The Present Behavioural Examination (PBE): the development of an interview to measure current behavioural abnormalities

Assessing behavioral and psychological symptoms of dementia: a comprehensive review of current options and future perspectives

The behavioral and psychological symptoms of dementia (BPSD) are a heterogeneous set of challenging disturbances of behavior, mood, perception, and thought that occur in almost all patients with dementia. A huge number of instruments have been developed to assess BPSD in different populations and settings. Although some of these tools are more widely used than others, no single instrument can be considered completely satisfactory, and each of these tools has its advantages and disadvantages. In this narrative review, we have provided a comprehensive overview of the characteristics of a large number of such instruments, addressing their applicability, strengths, and limitations. These depend on the setting, the expertise required, and the people involved, and all these factors need to be taken into account when choosing the most suitable scale or tool. We have also briefly discussed the use of objective biomarkers of BPSD. Finally, we have attempted to provide indications for future research in the field and suggest the ideal characteristics of a possible new tool, which should be short, easy to understand and use, and treatment oriented, providing clinicians with data such as frequency, severity, and triggers of behaviors and enabling them to find appropriate strategies to effectively tackle BPSD.

Repetitive Behaviors in Alzheimer's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Repetitive behaviors (RBs) are a well-known symptom of Alzheimer's disease (AD); however, they have been little studied and have not been the subject of any specific literature review.

OBJECTIVE

To conduct a systematic review of all studies to document RBs in AD.

METHODS

An extensive literature search combining five databases and a meta-analysis were conducted to investigate the frequency, nature, and cognitive correlates of RBs in AD.

RESULTS

Ten studies were included in the review. Seven studies out of ten investigated the frequency of RBs in patients with AD, which ranged from 52.3% to 87%. A meta-analysis showed an overall frequency of 66.3% (95% CI: 55.5; 77.1) of patients exhibiting RBs in AD, but important heterogeneity was observed between studies. Three studies investigated the predominant nature of RBs in AD. Verbal RBs, complex behavioral stereotypies, and simple motor stereotypies have been identified to different degrees depending on the level of dementia. Most verbal RBs are underpinned by episodic memory impairment, while simple motor stereotypies and complex behavioral stereotypies are mostly underpinned by executive dysfunction.

CONCLUSIONS

The current review seems to suggest that there are two types of mechanisms underpinning RBs involved in AD. The first is observed especially in the mild stages of the disease and is mediated by episodic memory impairment. The second occurs later and is mediated by executive impairment. Additional studies should be conducted to improve the knowledge about RBs in AD and thus improve their management.Systematic review registration number: PROSPERO 2022: CRD42022310027.

Instruments to Assess Social Functioning in Individuals with Dementia: A Systematic Review

BACKGROUND

Social functioning is an important parameter for the early detection and diagnosis of dementia, as well as the description of its course and the assessment of intervention effects. Therefore, valid and reliable instruments to measure social functioning in individuals with dementia are needed.

OBJECTIVE

We aimed to provide an overview of such instruments including information on feasibility and psychometric properties.

METHODS

The review is informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant literature was identified using a pre-specified search string in the databases MEDLINE, PsycINFO, and Web of Science. Information on the characteristics, feasibility, and psychometric properties of the identified instruments were extracted, summarized, and discussed.

RESULTS

Out of 5,307 articles, 8 were selected to be included in the study, describing a total of three instruments for measuring social functioning in individuals with dementia: the Nurses' Observation Scale for Geriatric Patients (NOSGER; dimension "social behavior"), the Socioemotional Dysfunction Scale (SDS), and the Social Functioning in Dementia Scale (SF-DEM). The validity of all the three instruments was overall acceptable. Reliability was high for the NOSGER scale "social behavior" and the SF-DEM. Information on the usability of the instruments tended to be scarce.

CONCLUSION

There are a few valid and reliable instruments to assess social functioning in individuals with dementia. Further considerations could comprise their feasibility with regard to measuring changes in social functioning over time, in additional target groups, e.g., different types and stages of dementia, and adaptions to different languages and cultural backgrounds.

Determinants of behavioral and psychological symptoms of dementia: A scoping review of the evidence

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are prevalent in people with neurodegenerative diseases.

PURPOSE

In this scoping review the Kales, Gitlin and Lykestos framework is used to answer the question: What high quality evidence exists for the patient, caregiver and environmental determinants of five specific BPSD: aggression, agitation, apathy, depression and psychosis?

METHOD

An a priori review protocol was developed; 692 of 6013 articles retrieved in the search were deemed eligible for review. Gough's Weight of Evidence Framework and the Cochrane Collaboration's tool for assessing risk of bias were used. The findings from 56 high quality/low bias articles are summarized.

DISCUSSION

Each symptom had its own set of determinants, but many were common across several symptoms: neurodegeneration, type of dementia, severity of cognitive impairments, and declining functional abilities, and to a lesser extent, caregiver burden and communication.

CONCLUSION

Research and policy implications are relevant to the National Plan to Address Alzheimer's Disease.

Longitudinal course of behavioural and psychological symptoms of dementia: systematic review

BACKGROUND

More information about the pattern of behavioural and psychological symptoms of dementia (BPSD) in the course of dementia is needed to inform patients and clinicians and to design future interventions.

AIMS

To determine the persistence and incidence of BPSD and their relation to cognitive function, in individuals with dementia or in cohorts investigated for dementia onset.

METHOD

A systematic literature review analysed the baseline prevalence, persistence and incidence of 11 symptoms. The review was conducted according to established guidelines with the exception that we could not exclude the possibilities of bias in the studies examined.

RESULTS

The 59 included studies showed considerable heterogeneity in their objectives and methods. The symptoms hyperactivity and apathy showed high persistence and incidence; depression and anxiety low or moderate persistence and moderate incidence; and psychotic symptoms low persistence with moderate or low incidence.

CONCLUSIONS

Despite heterogeneity across studies in terms of setting, focus and length of follow-up, there were clinically relevant differences in the longitudinal courses of different BPSD. Apathy was the only symptom with high baseline prevalence, persistence and incidence during the course of dementia.

Supporting people with dementia to walkabout safely outdoors: development of a structured model of assessment

People with dementia while missing are at risk of harm including death. Yet, welfare concerns arise when freedom to walkabout outdoors is restricted and in particular, getting lost is a risk factor for admission to long-term care. Accurate methods of assessing the risks posed to community-dwelling people with dementia from getting lost are needed to ensure intervention is proportionate. Currently available assessment tools focus upon the identification of dementia-related changes in a person's walking behaviour, traditionally referred to as 'wandering'. 'Wandering' and getting lost are conceptually distinct; measures of 'wandering' are not sufficient to support the assessment of risk while walking outdoors. The objective of this study was to develop an assessment schedule that can evaluate safety in community-dwelling people with dementia who walkabout outdoors. A structured assessment schedule was generated from research on the aetiology of getting lost, a review of existing assessment tools, an observational study of incidents of getting lost and qualitative data from families experiencing this issue. A content validity study was then undertaken with a panel of 17 health and social care practitioners and researchers in the field. A schedule of 7 domains and 38 items was generated, 33 of which were deemed valid by the expert panel. Panel feedback suggests the schedule needs to be used flexibly to reflect an individual's unique living circumstances. Reflecting the complex aetiology of getting lost, considerable challenges exist when assessing risk in this field. The implications of this study for practitioners are discussed with reference to the merits of narrative and structured models of assessment, and the balance between objective safety and subjective well-being that is required when making decisions about intervention. The direction of further research is examined as a means of supporting professional assessment of this complex issue.

Altered relaxin family receptors RXFP1 and RXFP3 in the neocortex of depressed Alzheimer's disease patients

RATIONALE

The G-protein-coupled relaxin family receptors RXFP1 and RXFP3 are widely expressed in the cortex and are involved in stress responses and memory and emotional processing. However, the identification of these receptors in human cortex and their status in Alzheimer's disease (AD), which is characterized by both cognitive impairments and neuropsychiatric behaviours, have not been reported.

OBJECTIVES

In this study, we characterized RXFP receptors for immunoblotting and measured RXFP1 and RXFP3 immunoreactivities in the postmortem neocortex of AD patients longitudinally assessed for depressive symptoms.

METHODS

RXFP1 and RXFP3 antibodies were characterized by immunoblotting with lysates from transfected HEK cells and preadsorption with RXFP3 peptides. Also, postmortem neocortical tissues from behaviourally assessed AD and age-matched controls were processed for immunoblotting with RXFP1 and RXFP3 antibodies.

RESULTS

Compared to controls, putative RXFP1 immunoreactivity was reduced in parietal cortex of non-depressed AD patients but unchanged in depressed patients. Furthermore, putative RXFP3 immunoreactivity was increased only in depressed AD patients. RXFP1 levels in the parietal cortex also correlated with severity of depression symptoms. In contrast, RXFP1 and RXFP3 levels did not correlate with dementia severity or β-amyloid burden.

CONCLUSION

Alterations of RXFP1 and RXFP3 may be neurochemical markers of depression in AD, and relaxin family receptors warrant further preclinical investigations as possible therapeutic targets for neuropsychiatric symptoms in dementia.

Neuropsychiatric symptoms in Alzheimer's disease: What might be associated brain circuits?

Neuropsychiatric symptoms (NPS) are very common in Alzheimer's disease (AD), particularly agitation, apathy, depression, and delusions. Brain networks or circuits underlying these symptoms are just starting to be understood, and there is a growing imaging and neurochemical evidence base for understanding potential mechanisms for NPS. We offer a synthetic review of the recent literature and offer hypotheses for potential networks/circuits underlying these NPS, particularly agitation, apathy, and delusions. Agitation in AD appears to be associated with deficits in structure and function of frontal cortex, anterior cingulate cortex, posterior cingulate cortex, amygdala, and hippocampus, and may be associated with mechanisms underlying misinterpretation of threats and affective regulation. Apathy in AD is associated with frontal cortex, anterior cingulate cortex, posterior cingulate cortex, as well as orbitofrontal cortex, and inferior temporal cortex, and may be associated with mechanisms underlying avoidance behaviors.

CB2 receptor and amyloid pathology in frontal cortex of Alzheimer's disease patients

The cannabinoid system seems to play an important role in various neurodegenerative diseases including Alzheimer's disease (AD). The relationship of cannabinoid receptors (CB(1)R and CB(2)R) to cognitive function and neuropathological markers in AD remains unclear. In the present study, postmortem cortical brain tissues (Brodmann area 10) from a cohort of neuropathologically confirmed AD patients and age-matched controls were used to measure CB(1)R and CB(2)R by immunoblotting. Correlational analyses were performed for the neurochemical and cognitive data. CB(1)R expression was significantly decreased in AD. Levels of CB(1)R correlated with hypophagia, but not with any AD molecular marker or cognitive status (Mini Mental State Examination score). The level of CB(2)R was significantly higher (40%) in AD. Increases in the expression of the glial marker glial fibrillar acidic protein were also found. CB(2)R expression did not correlate with cognitive status. Interestingly, expression levels of CB(2)R correlated with two relevant AD molecular markers, Aβ(42) levels and senile plaque score. These results may constitute the basis of CB(2)R-based therapies and/or diagnostic approaches.

Tau phosphorylation in human brain: relationship to behavioral disturbance in dementia

Agitation and aggressive behavior are common symptoms of Alzheimer's disease (AD), and tangle density in frontal cortex is a possible regional substrate of these behaviors. To investigate this further, 16 AD patients, 8 patients with non-AD dementia, and 13 age-matched control subjects for frontal cortex and, respectively, 21, 7, and 6 patients for parietal cortex were analyzed for tau and phospho-tau by enzyme-linked immunosorbent assay (ELISA). Agitation/aggression was determined by the Present Behavioural Examination. In a subset of cases, glycogen synthase kinase-3β (GSK-3β) phosphorylation and protein phosphatase 2A (PP2A) expression were measured. Phospho-tau and the phospho-tau/total tau ratio were elevated in AD in both cortical regions. In keeping with our hypothesis, the phospho-tau/total tau ratio was elevated in the frontal cortex of those patients with agitation/aggression during life, and there was a significant correlation (p = 0.024) between these behaviors and the phospho-tau/total tau ratio in the cortex. PP2A expression was lower (p < 0.01) in the frontal cortex of patients with high tau phosphorylation. This study confirms a link between tau phosphorylation and agitation/aggression and suggests that reducing tau phosphorylation may provide symptomatic relief.

Differential involvement of hippocampal serotonin1A receptors and re-uptake sites in non-cognitive behaviors of Alzheimer's disease

RATIONALE

Previous studies have shown extensive serotonergic deficits in the hippocampus of Alzheimer's disease (AD) patients. However, it is unclear whether such deficits play a role in non-cognitive, neuropsychiatric behaviors that occur frequently in AD and cause significant caregiver distress.

OBJECTIVES

In this study, we aimed to correlate serotonergic markers in the AD hippocampus with neuropsychiatric behaviors.

METHODS

Using postmortem hippocampal homogenates from aged controls as well as a cohort of longitudinally assessed AD patients, measurements of 5-HT(1A) receptors, 5-HT(2A) receptors, and serotonin re-uptake (5-HTT) sites were performed by binding with (3)H-labeled 8-OH-DPAT, ketanserin, and citalopram, respectively.

RESULTS

Alterations of 5-HT(1A) receptors and 5-HTT were found to be differentially involved in neuropsychiatric behaviors, with loss of 5-HT(1A) receptors specifically correlated with depressive symptoms, while 5-HTT sites were preserved or up-regulated in patients with aggressive behaviors.

CONCLUSIONS

Our data suggest that neuropsychiatric behaviors in AD share certain neurochemical features with psychiatric disorders like major depression and that serotonergic drugs used in psychiatric disorders may also be efficacious against behavioral symptoms in AD.

Pacing and lapping movements among institutionalized patients with dementia

Wandering is a complex behavior, and defining wandering has been challenging. The current study used the integrated circuit (IC) tag monitoring system to describe the distance moved per day and the spatial movements of patients with dementia. The study was conducted in a 60-bed semiacute dementia care unit in a general hospital in Japan over a 3-month period in 2006. The distance moved per day, the numbers of pacing and lapping movements, and the proportions of the distance moved that was paced or lapped were tabulated in 23 patients diagnosed with dementia. The distance moved per day and the numbers of pacing and lapping movements varied greatly within and among study participants. The median distance moved per day was inversely correlated with participants' age and Mini-Mental State Examination (MMSE) scores (adjusted r(2) = .34, P = .01). Consecutive lapping and pacing movements were rare patients with in Alzheimer's disease (AD), while 2 patients with frontotemporal dementia paced or lapped repeatedly.

A serotoninergic basis for hyperphagic eating changes in Alzheimer's disease

Hyperphagia and associated eating changes occur frequently in Alzheimer's disease (AD) and lead to considerable morbidity. However, the neurochemical basis for these neuropsychiatric behaviours is at present unclear. In this study, we measured serotonin transporters, 5-HT(1A), 5-HT(2A), and 5-HT(4) receptors using radioligand binding assays in the postmortem temporal cortex of a cohort of controls and AD patients longitudinally assessed for hyperphagia. We found significant decreases in 5-HT(4) receptor densities in the hyperphagic, but not normophagic, AD group. Our data suggest that 5-HT(4) receptor deficits may be a specific neurochemical correlate of hyperphagia, and point to the potential pharmacotherapeutic utility of 5-HT(4) agonists for these behaviours in AD.

A framework for managing wandering and preventing elopement

PURPOSE OF THE STUDY

A framework aids choice of interventions to manage wandering and prevent elopement in consideration of associated risks and mobility needs of wanderers.

DESIGN AND METHODS

A literature review, together with research results, published wandering tools, clinical reports, author clinical experience, and consensus-based judgments was used to build a decision-making framework.

RESULTS

Referencing a published definition of wandering and originating a clinical description of problematic wandering, authors introduce a framework comprising (1) wandering and related behaviors; (2) goals of wandering-specific care, (3) interpersonally, technologically, and policy-mediated wandering interventions, and (4) estimates of relative frequencies of wandering behaviors, magnitudes of elopement risk, and restrictiveness of strategies.

IMPLICATIONS

Safeguarding wanderers from elopement risk is rendered person-centered and humane when goals of care guide intervention choice. Despite limitations, a reasoned, systematized approach to wandering management provides a basis for tailoring a specialized program of care. The need for framework refinement and related research is emphasized.

Anxiety in dementia: a critical review

Until recently, little attention has been paid to anxiety symptoms in dementia. However, anxiety is common in this population, and associated with poor outcome and quality of life. The current review examines the existing literature around three major themes: the definition of anxiety in dementia, the properties of available instruments for assessment, and the clinical characteristics of anxiety in this population. Defining anxiety in individuals with dementia is complicated by the overlap between symptoms of anxiety, depression and dementia, and by the influence of the source of information. Several instruments are available to assess anxiety in this population, including general neuropsychiatric instruments and two scales designed specifically for this purpose. The reliability of these instruments is acceptable, but their validity has not been sufficiently examined, and they may discriminate poorly between anxiety and depression. Anxiety may be higher in vascular dementia than in Alzheimer's Disease, and it decreases in the severe stages of dementia. It is associated with poor quality of life and behavioral disturbances, even after controlling for depression. Little is known, however, about its social and environmental correlates. Limitations of the existing literature and key directions for future research are discussed.

Loss of [3H]4-DAMP binding to muscarinic receptors in the orbitofrontal cortex of Alzheimer's disease patients with psychosis

RATIONALE

Neuropsychiatric behaviours in Alzheimer's disease (AD) patients have been associated with neocortical alterations of presynaptic cholinergic and muscarinic M2 receptor markers. In contrast, it is unclear whether non-M2 muscarinic receptors have a role to play in AD behavioural symptoms.

OBJECTIVES

To correlate the alterations of neocortical postsynaptic muscarinic receptors with clinical features of AD.

MATERIALS AND METHODS

[(3)H]4-DAMP were used in binding assays with lysates of Chinese hamster ovary (CHO) cells stably transfected with M1-M5 receptors. [(3)H]4-DAMP was further used to measure muscarinic receptors in the postmortem orbitofrontal cortex of aged controls and AD patients longitudinally assessed for cognitive decline and behavioural symptoms.

RESULTS

[(3)H]4-DAMP binds to human postmortem brain homogenates and M1-, M3-, M4- and M5-transfected CHO lysates with subnanomolar affinity. Compared to the controls, the [(3)H]4-DAMP binding density is reduced only in AD patients with significant psychotic symptoms. The association between reduced [(3)H]4-DAMP binding and psychosis is independent of the effects of dementia severity or neurofibrillary tangle burden.

CONCLUSIONS

This study suggests that the loss of non-M2 muscarinic receptors in the orbitofrontal cortex may be a neurochemical substrate of psychosis in AD and provides a rationale for further development of muscarinic receptor ligands in AD pharmacotherapy.

Aggressive behavior and neuroleptic medication are associated with increased number of alpha1-adrenoceptors in patients with Alzheimer disease

OBJECTIVE

Aggressive behavior in dementia is a major clinical management problem.

METHOD

Postmortem brain tissue was obtained from 24 patients with Alzheimer disease (AD) and 25 comparison cases. [3H] Prazosin binding to alpha1-AdR was determined.

RESULTS

Aggressive behavior was significantly correlated with alpha1-adrenoceptor number in patients with AD (R(s)=0.454, N=24). Furthermore, patients receiving ongoing neuroleptics had significantly higher Bmax for [3H] prazosin (21 +/- 2, N=9) than those who were not (16 +/- 1, N=15).

CONCLUSIONS

Upregulation of alpha1-AdR is associated with aggressive behavior and chronic treatment with neuroleptic medication.

Feasibility study of the integrated circuit tag monitoring system for dementia residents in Japan

Videotaping, direct observation, and biomechanical devices have been used to measure the wandering behavior of institutionalized people with dementia and to identify patterns of movement. Owing to technical limitations, the variability in movement patterns or the distance traveled could not be examined. The present study examined the feasibility of an integrated circuit tag monitoring system to monitor the movement patterns of Japanese dementia residents. This system generated the following data: the frequency of detection by each receiver, the duration of stay in each location, the cumulative distance walked per day, and the graphic display of the movement pattern. This new system offers objective measurements of ambulation in time and space, which can be used to characterize demented patients and to evaluate the effects of treatment and care.

Down-regulation of vesicular glutamate transporters precedes cell loss and pathology in Alzheimer's disease

Alzheimer's disease (AD) is characterized pathologically by plaques, tangles, and cell and synapse loss. As glutamate is the principle excitatory neurotransmitter of the CNS, the glutamatergic system may play an important role in AD. An essential step in glutamate neurotransmission is the concentration of glutamate into synaptic vesicles before release from the presynaptic terminal. Recently a group of proteins responsible for uptake has been identified - the vesicular glutamate transporters (VGLUTs). The generation of antibodies has facilitated the study of glutamatergic neurones. Here, we used antibodies to the VGLUTs together with immunohistochemistry and western blotting to investigate the status of glutamatergic neurones in temporal, parietal and occipital cortices of patients with AD; these regions were chosen to represent severely, moderately and mildly affected regions at the end stage of the disease. There was no change in expression of the synaptic markers in relation to total protein in the temporal cortex, but a significant reduction in synaptophysin and VGLUT1 was found in both the parietal and occipital cortices. These changes were found to relate to the number of tangles in the temporal cortex. There were no correlations with either mental test score or behaviour syndromes, with the exception of depression.

Involvement of the GABAergic system in depressive symptoms of Alzheimer's disease

Cognitive and neuropsychiatric (BPSD) symptoms seen in Alzheimer's disease (AD) probably result from differential neurotransmitter alterations. The involvement of the glutamatergic and GABAergic system in cognitive and behavioral and psychological symptoms of dementia (BPSD) has been studied in post-mortem frontal and temporal cortex from AD patients who had been prospectively assessed with the Mini-Mental State Examination (MMSE) for cognitive impairment and with the Present Behavioral Examination (PBE) for BPSD. In addition to cholinergic deficits, significant decreases in gamma-amino butyric acid (GABA) content, with no changes in glutamate content, were found in frontal and temporal cortex. Both GABA levels and the glutamate/GABA ratio showed significant correlations with depression in AD. In the temporal cortex, higher densities of GABA(A)/benzodiazepine receptors also correlated with more severe depression. It can be suggested that in a situation of cholinergic deficit, such as AD, an imbalance between the excitatory glutamatergic tone and inhibitory GABAergic tone may be responsible for non-cognitive behavioral disturbances.

Cyclin-dependent kinase 5, Munc18a and Munc18-interacting protein 1/X11α protein up-regulation in Alzheimer’s disease

Besides formation of neurofibrillary tangles and neuron loss, the Alzheimer's disease brain is characterized by neuritic plaques consisting of beta-amyloid peptide deposits and impaired neurotransmission. The proteins Munc18a, Munc18-interacting protein 1 and Munc18-interacting protein 2 mediate exocytosis and decrease beta-amyloid peptide formation. Cyclin-dependent kinase 5 and its activator p35 disrupt Munc18a-syntaxin 1 binding, thereby promoting synaptic vesicle fusion during exocytosis. We investigated protein levels of the signaling pathway: p35, cyclin-dependent kinase 5, Munc18a, syntaxin 1A and 1B, Munc18-interacting protein 1 and Munc18-interacting protein 2 in Alzheimer's disease cortex and found that this pathway was up-regulated in the Alzheimer's disease parietal and occipital cortex. In the cortex of transgenic Tg2576 mice over-expressing human beta-amyloid precursor protein with the Swedish mutation known to lead to familial Alzheimer's disease, which have substantial levels of beta-amyloid peptide but lack neurofibrillary tangles and neuron loss, no alterations of protein levels were detected. These data suggest that the pathway is enhanced in dying or surviving neurons and might serve a protective role by compensating for decreased neurotransmission and decreasing beta-amyloid peptide levels early during the progression of Alzheimer's disease.

Repetitive behaviour in Alzheimer's disease: description, correlates and functions

BACKGROUND

Repetitive behaviour is among the most common and burdensome of the behavioural and psychological symptoms of Alzheimer's disease (AD), yet little research has been done to investigate its nature or correlates. Memory impairment may account for repetitive questioning, but its possible role in other repetitive behaviours is unclear. Attention and executive dysfunction may account for both repetitive speech and actions. The role of mood also merits investigation.

OBJECTIVES

To investigate cognitive and affective differences between patients with and without repetitive behaviours, and to identify themes and carer attributions for the function of such behaviours.

METHODS

Fifty-four participants aged > or = 65, meeting NINCDS-ADRDA criteria for probable AD, were assessed using the MMSE, WMS-III word list, Trailmaking test, Stroop, Modified WCST, Cornell Scale for Depression, DEX and a repetitive behaviour questionnaire. Regression analyses were used to identify significant predictors of repetitive behaviour.

RESULTS

Repetitive behaviours were manifest in 87% of the sample, with questions (68.5%) and statements/stories (61.1%) the most common types. Repetitive questions were predicted by high MMSE score (p = 0.013), low immediate list recall score (p = 0.013) and female gender (p = 0.004). Repetitive statements/stories were predicted by dysexecutiveness (p = 0.003) and younger age (p = 0.016). Repetitive actions were predicted by longer illness duration (p = 0.041), depressive symptoms (p = 0.035) and dysexecutiveness (p < 0.001). Themes and patterns were evident in repetitive behaviour.

CONCLUSIONS

Repetitive behaviours were common in a sample of patients with AD referred to hospital clinics. Vocal and motor repetitive behaviours were predicted by different cognitive, demographic and mood variables.

Loss of serotonin 5-HT2A receptors in the postmortem temporal cortex correlates with rate of cognitive decline in Alzheimer's disease

RATIONALE

Previous studies have demonstrated reductions of serotonin 5-HT 2A receptors in the neocortex of Alzheimer's disease (AD) patients. However, it is unclear whether such losses play a role in the cognitive decline of AD.

OBJECTIVES

To correlate neocortical 5-HT 2A receptor alterations with cognitive decline in AD.

METHODS

Postmortem frontal and temporal cortical 5-HT 2A receptors were measured by [3H]ketanserin binding in aged controls as well as in a cohort of AD patients who had been longitudinally assessed for cognitive decline and behavioral symptoms.

RESULTS

5-HT 2A receptor densities in both regions were reduced in severely demented AD patients compared to age-matched controls. In the temporal cortex, this reduction also correlated with the rate of decline of Mini-Mental State Examination (MMSE) scores. The association between 5-HT 2A receptor loss and cognitive decline was independent of the effects of choline acetyltransferase (ChAT) activity and presence of behavioral symptoms.

CONCLUSIONS

Our data suggest that loss of neocortical 5-HT 2A receptors may predict for faster cognitive decline in AD, and point to serotomimetics as potentially useful adjuvants to cholinergic replacement therapies.

Cholinergic-serotonergic imbalance contributes to cognitive and behavioral symptoms in Alzheimer's disease

Neuropsychiatric symptoms seen in Alzheimer's disease (AD) are not simply a consequence of neurodegeneration, but probably result from differential neurotransmitter alterations, which some patients are more at risk of than others. Therefore, the hypothesis of this study is that an imbalance between the cholinergic and serotonergic systems is related to cognitive symptoms and psychological syndromes of dementia (BPSD) in patients with AD. Cholinergic and serotonergic functions were assessed in post-mortem frontal and temporal cortex from 22 AD patients who had been prospectively assessed with the Mini-Mental State examination (MMSE) for cognitive impairment and with the Present Behavioral Examination (PBE) for BPSD including aggressive behavior, overactivity, depression and psychosis. Not only cholinergic deficits, but also the cholinacetyltransferase/serotonin ratio significantly correlated with final MMSE score both in frontal and temporal cortex. In addition, decreases in cholinergic function correlated with the aggressive behavior factor, supporting a dual role for the cholinergic system in cognitive and non-cognitive disturbances associated to AD. The serotonergic system showed a significant correlation with overactivity and psychosis. The ratio of serotonin to acetylcholinesterase levels was also correlated with the psychotic factor at least in women. It is concluded that an imbalance between cholinergic-serotonergic systems may be responsible for the cognitive impairment associated to AD. Moreover, the major findings of this study are the relationships between neurochemical markers of both cholinergic and serotonergic systems and non-cognitive behavioral disturbances in patients with dementia.

Validation of the Algase Wandering Scale (Version 2) in a cross cultural sample

This study examined the psychometric properties of an expanded version of the Algase Wandering Scale (Version 2) (AWS-V2) in a cross-cultural sample. A cross-sectional survey design was used. Study subjects were 172 English-speaking persons with dementia (PWD) from long-term care facilities in the USA, Canada, and Australia. Two or more facility staff rated each subject on the AWS-V2. Demographic and cognitive data (MMSE) were also obtained. Staff provided information on their own knowledge of the subject and of dementia. Separate factor analyses on data from two samples of raters each explained greater than 66% of the variance in AWS-V2 scores and validated four (persistent walking, navigational deficit, eloping behavior, and shadowing) of five factors in the original scale. Items added to create the AWS-V2 strengthened the shadowing subscale, failed to improve the routinized walking subscale, and added a factor, attention shifting as compared to the original AWS. Evidence for validity was found in significant correlations and ANOVAs between the AWS-V2 and most subscales with a single item indicator of wandering and with the MMSE. Evidence of reliability was shown by internal consistency of the AWS-V2 (0.87, 0.88) and its subscales (range 0.88 to 0.66), with Kappa for individual items (17 of 27 greater than 0.4), and ANOVAs comparing ratings across rater groups (nurses, nurse aids, and other staff). Analyses support validity and reliability of the AWS-V2 overall and for persistent walking, spatial disorientation, and eloping behavior subscales. The AWS-V2 and its subscales are an appropriate way to measure wandering as conceptualized within the Need-driven Dementia-compromised Behavior Model in studies of English-speaking subjects. Suggestions for further strengthening the scale and for extending its use to clinical applications are described.

Differential involvement of 5-HT(1B/1D) and 5-HT6 receptors in cognitive and non-cognitive symptoms in Alzheimer's disease

Growing evidence suggests that a compromised serotonergic system plays an important role in the pathophysiology of Alzheimer's disease (AD). We assessed the expression of 5-HT(1B/1D) and 5-HT(6) receptors and cholinacetyltransferase (ChAT) activity in post-mortem frontal and temporal cortex from AD patients who had been prospectively assessed for cognitive function using the Mini-Mental State Examination (MMSE) and behavioral changes using the Present Behavioral Examination (PBE). 5-HT(1B/1D) and 5-HT(6) receptor densities were significantly reduced in both cortical areas. 5-HT(1B/1D) receptor density was correlated to MMSE decline in the frontal cortex, supporting its implication in memory impairment. The best predictor for lowered 5-HT(6) receptor density in the temporal cortex was the PBE measure of overactivity. The 5-HT(6)/ChAT ratio was related to aggression both in the frontal and temporal cortex. Therefore, antagonists acting at 5-HT(6) receptors could be useful in the treatment of non-cognitive symptoms associated to AD.

Delusions and hallucinations in Alzheimer's disease: review of the brain decade

The authors reviewed studies published from 1990 to 2001 that address the epidemiology, phenomenology, course, etiology, assessment, and treatment of delusions and hallucinations in Alzheimer's disease. The prevalence of delusions in Alzheimer's disease patients ranged from 16% to 70% (median=36.5%) in the reviewed reports, and the prevalence of hallucinations ranged from 4% to 76% (median=23%). Delusions and hallucinations tended to persist over time, tended to recur often during the course of Alzheimer's disease, and were associated with sociodemographic and clinical correlates that differed from one study to another and with substantial consequences such as functional impairment and aggression. Psychosocial methods and both typical and atypical antipsychotics are effective in the treatment of delusions and hallucinations in Alzheimer's disease.

Reduced serotonin 5-HT1A receptor binding in the temporal cortex correlates with aggressive behavior in Alzheimer disease

Previous studies have implicated brain serotonin 5-HT(1A) receptors in several CNS functions, including cognition, mood and emotional states. In Alzheimer disease (AD), cognitive impairment and behavioral symptoms are the main clinical features. However, the biochemical basis of such changes is poorly understood. Results from recent in vivo studies suggest that 5-HT(1A) receptors may be related to aggressive traits in healthy subjects. The present study investigated the state of 5-HT(1A) receptors in the postmortem neocortex of 33 AD patients prospectively assessed for cognition and behavioral symptoms, together with 20 matched controls, by saturation [(3)H]8-OH-DPAT binding assays. 5-HT(1A) receptor binding affinity (K(D)) and density (B(max)) were unchanged in the overall AD group compared with controls. Within the AD group, 5-HT(1A) receptor B(max) in the temporal cortex inversely correlated with aggression and dementia severity. However, multiple regression analyses showed that 5-HT(1A) receptor B(max) remained the best predictor for aggression, while temporal cortical neurofibrillary tangle grading was the best predictor for dementia severity. This suggests that 5-HT(1A) receptor alteration is directly related to aggression in AD, while dementia severity is more strongly related to the neurodegenerative process. Our data indicate further study of 5-HT(1A) receptors as a pharmacological target for the treatment of behavioral symptoms in AD.

Estimating the relationship between disease progression and cost of care in dementia

BACKGROUND

Previous studies have shown a positive relationship between disease severity and cost.

AIMS

To explore the factors affecting time to institutionalisation and estimate the relationship between the costs of care and disease progression.

METHOD

Retrospective analysis of a longitudinal data-set for a cohort of 100 patients diagnosed with Alzheimer's disease or vascular dementia.

RESULTS

Changes in both Mini-Mental State Examination (MMSE) and Barthel scores have independent and significant marginal effects on costs. Each one-point decline in the MMSE score is associated with a pound sterling 56 increase in the four-monthly costs, whereas each one-point fall in the Barthel index is associated with a pound sterling 586 increase in costs.

CONCLUSIONS

It may be inappropriate for economic models of disease progression in dementia to be based solely on measures of cognitive change. MMSE and the Barthel index are independent significant predictors of time to institutionalisation and cost of care, but changes in the Barthel index are particularly important in predicting costs outside institutional care.

Noradrenergic changes, aggressive behavior, and cognition in patients with dementia

BACKGROUND

We wished to examine the integrity of the noradrenergic system in patients with Alzheimer's disease, mixed/other dementias and controls, and possible relationships between changes in the noradrenergic system and the presence of behavioral and psychiatric signs and symptoms in dementia.

METHODS

Alpha(2) adrenoceptor sites were measured by radioligand binding in three cortical regions of 46 individuals with dementia and 33 elderly normal controls together with cortical noradrenaline concentration and locus coeruleus cell and neurofibrillary tangle counts.

RESULTS

The alpha(2) adrenergic receptor density was unaltered in patients with Alzheimer's disease, mixed/other dementias compared with controls; however, there was a loss of locus coeruleus cells in subjects with dementia, reaching 50% within the rostral nucleus. In addition, a significant reduction was seen in the midtemporal cortical noradrenaline concentration (31% decrease) in patients with Alzheimer's disease. In subjects with dementia, there was a positive correlation between aggressive behavior and magnitude of rostral locus coeruleus cell loss, while the reduction in noradrenaline concentration correlated with cognitive impairment.

CONCLUSIONS

Subgroups of patients with Alzheimer's disease may have different neurochemical changes from patients lacking these changes. Therefore, this study may have implications for the treatment of behavioral and psychiatric signs and symptoms in dementia, particularly aggressive behavior in patients with dementia.

Rating scales in old age psychiatry

BACKGROUND

There is a vast array of scales available to assess all aspects of mental and physical health in older people which may be of relevance to the work of old age psychiatrists.

AIMS

To summarise some of the scales that may be commonly used in clinical and research practice and to give the reader guidelines as to where further information can be obtained.

METHOD

The scales were selected on the basis of the authors' own clinical and research knowledge and information was gathered from a comprehensive text on assessment scales in old age psychiatry. Results The selected scales are described in brief and a table outlines the purposes for which they are most suitable.

CONCLUSIONS

Although many scales are available, the choice of the individual scale relies specifically on the question that is to be asked. The ideal scale does not exist.

Synaptic pathology in prefrontal cortex is present only with severe dementia in Alzheimer disease

Synaptic pathology is proposed to be integral to the clinical expression of Alzheimer disease (AD). Most studies have assessed only the vesicle protein synaptophysin as a measure of synaptic integrity. The interrelationships of synaptophysin, other presynaptic proteins, the cholinergic system, and severity of dementia in AD remain unclear. We studied the presynaptic proteins synaptophysin, syntaxin and SNAP-25, along with choline acetyltransferase (ChAT) activity in prefrontal cortex (BA 46) samples from 18 subjects with AD and 16 controls. Mean values of presynaptic protein immunoreactivities were significantly reduced, by 21%-28%, and ChAT activity was reduced by 41% in the AD groups. Synaptic protein immunoreactivity and ChAT activity were correlated with Mini-Mental State Examination scores obtained 1 yr prior to death. When AD cases were subgrouped into mild/moderate and severe illness at time of death, all differences in presynaptic proteins and ChAT activity were significant between controls and severe cases. However, no significant differences were detected in BA 46 between controls and mild/moderate cases. Considerable synaptic reserve or plasticity remains in BA 46 until the late stages of AD. Synaptophysin and ChAT appear to be more vulnerable in severe AD than are syntaxin or SNAP-25.

Death and dementia

OBJECTIVE

To investigate the last phase of dementia and the causes of death; comparing autopsy and death certificate diagnoses.

DESIGN

Prospective, 11-year, longitudinal study of behavioural and psychological changes in dementia, with autopsy follow-up.

SETTING

Participants with dementia, living at home with a carer. All lived in Oxfordshire, UK.

PARTICIPANTS

Ninety-one people with dementia (Alzheimer's disease and/or vascular dementia) who died during the course of the study.

MEASURES

At four-monthly intervals, carers were interviewed about the participants' behaviour using the Present Behavioural Examination. Participants were also assessed cognitively. Causes of death were established from death certificates and, where possible, from post-mortem examination.

RESULTS

The main immediate cause of death recorded at autopsy was pneumonia (57%), followed by cardiovascular disease (16%) and pulmonary embolus (14%). This agreed with the immediate cause of death on 53% of death certificates. Pulmonary embolism and bronchopneumonia were under-reported on death certificates. Dementia was mentioned on 73% of death certificates. The dementing illness lasted for a mean of 8.5 years with 58% dying in a debilitated state associated with severe dementia. In the period before death, 35% were unable to walk, 58% were hypophagic, 73% were incontinent of urine, 21% incontinent of faeces and 76% entered an institution permanently for a mean period of 18 months.

CONCLUSION

Family and professional carers of people with dementia can be given some information about prognosis to help them plan for the likely outcome of dementia.

Psychometric evaluation of a short observational tool for small-scale research projects in dementia

Dementia is a degenerating illness and the lack of a reliable measure of self-report in particular presents particular difficulties for research. Often in the later stages of dementia behavioural measurement is the only tool available for the evaluation of treatment techniques. This paper describes and evaluates a short observational tool suitable for clinical assessment purposes. The scale has been shown to have the potential for adequate inter-rater reliability, test retest reliability, and convergent and divergent validity, if the study limitations reflecting statistical rather than ecological validity, and limitations of sample size are borne in mind.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Immunocytochemical study of the dorsal and median raphe nuclei in patients with Alzheimer's disease prospectively assessed for behavioural changes

The dorsal and median raphe nuclei were examined with immunocytochemistry to display the 5-HT neurones in 16 cases of post-mortem-proven Alzheimer's disease (AD) and 12 age and sex-matched controls. The AD cases had been prospectively assessed during life for expression of behavioural changes as well as for cognitive decline. A significant (P < 0.001) 41% reduction in density of dorsal raphe neurones was found along with a significant (P < 0.02) 29% reduction in density of median raphe neurones in AD. There were significantly more neurofibrillary tangles in both dorsal and median raphe nuclei in AD than in controls (P < 0.001). There was no correlation between reduction in neurone density in these nuclei and behavioural change, cognitive decline, neurofibrillary tangle counts in these nuclei or plaque and tangle pathology in frontal and temporal cortex. It was concluded from these findings that the raphe nuclei are significantly affected by the pathology of AD and that plasticity in the 5-HT system is the probable reason for the lack of correlation of reduced 5-HT neurone density and clinical disease parameters.

Neuropsychiatric aspects of Alzheimer's disease

The increase in research studies focusing on neuropsychiatric symptoms over the last decade has greatly increased our knowledge base, particularly with regard to the frequency of these symptoms and their impact on both patients and carers. We still have a poor understanding of the natural course of these symptoms and their biologic correlates, however, and more specific treatment studies are needed to inform clinical management.

Natural history of aggressive behaviour in dementia

OBJECTIVE

This article analyses changes in aggressive behaviour throughout the course of dementia.

DESIGN

Prospective, 10 year, longitudinal study of aggressive behaviour in dementia, with autopsy follow-up.

SETTING

Subjects with dementia, living at home with a carer, Oxfordshire, UK.

PARTICIPANTS

Ninety-nine people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer.

MEASURES

At 4-monthly intervals, the carers were interviewed about the subjects and the subjects were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections monitoring behavioural and psychological change. Eight different aspects of aggressive behaviour were assessed in detail and comparison made with other relevant factors.

RESULTS

Verbal aggression is the most common and longest lasting form of aggressive behaviour. Aggressive resistance and physical aggression are most likely to persist until death. Intimate care is the main factor precipitating aggressive behaviour. There are no correlations between any type of aggressive behaviour and age, gender or time since onset of dementia.

CONCLUSIONS

Aggressive behaviour creates problems for carers. In general, the physical types of aggressive behaviour are most prevalent in people with more severe dementia.

Development and testing of the Resistiveness to Care Scale

A conceptual model and objective scale for measuring resistiveness to care in individuals with advanced dementia of the Alzheimer type (DAT) were empirically generated from the perspective of nursing staff caregivers and through observation of residents with DAT. The resistiveness to care scale (RTC-DAT) was judged to have content validity and reduced to 13 items. Quantifiable scoring procedures and methods for rating videotapes and conducting clinical observations were developed. The RTC-DAT was tested with 68 subjects at three sites. The RTC has a range of 0-156. Initial testing provided reliability estimates of .82-.87 for internal consistency and good to excellent kappas. Criterion-related validity with observed discomfort and construct validity by factor analysis support the RTC-DAT. Measurement issues and recommendations for use in research are discussed.

Natural history of behavioural changes and psychiatric symptoms in Alzheimer's disease. A longitudinal study

BACKGROUND

Alzheimer's disease and other types of dementia are characterised by numerous psychiatric and behavioural changes. Little is known of their natural history.

AIMS

To investigate the sequence and pattern of these changes throughout the course of dementia.

METHOD

One hundred people, initially living at home with carers, entered a prospective, longitudinal study. At four-monthly intervals, behavioural and psychiatric symptoms were assessed using the Present Behavioural Examination and Mini-Mental State Examination. Follow-up continued for up to nine years (mean 3.3 years; s.d. 2.4). Patterns of onset and disappearance of these symptoms, their sequence and association with time of death and cognitive decline were analysed. Autopsy confirmed a diagnosis of pure Alzheimer's disease in 48 subjects. Data for this subgroup are presented.

RESULTS

Some changes tend to occur earlier than others but changes can occur at almost any time in the course of dementia.

CONCLUSIONS

The natural history of behaviour changes in Alzheimer's disease shows great individual variation although some changes tend to follow a recognisable sequence.

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.