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Betz ME, Frattaroli S, Knoepke CE, Johnson R, Christy A, Schleimer JP, Pear VA, McCarthy M, Kapoor R, Norko MA, Rowhani-Rahbar A, Ma W, Wintemute GJ, Swanson JW, Zeoli AM. Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study. Clin Gerontol 2024; 47:536-543. [PMID: 37688772 PMCID: PMC11229607 DOI: 10.1080/07317115.2023.2254279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2023]
Abstract
OBJECTIVES Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.
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Affiliation(s)
- Marian E Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Firearm Injury Prevention Initiative, University of Colorado School of Medicine, Aurora, Colorado, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, USA
| | - Shannon Frattaroli
- Center for Gun Violence Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Christopher E Knoepke
- Firearm Injury Prevention Initiative, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult & Child Consortium for Outcomes Research & Delivery Science, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rachel Johnson
- Center for Innovative Design & Analysis, Department of Biostatistics & Informatics, Colorado School of Public health, Aurora, Colorado, USA
| | - Annette Christy
- Department of Mental Health Law and Policy at the de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida, Tampa, Florida, USA
| | - Julia P Schleimer
- Violence Prevention Research Program, University of California Davis School of Medicine, Sacramento, California, USA
- Firearm Injury & Policy Research Program, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Veronica A Pear
- Violence Prevention Research Program, University of California Davis School of Medicine, Sacramento, California, USA
| | - Megan McCarthy
- Firearm Injury Prevention Initiative, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Reena Kapoor
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael A Norko
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ali Rowhani-Rahbar
- Firearm Injury & Policy Research Program, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Wenjuan Ma
- Center for Statistical Training and Consulting, Michigan State University, Lansing, Michigan, USA
| | - Garen J Wintemute
- Violence Prevention Research Program, University of California Davis School of Medicine, Sacramento, California, USA
| | - Jeffrey W Swanson
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - April M Zeoli
- Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, Michigan, USA
- Institute for Firearm Injury Prevention, University of Michigan, Ann Arbor, Michigan, USA
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Barnestein-Fonseca P, Guerrero-Pertiñez G, Gúzman-Parra J, Valera-Moreno E, Mayoral-Cleries F. Is it possible to diagnose therapeutic adherence in mild cognitive impairment and dementia patients in clinical practice? Front Pharmacol 2024; 15:1362168. [PMID: 38841377 PMCID: PMC11151088 DOI: 10.3389/fphar.2024.1362168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/16/2024] [Indexed: 06/07/2024] Open
Abstract
Background Non-adherence is common and contributes to adverse health outcomes, reduced quality of life, and increased healthcare expenditure. The objective of this study was to assess the diagnostic validity to estimate the prevalence of non-adherence in patients with mild cognitive impairment (MCI) and dementia using two self-reported methods (SRMs) that are useful and easy in clinical practice, considering the pill count as a reference method (RM). Methods The cohort study was nested in a multicenter randomized controlled trial NCT03325699. A total of 387 patients from 8 health centers were selected using a non-probabilistic consecutive sampling method. Inclusion criteria were as follows: a score of 20-28 points on the Mini-Mental State Examination (MMSE); older than 55 years; taking prescribed medication; and are in charge of their own medication use. Participants were followed up for 18 months after the baseline visit, i.e., 6, 12, and 18 months. Variables related with treatment adherences were measured in all visits. The variables included age, sex, treatment, comorbidities, and the MMSE test. Adherences included pill counts and Morisky-Green test (MGT) and Batalla test (BT) as SRMs. Statistical analysis included descriptive analysis and 95% confidence intervals (CIs). The diagnostic validity included the following: 1) open comparison statistical association between SRMs and RMs and 2) hierarchy comparison: the RM as the best method to assess non-adherence, kappa value (k), sensitivity (S), specificity (Sp), and likelihood ratio (PPV/PPN). Results A total of 387 patients were recruited with an average age of 73.29 years (95% CI, 72.54-74.04), of which 59.5% were female. Comorbidities were 54.4% HTA, 35.9% osteoarticular pathology, and 24.5% DM. The MMSE mean score was 25.57 (95% CI, 25.34-25.8). The treatment adherence for the RM oscillates between 22.5% in the baseline and 26.3%, 14.8%, and 17.9% in the follow-up visits. For SRMs, the treatment adherence oscillates between 43.5% in the baseline and 32.4%, 21.9%, and 20.3% in the follow-up visits. The kappa value was statistically significant in all the comparison in all visits with a score between 0.16 and 035. Regarding the diagnostic validity, for the MGT, the sensibility oscillated between 0.4 and 0.58, and the specificity oscillated between 0.68 and 0.87; for the BT, the sensibility oscillated between 0.4 and 0.7, and the specificity oscillated between 0.66 and 0.9; and when both tests were used together, the sensibility oscillated between 0.22 and 0.4, and the specificity oscillated between 0.85 and 0.96. Conclusion SRMs classify non-adherent subjects correctly. They are very easy to use and yield quick results in clinical practice, so SRMs would be used for the non-adherence diagnosis in patients with MCI and mild dementia.
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Affiliation(s)
- Pilar Barnestein-Fonseca
- Research Unit, Instituto CUDECA de Estudios e Investigación en Cuidados Paliativos, Fundación CUDECA, Málaga, Spain
- Instituto IBIMA-Plataforma Bionand, Málaga, Spain
| | - Gloria Guerrero-Pertiñez
- Instituto IBIMA-Plataforma Bionand, Málaga, Spain
- UGC Mental-Health, Hospital Regional de Málaga, Andalusian Health Service, Málaga, Spain
| | - Jose Gúzman-Parra
- Instituto IBIMA-Plataforma Bionand, Málaga, Spain
- UGC Mental-Health, Hospital Regional de Málaga, Andalusian Health Service, Málaga, Spain
| | - Esperanza Valera-Moreno
- Instituto IBIMA-Plataforma Bionand, Málaga, Spain
- UGC Mental-Health, Hospital Regional de Málaga, Andalusian Health Service, Málaga, Spain
| | - Fermín Mayoral-Cleries
- Instituto IBIMA-Plataforma Bionand, Málaga, Spain
- UGC Mental-Health, Hospital Regional de Málaga, Andalusian Health Service, Málaga, Spain
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Mohd Sahini SN, Mohd Nor Hazalin NA, Srikumar BN, Jayasingh Chellammal HS, Surindar Singh GK. Environmental enrichment improves cognitive function, learning, memory and anxiety-related behaviours in rodent models of dementia: Implications for future study. Neurobiol Learn Mem 2024; 208:107880. [PMID: 38103676 DOI: 10.1016/j.nlm.2023.107880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 12/19/2023]
Abstract
Environmental enrichment (EE) is a process of brain stimulation by modifying the surroundings, for example, by changing the sensory, social, or physical conditions. Rodents have been used in such experimental strategies through exposure to diverse physical, social, and exploration conditions. The present study conducted an extensive analysis of the existing literature surrounding the impact of EE on dementia rodent models. The review emphasised the two principal aspects that are very closely related to dementia: cognitive function (learning and memory) as well as psychological factors (anxiety-related behaviours such as phobias and unrealistic worries). Also highlighted were the mechanisms involved in the rodent models of dementia showing EE effects. Two search engines, PubMed and Science Direct, were used for data collection using the following keywords: environmental enrichment, dementia, rodent model, cognitive performance, and anxiety-related behaviour. Fifty-five articles were chosen depending on the criteria for inclusion and exclusion. The rodent models with dementia demonstrated improved learning and memory in the form of hampered inflammatory responses, enhanced neuronal plasticity, and sustained neuronal activity. EE housing also prevented memory impairment through the prevention of amyloid beta (Aβ) seeding formation, an early stage of Aβ plaque formation. The rodents subjected to EE were observed to present increased exploratory activity and exert less anxiety-related behaviour, compared to those in standard housing. However, some studies have proposed that EE intervention through exercise would be too mild to counteract the anxiety-related behaviour and risk assessment behaviour deficits in the Alzheimer's disease rodent model. Future studies should be conducted on old-aged rodents and the duration of EE exposure that would elicit the greatest benefits since the existing studies have been conducted on a range of ages and EE durations. In summary, EE had a considerable effect on dementia rodent models, with the most evident being improved cognitive function.
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Affiliation(s)
- Siti Norhafizah Mohd Sahini
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Selangor Branch, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor, Malaysia; Outpatient Pharmacy Department, Hospital Raja Permaisuri Bainun, 30450 Ipoh, Perak, Malaysia
| | - Nurul Aqmar Mohd Nor Hazalin
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Selangor Branch, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor, Malaysia; Integrative Pharmacogenomics Institute (iPROMiSE), Level 7, FF3, Universiti Teknologi MARA, Selangor Branch, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor, Malaysia
| | - Bettadapura N Srikumar
- Department of Neurophysiology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Hosur Road, Bengaluru - 560029, India
| | - Hanish Singh Jayasingh Chellammal
- Department of Pharmacology and Pharmaceutical Chemistry, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Selangor Branch, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor, Malaysia; Brain Degeneration and Therapeutics Group, Universiti Teknologi MARA (UiTM), 40450 Shah Alam, Selangor, Malaysia
| | - Gurmeet Kaur Surindar Singh
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Selangor Branch, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor, Malaysia; Brain Degeneration and Therapeutics Group, Universiti Teknologi MARA (UiTM), 40450 Shah Alam, Selangor, Malaysia.
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Muacevic A, Adler JR, Shukla S, Kumar S. Neuropsychiatric Manifestations of Thyroid Diseases. Cureus 2023; 15:e33987. [PMID: 36811059 PMCID: PMC9938951 DOI: 10.7759/cureus.33987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/20/2023] [Indexed: 01/21/2023] Open
Abstract
Thyroid disorders are known to cause neuropsychiatric manifestations. Various neuropsychiatric manifestations are depression, dementia, mania, and autoimmune Hashimoto encephalopathy. Numerous investigations carried out in the previous 50-60 years have been evaluated critically. The pathophysiology of neuropsychiatric symptoms of thyroid diseases is described in the current study and its link with autoimmune Hashimoto encephalopathy is also discussed. Furthermore, this paper also describes the association between thyroid-stimulating hormones and cognitive impairment. Hypothyroidism is associated with depression and mania, and hyperthyroidism is linked with dementia and mania. The association between Graves' disease and various mental disorders such as depressive and anxiety disorders is also discussed. The aim of this study is to review the relationship between various neuropsychiatric disorders and thyroid diseases. A literature search from the PubMed database to find various neuropsychiatric manifestations of thyroid disorders in the adult population was conducted. According to the review of the studies, cognitive impairment can result from thyroid disease. It has not been possible to demonstrate how hyperthyroidism can hasten the process of developing dementia. However, subclinical hyperthyroidism, thyroid-stimulating hormone (TSH) levels below the normal range, and high free thyroxine (T4) levels all raise the risk of dementia in the elderly. Additionally, the potential mechanisms underlying this association have been examined. A quick summary of the research on mania as a clinical symptom of hypothyroidism and its likely causes and pathogenesis is also reviewed. There is no dearth of evidence that describes various neuropsychiatric manifestation in thyroid disorders.
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Dijk MT, Tabak S, Hertogh CMPM, Kok RM, van Marum RJ, Zuidema SU, Sizoo EM, Smalbrugge M. Psychotropic drug treatment for agitated behaviour in dementia: what if the guideline prescribing recommendations are not sufficient? A qualitative study. Age Ageing 2022; 51:6691372. [PMID: 36057986 PMCID: PMC9441198 DOI: 10.1093/ageing/afac189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Agitation is a common challenging behaviour in dementia with a negative influence on patient's quality of life and a high caregiver burden. Treatment is often difficult. Current guidelines recommend restrictive use of psychotropic drug treatment, but guideline recommendations do not always suffice. OBJECTIVE To explore how physicians decide on psychotropic drug treatment for agitated behaviour in dementia when the guideline prescribing recommendations are not sufficient. METHODS We conducted five online focus groups with a total of 22 elderly care physicians, five geriatricians and four old-age psychiatrists, in The Netherlands. The focus groups were thematically analysed. RESULTS We identified five main themes. Transcending these themes, in each of the focus groups physicians stated that there is 'not one size that fits all'. The five themes reflect physicians' considerations when deciding on psychotropic drug treatment outside the guideline prescribing recommendations for agitated behaviour in dementia: (1) 'reanalysis of problem and cause', (2) 'hypothesis of underlying cause and treatment goal', (3) 'considerations regarding drug choice', (4) 'trial and error' and (5) 'last resort: sedation'. CONCLUSION When guideline prescribing recommendations do not suffice, physicians start with reanalysing potential underlying causes. They try to substantiate and justify medication choices as best as they can with a hypothesis of underlying causes or treatment goal, using other guidelines, and applying personalised psychotropic drug treatment.
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Affiliation(s)
- Margaretha T Dijk
- Address correspondence to: Margaretha T. Dijk, Amsterdam University Medical Center, Location VUmc, department of Elderly Care Medicine, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.
| | - Sarah Tabak
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands,Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands
| | - Rob M Kok
- Department of Old Age Psychiatry, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Rob J van Marum
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands,Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands,Jeroen Bosch Hospital, Geriatric Department and Center for Clinical Pharmacology, 's-Hertogenbosch, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eefje M Sizoo
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands,Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands,Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands
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Unsupervised statistical concept drift detection for behaviour abnormality detection. APPL INTELL 2022. [DOI: 10.1007/s10489-022-03611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AbstractAbnormal behaviour can be an indicator for a medical condition in older adults. Our novel unsupervised statistical concept drift detection approach uses variational autoencoders for estimating the parameters for a statistical hypothesis test for abnormal days. As feature, the Kullback–Leibler divergence of activity probability maps derived from power and motion sensors were used. We showed the general feasibility (min. F1-Score of 91 %) on an artificial dataset of four concept drift types. Then we applied our new method to our real–world dataset collected from the homes of 20 (pre–)frail older adults (avg. age 84.75 y). Our method was able to find abnormal days when a participant suffered from severe medical condition.
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The perceptions, needs and preferences of informal caregivers of nursing home residents with dementia regarding physical therapy: A qualitative study. Geriatr Nurs 2022; 44:167-175. [PMID: 35182805 DOI: 10.1016/j.gerinurse.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Informal caregivers often support nursing home residents with dementia in making therapeutic decisions. We explored the perceptions, needs and preferences of informal caregivers of nursing home residents with dementia regarding physical therapy. METHOD We conducted eleven semi-structured interviews. Thematic analysis was used. RESULTS Five themes emerged: 1) visibility and familiarity; 2) communication; 3) aim and content; 4) dosage and location; 5) level of expertise and the role of the physical therapist within the interdisciplinary team. Informal caregivers' perceptions of physical therapy included a lack of visibility and familiarity. They needed more communication, and empathic communication skills of the physical therapists. Preferences included physical therapy to be enjoyable, accessible and tailored to the needs of the resident. CONCLUSION Physical therapists need to involve informal caregivers in physical therapy care. Implementing shared decision-making will help to get informal caregivers more involved, but has yet to be studied in this setting.
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Mohseni-Moghaddam P, Ghobadian R, Khaleghzadeh-Ahangar H. Dementia in Diabetes mellitus and Atherosclerosis; Two Interrelated Systemic Diseases. Brain Res Bull 2022; 181:87-96. [DOI: 10.1016/j.brainresbull.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/18/2021] [Accepted: 01/24/2022] [Indexed: 12/06/2022]
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Lin YC, Fan J, Tate JA, Sarkar N, Mion LC. Use of robots to encourage social engagement between older adults. Geriatr Nurs 2022; 43:97-103. [PMID: 34847509 PMCID: PMC8821416 DOI: 10.1016/j.gerinurse.2021.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 01/03/2023]
Abstract
We designed a robotic architecture system within a commercially available socially assistive robot to engage pairs of older adults in multimodal activities over 3 weeks for 6 sessions. The study took place in two assisted living facilities. Seven pairs (14 individuals) completed the experiment. Ages ranged from 70 to 90 years with a mean age of 83.0 (± 6.1). Most were women (79%). Three adults were screened as having normal cognition, 10 had mild cognitive impairment, and 1 adult self-reported a diagnosis of Alzheimer's disease. All sessions were video recorded and analyzed using Noldus Observer XT. Individuals demonstrated high levels of both human-human interaction and human-robot interaction, but the activity influenced the type of interaction. Engagement measures (visual, verbal, behavioral) also varied by type of activity. Future studies will focus on further development of activities that can engage older adults with varying levels of cognitive impairment and apathy.
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Affiliation(s)
- Yi-Chun Lin
- At the time of the study, Research Assistant at the Ohio State University College of Nursing, Columbus OH
| | - Jing Fan
- At the time of the study, Research Assistant at Vanderbilt University Electrical and Engineering and Computer Science Department, Nashville TN
| | - Judith A. Tate
- Associate Professor, College of Nursing, Ohio State University, Columbus OH
| | - Nilanjan Sarkar
- David K. Wilson Professor of Engineering at Vanderbilt University School of Engineering; Chair of Mechanical Engineering and Professor of Electrical and Computer Science
| | - Lorraine C. Mion
- Research Professor, College of Nursing, Ohio State University, Columbus OH
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Efjestad AS, Ihle-Hansen H, Hjellvik V, Engedal K, Salvesen Blix H. Sex differences in psychotropic and analgesic drug use before and after initiating treatment with acetylcholinesterase inhibitors. PLoS One 2021; 16:e0243804. [PMID: 34543268 PMCID: PMC8452043 DOI: 10.1371/journal.pone.0243804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 04/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The aim was to explore the impact of sex on prevalence, patterns and trends in the prescription of psychotropics and analgesics in users of acetylcholinesterase inhibitors (AChEIs), before and after AChEI initiation, compared to the general population. METHODS A prospective study applying data from the Norwegian Prescription Database (NorPD) in the period 2004-2016. Prescription of antidepressants, antipsychotics, analgesics including opioids, benzodiazepines and z-hypnotics in persistent AChEI users was studied in a follow-up period from four years before to two years after AChEI initiation in men and women of four age groups: 37-64, 65-72, 73-80 and 81-88 years. RESULTS Use of antidepressants, antipsychotics and weaker analgesics increased in both sexes during the follow-up period in 11.764 persistent AChEI users. Women with pre-dementia and dementia stages of AD showed a prescription pattern with more use of psychotropics and opioids than men, except for antipsychotics. CONCLUSION Female sex showed to have a significant influence on the prescriptions of psychotropics and analgesics in AD patients in a pre-dementia and dementia stage. The exception is for antipsychotics, that men used more than women. The prescription pattern showed a higher extent of polypharmacy of psychotropics and/or opioids in women than in men. The total prescription pattern of analgesics could indicate an undertreatment of pain in pre-dementia and dementia stages, most pronounced in men.
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Affiliation(s)
- Anne Sverdrup Efjestad
- Hospital Pharmacy Ahus, Loerenskog, Hospital Pharmacy Enterprices, South Eastern Norway, Oslo, Norway
- * E-mail:
| | - Hege Ihle-Hansen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | | | - Knut Engedal
- Norwegian National Advisory Unit on Ageing and Health, Vestfold County Hospital, Tønsberg, Norway
- Department of Geriatrics, Oslo University Hospital, Oslo, Norway
| | - Hege Salvesen Blix
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Pharmacy, University of Oslo, Oslo, Norway
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Dobbs D, Zimmerman S, Carder P, Beeber AS, Palmertree SJ. Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities. THE GERONTOLOGIST 2021; 62:169-180. [PMID: 33993241 DOI: 10.1093/geront/gnab059] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Assisted living (AL) residents with dementia commonly exhibit behavioral expressions (BEs), yet no study has examined how AL staff perceive of and respond to BEs in terms of the "ABC" model of antecedents, behaviors and consequences, or how perceptions relate to organizational characteristics. Understanding staff perceptions may inform interventions. RESEARCH DESIGN AND METHODS A convergent, mixed-methods design was used in a study of health care supervisors from 250 AL communities in seven states who reported 366 cases of resident BEs (one successful and one unsuccessful case). Qualitative analysis identified antecedents, BEs, staff responses, resident outcomes, and disposition (aging in place or discharge). Content analysis identified themes and compared case types. Descriptive statistics examined organizational characteristics associated with identifying antecedents. RESULTS One-quarter of cases recognized antecedents; slightly more were identified in successful (28%) compared to unsuccessful cases (20%); staff in dementia-only and smaller communities identified antecedents more often. Combativeness and anxiety were the most frequently reported BEs. The majority of both types of cases reported staff responses. Medication management was enacted as a response in 40% of cases compared to psychiatric assessment in 33% of cases. DISCUSSION AND IMPLICATIONS Staff training is indicated to increase AL staff recognition of antecedents; doing so might reduce use of antipsychotic medications. Psychiatric assessment plays an important role in dementia care in AL and warrants further examination. Results could be helpful for applied behavioral researchers interested in developing ways to improve identification of antecedents of BEs of persons with dementia.
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Affiliation(s)
- Debra Dobbs
- Florida Policy Exchange Center of Aging, School of Aging Studies, University of South Florida, Tampa, Florida, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paula Carder
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon, USA
| | - Anna S Beeber
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephanie J Palmertree
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Choukou MA, Mbabaali S, East R. Healthcare Professionals' Perspective on Implementing a Detector of Behavioural Disturbances in Long-Term Care Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:2720. [PMID: 33800257 PMCID: PMC7967440 DOI: 10.3390/ijerph18052720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 11/25/2022]
Abstract
The number of Canadians with dementia is expected to rise to 674,000 in the years to come. Finding ways to monitor behavioural disturbance in patients with dementia (PwDs) is crucial. PwDs can unintentionally behave in ways that are harmful to them and the people around them, such as other residents or care providers. Current practice does not involve technology to monitor PwD behaviours. Events are reported randomly by nonstaff members or when a staff member notices the absence of a PwD from a scheduled event. This study aims to explore the potential of implementing a novel detector of behavioural disturbances (DBD) in long-term care homes by mapping the perceptions of healthcare professionals and family members about this technology. Qualitative information was gathered from a focus group involving eight healthcare professionals working in a tertiary care facility and a partner of a resident admitted in the same facility. Thematic analysis resulted in three themes: (A) the ability of the DBD to detect relevant dementia-related behavioural disturbances that are typical of PwD; (B) the characteristics of the DBD and clinical needs and preferences; (C) the integration of the DBD into daily routines. The results tend to confirm the adequacy of the DBD to the day-to-day needs for the detection of behavioural disturbances and hazardous behaviours. The DBD was considered to be useful and easy to use in the tertiary care facility examined in this study. The participants intend to use the DBD in the future, which means that it has a high degree of acceptance.
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Affiliation(s)
- Mohamed-Amine Choukou
- Department of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, MB R3E 0T6, Canada; (S.M.); (R.E.)
- Riverview Health Centre, Winnipeg, MB R3L 2P4, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Sophia Mbabaali
- Department of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, MB R3E 0T6, Canada; (S.M.); (R.E.)
| | - Ryan East
- Department of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, MB R3E 0T6, Canada; (S.M.); (R.E.)
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Fan J, Ullal A, Beuscher L, Mion LC, Newhouse P, Sarkar N. Field Testing of Ro-Tri, a Robot-Mediated Triadic Interaction for Older Adults. Int J Soc Robot 2021; 13:1711-1727. [PMID: 33643494 PMCID: PMC7897418 DOI: 10.1007/s12369-021-00760-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2021] [Indexed: 01/10/2023]
Abstract
Older adults residing in long term care (LTC) settings commonly experience apathy, a neuropsychiatric condition with adverse consequences of increased morbidity and mortality. Activities that combine social, physical and cognitive stimuli are most effective in engaging older adults with apathy but are time consuming and require significant staff resources. We present the results from an initial pilot field study of our socially assistive robotic (SAR) system, Ro-Tri, capable of multi-modal interventions to foster social interaction between pairs of older adults. Seven paired participants attended two sessions a week for three weeks. Sessions consisted of robot-mediated triadic interactions with three types of activities repeated once over the 3 weeks. Ro-Tri gathered quantitative interaction data, head pose, vocal sound, and physiological signals to automatically evaluate older adults' activity and social engagement. Ro-Tri functioned smoothly without any technical issues. Older adults had > 90% attendance and 100% completion rate and remained engaged with the system throughout the study duration. Participants' visual attention toward the SAR system and their partners increased 7.2% and 4.7%, respectively, with their interaction effort showing an increase of 2.9%. Older adults and LTC staff had positive perceptions with the system. These initial results demonstrate Ro-Tri's ability to engage older adults, encourage social human-to-human interaction, and assess the changes using quantitative metrics. Future studies will determine SAR's impact on apathy in LTC older adults.
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Affiliation(s)
- Jing Fan
- Department of EECS, Vanderbilt University, Nashville, TN USA
| | - Akshith Ullal
- Department of EECS, Vanderbilt University, Nashville, TN USA
| | - Linda Beuscher
- School of Nursing, Vanderbilt University, Nashville, TN USA
| | | | - Paul Newhouse
- Center for Cognitive Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Geriatric Research, Education and Clinical Center, Tennessee Valley Veterans Affairs Medical Center, Nashville, TN USA
| | - Nilanjan Sarkar
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN USA
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Gimeno I, Val S, Cardoso Moreno MJ. Relation among Caregivers' Burden, Abuse and Behavioural Disorder in People with Dementia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031263. [PMID: 33572503 PMCID: PMC7908463 DOI: 10.3390/ijerph18031263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 11/16/2022]
Abstract
Dementia produces a loss of independence to carry out the activities of daily life. The great demand for care that these people need usually falls on the family through informal care. This study aims to analyse the burden showed by the informal caregiver of a person with dementia. In addition, we analyse whether this burden present in informal caregivers could be related to abusive behaviour. We also study the relationship between the stage of the disease, the appearance of behavioural disorders and the level of burden in the caregiver using the Scales of Zarit, CASE and FAST. The data showed that 45.50 per cent of caregivers have light burden or burden. After the research, it was identified that the presence of behavioural disorders in patients with dementia showed a correlation with the increase in both the main caregiver burden and abuse. An increase in the level of burden is followed by an increase in the level of abuse (r = 0.844; p = 0.000). Furthermore, we analysed several conditions that could have a correlation with this burden and abuse. It was found that burden in the caregiver could be linked with the presence of behavioural disorders, like aggression (r = 0.577; p = 0.008) and irritability (r = 0.600; p = 0.005) at the moderate stage of the disease. On the other hand, there is a positive correlation between the probability that people with dementia suffer abuse in the moderate stage of the disease and the presence of aggression (r = 0.732; p = 0.000), lack of inhibition (r = 0.571; p = 0.009) and irritability (r = 0.827; p = 0.000). Taking this data into account, burden and abuse seem to be linked to the presence of behavioural disorders in patients with dementia in the moderate stage.
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Affiliation(s)
- Ignacio Gimeno
- Department of Psychology and Sociology, Faculty of Health of Sciences, University of Zaragoza, 50009 Zaragoza, Spain;
| | - Sonia Val
- EINA, Design and Manufacturing Engineering Department, University of Zaragoza, 50009 Zaragoza, Spain;
| | - María Jesús Cardoso Moreno
- Department of Psychology and Sociology, Faculty of Health of Sciences, University of Zaragoza, 50009 Zaragoza, Spain;
- Correspondence:
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Manini A, Brambilla M, Maggiore L, Pomati S, Pantoni L. The impact of lockdown during SARS-CoV-2 outbreak on behavioral and psychological symptoms of dementia. Neurol Sci 2021; 42:825-833. [PMID: 33442845 PMCID: PMC7806279 DOI: 10.1007/s10072-020-05035-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 12/31/2020] [Indexed: 01/10/2023]
Abstract
Background During Covid-19 pandemic, the Italian government adopted restrictive limitations and declared a national lockdown on March 9, which lasted until May 4 and produced dramatic consequences on people’s lives. The aim of our study was to assess the impact of prolonged lockdown on behavioral and psychological symptoms of dementia (BPSD). Methods Between April 30 and June 8, 2020, we interviewed with a telephone-based questionnaire the caregivers of the community-dwelling patients with dementia who had their follow-up visit scheduled from March 9 to May 15 and canceled due to lockdown. Among the information collected, patients’ BPSDs were assessed by the Neuropsychiatric Inventory (NPI). Non-parametric tests to compare differences between NPI scores over time and logistic regression models to explore the impact of different factors on BPSD worsening were performed. Results A total of 109 visits were canceled and 94/109 caregivers completed the interview. Apathy, irritability, agitation and aggression, and depression were the most common neuropsychiatric symptoms experienced by patients both at baseline and during Covid-19 pandemic. Changes in total NPI and caregiver distress scores between baseline and during lockdown, although statistically significant, were overall modest. The logistic regression model failed to determine predictors of BPSD worsening during lockdown. Conclusion This is one of the first studies to investigate the presence of BPSD during SARS-CoV-2 outbreak and related nationwide lockdown, showing only slight, likely not clinically relevant, differences in BPSD burden, concerning mostly agitation and aggression, anxiety, apathy and indifference, and irritability. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-020-05035-8.
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Affiliation(s)
- Arianna Manini
- Stroke and Dementia Lab, "Luigi Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi 74, 20157, Milan, Italy
| | - Michela Brambilla
- Center for Cognitive Disorders and Dementias (CDCD), Neurology Unit, Ospedale Luigi Sacco, Milan, Italy
| | - Laura Maggiore
- Center for Cognitive Disorders and Dementias (CDCD), Neurology Unit, Ospedale Luigi Sacco, Milan, Italy
| | - Simone Pomati
- Center for Cognitive Disorders and Dementias (CDCD), Neurology Unit, Ospedale Luigi Sacco, Milan, Italy
| | - Leonardo Pantoni
- Stroke and Dementia Lab, "Luigi Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi 74, 20157, Milan, Italy.
- Center for Cognitive Disorders and Dementias (CDCD), Neurology Unit, Ospedale Luigi Sacco, Milan, Italy.
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Joy Mathew C, Jose MT, Elshaikh AO, Shah L, Lee R, Cancarevic I. Is Hyperthyroidism a Possible Etiology of Early Onset Dementia? Cureus 2020; 12:e10603. [PMID: 33133806 PMCID: PMC7586400 DOI: 10.7759/cureus.10603] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Dementia, a disabling syndrome of the elderly characterized by the decline in memory and cognition, is increasing in incidence and affects not only the individual but also their family and close ones. Hyperthyroidism can mimic many other diseases and untreated hyperthyroidism can lead to adverse problems of various systems including the heart, bones, muscles, menstrual cycle, and fertility. In this article, we have tried to evaluate the association between hyperthyroidism and dementia, as well as the impact of hyperthyroidism management in the treatment and prevention of dementia. Studies available in the PubMed database have been used, excluding animal studies and including studies of adults above the age of 50. The analysis of studies reveals that thyroid dysfunction can lead to cognitive impairment. It has not been able to prove that hyperthyroidism can lead to an earlier onset of dementia. But subclinical hyperthyroidism, thyroid-stimulating hormone (TSH) levels below the normal range, and high free thyroxine (T4) levels increase the risk of dementia among the elderly. The possible mechanisms involved in this association have also been discussed. Thus, we concluded that it is essential to detect and manage hyperthyroidism at an earlier stage since hyperthyroidism increases the risk of dementia. The possibility of using antithyroid treatment in euthyroid dementia is yet to be studied extensively.
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Affiliation(s)
| | - Merin Tresa Jose
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abeer O Elshaikh
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lisa Shah
- Family and Community Medicine, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, IND
| | - Robert Lee
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Regier NG, Hodgson NA, Gitlin LN. Neuropsychiatric symptom profiles of community-dwelling persons living with dementia: Factor structures revisited. Int J Geriatr Psychiatry 2020; 35:1009-1020. [PMID: 32363605 PMCID: PMC8942615 DOI: 10.1002/gps.5323] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/18/2020] [Accepted: 04/25/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Most persons living with dementia (PLWD) will develop neuropsychiatric symptoms (NPS) at some point. NPS are often clustered into subsyndromes with other related symptoms, but the evidence supporting commonly used clusters is insufficient. We reexamine behavioral clusters in community-dwelling PLWD and identify associated risk factors and potential contributors. METHODS This study used baseline data from a longitudinal behavioral intervention study of 250 community-dwelling older adults with dementia and their caregivers. Using exploratory factor analysis (principal component analysis [PCA]), the factor structure of NPS frequency scores of the Neuropsychiatric Inventory (NPI-C) was evaluated. Multiple linear regressions assessed the association of the derived behavioral clusters with caregiver burden, caregiver depression, and quality of life of the PLWD. RESULTS PCA yielded eight behavioral clusters (factors): 1 = Aggression/Rejection of Care, 2 = Apathy/Withdrawal, 3 = Restlessness/Agitation, 4 = Anxiety, 5 = Impulsivity/Disinhibition, 6 = Psychosis, 7 = Circadian Disturbance, and 8 = Depression. In multiple linear regressions, caregiver burden was significantly influenced by the anxiety cluster, caregiver depression was significantly influenced by the apathy/withdrawal cluster, and quality of life of the PLWD was significantly associated with the anxiety and circadian disturbance clusters. CONCLUSIONS Our eight derived behavioral clusters suggest that commonly accepted clusters of NPS may not reflect the clinical reality for community-dwelling PLWD. Behavioral clusters appear to differentially impact and put caregivers and PLWD at risk such that personalized intervention strategies are warranted. J Am Geriatr Soc 68:-, 2020.
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Affiliation(s)
- Natalie G. Regier
- Johns Hopkins University School of Nursing, Baltimore, MD,Johns Hopkins Center for Innovative Care in Aging, Baltimore, MD
| | - Nancy A. Hodgson
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Laura N. Gitlin
- Johns Hopkins University School of Nursing, Baltimore, MD,Johns Hopkins Center for Innovative Care in Aging, Baltimore, MD,Drexel College of Nursing and Health Professions, Philadelphia, PA
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Pharmacogenomics of Cognitive Dysfunction and Neuropsychiatric Disorders in Dementia. Int J Mol Sci 2020; 21:ijms21093059. [PMID: 32357528 PMCID: PMC7246738 DOI: 10.3390/ijms21093059] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
Symptomatic interventions for patients with dementia involve anti-dementia drugs to improve cognition, psychotropic drugs for the treatment of behavioral disorders (BDs), and different categories of drugs for concomitant disorders. Demented patients may take >6–10 drugs/day with the consequent risk for drug–drug interactions and adverse drug reactions (ADRs >80%) which accelerate cognitive decline. The pharmacoepigenetic machinery is integrated by pathogenic, mechanistic, metabolic, transporter, and pleiotropic genes redundantly and promiscuously regulated by epigenetic mechanisms. CYP2D6, CYP2C9, CYP2C19, and CYP3A4/5 geno-phenotypes are involved in the metabolism of over 90% of drugs currently used in patients with dementia, and only 20% of the population is an extensive metabolizer for this tetragenic cluster. ADRs associated with anti-dementia drugs, antipsychotics, antidepressants, anxiolytics, hypnotics, sedatives, and antiepileptic drugs can be minimized by means of pharmacogenetic screening prior to treatment. These drugs are substrates, inhibitors, or inducers of 58, 37, and 42 enzyme/protein gene products, respectively, and are transported by 40 different protein transporters. APOE is the reference gene in most pharmacogenetic studies. APOE-3 carriers are the best responders and APOE-4 carriers are the worst responders; likewise, CYP2D6-normal metabolizers are the best responders and CYP2D6-poor metabolizers are the worst responders. The incorporation of pharmacogenomic strategies for a personalized treatment in dementia is an effective option to optimize limited therapeutic resources and to reduce unwanted side-effects.
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Deardorff WJ, Grossberg GT. Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:5-32. [PMID: 31727229 DOI: 10.1016/b978-0-444-64012-3.00002-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent and represent a significant burden for patients and their caregivers. Early recognition and management of these symptoms is crucial as they are associated with increased risk of institutionalization, impairments in daily functioning, reduced quality of life, and more rapid progression to severe dementia. This chapter will discuss the pathophysiology, proposed diagnostic criteria, clinical features, and management of BPSD, including apathy, depression, agitation/aggression, psychosis, and sleep disturbances. Apathy and depression are the most common overall, and apathy is associated with high symptom severity likely because of its greater persistence. Symptoms such as agitation, aggression, hallucinations, and delusions may be especially distressing and dangerous to patients and caregivers. Nonpharmacologic management should be considered first-line therapy in most cases due to the modest and inconsistent evidence base for pharmacologic agents and greater risk of harm. However, the judicious use of pharmacologic agents may be warranted when symptoms are dangerous and/or severely distressing.
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Affiliation(s)
- William James Deardorff
- Department of Psychiatry and Behavioral Neuroscience, St. Louis University School of Medicine, St Louis, MO, United States
| | - George T Grossberg
- Department of Psychiatry and Behavioral Neuroscience, St. Louis University School of Medicine, St Louis, MO, United States.
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