The management of other psychiatric states. Hallucinations, delusions, and other disturbances

Assessment and management of behavioral disturbances in nursing home patients with dementia

Behavioral disturbances among nursing home patients with dementia are common and substantially affect patients and caregivers. Assessing the environmental, medical, and psychiatric causes of problematic behaviors and implementing a plan of behavioral, medical, and psychiatric management can reduce difficult target behaviors. This article presents a multifaceted approach to assessing patients with dementia who have behavioral problems, reviews medical and pharmacological management of these problems, and presents a multidisciplinary approach to developing treatment plans aimed at reducing such behaviors among nursing home patients with dementia.

Assessing the impact of neuropsychiatric symptoms in Alzheimer's disease: the Neuropsychiatric Inventory Caregiver Distress Scale

OBJECTIVES

To develop an adjunct scale to the Neuropsychiatric Inventory (NPI) for assessing the impact of neuropsychiatric symptoms in Alzheimer's disease (AD) patients on caregiver distress.

DESIGN

Cross-sectional descriptive and correlational study.

SETTING

University out-patient memory disorders clinics.

PARTICIPANTS

Eighty-five AD subjects and their caregivers (54 spouses, 31 children).

MEASUREMENTS

The NPI and NPI Caregiver Distress Scale (NPI-D) were used to assess neuropsychiatric symptoms in AD patients and related caregiver distress, respectively. Criterion validity of the NPI-D was examined (N = 69) by comparison with an abridged version of the Relatives' Stress Scale (RSS'), a general measure of caregiver stress, using item clusters that had previously been correlated to behavioral disturbances in demented patients. Test-retest (n = 20) and inter-rater reliability (n = 16) of the NPI-D were also assessed.

RESULTS

Test-retest and interrater reliability of the NPI-D were both adequate. Overall, caregiver NPI-D distress ratings were correlated significantly with the RSS' (r = .60, P < .001). RSS' ratings correlated strongly with NPI scores (r = .64, P < .001), even after controlling for degree of cognitive impairment based on the Mini-Mental State Exam (MMSE) score (r = .61). MMSE scores showed a moderate correlation to RSS' ratings (-.30, P = .02), but this association was markedly attenuated when controlling for the degree of neuropsychiatric disturbance based on the NPI score (r = -. 14). NPI-D ratings for 9 of 10 NPI symptom domains correlated most strongly with either NPI symptom severity or total (frequency x severity) scores. Agitation, dysphoria, irritability, delusions, and apathy were the symptoms most often reported to be severely distressing to caregivers.

CONCLUSIONS

The NPI-D provides a reliable and valid measure of subjective caregiver distress in relation to neuropsychiatric symptoms measured by the NPI. Neuropsychiatric alterations are more strongly associated than cognitive symptoms to caregiver distress. The NPI-D may be useful in both clinical and research settings for assessing the contribution to caregiver distress of neuropsychiatric symptoms in AD patients.

The clinical epidemiology of Alzheimer's disease

Alzheimer's disease is a more common and malignant illness than was appreciated just 2 decades ago. In addition to being a major cause of mortality, it is costly and uniquely distressing for patients and their families. All indications are that the problem will grow as elderly populations expand. Fatalism regarding AD is premature, however. Much has been learned about this disease in only a few years, and it is hoped that this rate of discovery can be maintained or even accelerated in the future.

Management of dementia-related behavioral disturbances: a nonpharmacologic approach

OBJECTIVE

To describe practical nonpharmacologic approaches to dementia-related behavioral problems for enhancement of the function and care of elderly patients with dementia.

DESIGN

We reviewed the pertinent medical literature and summarized strategies and available resources for management of geriatric patients with dementia and behavior problems.

RESULTS

For optimal care of older patients with dementia, key concepts of related behavior problems must be understood. Agitation and aggression, resisting help with care, wandering, incontinence, sleep disturbance, and emotional lability can become difficult management issues with such patients. In some patients, these disruptions can lead to overmedication and nursing home placement. Herein, practical nonpharmacologic measures for management of behavior problems that arise among community-dwelling and institutionalized elderly patients with dementia are discussed. Attention is directed to the medical, psychologic, environmental, and social factors that may contribute to unwanted behaviors.

CONCLUSION

Nonpharmacologic approaches can help ameliorate behavioral problems and assist in the overall care of elderly patients with dementia.