity of dementia and P-ADL function, and to study if additional factors such as neuropsychiatric symptoms, type of nursing home unit, and use of medication were associated with P-ADL function.

Methods

A total of 582 nursing home residents with dementia, included at admission to the nursing home, were followed with biannual assessments for 36 months. P-ADL was assessed using the Physical Self-Maintenance scale, and severity of dementia was measured with the Clinical Dementia Rating scale. In addition, neuropsychiatric symptoms, general physical health, and use of medications were assessed at the same time points. Demographic information was collected at baseline. Linear mixed models were estimated.

Results

There was a significant (p < 0.05) non-linear decline in P-ADL function over time in analysis not adjusting for any characteristics. More severe dementia at baseline and at the follow-up assessments was associated with lower P-ADL function (p < 0.001), with the association being stable over time. A higher level of neuropsychiatric symptoms, not using anti-dementia medication, being in a regular care unit as compared to a special care unit and having poor/fair general physical health as compared to good/excellent, were associated with a lower P-ADL function.

Conclusion

The association between more severe dementia and lower P-ADL function was stable over a 36-month follow-up period of nursing home residents with dementia. Health care planners and clinicians should be aware of this when planning for and treating nursing home residents.

Animal-Assisted and Pet-Robot Interventions for Ameliorating Behavioral and Psychological Symptoms of Dementia: A Systematic Review and Meta-Analysis

Patients with dementia suffer from psychological symptoms such as depression, agitation, and aggression. One purpose of dementia intervention is to manage patients’ inappropriate behaviors and psychological symptoms while taking into consideration their quality of life (QOL). Animal-assisted intervention (AAI) and pet-robot intervention (PRI) are effective intervention strategies for older people with cognitive impairment and dementia. In addition, AAI and PRI have been shown to have positive effects on behavioral and psychological symptoms of dementia (BPSD). However, studies into the association between AAI/PRI and BPSD have elicited inconsistent results. Thus, we performed a meta-analysis to investigate this association. We analyzed nine randomized controlled trials on AAI and PRI for dementia patients published between January 2000 and August 2019 and evaluated the impact of AAI/PRI on agitation, depression, and QOL. We found that AAI and PRI significantly reduce depression in patients with dementia. Subsequent studies should investigate the impact of AAI and PRI on the physical ability and cognitive function of dementia patients and conduct a follow-up to investigate their effects on the rate of progression and reduction of symptoms of dementia. Our research will help with neuropsychological and environmental intervention to delay or improve the development and progression of BPSD.

BESI: Behavioral and Environmental Sensing and Intervention for Dementia Caregiver Empowerment-Phases 1 and 2

BACKGROUND AND OBJECTIVES

Caregiver burden associated with dementia-related agitation is one of the commonest reasons a community-dwelling person with dementia (PWD) transitions to a care facility. Behavioral and Environmental Sensing and Intervention for Dementia Caregiver Empowerment (BESI) is a system of body-worn and in-home sensors developed to provide continuous, noninvasive agitation assessment and environmental context monitoring to detect early signs of agitation and its environmental triggers.

RESEARCH DESIGN AND METHODS

This mixed methods, remote ethnographic study is explored in a 3-phase, multiyear plan. In Phase 1, we developed and refined the BESI system and completed usability studies. Validation of the system and the development of dyad-specific models of the relationship between agitation and the environment occurred in Phase 2.

RESULTS

Phases 1 and 2 results facilitated targeted changes in BESI, thus improving its overall usability for the final phase of the study, when real-time notifications and interventions will be implemented.

CONCLUSION

Our results show a valid relationship between the presence of dementia related agitation and environmental factors and that persons with dementia and their caregivers prefer a home-based monitoring system like BESI.

Multiple-Instance Learning for Sparse Behavior Modeling from Wearables: Toward Dementia-Related Agitation Prediction

Agitation in persons with dementia (PWD) poses major health risks both for themselves and for their caregivers. Passive sensing based continuous behavior tracking can prevent the escalation of such episodes. But, predicting such behavior from sensor streams, especially in real-world residential settings, is still an active area of research. Major challenges include the sparsity, unpredictability, and variations in such behavior, as well as the "weak" annotations from real-world participants. This paper proposes a novel approach to overcome these issues in predicting agitation episodes from the PWD's wrist motion data. In a transdisciplinary study on dementia dyads residing in their homes, the PWD motion is continuously sensed from their smart watch inertial sensors, while agitation episodes are actively marked by the caregivers. The data from 10 residential deployments, each with 30 days duration, are analyzed in this paper, and multiple-instance learning (MIL) based models are implemented to learn from such sparse and weakly annotated data. These models are compared with single-instance models in predicting the agitated behavior. The results show the potential of MIL models in sparsely labeled behavior inference from wearables in-the-wild.

Emerging treatments for the behavioral and psychological symptoms of dementia

Dementia is referred to a loss of memory and decline in other mental abilities at levels critical enough to hinder performance of daily activities. It can be of several types, depending on the underlying pathophysiology. The behavioral and psychological symptoms of dementia (BPSD) are various, but the most clinically significant are depression, apathy, and anxiety. Other BPSD include agitation, aberrant motor behavior, elation, hallucinations, and alterations in sleep and appetite. About 90% of sufferers of dementia are affected by BPSD during the course of the illness. These symptoms occur in demented patients irrespective of the dementia subtype. However, there has not been significant development in the areas of disease-modifying pharmacotherapeutics for dementia. Therefore, tackling BPSD has emerged as a research avenue in the recent past. Existing antidepressants, antipsychotics, and cholinergic agents have been extensively used in the treatment of BPSD, independently and in different combinations. However, these agents have not successful in completely alleviating such symptoms. Research in this field is going on globally, but it is still limited by various factors. There is a strong need to develop new entities and test them clinically. This review focuses on emerging treatments for the management of clinically significant BPSD.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Association between altered neurochemical metabolites and apathy in patients with Alzheimer's disease

ABSTRACTBackground:Apathy is a condition characterized by a lack of motivation that manifests in emotional, behavioral, and cognitive domains. Although previous studies have indicated that apathy is associated with frontal lesions, few studies have focused on the different subdomains of apathy, and no in vivo human biochemical data have been obtained to examine the neurochemical changes related to apathy in patients with Alzheimer's disease (AD). Thus, we investigated the frontal neurochemical alterations related to apathy among patients with AD using proton magnetic resonance spectroscopy (1H MRS).

METHODS

Apathy was assessed through the Apathy Evaluation Scale (AES). 1H MRS was performed to measure neurochemical metabolite levels in the anterior cingulate region and right orbitofrontal region. Associations between neurochemical metabolites and the total score and subscores of each domain of the AES were analyzed.

RESULTS

Altogether, 36 patients completed the study. Patients with lower N-acetylaspartate/creatine ratios (NAA/Cr) in the anterior cingulate region demonstrated higher total apathy scores (β = -0.56, p = 0.003) with adjustments for age, gender, educational level, dementia severity, and depression severity. In a further analysis, a lower NAA/Cr in the anterior cingulate region was associated with all subdomains of apathy, including cognition (β = -0.43, p = 0.028), behavior (β = -0.55, p = 0.002), and emotion (β = -0.50, p = 0.005). No statistically significant associations were discovered in the right orbitofrontal region.

CONCLUSIONS

Our results suggest that apathy, in each of its cognitive, behavioral, or emotional subdomains is associated with brain neurochemical alterations in the anterior cingulate region. Abnormal neuronal integrity over the anterior cingulate cortex may exhibit a central role in causing all aspects of apathy in patients with AD.

Animal-Assisted Intervention and Dementia: A Systematic Review

This review discusses the relationship between animal-assisted interventions (AAI) and behavioral and psychological symptoms of dementia (BPSD). A systematic search was conducted within CINAHL, Web of Science CAB Abstracts, PubMed, Abstracts in Social Gerontology, Google Scholar, and PsycINFO for primary research articles. A total of 32 studies were included in the final review. Variation was noted in study designs and in study setting. Twenty-seven of 32 studies used dogs as the intervention. Agitation/aggression showed a significant decrease in nine of 15 studies. Eleven of 12 studies demonstrated increased social interaction with AAI. Mood had mixed results in nine studies. Quality of life was increased in three of four studies. Resident activity and nutritional intake were each increased in two studies. Animal assisted activities/interventions showed a strong positive effect on social behaviors, physical activity, and dietary intake in dementia patients and a positive effect on agitation/aggression and quality of life.

Effectiveness of treatment in wards for patients with dementia and issues associated with this treatment: A prospective analysis

In order to optimize the treatment in wards for patients with dementia, we investigated predictors of the length of stay in the ward for patients with dementia. A prospective analysis of 72 patients with dementia was conducted in two wards for patients with dementia. Severity of dementia was assessed by the Clinical Dementia Rating, basic activities of daily living were evaluated using the Physical Self-Maintenance Scale, and severity of behavioral and psychological symptoms of dementia and caregiver distress were determined with the Nursing Home version of the Neuropsychiatric Inventory. Stepwise regression analysis was used to identify predictors of the length of stay. Fewer patients were discharged to home compared to those discharged to institutions or transferred to a different hospital or ward. The mean length of stay was 92.0 days. Clinical Dementia Rating and total distress scale score on the Nursing Home version of the Neuropsychiatric Inventory were significant independent predictors of the length of stay. The total Nursing Home version of the Neuropsychiatric Inventory score and total distress scale score on the Nursing Home version of the Neuropsychiatric Inventory were significantly improved through treatment. Our results suggest that treatment in the wards for patients with dementia is effective for improvement of behavioral and psychological symptoms of dementia. However, some patients could not be discharged to their home despite improvement of behavioral and psychological symptoms of dementia, and this may be related to caregiver burden at admission.

Physical Activity: A Viable Way to Reduce the Risks of Mild Cognitive Impairment, Alzheimer's Disease, and Vascular Dementia in Older Adults

A recent alarming rise of neurodegenerative diseases in the developed world is one of the major medical issues affecting older adults. In this review, we provide information about the associations of physical activity (PA) with major age-related neurodegenerative diseases and syndromes, including Alzheimer's disease, vascular dementia, and mild cognitive impairment. We also provide evidence of PA's role in reducing the risks of these diseases and helping to improve cognitive outcomes in older adults. Finally, we describe some potential mechanisms by which this protective effect occurs, providing guidelines for future research.

Persistent use of psychotropic drugs in nursing home residents in Norway

Background

The prevalence of psychotropic drug (PTD) use in NH residents is high, but few have explored prevalence and persistency in PTD in NH residents and factors associated with persistency. This at the same time as we know that risk of side events may be higher with long- term use in older adults. Thus, the aim of this study was to describe the prevalence and persistence in use of PTD and to explore factors associated with persistence in use of PTD at two consecutive time points in nursing home (NH) residents.

Methods

We included 1163 NH residents in a 72-month longitudinal study with five assessments. Use of PTD, neuropsychiatric symptoms (NPS), severity of dementia and physical health were assessed each time.

Results

The prevalence over time and persistent use of antipsychotic drugs, antidepressants, anxiolytics and sedatives at two consecutive time points were high in residents with and without dementia. There was an association between greater NPS at the first time point, and persistent use of these drugs, but changes in NPS between time points, did not explain such use. A longer NH stay increased the odds for persistent use of antipsychotics.

Conclusion

Psychotropic drugs are frequently used as a long-term treatment among NH residents and are associated with severity of neuropsychiatric symptoms, but not with severity of dementia. Closer attention should be paid to follow-up of psychotropic drug treatment, and especially for long –term use of antipsychotics, since the duration of such treatment should be as short as possible.

Dementia Caregiver Empowerment Using a Cyber-socio-physical Model

Agitation in dementia patients is characterized by several features, such as physical and verbal aggressive and non-aggressive behaviors. Such behaviors affect not only the patients, but also the caregivers’ quality of life. The onset of agitated behaviors can be unpredictable and can also be influenced by environmental factors, which presents challenges to caregivers. The work presented here is part of a research which is aimed at implementing a cyber-socio-physical model to monitor agitation epochs in persons with dementia (PWD). We present a data framework which was developed for the implementation of the cyber -socio- physical system. The data framework helps to collect, structure, extract, analyze and interpret multiple forms of qualitative and quantitative data obtained through behavioral and environmental sensors. This approach helps to conceptualize the lived context of PWD. The information acquired will be used to generate trained models to identify the patterns of agitation associated with the environmental factors. It will also be used to develop a monitoring and dashboard system which sends real time notifications to caregivers and healthcare providers. The research outcome will provide cost effective technology to reduce or prevent agitation in dementia.

Managing behavioural and psychological symptoms in dementia

Most patients with dementia have some behavioural and psychological symptoms. While aggression and agitation are easily recognised, symptoms such as apathy may be overlooked. Behavioural and psychological symptoms should be managed without drugs whenever possible. Although there is little evidence to support their use, antipsychotic drugs are often prescribed to people with dementia. Before prescribing it is important to exclude other causes of altered behaviour, such as pain or infection. Some symptoms may be artefacts of memory loss rather than psychosis. Patients with dementia who are prescribed antipsychotic drugs have an increased risk of falls, hospitalisation and death. They should be regularly monitored for adverse effects. If the patient's symptoms resolve with drug treatment, reduce the dose after two or three months. Stop the drug if the symptoms do not return.

Severity of Neuropsychiatric Symptoms in Nursing Home Residents

We aimed at assessing time shift in the severity of neuropsychiatric symptoms (NPS) in nursing home residents between 2004/2005 and 2010/2011 and associations between NPS and socio-demographic variables, physical health status, dementia severity, and the use of psychotropic drugs. The Neuropsychiatric Inventory Nursing Home Version was used in 2004/2005 (n = 1,163) and 2010/2011 (n = 1,858). Linear mixed model analysis was applied. There was no time shift in the severity of apathy, psychosis, and affective symptoms, but agitation did exhibit a time shift. Agitation was less severe in 2010/2011 than in 2004/2005 in residents with a Clinical Dementia Rating (CDR) sum of boxes score ≤4, and more severe in residents with a CDR sum of boxes score >16. Higher CDR sum of boxes scores and use of psychotropic medication were associated with more severe apathy, agitation, psychosis, and affective symptoms. Poor physical health was associated with more severe apathy, psychosis, and affective symptoms. Women had more severe agitation and less severe affective symptoms than men. A longer stay in a nursing home was associated with more severe agitation and less severe affective symptoms. In conclusion, agitation was less severe in 2010/2011 than in 2004/2005 among nursing home residents with a milder degree of dementia, and more severe in residents with severe dementia.

Behavioral Characteristics of Bowel Movement and Urination Needs in Patients With Dementia in Taiwan

Patients with dementia, especially those with advanced dementia, may not be able to express their bowel movement and urination needs using lucid language, and instead do so through behaviors. The aim of the current study was to understand and compare the behavioral characteristics of bowel movement and urination needs in patients with dementia. Observations were made by caregivers of 187 patients with dementia based on the Behavior Checklist developed by the research team for bowel movement and urination. Sixteen behavioral characteristics were identified for both bowel movement and urination; among these, anxiety, taking off/putting on clothes inappropriately, restlessness, attempting to go elsewhere, scratching skin, repeated behavior, and making strange sounds were commonly reported. Facial expressions of sorrow, restlessness, and anxiety were the three most common behaviors related to bowel movement needs, whereas anxiety, taking off/putting on clothes inappropriately, and constant moaning were the most common behaviors for urination needs. The findings suggest that the common behavioral characteristics could be seen as indicators of excretion need and the others can be used to distinguish between the need for bowel movement and urination.

Grouping of behavioural and psychological symptoms of dementia

OBJECTIVE

A wide range of behavioural and psychological symptoms (BPSD) are common in dementia, and it has been suggested that groups of correlated symptoms should be studied together. Here, we describe the groups of BPSD that have been identified in the literature and how they have been used to study associations, burden, treatment and underlying biology.

METHODS

The literature database PubMed was searched for articles that identified clusters or factors of BPSD or used previously defined symptom groups.

RESULTS

Sixty-two studies were included. Generally, the following symptom groups were suggested: affective symptoms, including depression and anxiety; psychosis, including delusions and hallucinations; hyperactivity, including irritability and aggression; and euphoria. Symptoms that did not show consistent results include apathy, eating disturbances, night-time behaviour disturbances, disinhibition and aberrant motor behaviour. Symptom groups differed in their associations, treatment and biology.

CONCLUSIONS

Studies investigating symptom groups show relatively consistent results. Studying symptom groups allows similar symptoms to be studied together, which might strengthen results and may point to differences in their aetiology and treatment. However, a large amount of the individual variability of the symptoms could not be explained by the factors, and authors should carefully address their research question and hypotheses to decide if symptoms should be studied in groups or individually. Clinicians need to consider each symptom in its own right and also to be aware of the interrelations between them when assessing patients and developing strategies for treatment.

A 52 month follow-up of functional decline in nursing home residents - degree of dementia contributes

Background

Few have studied how personal activities of daily living (P-ADL) develop over time in nursing home residents with dementia. Thus, the aim was to study variables associated with the development of P-ADL functioning over a 52-month follow-up period, with a particular focus on the importance of the degree of dementia.

Method

In all, 932 nursing home residents with dementia (Clinical Dementia Rating–CDR- Scale ≥1) were included in a longitudinal study with four assessments of P-ADL functioning during 52 months. P-ADL was measured using the Lawton and Brody’s Physical Self-Maintenance Scale. Degree of dementia (CDR), neuropsychiatric symptoms and use of psychotropic medication were assessed at the same four time points. Demographic information and information about physical health was included at baseline. Linear regression models for longitudinal data were estimated.

Results

Follow-up time was positively associated with a decline in P-ADL functioning. Degree of dementia at baseline was associated with a decline in P-ADL functioning over time. The association between degree of dementia and P-ADL functioning was strongest at baseline, and then flattened over time. A higher level of neuropsychiatric symptoms such as agitation and apathy and no use of anxiolytics and antidementia medication were associated with a decline in P-ADL functioning at four time points. Higher physical co-morbidity at baseline was associated with a decline in P-ADL functioning.

Conclusion

P-ADL functioning in nursing home patients with dementia worsened over time. The worsening was associated with more severe dementia, higher physical comorbidity, agitation, apathy and no use of anxiolytics and antidementia medication. Clinicians should pay attention to these variables (associates) in order to help the nursing home residents with dementia to maintain their level of functioning for as long as possible.

Treatment in a ward for elderly patients with dementia in Japan

BACKGROUND

Japan has become the world's most aged country. The percentage of elderly people in Japan is estimated to reach 25.2% in 2013, and the number of patients with dementia is estimated to reach 2.5 million in 2015. In addition to its deterioration of physical function and activities of daily living (ADL), behavioral and psychological symptoms of dementia (BPSD) often become major clinical problems, greatly annoying patients and their caregivers. In Japan, we utilize wards for elderly patients with dementia (WEDs) for BPSD treatment. However, there are few studies investigating the effectiveness of treatment in a WED. In such treatment, physical complications are a challenge physicians must overcome while treating BPSD and safely returning patients home or to the institutions in which they live. Therefore, we investigated the effectiveness of treatment in a WED, focusing on physical complications.

METHODS

The subjects were 88 patients who were admitted to and discharged from a WED. Severity of dementia, basic ADL, and BPSD were investigated using the Clinical Dementia Rating, Physical Self-Maintenance Scale (PSMS), and Neuropsychiatric Inventory. Differences in characteristics between patients discharged from the WED because of physical complications and all other patients were also examined.

RESULTS

We found significant improvements in the PSMS score and decreases in delusions and sleep disturbances in all patients. Patients discharged from the WED because of physical complications had significantly greater severity of dementia at discharge compared to all other patients.

CONCLUSION

Treatment in a WED seems to be effective for BPSD and ADL, but care should be taken regarding physical complications, especially in patients with advanced dementia.

Relationships between behavioral syndromes and cognitive domains in Alzheimer disease: the impact of mood and psychosis

OBJECTIVES

Behavioral disturbances occur in nearly all Alzheimer disease (AD) patients together with an array of cognitive impairments. Prior investigations have failed to demonstrate specific associations between them, suggesting an independent, rather than shared, pathophysiology. The objective of this study was to reexamine this issue using an extensive cognitive battery together with a sensitive neurobehavioral and functional rating scale to correlate behavioral syndromes and cognitive domains across the spectrum of impairment in dementia.

DESIGN

Cross-sectional study of comprehensive cognitive and behavioral ratings in subjects with AD and mild cognitive impairment.

SETTING

Memory disorders research center.

PARTICIPANTS

Fifty subjects with AD and 26 subjects with mild cognitive impairment; and their caregivers.

MEASUREMENTS

Cognitive rating scales administered included the Mini-Mental State Examination; the Modified Mini-Mental State Examination; the Boston Naming Test; the Benton Visual Retention Test; the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychology Assessment; the Controlled Oral Word Test; the Wechsler Memory Scale logical memory I and logical memory II task; the Wechsler Memory Scale-Revised digit span; the Wechsler Adult Intelligence Scale-Revised digit symbol task; and the Clock Drawing Task together with the Clinical Dementia Rating Scale and the Neuropsychiatric Inventory.

RESULTS

Stepwise regression of cognitive domains with symptom domains revealed significant associations of mood with impaired executive function/speed of processing (Δr = 0.22); impaired working memory (Δr = 0.05); impaired visual memory (Δr = 0.07); and worsened Clinical Dementia Rating Scale (Δr = 0.08). Psychosis was significantly associated with impaired working memory (Δr = 0.13).

CONCLUSIONS

Mood symptoms appear to impact diverse cognitive realms and to compromise functional performance. Among neuropsychological indices, the unique relationship between working memory and psychosis suggests a possible common underlying neurobiology.

Stability of the factor structure of the Neuropsychiatric Inventory in a 31-month follow-up study of a large sample of nursing-home patients with dementia

BACKGROUND

Neuropsychiatric symptoms (NPS) are highly prevalent among nursing home patients with dementia. Several studies have investigated subsyndromes of NPS but the stability of these subsyndromes over time has rarely been examined. We have examined the stability over time of the factor structure of the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) in a large sample of nursing-home patients with dementia.

METHODS

Nursing-home patients with dementia were assessed with the NPI-NH at baseline (n = 895), and at 12-month (n = 592) and 31-month (n = 278) follow-up assessments, giving three partly overlapping samples. Exploratory factor analysis was done to investigate neuropsychiatric subsyndromes of the NPI-NH at each assessment in these samples.

RESULTS

Three- or four-factor solutions were found, termed agitation, psychosis, apathy, and affective symptoms. Depression and anxiety (affective), delusion and hallucination (psychosis), and agitation and irritability (agitation) were the symptoms that most often co-occurred in the same factor. Apathy did not load together with affective symptoms at any of the assessments.

CONCLUSIONS

Subsyndromes of the NPI-NH are relatively stable over 31-month follow-up assessments in nursing-home patients with dementia, indicating that these subsyndromes may be useful for following the natural course of symptoms as well as observing the effect of interventions. Our findings lend support to the distinction between apathy and affective symptoms, which may have important clinical implications.

Quality of life of residents with dementia in long-term care settings in the Netherlands and Belgium: design of a longitudinal comparative study in traditional nursing homes and small-scale living facilities

BACKGROUND

The increase in the number of people with dementia will lead to greater demand for residential care. Currently, large nursing homes are trying to transform their traditional care for residents with dementia to a more home-like approach, by developing small-scale living facilities. It is often assumed that small-scale living will improve the quality of life of residents with dementia. However, little scientific evidence is currently available to test this. The following research question is addressed in this study: Which (combination of) changes in elements affects (different dimensions of) the quality of life of elderly residents with dementia in long-term care settings over the course of one year?

METHODS/DESIGN

A longitudinal comparative study in traditional and small-scale long-term care settings, which follows a quasi-experimental design, will be carried out in Belgium and the Netherlands. To answer the research question, a model has been developed which incorporates relevant elements influencing quality of life in long-term care settings. Validated instruments will be used to evaluate the role of these elements, divided into environmental characteristics (country, type of ward, group size and nursing staff); basic personal characteristics (age, sex, cognitive decline, weight and activities of daily living); behavioural characteristics (behavioural problems and depression); behavioural interventions (use of restraints and use of psychotropic medication); and social interaction (social engagement and visiting frequency of relatives). The main outcome measure for residents in the model is quality of life. Data are collected at baseline, after six and twelve months, from residents living in either small-scale or traditional care settings.

DISCUSSION

The results of this study will provide an insight into the determinants of quality of life for people with dementia living in traditional and small-scale long-term care settings in Belgium and the Netherlands. Possible relevant strengths and weaknesses of the study are discussed in this article.

TRIAL REGISTRATION

ISRCTN: ISRCTN23772945.

Neuropsychiatric symptoms and syndromes in institutionalized elderly people without dementia

BACKGROUND

Neuropsychiatric disorders are mainly studied in people with dementia but estimates are still not available for institutionalized elderly people without dementia. The aim of this work was to investigate neuropsychiatric syndromes in non-demented elderly people living in residential facilities (RFs).

METHODS

Data from the PROGRES-Older people project, including 95 RFs in Italy, were analyzed. From a total of 1215 people, 252 without dementia were recruited. Behavioral syndromes were identified using both factor and cluster analysis of results from the 12-item Neuropsychiatric Inventory. Logistic regression was used to assess factors associated with behavioral syndromes. Global cognitive functioning was assessed with the Mini-mental State Examination (MMSE). Current pharmacological treatments were taken from the residents' records.

RESULTS

Five neuropsychiatric syndromes were identified: (1) Affective (depression, anxiety, night-time behaviors); (2) Hyperactive (agitation, irritability, appetite abnormalities); (3) Psychotic (delusions and hallucinations); (4) Manic (euphoria and disinhibition); (5) Apathetic (apathy and aberrant motor behavior). The risk of having a neuropsychiatric syndrome was higher in people with younger age (OR: 5.1, 1.3-20.0), higher education (OR: 7.3, 2.4-22.1), and low MMSE score (OR: 6.5, 1.9-22.2). Almost half of people with behavioral syndromes were not undergoing psychotropic treatment. Hypnotic and anxiolytic agents were the most frequently used drugs for most of the syndromes.

CONCLUSIONS

Older people without dementia living in RFs exhibit a syndrome pattern of neuropsychiatric behaviors different from those observed in patients with dementia, which are associated with cognitive and sociodemographic characteristics. A large proportion of non-demented older people with neuropsychiatric syndromes are not having adequate treatment for their psychiatric disturbances.

Syndromic association of behavioral and psychological symptoms of dementia in Alzheimer disease and patient classification

OBJECTIVES

To identify patient groups with Alzheimer disease (AD) according to the presence of psychological and behavioral syndromes and to determine the clinical differences among these groups.

METHODS

Cross-sectional and observational study of 491 patients with probable AD whom were administered the Neuropsychiatric Inventory (NPI) at the baseline visit and reevaluated after 12 months.

RESULTS

Principal component analysis (PCA) of baseline NPI data revealed three factors, including a psychosis factor (delusions, hallucinations, and aberrant motor behavior), a depressive factor (depression, anxiety, irritability, agitation, and apathy) and a hypomanic factor (euphoria and disinhibition). Cluster analysis of factor scores indicated the presence of three patient groups: one group was characterized by low scores in factors, a second group including patients with high scores in the depressive factor, and a third group that included patients with high scores in the three factors. The PCA of the NPI scores carried out after 1 year showed the persistence of the three factors. The cluster analysis of their factor scores also showed the presence of the same three patient groups but with a few differences in certain symptoms. A higher frequency of personal psychiatric history but no family history was observed in the cluster with depressive symptoms.

CONCLUSIONS

Three neuropsychiatric syndromes have been identified, which have made it possible to classify patients with AD in three distinct large groups. A temporal stability is evidenced among the group with low symptoms. Patients with high scores in depressive factor or in three factors showed greater temporal instability. Certain differences among the groups suggest that different physiopathogenic mechanisms may be involved in neuropsychiatric syndromes.

Longitudinal assessment of psychotherapeutic day hospital treatment for neuropsychiatric symptoms in dementia

OBJECTIVE

Behavioral and psychological symptoms (BPSD) of dementia are associated with more rapid cognitive deterioration as well as increased caregiver stress. The effectiveness of psychiatric day hospital care for this condition remains disputed. We report here the assessment of a psychotherapeutic day hospital program in a series of elderly people with dementia and concomitant BPSD.

METHODS

Treatment setting: The day hospital program combined music, movement, psychodynamic group therapies, sociotherapy as well as individual interviews and family interventions.

PARTICIPANTS

76 individuals with mild to moderate dementia.

OUTCOME MEASURES

The Neuropsychiatric Inventory (NPI), Therapeutic Community Assessment scale including staff (SAS) and client assessments (CAS) and a Group Evaluation Scale (GES) were administrated at admission, 3, 6 and 12 months and discharge.

RESULTS

Linear regression analysis showed that SAS (but not CAS) and GES scores significantly increased while the NPI total scores decreased across the different time points. NPI item score modifications were significant for anxiety and apathy. These changes remained significant when demographic variables, drug treatment changes and occurrence of life events were also considered.

CONCLUSION

A psychotherapeutic day hospital program designed for older people with dementia and neuropsychiatric symptoms allows for a significant reduction of anxiety and apathy, better adhesion to therapeutic community treatment and clinical progress in group therapy. Controlled interventional studies are needed to further confirm these data.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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