Sex differences in the prevalence of behavioral and psychological symptoms of dementia

The Moral and Gender Implications of Measures Used to Modulate the Mobility of People With Dementia Living in Residential Care Environments: A Scoping Review

BACKGROUND AND OBJECTIVES

Policies and measures often restrict the mobility of people with dementia living in residential care environments to protect them from harm. However, such measures can violate human rights and affect the quality of life. This review aims to summarize the literature on what is known about measures used to modulate the life-space mobility of residents with dementia living in a residential care environment. Furthermore, moral and sex and gender considerations were explored.

RESEARCH DESIGN AND METHODS

A scoping review framework was referenced to summarize the literature. A total of 5 databases were searched: PubMed, Embase, CINAHL, SCOPUS, and Web of Science. The studies for eligibility using the Rayyan screening tool.

RESULTS

A total of 30 articles met the inclusion criteria. A narrative description of the findings of the articles is presented across 3 themes: (1) measures and strategies used to modulate the life-space mobility; (2) moral aspects; and (3) sex and gender considerations.

DISCUSSION AND IMPLICATIONS

Various measures are used to modulate the life-space mobility of people with dementia living in residential care facilities. Research exploring the sex and gender differences of people with dementia is lacking. With a focus on human rights and quality of life, measures used to restrict or support mobility must support the diverse needs, capacity, and dignity of people with dementia. Noting the capacity and diversity of people with dementia will require society and public space to adopt strategies that promote safety and mobility to support the quality of life of people with dementia.

[Use of antipsychotics in patients with dementia in Spain: Comparison with prescription of acetylcholinesterase inhibitors and memantine and analysis of associations]

OBJECTIVE

We have analyzed the prevalence of antipsychotics in patients with dementia in Spain, their age distribution and the influence of treatment with IACEs and memantine on their prescription.

METHOD

Descriptive, retrospective and cross-sectional study of the 2017 BIFAP database in over 65 years of age with dementia. Prescriptions of antipsychotics, IACEs and memantine were collected. For antipsychotics were also collected, the duration of treatment and time from dementia diagnosis to prescription.

RESULTS

A total of 1,327,792 subjects were retrieved, 89,464 (6.73%) with dementia. Antipsychotics were prescribed in 31.76%; by frequency: quetiapine (58.47%), risperidone (21%) and haloperidol (19.34%). Prescriptions of IACEs and memantine were clustered in those younger than 84 years and antipsychotics in those older than 85 (P<.001). Antipsychotics were maintained for a mean of 1174.5 days. In 26.4% of cases they were prescribed alone, OR 0.61 (95% CI: 0.59-0.62), in 35.85% associated with IACEs, OR 1.26 (95% CI: 1.22-1.30) and in 42.4% with memantine, OR 1.69 (95% CI: 1.62-1.78) (P<.000). From the diagnosis of dementia, 461 days (±1576.5) elapsed when isolated drugs were prescribed; 651 days (±1574.25) associated with IACEs and 1224 (±1779) with memantine.

CONCLUSIONS

One third of patients with dementia were prescribed antipsychotics, mostly atypical, more frequently in those older than 85 years and for prolonged periods. IACEs and memantine were associated with the risk of antipsychotic prescription, but paradoxically, with prolonged time to onset.

Patient and caregiver experiences of living with dementia in Tanzania

Introduction: Tanzania is a low-income country with an increasing prevalence of dementia, which provides challenges for the existing healthcare system. People with dementia often don't receive a formal diagnosis, and with a lack of formal healthcare, are often predominantly supported by family relatives. There are very few published data relating to lived experiences of people with dementia in Tanzania. This study aimed to understand people with dementia, and their caregivers' experiences of living with dementia in Tanzania and the perceived needs of people with dementia.Methods: Qualitative, semi-structured interviews were conducted with 14 people with dementia and 12 caregivers in Moshi, Tanzania. Interviews were audio-recorded, translated, transcribed and analysed using a Framework Analysis approach.Results: Three sub-themes were identified within data describing the experience of 'Living with Dementia in Tanzania': 'Deteriorations in Health', 'Challenges to living with Dementia in Tanzanian Culture', and 'Lack of Support': people with dementia faced challenges due to social isolation, stigmatisation, and lack of caregiver knowledge on how best to provide support. Collectively, these impacted on both the physical and mental health of people with dementia. Misconceptions about dementia aetiology related to age, stresses of daily life and other co-morbidities. People with dementia were motivated to access treatment, exhibiting pluralistic health-seeking behaviours. There was an overall preference for non-pharmacological interventions over medication, with high levels of trust in medical professional opinions.Conclusions: Living with dementia in Tanzania is influenced by both cultural and religious factors. More work is needed to target supplementary healthcare (with efforts to promote accessibility), support for caregivers and public health education about dementia to overcome existent misconceptions and stigma.

Gender differences in interactions and depressive symptoms among hospitalized older patients living with dementia

Alzheimer's disease or a related dementia (ADRD) disproportionately affects women with two-thirds of individuals with ADRD comprised of women. This study examined gender-related differences in the quality of staff-patient interactions and depressive symptoms among hospitalized older patients living with dementia. This secondary analysis utilized baseline data of 140 hospitalized older patients with dementia who participated in the final cohort of a randomized controlled trial (ClinicalTrials.gov identifier: NCT03046121) implementing Family centered Function-focused Care (Fam-FFC). On average, the participants (male = 46.1%, female = 52.9%) were 81.43 years old (SD = 8.29), had positive interactions with staff and lower depressive symptoms based on Quality of Interaction Schedule (QUIS) scores and Cornell Scale for Depression in Dementia (CSDD) scores, respectively. Although males had more positive interactions (male = 6.06, SD = 1.13; female = 5.59, SD = 1.51) and lesser depressive symptoms (male = 7.52, SD = 4.77; female = 8.03, SD = 6.25) than females, no statistically significant gender differences were observed in linear models with appropriate covariates or multivariant analysis of covariant (MANCOVA). However, the multigroup regression conducted to further probe marginally significant moderation effect of gender and pain on staff-patient interactions demonstrated that greater pain was significantly related to lower quality or less positive staff-patient interactions for females compared to males (χ2diff (1) = 4.84, p = .03). Continued evaluation of gender differences is warranted to inform care delivery and interventions to improve care for hospitalized older patients with dementia.

Social and spatial inequalities in healthcare use among people living with dementia in England (2002-2016)

OBJECTIVES

Healthcare services for people living with dementia (PLWD) are stretched, and government promises of increased funding remain undelivered. With the UK dementia population to surpass 1 million by 2024, and dementia care costs predicted to almost treble by 2040, it is essential we understand differences in healthcare use among PLWD. This study aimed to explore social and spatial variations in healthcare use among people diagnosed with dementia (2002-2016).

METHODS

Data were derived from Electronic Health Records of Clinical Practice Research Datalink GP patients in England (n = 142,302). To standardise healthcare contacts, rates of healthcare contacts per year were calculated for three primary (GP observations and medications) and three secondary healthcare types [Accident & Emergency (A&E) attendances and, emergency and elective hospital admissions]. Fully-adjusted generalised linear regression models were used to identify healthcare use variation by social and spatial groups. Twelve models were generated, one for each healthcare type in early- and late-onset populations separately.

RESULTS

This study highlights numerous social and spatial variations in healthcare use among PLWD. Among PLWD, several groups tended to have healthcare service use more closely associated with negative outcomes, including a greater likelihood of A&E attendances and emergency and elective hospital admissions. These groups include: men, people from White ethnicity groups and people from more deprived and rural areas.

CONCLUSIONS

Systemic and social measures are needed to reduce variations in healthcare use inequalities in PWLD. These include greater healthcare continuity, health checks and medicines reviews, culturally appropriate services, better and more accessible treatment and improved infrastructure.

White matter hyperintensities and smaller cortical thickness are associated with neuropsychiatric symptoms in neurodegenerative and cerebrovascular diseases

BACKGROUND

Neuropsychiatric symptoms (NPS) are a core feature of most neurodegenerative and cerebrovascular diseases. White matter hyperintensities and brain atrophy have been implicated in NPS. We aimed to investigate the relative contribution of white matter hyperintensities and cortical thickness to NPS in participants across neurodegenerative and cerebrovascular diseases.

METHODS

Five hundred thirteen participants with one of these conditions, i.e. Alzheimer's Disease/Mild Cognitive Impairment, Amyotrophic Lateral Sclerosis, Frontotemporal Dementia, Parkinson's Disease, or Cerebrovascular Disease, were included in the study. NPS were assessed using the Neuropsychiatric Inventory - Questionnaire and grouped into hyperactivity, psychotic, affective, and apathy subsyndromes. White matter hyperintensities were quantified using a semi-automatic segmentation technique and FreeSurfer cortical thickness was used to measure regional grey matter loss.

RESULTS

Although NPS were frequent across the five disease groups, participants with frontotemporal dementia had the highest frequency of hyperactivity, apathy, and affective subsyndromes compared to other groups, whilst psychotic subsyndrome was high in both frontotemporal dementia and Parkinson's disease. Results from univariate and multivariate results showed that various predictors were associated with neuropsychiatric subsyndromes, especially cortical thickness in the inferior frontal, cingulate, and insula regions, sex(female), global cognition, and basal ganglia-thalamus white matter hyperintensities.

CONCLUSIONS

In participants with neurodegenerative and cerebrovascular diseases, our results suggest that smaller cortical thickness and white matter hyperintensity burden in several cortical-subcortical structures may contribute to the development of NPS. Further studies investigating the mechanisms that determine the progression of NPS in various neurodegenerative and cerebrovascular diseases are needed.

The role of sex differences in depression in pathologically defined Alzheimer's disease

Introduction

Sex differences in Alzheimer's disease (AD) may contribute to disease heterogeneity and affect prevalence, risk factors, disease trajectories and outcomes. Depression impacts a large number of patients with AD and has been reported to be more prevalent in women. We aimed to better understand the interaction between sex, depression and AD neuropathology, which could have implications for detection of symptoms, earlier diagnosis, therapeutic management, and enhanced quality of life.

Methods

We compared 338 cases with clinicopathologically confirmed AD (46% women) to 258 control cases (50% women), without dementia, parkinsonism or a significant pathological diagnosis. Depression was assessed both, using the Hamilton Depression Scale (HAM-D), and as being reported in their medical history combined with treatment with antidepressant medication.

Results

In the control group, women showed a higher depression severity, and a higher proportion of women were found to meet the cut-off score for depression on the HAM-D (32 vs. 16%) and having an history of depression (33 vs. 21%), while these sex differences were not observed in AD. Further, in both groups, female sex independently predicted the presence of depression, with covariates for age and cognitive status. AD subjects had higher mean HAM-D scores, were more likely to meet cutoff scores for depression (41 vs. 24%) and have a history of depression than controls (47 vs. 27%). When comparing the increase in frequency of depression in controls versus AD, the difference was significantly greater in men (AD men - control men: 24%) than in women (AD women - control women: 9%). Although subjects with depression were more likely to have higher levels of AD neuropathology, these differences were not observed when investigating the control or AD group separately.

Discussion

Control women had a higher likelihood and severity of depression than control men, but this sex difference was not noted when considering only those with pathologically defined AD, emphasizing the importance of considering sex in aging studies. AD was associated with higher rates of depression and men may be more likely to report or be diagnosed with depression once they develop AD indicating the importance of more frequent depression screenings in men.

Ten-Year Trends in Psychotropic Prescribing and Polypharmacy in Australian General Practice Patients with and without Dementia

OBJECTIVE

Little research has evaluated trends in psychotropic prescribing and polypharmacy in primary care patients, especially those with dementia. We sought to examine this in Australia from 2011 to 2020 using the primary care dataset, MedicineInsight.

METHODS

Ten consecutive serial cross-sectional analyses were performed to evaluate the proportion of patients aged 65 years or more, with a recorded diagnosis of dementia, who were prescribed psychotropic medications within the first six months of each year from 2011 to 2020. This proportion was compared with propensity score-matched control patients without dementia.

RESULTS

Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. In 2011, 42% (95% confidence interval [CI] 40.5-43.5%) of patients in the dementia group had at least one recorded prescription of a psychotropic medication, which declined to 34.2% (95% CI 33.3-35.1%; p for trend < 0.001) by 2020. However, it remained unchanged for matched controls (36% [95% CI 34.6-37.5%] in 2011 and 36.7% [95% CI 35.7-37.6%] in 2020). The greatest decline in the dementia groups by medication class was for antipsychotics (from 15.9% [95% CI 14.8-17.0%] to 8.8% [95% CI 8.2-9.4%]; p for trend < 0.001). During this period, the prevalence of psychotropic polypharmacy (use of two or more individual psychotropics) also decreased from 21.7% (95% CI 20.5-22.9%) to 18.1% (95% CI 17.4-18.9%) in the dementia groups, and slightly increased from 15.2% (95% CI 14.1-16.3%) to 16.6% (95% CI 15.9-17.3%) in the matched controls.

CONCLUSIONS

The decline in psychotropic prescribing, particularly antipsychotics, in Australian primary care patients with dementia is encouraging. However, psychotropic polypharmacy still occurred in almost one in five patients with dementia at the end of the study period. Programs focused on encouraging further reductions in the use of multiple psychotropic drugs in patients with dementia are recommended, particularly in rural and remote regions.

Preparing future health care workers for interactions with people with dementia: A mixed methods study

Strategies used in training future health professionals have expanded from traditional methods to a variety of approaches, including sensitivity training. Students who receive disease-specific sensitivity training are more compassionate to patients. Alzheimer's disease (AD) sensitivity training includes deficit-focused dementia tours that physically alter sensations. This embedded-experimental (between-subjects) variant mixed-methods study assessed the effectiveness of virtual reality as a delivery format for dementia tours compared to dementia tours that physically alter sensations. It also compared the effectiveness of deficit-focused dementia sensitivity training to reading strengths-focused case studies, a traditional instruction method. Forty-one university students were randomized into one of three conditions. All participants completed pre- and post-assessments and were interviewed. Quantitative results indicate that a dementia tour offered through virtual reality is as effective as a physical-based tour; however, compared to reading case studies, participants reported poorer attitudes about living with AD and feeling less prepared for caregiving. The qualitative results show an increase in empathy across all conditions. Integration of findings indicates that dementia tours in both formats are effective at encouraging empathy and that both strengths-based and deficit-based sensitivity training are important components of education for future health care workers.

Food Hardness Modulates Behavior, Cognition, and Brain Activation: A Systematic Review of Animal and Human Studies

Food hardness is one of the dietary features that may impact brain functions. We performed a systematic review to evaluate the effect of food hardness (hard food versus soft food diet) on behavior, cognition, and brain activation in animals and humans (PROSPERO ID: CRD42021254204). The search was conducted on 29 June 2022 using Medline (Ovid), Embase, and Web of Science databases. Data were extracted, tabulated by food hardness as an intervention, and summarized by qualitative synthesis. The SYRCLE and JBI tools were used to assess the risk of bias (RoB) of individual studies. Of the 5427 studies identified, 18 animal studies and 6 human studies met the inclusion criteria and were included. The RoB assessment indicated that 61% of animal studies had unclear risks, 11% had moderate risks, and 28% had low risks. All human studies were deemed to have a low risk of bias. The majority (48%) of the animal studies showed that a hard food diet improved behavioral task performance compared to soft food diets (8%). However, 44% of studies also showed no differential effects of food hardness on behavioral tests. It was also evident that certain regions of the brain were activated in response to changes in food hardness in humans, with a positive association between chewing hard food, cognition performance, and brain function. However, variations in the methodologies of the included studies hindered the meta-analysis execution. In conclusion, our findings highlight the beneficial effects of dietary food hardness on behavior, cognition, and brain function in both animals and humans, however, this effect may depend on several factors that require further understanding of the causality.

Relations of neuropsychiatric symptoms with disease stage, sex, and daily function in mild cognitive impairment and dementia due to Alzheimer's disease: A cross-sectional study

OBJECTIVE

To reveal the relations between neuropsychiatric symptoms (NPS), stages of cognitive impairment, sex, and daily function in patients with mild cognitive impairment (MCI) and dementia due to Alzheimer's disease (AD).

METHODS

A cross-sectional study was conducted from 2014 to 2021 on 1154 patients. Cognitive function, disease severity, NPS, and daily function were evaluated by Mini-mental State Examination, Clinical Dementia Rating Scale, Neuropsychiatric Inventory, and Activities of Daily Living (ADL) respectively. Multivariate logistic regression and linear regression were used to explore the correlations between NPS, disease stage, sex and ADL.

RESULTS

Affective disturbance displayed the highest prevalence from MCI (52.7%) to severe dementia due to AD (98.2%). Multivariate logistic regression revealed that aberrant motor behavior displayed higher prevalence between groups from MCI to severe dementia due to AD (OR = 4.710, P &lt; 0.001; OR = 3.141, P &lt; 0.001; OR = 2.722, P = 0.002, respectively). In patients with dementia due to AD, hallucination and depression were more prevalent in female (OR = 1.730, P = 0.001; OR = 2.376, P &lt; 0.001, respectively) while male presented higher prevalence in apathy (OR = 0.608, P = 0.002). Linear regression analysis showed that delusion and sleep disturbance were significantly associated with basic ADL across all dementia due to AD stages (delusion: mild: β = 0.113, P = 0.015; moderate: β = 0.159, P = 0.019; severe: β = 0.317, P = 0.018; sleep disturbance: mild: β = 0.164, P &lt; 0.001; moderate: β = 0.167, P = 0.013; severe: β = 0.308, P = 0.025) while anxiety was correlated with instrumental ADL from MCI to moderate dementia due to AD (MCI: β = 0.119, P = 0.006; mild: β = 0.149, P &lt; 0.001; moderate: β = 0.130, P = 0.042).

CONCLUSION

Different subitems of NPS are strongly correlated with sex, stage of cognitive impairment, and ADL.

How do predisposing factors differ between delirium motor subtypes? A systematic review and meta-analysis

BACKGROUND

Delirium is a common neurocognitive disorder in hospitalised older adults with vast negative consequences. The predominant method of subtyping delirium is by motor activity profile into hypoactive, hyperactive and mixed groups.

OBJECTIVE

This systematic review and meta-analysis investigated how predisposing factors differ between delirium motor subtypes.

METHODS

Databases (Medline, PsycINFO, Embase) were systematically searched for studies reporting predisposing factors (prior to delirium) for delirium motor subtypes. A total of 61 studies met inclusion criteria (N = 14,407, mean age 73.63 years). Random-effects meta-analyses synthesised differences between delirium motor subtypes relative to 22 factors.

RESULTS

Hypoactive cases were older, had poorer cognition and higher physical risk scores than hyperactive cases and were more likely to be women, living in care homes, taking more medications, with worse functional performance and history of cerebrovascular disease than all remaining subtypes. Hyperactive cases were younger than hypoactive and mixed subtypes and were more likely to be men, with better cognition and lower physical risk scores than all other subtypes. Those with no motor subtype (unable to be classified) were more likely to be women and have better functional performance. Effect sizes were small.

CONCLUSIONS

Important differences in those who develop motor subtypes of delirium were shown prior to delirium occurrence. We provide robust quantitative evidence for a common clinical assumption that indices of frailty (institutional living, cognitive and functional impairment) are seen more in hypoactive patients. Motor subtypes should be measured across delirium research. Motor subtyping has great potential to improve the clinical risk assessment and management of delirium.

Effects of manual massage given by family caregivers for patients with dementia: A preliminary investigation

OBJECTIVES

To explore the effects of a 10-week manual massage intervention given by caregivers of patients with dementia on the behavioral and psychological symptoms of dementia (BPSD) and caregiver burden.

METHODS

Twelve pairs of participants-patients with dementia and their family caregivers-were recruited. Before the intervention, caregivers received a four-hour full body manual massage training course. Thereafter, the caregivers gave a 30-min massage to the patients once a week for a 10-week period. The Cornell Scale for Depression in Dementia, Cohen-Mansfield Agitation Inventory, and Zarit Burden Scale were administered pre- and post-intervention.

RESULTS

Total scores on all questionnaires significantly decreased after the intervention (p < .05). Moreover, two subscale scores of the Cornell Scale for Depression in Dementia-behavioral disturbance and physical signs-reduced significantly (p < .05).

CONCLUSIONS

This study provides preliminary evidence on the benefits of manual massage given by caregivers for the management of BPSD and caregiver burden.

Clinicodemographic and Psychosocial Factors Related to Presentation or Severity of Delusions of Theft among Females with Amnestic Mild Cognitive Impairment and Alzheimer's Disease

Objectives: We examined the clinicodemographic and psychosocial factors that relate to the presentation and severity of delusions of theft among female patients with amnestic mild cognitive impairment (a-MCI) and Alzheimer's disease (AD).Methods: We enrolled a total of 177 female patients with a-MCI or AD, of whom 40 presented with delusions of theft. We compared the differences in clinicodemographic and psychosocial factors of the 40 patients (delusions of theft group) with 50 age- and Mini-Mental State Examination (MMSE)-matched controls without delusions (control group). Furthermore, we identified the factors associated with the presentation of delusions of theft using a general linear model (GLM). The severity of delusions of theft was calculated using the Neuropsychiatric Inventory Questionnaire, and correlations between the clinicodemographic and psychosocial factors were examined.Results: Between the two groups, the delusions of theft group had lower scores on the Physical Self-Maintenance Scale and instrumental activities of daily living (IADL) and higher scores on the Japanese version of the Zarit Caregiver Burden Interview (ZBI-J) than the control group. GLM analysis revealed that the IADL score was related to the presentation of delusions of theft. The severity of delusions of theft correlated with the MMSE and the ZBI-J scores in the delusions of theft group.Conclusions: The two groups had several differences regarding clinicodemographic and psychosocial factors. Furthermore, lower IADL scores were related to symptom presentation. Symptom severity correlated with cognitive functioning and caregiver burden.Clinical Implications: In the determination of treatment or care, differences in these factors should be considered.

Gender differences in outpatients with dementia from a large psychiatric hospital in China

BACKGROUND

The sociodemographic characteristics and clinical features of dementia patients in psychiatric hospitals have not been thoroughly studied in China. This study aimed to explore the psychiatric outpatient attendance of dementia patients at a psychiatric hospital in China, with particular emphasis on gender differences.

METHODS

This retrospective study examined outpatients with dementia from January 2013 to August 2019 using data in the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM) in Beijing Anding Hospital. Age, sex, number of visits, use of drugs and comorbid conditions were extracted from medical records.

RESULTS

Nine thousand four patients were recruited from a specific outpatient clinic of a hospital in Beijing, and the mean number of visits was 6.92. There were 3,433 (38.13%) male patients and 5,571 (61.87%) female patients. The most common comorbidities were generalized anxiety disorder, nonorganic insomnia, delusional disorder and depressive disorder. The proportion of patients using antidementia was the highest, with the rate of 68.3%, followed by benzodiazepines (48.83%), antipsychotics (45.43%), antidepressants (22.24%) and nonbenzodiazepines (19.96%). Patients with dementia showed a significant gender difference in average age (t = 6.36, P < 0.0001). Compared to male patients, female patients had a higher number of visits (7.40 ± 12.90 vs 6.15 ± 10.50, t = 4.81, P < 0.0001). There were significant differences in comorbidity composition between male and female patients (t = 23.09, P < 0.0001).

CONCLUSIONS

Our present findings suggested significant gender differences in the proportion of age, number of visits and comorbidity composition in outpatients with dementia.

Psychological Distress in Caregivers for People with Dementia: A Population-Based Analysis of a National Cross-Sectional Study

BACKGROUND

Taking care of patients with dementia is often stressful and exhausting. The burden placed on caregivers (CGs) for care recipients with dementia (CRDs) has been reported to cause psychological distress.

OBJECTIVE

The aim of this study was to evaluate the psychological distress experienced by CGs for CRDs and identify the sociodemographic factors affecting that distress.

METHODS

We utilized the 2013 Comprehensive Survey of the Living Conditions for CRDs and CGs. Linked data from 643 pairs of CRDs and CGs were extracted. Serious psychological distress experienced by CGs was measured by Kessler's Psychological Distress scale (K6) with a cutoff point of 13. Factors predictive of psychological distress were evaluated using multivariable logistic regression analysis with the forward selection method.

RESULTS

Overall, the mean age of the CGs was 63.5±11.6 years, and 5.3%(34/643) experienced serious psychological distress. Male sex of CRDs, knowing how to access consulting services, spending almost all day for nursing care, and having subjective symptoms within a few days of completing the survey were associated with having serious psychological distress, while older age, participating in shopping as part of the nursing activities, and having their own house were related to freedom from serious psychological distress.

CONCLUSION

Clinicians should be aware of the risk factors for psychological distress in CGs and consider providing support to reduce the distress imposed by modifiable factors. Further studies are warranted to examine whether such efforts would improve the mental health of CGs for CRDs.

Psychotropic drug use among older people with major neurocognitive disorder: a cross-sectional study based on Swedish national registries

AIM

Psychotropic medications include many drugs that may be inappropriate for older individuals with cognitive impairment. In Sweden, many people become registered in the Swedish Dementia Registry when they are diagnosed with major neurocognitive disorder (NCD). In this study, we aim to describe psychotropic drug use and associated factors among older Swedish people with major NCD.

METHODS

This study included 38,251 people ≥ 65 years from the Swedish registry for cognitive/dementia disorders diagnosed during 2007-2017. Drug use was defined as one or more filled prescription(s) recorded in the Swedish Prescribed Drug Register during 1 July to 31 December 2017. Associations between psychotropics and age, sex, diagnosis date, Mini-Mental State Examination score and major NCD subtype were analysed through multiple logistic regression.

RESULTS

We found that 12.0% of the individuals filled at least one prescription for antipsychotics, 22.0% for anxiolytics, 23.0% for sedatives or hypnotics, 43.2% for antidepressants and 56.7% for antidementia drugs. In brief, psychotropic use was associated with female sex, higher age, longer time since diagnosis and specific subtypes of major NCD; the strongest association was found between antipsychotics and Lewy body dementia (odds ratio 2.40, 95% confidence interval 2.04-2.82).

CONCLUSION

Psychotropic drugs were frequently dispensed among older Swedish people with major NCD. The use of antipsychotics and medications with sedative properties warrants concern, especially among those with Lewy body dementia who are severely sensitive to antipsychotics. A more restrictive prescribing pattern regarding these medications might reduce the risk of drug-related problems in this vulnerable group of people.

Sex Differences in Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis

Background: Cerebral small vessel disease (SVD) is a common cause of stroke, mild cognitive impairment, dementia and physical impairments. Differences in SVD incidence or severity between males and females are unknown. We assessed sex differences in SVD by assessing the male-to-female ratio (M:F) of recruited participants and incidence of SVD, risk factor presence, distribution, and severity of SVD features. Methods: We assessed four recent systematic reviews on SVD and performed a supplementary search of MEDLINE to identify studies reporting M:F ratio in covert, stroke, or cognitive SVD presentations (registered protocol: CRD42020193995). We meta-analyzed differences in sex ratios across time, countries, SVD severity and presentations, age and risk factors for SVD. Results: Amongst 123 relevant studies (n = 36,910 participants) including 53 community-based, 67 hospital-based and three mixed studies published between 1989 and 2020, more males were recruited in hospital-based than in community-based studies [M:F = 1.16 (0.70) vs. M:F = 0.79 (0.35), respectively; p < 0.001]. More males had moderate to severe SVD [M:F = 1.08 (0.81) vs. M:F = 0.82 (0.47) in healthy to mild SVD; p < 0.001], and stroke presentations where M:F was 1.67 (0.53). M:F did not differ for recent (2015-2020) vs. pre-2015 publications, by geographical region, or age. There were insufficient sex-stratified data to explore M:F and risk factors for SVD. Conclusions: Our results highlight differences in male-to-female ratios in SVD severity and amongst those presenting with stroke that have important clinical and translational implications. Future SVD research should report participant demographics, risk factors and outcomes separately for males and females. Systematic Review Registration: [PROSPERO], identifier [CRD42020193995].

Prevalence of psychotropic polypharmacy in nursing home residents with dementia: a meta-analysis

OBJECTIVES

Nursing home (NH) residents with dementia is exposed to high rates of psychotropic prescriptions. Our objectives were to: (1) pool the prevalence estimates of psychotropic polypharmacy from the existing literature and (2) examine potentially influential factors that are related to a higher or lower prevalence.

DESIGN

Meta-analysis of data collected from randomized trials, quasi-experimental, prospective or retrospective cohort, and cross-sectional studies. English-language searches of PubMed and PsycINFO were completed by November 2020. Included studies reported prevalence estimates of psychotropic polypharmacy (i.e. defined as either two-or-more or three-or-more medications concurrently) in NH residents with dementia.

SETTING AND PARTICIPANTS

NH residents with dementia.

MEASUREMENTS

Random-effects models were used to pool the prevalence of psychotropic polypharmacy in NH residents with dementia across studies. Estimates were provided for both two-or-more and three-or-more concurrent medications. Heterogeneity and publication bias were measured. Meta-regression examined the influence of the percentage of the sample who were male, mean age of the sample, geographic region (continent), sample size, and study year on the prevalence of psychotropic polypharmacy.

RESULTS

Twenty-five unique articles were included comprising medications data from 92,370 NH residents with dementia in 12 countries. One-in-three (33%, [95% CI: 28%, 39%]) NH residents with dementia received two-or-more psychotropic medications concurrently. One-in-eight (13%, [95% CI: 10%, 17%]) received three-or-more psychotropic medications concurrently. Estimates were highly variable across both definitions of psychotropic polypharmacy (p < 0.001). Among study-level demographics, geographic region, sample size, or study year, only male sex was associated with greater use of two-or-more psychotropic medications (Unadjusted OR = 1.02, p = 0.006; Adjusted OR = 1.04, p = 0.07).

CONCLUSIONS

Psychotropic polypharmacy is common among NH residents with dementia. Identifying the causes of utilization and the effects on resident health and well-being should be prioritized by federal entities seeking to improve NH quality.

Gender Differences in Neuropsychiatric Symptoms Among Community-Dwelling Mexican Americans Aged 80 and Older

Background and ObjectivesTo assess gender differences in prevalence of neuropsychiatric symptoms (NPS) among community-dwelling Mexican Americans ≥80 years. Research Design and Methods: Using data from Wave 7 (2010-2011) of the Hispanic Established Population for the Epidemiological Study of the Elderly, we analyzed the NPS of 914 participants as determined by the Neuropsychiatric Inventory (NPI) with assessments conducted by their caregivers. Multivariate logistic regression models were used to test the association of individual NPS with gender, adjusting for relevant characteristics. Results: The average age of our sample was 86.1 years, and 65.3% were women. Over 60% of participants had at least one informant/caregiver reported NPS. After adjustment, women had lower odds than men of agitation/aggression but higher odds of dysphoria/depression and anxiety. Discussion: Recognizing gender differences in NPS phenotype could help guide development of culturally appropriate NPS screening and treatment programs.

Sex differences in psychotropic and analgesic drug use before and after initiating treatment with acetylcholinesterase inhibitors

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.

Biting the Bullet: Firearm Ownership in Persons with Dementia. A Registry-Based Observational Study

Background:

In Sweden, 2,296,000 firearms were legally owned by private persons in 2017 and there were 150,000 persons living with a dementia diagnosis. A proportion of these persons owning a firearm may pose safety concerns.

Objective:

The aim was to describe firearm ownership in persons with dementia in Sweden and examine which characteristics are explaining physicians’ decision to report a person to the police as unsuitable to possess a firearm.

Methods:

This was a registry-based observational study. 65,717 persons with dementia registered in the Swedish Dementia Registry were included in the study. Logistic regression was used to evaluate which of the persons’ characteristics were most important in predicting the likelihood of being reported as unsuitable to possess a firearm. Relative importance of predictors was quantified using standardized coefficients (SC) and dominance analysis (DA).

Results:

Out of 53,384 persons with dementia, 1,823 owned a firearm and 419 were reported to the police as unsuitable owners. Firearm owners were predominantly younger, males, living alone, and without assistance of homecare. The most important predictors of being reported to the police were: living with another person (SC = 0.23), frontotemporal dementia (SC = 0.18), antipsychotics prescription (SC = 0.18), being diagnosed in a memory/cognitive clinic (SC = –0.27), female gender (SC = 0.18), mild (SC = –0.25) and moderate (SC = –0.21) dementia, and hypnotics prescription (SC = 0.17).

Conclusion:

Firearm owners with dementia were mostly younger males who were still living more independent lives. The decision to remove a weapon was not solely based on a diagnosis of dementia but a combination of factors was considered.

Sex Differences in Behavioral and Psychological Signs and Symptoms of Dementia Presentation Regarding Nursing Home Residents with Cognitive Impairment Suffering from Pain - Results of the Services and Health for Elderly in Long-Term Care Study

OBJECTIVE

Behavioral and psychological symptoms of dementia (BPSD) place a heavy burden on patients as well as caregivers. Recently, pain was identified as an important determinant of BPSD. However, it is not yet known what influence sex has on BPSD and pain. Thus, the present study aimed to identify possible associations between BPSD, pain, and sex.

DESIGN

A retrospective evaluation of cross-sectional data derived from the Services and Health for Elderly in Long-Term Care (SHELTER) Study database, a cross-national European study on nursing home residents.

SETTING AND PARTICIPANTS

The study involved 4156 residents who were assessed using the interRAI instrument for Long-Term Care Facilities. Included in the analysis were only patients with cognitive impairment (n = 2822) (67.9%) of which 712 (25.2%) were male and 2110 (74.8%) were female.

METHODS

Differences in prevalence were tested using the χ² test while bivariate logistic regression models were used to evaluate factors associated with sex.

RESULTS

Men showed behavioral symptoms such as wandering, verbal and physical abuse as well as sexual uninhibited behavior significantly more often than women. Regarding psychiatric symptoms, only depression was significantly more frequent in women. Surprisingly, in the presence of pain these differences in BPSD incidence between men and women were no longer detectable. Logistic regression analysis showed that in women with dementia/communication problems, the presence of pain could be indicated by resistance to care, sleeping disorders, and possibly by the presence of delusions and anxiety whereas in men it was related to abnormal thought processes, and in both sexes to depression CONCLUSIONS AND IMPLICATIONS: From a clinical point of view, resistance to care and sleeping disorders in women and abnormal thought processes in men as well as depression in both sexes should be seen as indicators of possible underlying pain in noncommunicative people. Thus, knowledge of sex-specific BPSD presentations can improve pain management in this particularly patient group.

Measuring the prevalence of sleep disturbances in people with dementia living in care homes: a systematic review and meta-analysis

Study Objectives

Sleep disturbances are a feature in people living with dementia, including getting up during the night, difficulty falling asleep, and excessive daytime sleepiness and may precipitate a person with dementia moving into residential care. There are varying estimates of the frequency of sleep disturbances, and it is unknown whether they are a problem for the individual. We conducted the first systematic review and meta-analysis on the prevalence and associated factors of sleep disturbances in the care home population with dementia.

Methods

We searched Embase, MEDLINE, and PsycINFO (29/04/2019) for studies of the prevalence or associated factors of sleep disturbances in people with dementia living in care homes. We computed meta-analytical estimates of the prevalence of sleep disturbances and used meta-regression to investigate the effects of measurement methods, demographics, and study characteristics.

Results

We included 55 studies of 22,780 participants. The pooled prevalence on validated questionnaires of clinically significant sleep disturbances was 20% (95% confidence interval, CI 16% to 24%) and of any symptom of sleep disturbance was 38% (95% CI 33% to 44%). On actigraphy using a cutoff sleep efficiency of <85% prevalence was 70% (95% CI 55% to 85%). Staff distress, resident agitation, and prescription of psychotropic medications were associated with sleep disturbances. Studies with a higher percentage of males had a higher prevalence of sleep disturbance.

Conclusions

Clinically significant sleep disturbances are less common than those measured on actigraphy and are associated with residents and staff distress and the increased prescription of psychotropics. Actigraphy appears to offer no benefit over proxy reports in this population.

Differences in Clinical Presentation of Behavioral and Psychological Symptoms of Dementia in Alzheimer's Disease According to Sex and Education Level

BACKGROUND

The behavioral and psychological symptoms of dementia (BPSD) seriously affect the quality of life of patients with Alzheimer's disease (AD) and their caregivers.

OBJECTIVE

We aimed to identify associations between demographic/genetic factors and clinical presentations of BPSD.

METHODS

In a cohort of 463 AD patients with BPSD, we retrospectively analyzed sex, education level, AD severity (assessed using the Clinical Dementia Rating and Mini-Mental Status Examination), and BPSD severity (assessed using the Neuropsychiatry Inventory, NPI). Severe BPSD was defined as NPI ≥10 for 3 consecutive years.

RESULTS

Among patients with severe BPSD (NPI ≥10), we observed more female patients (62.96%) and a lower level of education (6.03±4.77 years) as compared to those with mild BPSD (NPI <10) (female: 51.09%, p = 0.007; education years: 7.91±4.93, p < 0.001). Females had a lower level of education (5.72±4.50 years) and higher scores for depression/dysphoria (1.22±2.05) compared with males (education: 8.96±4.89 years, p < 0.001; depression/dysphoria: 0.78±1.42, p = 0.047). Patients with a high level of education (defined as ≥12 years) had higher scores for appetite/eating (0.90±2.02) than did those without (0.69±1.79; p = 0.001). Genetic analysis showed similar total and subscale NPI scores between patients with and without APOE4 and with and without the GRN rs5848 genotype.

CONCLUSION

Our findings indicate potential contributions of sex and education to the presentation of BPSD. Further study is warranted to provide models for tailoring therapeutic programs to individual AD patients according to these factors.

Acupuncture and Acupressure for Dementia Behavioral and Psychological Symptoms: A Scoping Review

Due to the dangers associated with psychotropic medications, there is an urgent need for non-pharmacologic therapies to treat behavioral and psychological symptoms of dementia (BPSD). Acupuncture and acupressure are safe and well-tolerated non-pharmacologic therapies for this population, but currently no review has explored acutherapy for management of distressing dementia symptoms. This review synthesizes research on acupuncture and acupressure for BPSD. Upon searching five databases, 15 studies met inclusion/exclusion criteria. Nine examined acupressure, six acupuncture, and eight were randomized controlled trials. The percent of studies demonstrating statistically significant improvements in symptoms were: activities of daily living (ADLs; 75%), agitation (100%), anxiety (67%), depression (100%), mood (100%), neuropsychological disturbances (67%), and sleep disturbances (100%). Variations in study design, intervention procedures, and outcomes limit interpretations about effectiveness. It is recommended that further research be done to examine the efficacy of these therapies and promote generalizability.

Sex Differences in Antipsychotic and Benzodiazepine Prescribing Patterns: A Cohort Study of Newly Admitted Nursing Home Residents with Dementia in Ontario, Canada

BACKGROUND

In nursing homes, residents with dementia frequently receive potentially inappropriate medications that are associated with an increased risk of adverse events. Despite known sex differences in clinical presentation and sociodemographic characteristics among persons with dementia, few studies have examined sex differences in patterns and predictors of potentially inappropriate medication use.

OBJECTIVES

The objectives of this study were to examine sex differences in the patterns of antipsychotic and benzodiazepine use in the 180 days following admission to a nursing home, estimate clinical and sociodemographic predictors of antipsychotic and benzodiazepine use in male and female residents, and explore the effects of modification by sex on the predictors of using these drug therapies.

METHODS

We conducted a retrospective cohort study of 35,169 adults aged 66 years and older with dementia who were newly admitted to nursing homes in Ontario, Canada between 2011 and 2014. Health administrative databases were linked to detailed clinical assessment data collected using the Resident Assessment Instrument (RAI-MDS 2.0). Cox proportional hazards models were adjusted for clinical and sociodemographic covariates to estimate the rate of antipsychotic and benzodiazepine initiation and discontinuation in the 180 days following nursing home admission in the total sample and stratified by sex. Sex-covariate interaction terms were used to assess whether sex modified the association between covariates and the rate of drug therapy initiation or discontinuation following nursing home entry.

RESULTS

Across 638 nursing homes, our analytical sample included 22,847 females and 12,322 males. At admission, male residents were more likely to be prevalent antipsychotic users than female residents (33.8% vs 28.3%; p < 0.001), and female residents were more likely to be prevalent benzodiazepine users than male residents (17.2% vs 15.3%, p < 0.001). In adjusted models, female residents were less likely to initiate an antipsychotic after admission (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.73-0.86); however, no sex difference was observed in the rate of benzodiazepine initiation (HR 1.04, 95% CI 0.96-1.12). Female residents were less likely than males to discontinue antipsychotics (HR 0.89, 95% CI 0.81-0.98) and benzodiazepines (HR 0.82, 95% CI 0.75-0.89). Sex modified the association between some covariates and the rate of changes in drug use (e.g., widowed males exhibited an increased rate of antipsychotic discontinuation (p-interaction = 0.03) compared with married males), but these associations were not statistically significant among females. Sex did not modify the effect of frailty on the rates of initiation and discontinuation.

CONCLUSIONS

Males and females with dementia differed in their exposure to antipsychotics and benzodiazepines at nursing home admission and their patterns of use following admission. A greater understanding of factors driving sex differences in potentially inappropriate medication use may help tailor interventions to reduce exposure in this vulnerable population.

Antipsychotic Drugs and Hip Fracture: Associations Before and After the Initiation of Treatment

OBJECTIVE

To study the association between antipsychotic drug treatment and hip fracture, before and after the initiation of treatment.

DESIGN

Nationwide cohort study.

SETTING AND PARTICIPANTS

In this study based on several Swedish registers, all individuals age ≥65 years who filled prescriptions for antipsychotic drugs in 2007-2017 were matched 1:1 by sex and age with controls, resulting in a cohort of 255,274 individuals.

MEASURES

Associations between antipsychotic drug treatment and hip fracture were investigated using multivariable conditional logistic regression models and flexible parametric survival models for nonproportional hazards, starting 1 year before the first prescription was filled and extending to 1 year thereafter.

RESULTS

The studied cohort had a mean age of 81.5 (standard deviation, 8.1) years; 152,890 (59.9%) individuals were women. Antipsychotic drug use was associated with an increased risk of hip fracture in all studied time frames, before and after the initiation of treatment. The risk was highest 16-30 days before the initiation of treatment (odds ratio 9.09; 95% confidence interval 7.00-11.81). The pattern was consistent in subgroup analyses of users of conventional and atypical antipsychotics, men and women, as well as in younger old and older old participants. The association with hip fracture was not influenced by antipsychotic drug dose.

CONCLUSIONS AND IMPLICATIONS

The association between antipsychotic drug use and the risk of hip fracture was observed before the initiation of antipsychotic treatment. This finding suggests that factors other than exposure to antipsychotic drugs are responsible for the increased risk of hip fracture in the treatment group.

Gender differences in presentation and management of behavioral and psychological symptoms associated with dementia among nursing home residents with moderate to severe dementia

Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.

Sex differences in the severity of neuropsychiatric symptoms and their relationship with clinico-demographic and psychosocial factors in patients with amnestic mild cognitive impairment and mild Alzheimer's disease

Objectives: We examined differences in the severity of neuropsychiatric symptoms (NPS) according to sex and identified NPS-related clinico-demographic and psychosocial factors among community-living patients with amnestic-mild cognitive impairment (a-MCI) or mild Alzheimer's disease (AD).Method: Overall, 111 patients (44 males, 67 females) with mild a-MCI (n = 64) or mild AD (n = 47) were included. We divided the patients according to sex and compared their clinico-demographic and psychosocial factors, explored the severity of NPS using the subscales from the Neuropsychiatric Inventory-Questionnaire (NPI-Q), and further identified variables related to NPS.Results: Significant differences in several clinico-demographic and psychosocial characteristics were observed between the sexes. The severity of delusions was higher among females (mean, 0.48; SD, 1.60) than males (mean, 0.23; SD, 1.07; p = .02), while the severity of irritability was higher among males (mean, 0.97; SD, 1.92) than females (mean, 0.49; SD, 1.40; p = .03). The severity of delusions among females was related to the duration of cognitive decline (B = 0.37, p = .03), while the severity of irritability among males was related to general cognition (B = -0.40, p = .003).Conclusion: The severity of NPS among patients with a-MCI or mild AD differed according to sex. We identified NPS-related clinico-demographic factors among these patients. Sex differences should be considered when determining the need for NPS interventions.

Behavioural and psychological symptoms of dementia in mouse models of Alzheimer's disease-related pathology

Transgenic mouse models have been used extensively to model the cognitive impairments arising from Alzheimer's disease (AD)-related pathology. However, less is known about the relationship between AD-related pathology and the behavioural and psychological symptoms of dementia (BPSD) commonly presented by patients. This review discusses the BPSD-like behaviours recapitulated by several mouse models of AD-related pathology, including the APP/PS1, Tg2576, 3xTg-AD, 5xFAD, and APP23 models. Current evidence suggests that social withdrawal and depressive-like behaviours increase with progressive neuropathology, and increased aggression and sleep-wake disturbances are present even at early stages; however, there is no clear evidence to support increased anxiety-like behaviours, agitation (hyperactivity), or general apathy. Overall, transgenic mouse models of AD-related pathology recapitulate some of the BPSD-like behaviours associated with AD, but these behaviours vary by model. This reflects the patient population, where AD patients typically exhibit one or more BPSD, but rarely all symptoms at once. As a result, we suggest that transgenic mouse models are an important tool to investigate the pathology underlying BPSD in human AD patients.

Reduced social investigation and increased injurious behavior in transgenic 5xFAD mice

Social withdrawal and agitation/aggression are common behavioral and psychological symptoms of dementia presented by Alzheimer's disease (AD) patients, with males exhibiting more aggressive behaviors than females. Some transgenic mouse models of AD also exhibit social withdrawal and aggression, but many of these models only recapitulate the early stages of the disease. By comparison, the 5xFAD mouse model of AD exhibits rapid, progressive neurodegeneration, and is suitable for modeling cognitive and behavioral deficits at early, mid-, and late-stage disease progression. Anecdotal reports suggest that transgenic 5xFAD males exhibit high levels of aggression compared to wild-type controls, but to date, indirect genetic effects in this strain have not been studied. We measured home-cage behaviors in 5xFAD males housed in three different group-housing conditions (transgenic-only, wild-type only, and mixed-genotype) and social approach behaviors when exposed to a novel free-roaming or restrained, wild-type or transgenic conspecific. Transgenic-only home cages required earlier separation due to injuries arising from aggression compared to wild-type-only or mixed-genotype cages, despite no obvious increase in the frequency of aggressive behaviors. Transgenic 5xFAD males and females also spent less time investigating free-roaming conspecifics compared to wild-type controls, but they showed normal investigation of restrained conspecifics; the genotype of the conspecific did not affect approach behavior, and there was no aggression observed in transgenic males. These findings provide evidence in an animal model that amyloid pathology ultimately leads to avoidance of novel social stimuli, and that frequent interactions between individuals exhibiting an AD phenotype further exacerbates aggressive behaviors.

Impact of Social Isolation on the Behavioral, Functional Profiles, and Hippocampal Atrophy Asymmetry in Dementia in Times of Coronavirus Pandemic (COVID-19): A Translational Neuroscience Approach

The impact of COVID-19 on the elderly is devastating, and nursing homes are struggling to provide the best care to the most fragile. The urgency and severity of the pandemic forces the use of segregation in restricted areas and confinement in individual rooms as desperate strategies to avoid the spread of disease and the worst-case scenario of becoming a deadly trap. The conceptualization of the post-COVID-19 era implies strong efforts to redesign all living conditions, care/rehabilitation interventions, and management of loneliness forced by social distance measures. Recently, a study of gender differences in COVID-19 found that men are more likely to suffer more severe effects of the disease and are over twice as likely to die. It is well-known that dementia is associated with increased mortality, and males have worse survival and deranged neuro-immuno-endocrine systems than females. The present study examines the impact of long-term isolation in male 3xTg-AD mice modeling advanced stages of Alzheimer's disease (AD) and as compared to age-matched counterparts with normal aging. We used a battery of ethological and unconditioned tests resembling several areas in nursing homes. The main findings refer to an exacerbated (two-fold increase) hyperactivity and emergence of bizarre behaviors in isolated 3xTg-AD mice, worrisome results since agitation is a challenge in the clinical management of dementia and an important cause of caregiver burden. This increase was consistently shown in gross (activity in most of the tests) and fine (thermoregulatory nesting) motor functions. Isolated animals also exhibited re-structured anxiety-like patterns and coping-with-stress strategies. Bodyweight and kidney weight loss were found in AD-phenotypes and increased by isolation. Spleen weight loss was isolation dependent. Hippocampal tau pathology was not modified, but asymmetric atrophy of the hippocampus, recently described in human patients with dementia and modeled here for the first time in an animal model of AD, was found to increase with isolation. Overall, the results show awareness of the impact of isolation in elderly patients with dementia, offering some guidance from translational neuroscience in these times of coronavirus and post-COVID-19 pandemic. They also highlight the relevance of personalized-based interventions tailored to the heterogeneous and complex clinical profile of the individuals with dementia and to consider the implications on caregiver burden.

Threshold for a Reduction in Anticholinergic Burden to Decrease Behavioral and Psychological Symptoms of Dementia

BACKGROUND

A high anticholinergic burden (AB) is associated with the occurrence of behavioral and psychological symptoms (BPSDs), which are frequent in dementia.

OBJECTIVES

Our aim was to determine the threshold for a reduction in AB that would lead to a clinically significant improvement in BPSDs (in terms of frequency, severity, and disruptiveness).

DESIGN

A single-center prospective study.

SETTINGS

Dedicated geriatric care unit specializing in the management of patients with dementia.

PARTICIPANTS

The study involved older patients with dementia, hospitalized for management of BPSDs.

METHODS

One hundred forty-seven patients were included (mean age = 84.1 ± 5.2 years). The AB was assessed using 3 scales, namely, the Anticholinergic Drug Scale (ADS), the Anticholinergic Cognitive Burden scale (ACB), and the Anticholinergic Risk Scale (ARS). A clinically significant improvement in BPSDs was defined as a reduction of 4 points in the frequency × severity (F×S) score of the Neuropsychiatric Inventory-Nursing Home (NPI-NH) questionnaire. The threshold for a reduction in AB that corresponded to a clinically significant improvement in BPSDs was determined by multiple linear regression.

RESULTS

One hundred forty-seven patients were included (mean age = 84.1 ± 5.2 years). Using the ADS, a reduction of 2 points in AB in patients with moderate-intensity BPSDs was associated with a clinically significant improvement in the F×S score of the NPI-NH [6.34, 95% confidence interval (CI) 4.54-8.14], and a reduction of 3 points was associated with a clinically significant improvement in the occupational disruptiveness score (4.26, 95% CI 3.11-5.41).

CONCLUSIONS/IMPLICATIONS

In older patients with dementia presenting BPSDs, the risk-benefit ratio of anticholinergic drugs is debatable and, where possible, drugs with a lower AB would be preferable. Because BPSDs are a frequent cause of hospitalization, a standardized approach to analysis and reduction of AB is warranted in this population. Depending on the scale used to assess anticholinergic burden (AB), a small reduction in AB is associated with a decrease in frequency, severity, and disruptiveness of moderate-intensity BPSDs. Drugs with a high AB should be avoided where possible in older patients with dementia, and drugs with a lower AB would be preferable. Heterogeneity between the assessment scales for AB precludes generalization of the impact of a reduction in AB on BPSDs.

Sex Differences in the Neuropsychiatric Symptoms of Patients With Alzheimer's Disease

The aim of this study was to describe sex differences in neuropsychiatric symptoms (NPSs) in patients with Alzheimer's disease (AD). Baseline scores on the Cohen-Mansfield Agitation Inventory, Neurobehavioral Rating Scale-Agitation subscale, and the Neuropsychiatric Inventory from patients with AD enrolled in a multicenter trial of citalopram for the treatment of agitation were analyzed. We found not only that patients with AD having agitation were likely to exhibit many other NPSs but also that the women in this study were more likely to exhibit a broader range of NPS than were the men. These results suggest greater heterogeneity in the clinical presentation of women compared to men, and thus in the potential targets for treatment in these patients. Further characterization of sex differences in NPS can inform future efforts aimed at establishing subtypes of patients for whom various treatment approaches will be most appropriate.

Psychotropic drugs use and psychotropic polypharmacy among persons with Alzheimer's disease

Psychotropic drugs are frequently used for the treatment of behavioural and psychological symptoms of dementia in persons with Alzheimer's disease (AD). Evidence for benefits are limited and concerns have been raised about the safety, especially for the concomitant use of multiple psychotropic drugs. The objective of this study was to investigate prevalence of psychotropic drug and psychotropic polypharmacy (PPP) use and associations with PPP among persons with and without AD, from five years before until four years after AD diagnosis at time points every six months. Data is a part of the nationwide MEDALZ cohort, including all community-dwelling persons who received a clinically verified diagnosis of AD between 2005 and 2011 in Finland (n = 70,719). Register-based data included purchased prescription drugs, comorbidities, and hospital discharge diagnoses. Prevalence and factors associated with PPP were studied with logistic regression. The prevalence of psychotropic drug use, especially use of antipsychotics and antidepressants, increased during the course of AD. The use of ≥ 2 psychotropic drugs increased from 5.9% five years before to 18.3% four years after AD diagnosis. The most frequently used combination was antipsychotics and antidepressants. Predictors for PPP were younger age (< 75 years), female sex and history of psychiatric disease. The use of acetylcholinesterase inhibitors was inversely associated with PPP. The high prevalence of PPP is concerning because of possible higher risks for adverse effects and events.

Factors affecting sensitivity and specificity of head-turning sign in the studies

We read with interest the comment by Williamson and Larner on our recent study titled "Attended With and Head-Turning Sign can be clinical markers of cognitive impairment in older adults" (Soysal et al., 2017). After the authors read the study, they re-examined their data according to the presence of Attended With (AW) and Head-Turning Sign (HTS), and compared their results with ours (Larner, 2014). Then, they found that while the sensitivity, specificity, positive predictive value, and negative predictive value of AW in detecting cognitive impairment were similar to ours, HTS had lower sensitivity (80.95% vs. 65.0%) and higher specificity (64.7% vs. 95.0%) than our results (Larner, 2014; Soysal et al., 2017). We think that some methodological and cultural differences may explain these discrepancies between the two.

Frontal White Matter Hyperintensity Is Associated with Verbal Aggressiveness in Elderly Women with Alzheimer Disease and Amnestic Mild Cognitive Impairment

Background/Aims

Behavioral and psychological symptoms of dementia (BPSD) are exhibited in most patients with Alzheimer disease (AD). Although white matter hyperintensity (WMH) is often observed with AD, the precise role of WMH in BPSD remains unclear. The current study aimed to identify the impact of regional WMH on specific features of BPSD in persons with mild to moderate AD and amnestic mild cognitive impairment (aMCI).

Methods

A sample of 256 female outpatients with AD (n = 217) and aMCI (n = 39) were recruited. We assessed BPSD using the Dementia Behavior Disturbance Scale. WMH and brain atrophy were evaluated using an automatic segmentation program. Regional WMH was evaluated as periventricular hyperintensity (PVH) and deep WMH in frontal, temporal, occipital, and parietal lobes.

Results

Whole-brain WMH was associated with verbal aggressiveness. In multivariate analysis, PVH in the frontal lobe was independently associated with verbal aggressiveness after adjustment for brain atrophy and clinical confounders.

Conclusion

The current results indicated that PVH in the frontal lobe was independently associated with verbal aggressiveness.

Prevalence estimates of mild behavioral impairment in a population-based sample of pre-dementia states and cognitively healthy older adults

BACKGROUND

A dearth of population-based epidemiological research examines neuropsychiatric symptom (NPS) in sub-clinical populations across the spectrum from normal aging to mild cognitive impairment (MCI). The construct of mild behavioral impairment (MBI) describes the emergence of sustained and impactful NPS in advance of or in combination with MCI. This is the first epidemiological study to operationalize the recently published diagnostic criteria for MBI and determine prevalence estimates across the spectrum from cognitively normal to MCI.

METHODS

MBI was assessed in 1,377 older (age range 72-79 years; 52% male; MCI ;= 133; cognitively normal, but-at-risk = 397; cognitively healthy = 847). MBI was assessed in accordance with the ISTAART-AA diagnostic criteria for MBI using the neuropsychiatric inventory.

RESULTS

34.1% of participants met the criteria for MBI. High prevalence of MBI across the cognitive spectrum was reported (48.9% vs. 43.1% vs. 27.6%). Irrespective of level of cognitive impairment, impulse dyscontrol (33.8% vs. 28.7% vs. 17.2%) and decreased motivation (32.3% vs. 26.2% vs. 16.3%) were the most frequently met MBI domains. MBI was more prevalent in men (χ2 = 4.98, p = 0.026), especially the domains of decreased motivation and impulse dyscontrol.

CONCLUSIONS

This study presents the first population-based prevalence estimates for MBI using the recently published ISTAART-AA diagnostic criteria. Findings indicate relatively high prevalence of MBI in pre-dementia clinical states and amongst cognitively healthy older adults. Findings were gender-specific, with MBI affecting more men than women. Knowing the estimates of these symptoms in the population is essential for understanding and differentiating the very early development of clinical disorders.

A Comparison of Sex Differences in Psychotropic Medication Use in Older People with Alzheimer's Disease in the US and Finland

AIMS

Given the high prevalence of psychotropic medication use in people with dementia and the potential for different prescribing practices in men and women, our study aimed to investigate sex differences in psychotropic medication use in older adults with Alzheimer's disease (AD) living in the US and Finland.

METHODS

We used data collected between 2005 and 2011 as part of the National Alzheimer's Coordinating Center (NACC) in the US, and Medication use and Alzheimer's disease (MEDALZ) cohorts in Finland. We evaluated psychotropic medication use (antidepressant, antipsychotic, anxiolytic, sedative, or hypnotic) in participants aged 65 years or older. We employed multivariable logistic regression adjusted for demographics, co-morbidities, and other medications to estimate the magnitude of the association (adjusted odds ratio [aOR] with 95% confidence intervals [CIs]) according to sex.

RESULTS

We included 1099 NACC participants (502 [45.68%] men, 597 [54.32%] women), and 67,049 participants from the MEDALZ cohort (22,961 [34.24%] men, 44,088 [65.75%] women). Women were more likely than men to use psychotropic medications: US, 46.2% vs. 33.1%, p < 0.001; Finland, 45.3% vs. 36.1%, p < 0.001; aOR was 2.06 (95% CI 1.58-2.70) in the US cohort and 1.38 (95% CI 1.33-1.43) in the Finnish cohort. Similarly, of the different psychotropic medications, women were more likely to use antidepressants (aOR-US: 2.16 [1.44-3.25], Finland: 1.52 [1.45-1.58]) and anxiolytics (aOR-US: 2.16 [1.83-3.96], Finland: 1.17 [1.13-1.23]) than men.

CONCLUSION

Older women with AD are more likely to use psychotropic medications than older men, regardless of study population and country. Approaches to mitigate psychotropic medication use need to consider different prescribing habits observed in older women vs. men with AD.

Gender differences in behavioral and psychological symptoms of patients with Alzheimer's disease

Behavioral and psychological symptoms of dementia (BPSD) in patients with Alzheimer's disease have a strong correlation with cognitive impairment and impairment in activities of daily living. Although recent studies have reported that gender may play a role in BPSD, this finding was not evident in several other studies. The present study classified patients with Alzheimer's disease into groups with mild and moderate dementia to examine the gender differences in BPSD in each group. We divided a total of 125 patients diagnosed with Alzheimer's disease according to the criteria of the fifth edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-5) into groups with mild and moderate dementia. Then we examined whether the groups showed differences in memory functions, activities of daily living, and BPSD depending on gender. Our results showed a significant gender difference in Depression/Dysphoria symptoms (BPSD) among the patients in the mild dementia group (t=-2.344, p<0.05), but there was no significant gender difference among the patients in the moderate dementia group. For both the mild and moderate dementia groups, there were no significant gender differences in memory functions and activities of daily living. The results of this study indicated that female patients with mild dementia are more vulnerable to depression than male patients. Future studies should more continuously examine a variety of factors that affect BPSD depending on the severity of Alzheimer's disease.

Gender differences in clusters of NPS in Dutch nursing homes - a factor analysis

BACKGROUND

Neuropsychiatric symptoms (NPS) have a high prevalence among patients with dementia, up to 80%. NPS can be grouped by type and stage of dementia. However, NPS have not previously been grouped by gender. Our objective was to investigate whether NPS cluster differently in men or women in the nursing home patients.

METHODS

Factor analysis to assess the clustering of items in the Cohen-Mansfield Agitation Inventory (CMAI) and Neuropsychiatric Inventory-Nursing home version (NPI-NH) into components, for both scales and for gender. Differences in symptom clustering between male and female patients were assessed using a three-step procedure: (1) identifying a gender specific distinctive item, (2) describe the correlation between the distinctive item with any other item in this cluster, (3) testing whether the correlation between a distinctive item and any other item in the cluster (which is present in both sexes) is different for males and females using a general linear model.

RESULTS

Our database consisted of 1,609 patients. There were five male and three female clusters for NPI-NH and eight male and seven female clusters for CMAI. There were three distinctive items in the NPI-NH and ten in the CMAI.

CONCLUSIONS

There are other clusters of NPS in males and females. Our analysis revealed more significant relations in female than male patients. This might have an implication on the clinical course.

Severity of Neuropsychiatric Symptoms in Nursing Home Residents

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

Educational disparities in antipsychotic drug use among older people with and without dementia in Sweden

OBJECTIVE

Antipsychotic drugs are commonly used to treat behavioural and psychological symptoms of dementia. The aim was to investigate if socioeconomic position was associated with antipsychotic drug treatment among older adults with and without dementia.

METHOD

By record linkage of the Swedish Prescribed Drug Register, Patient Register, and Educational Register, we obtained information on antipsychotics, dementia status, and educational level for 641,566 persons aged 75-89 year old in Sweden 2005.

RESULTS

Among persons diagnosed with dementia (n = 32 092), 21% used antipsychotics compared with 4% in the total sample (n = 641,566). Lower education was associated with a higher probability of antipsychotic use in the total sample (adjusted odds ratio [OR] low vs. high education: 1.56; 95% confidence interval [CI]: 1.48-1.64). In the dementia subpopulation, lower education was also associated with a higher likelihood of use of antipsychotics (adjusted OR(low vs. high) 1.43; 95% CI: 1.28-1.59).

CONCLUSION

People with dementia were five times more likely to use antipsychotic drugs than the general population of older adults. Also, lower education was associated with a higher use of antipsychotics, both in the general population and in the subgroup of persons with dementia. This finding highlights the importance of investigating healthcare inequalities also among cognitively impaired older adults.

Neuropsychiatric Symptoms in Patients With Alzheimer's Disease: The Role of Caregiver Burden and Coping Strategies

This study was conducted to obtain data regarding the association of caregiver burden (CB) and neuropsychiatric symptoms (NPSs) in patients with Alzheimer's disease. We conducted a series of multiple linear regressions to determine the relationship between CB and NPSs and whether the caregiver coping strategies mediated this relationship. The NPSs were assessed using the Neuropsychiatric Inventory, and caregivers were evaluated with the Caregiver Burden Interview and the Inventory and the Coping Strategies Inventory. Results show that patients with more frequent and severe NPS were more likely to be cared for by more burdened caregivers, and this was partially mediated by caregiver coping strategies. More disengagement (β = .330,P< .001) and less engagement coping (β = -.347,P< .001) were predictors for NPS after adjusting for patient and caregiver characteristics. These results may be useful with a view to designing treatment interventions that aim to modify the use of caregiver coping strategies and to reduce NPSs.

Effect of medications on physical function and cognition in nursing home residents with dementia

OBJECTIVES

To assess the effectiveness of medications used in the management of Alzheimer's disease and related dementias (ADRD) on cognition and activity of daily living (ADL) trajectories and to determine whether sex modifies these effects.

DESIGN

Two-year (2007-2008) longitudinal study.

SETTING

Medicare enrollment and claims data linked to the Minimum Dataset 2.0.

PARTICIPANTS

Older nursing home (NH) residents with newly diagnosed ADRD (n = 18,950).

MEASUREMENTS

Exposures included four medication classes: antidementia medications (ADMs), antipsychotics, antidepressants, and mood stabilizers. Outcomes included ADLs and cognition (Cognitive Performance Scale (CPS)). Marginal structural models were employed to account for time-dependent confounding.

RESULTS

The mean age was 83.6, and 76% of the sample was female. Baseline use of ADMs was 15%, antidepressants was 40%, antipsychotics was 13%, and mood stabilizers was 3%. Mean baseline ADL and CPS scores were 16.6 and 2.1, respectively. ADM use was not associated with change in ADLs over time but was associated with a slower CPS decline (slope difference: -0.09 points/year, 99% confidence interval (CI) = -0.14 to -0.03). Antidepressant use was associated with slower declines in ADL (slope difference: -0.36 points/year, 99% CI = -0.58 to -0.14) and CPS (slope difference: -0.12 points/year, 99% CI = -0.17 to -0.08). Sex modified the effect of both antipsychotic and mood stabilizer use on ADLs; female users declined most quickly. Antipsychotic use was associated with slower CPS decline (slope difference: -0.11 points/year, 99% CI = -0.17 to -0.06), whereas mood stabilizer use had no effect.

CONCLUSION

Despite the observed statistically significantly slower declines in cognition with ADMs, antidepressants, and antipsychotics and the slower ADL decline found with antidepressants, it is unlikely that these benefits are of clinical significance.