Violent and criminal manifestations in dementia patients

Characteristics of forensic psychiatric patients with a neurocognitive disorder

BACKGROUND

Emotional and behavioural disturbances accompanying neurocognitive disorders may sometimes lead to a criminal offence. Our knowledge of this specific forensic subpopulation is lagging behind the knowledge on, and attention for, 'classic' psychiatric disorders in forensic populations.

AIMS

To gain knowledge on the prevalence and characteristics of individuals with neurocognitive disorders in the forensic population.

METHOD

This retrospective database study uses an anonymised data-set of the National Database of penitentiary psychiatric centres (PPC) (N = 8391), which collects data on all patients admitted to one of the four PPCs (mental health clinics within the prison system) in The Netherlands since May 2013. Inclusion criterion for this study was the presence of a Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) or Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic code belonging to the category of neurocognitive disorders.

RESULTS

A DSM-IV-TR or DSM-5 diagnostic code of a neurocognitive disorder was classified in 254 out of 8391 unique individuals, resulting in a prevalence of 3.0% in the total PPC population. The most prevalent diagnosis was unspecified neurocognitive disorder (59.1%). The neurocognitive disorder group significantly differed from a random control group from the database (n = 762) on demographic, clinical and criminological variables.

CONCLUSIONS

The prevalence of neurocognitive disorders in this real-world clinical sample is remarkably lower than in two earlier studies in similar populations. Also remarkable is the relatively high prevalence of an unspecified neurocognitive disorder. These findings lead us to hypothesise that neurocognitive disorders may be underdiagnosed in this population. Forensic psychiatric settings should evaluate whether they have sufficient expertise available in neuropsychological assessment.

Criminal behavior in alcohol-related dementia and Wernicke-Korsakoff syndrome: a Nationwide Register Study

BACKGROUND

Chronic heavy alcohol use may lead to permanent brain damage, cognitive impairment, and dementia. While the link between alcohol use and crime is strong, virtually no research exists on the criminal behavior of patients with the alcohol-related neurocognitive disorders of Wernicke-Korsakoff syndrome (WKS) and alcohol-related dementia (ARD).

METHODS

The study population included all persons diagnosed with WKS (n = 1149) or ARD (n = 2432) in Finland in 1998-2015. Data on diagnoses, mortality, and crime were obtained from Finnish nationwide registers. Crime incidences were calculated 4 years before and after diagnosis. Crime types, incidences, and mortality were compared between disorders and with the general population.

RESULTS

Altogether 35.6% of WKS patients and 23.6% of ARD patients had committed crimes in the 4 years preceding diagnosis, most commonly property and traffic crimes, followed by violent crimes. The incidence of criminal behavior decreased significantly after diagnosis; in WKS patients, the standardized criminality ratio (SCR), the ratio of observed to expected number of crimes (95% CI), was 3.91 (3.72-4.10) in 4 years before and 2.80 (2.61-3.00) in 4 years after diagnosis. Likewise, in ARD patients, the SCRs were 2.63 (2.51-2.75) before and 0.84 (0.75-0.92) after diagnosis. No significant difference emerged in mortality between persons with and without a criminal history.

CONCLUSIONS

Persons with alcohol-related neurocognitive disorders frequently engage in criminal behavior prior to diagnosis, especially multiple offending. In the 4 years before and after diagnosis, crime rates declined in a linear fashion, with a marked reduction after diagnosis.

Risk management and decision-making in dementia care

What constitutes a risk for a person living with dementia may be perceived and prioritised differently by nurses from varying clinical backgrounds. Furthermore, risk may be perceived differently according to the context. This article outlines some of the social, psychological and physical risk factors relevant to people living with dementia across the life course of the condition. It is important that nurses understand their role in identifying, assessing and managing risk and are aware of the resources, policies, legislation and processes designed to support decision-making and minimise the risk of harm to people living with dementia, their families and carers. The authors hope that this article will support nurses to become more confident in identifying risk while encouraging them to adopt a proactive and person-centred approach to risk assessment and management.

The Implications of Moral Neuroscience for Brain Disease: Review and Update

The last 2 decades have seen an explosion of neuroscience research on morality, with significant implications for brain disease. Many studies have proposed a neuromorality based on intuitive sentiments or emotions aimed at maintaining collaborative social groups. These moral emotions are normative, deontological, and action based, with a rapid evaluation of intentionality. The neuromoral circuitry interacts with the basic mechanisms of socioemotional cognition, including social perception, behavioral control, theory of mind, and social emotions such as empathy. Moral transgressions may result from primary disorders of moral intuitions, or they may be secondary moral impairments from disturbances in these other socioemotional cognitive mechanisms. The proposed neuromoral system for moral intuitions has its major hub in the ventromedial prefrontal cortex and engages other frontal regions as well as the anterior insulae, anterior temporal lobe structures, and right temporoparietal junction and adjacent posterior superior temporal sulcus. Brain diseases that affect these regions, such as behavioral variant frontotemporal dementia, may result in primary disturbances of moral behavior, including criminal behavior. Individuals with focal brain tumors and other lesions in the right temporal and medial frontal regions have committed moral violations. These transgressions can have social and legal consequences for the individuals and require increased awareness of neuromoral disturbances among such individuals with brain diseases.

Criminal Behaviour After Diagnosis of a Neurocognitive Disorder: A Nationwide Finnish Register Study

OBJECTIVE

To explore criminal behavior of individuals with Alzheimer's disease (AD), frontotemporal dementia (FTD), or Lewy body dementias (LBD) after the diagnosis.

DESIGN

Nationwide register study.

SETTING

Information on diagnoses and criminality was received from Finnish registers. Crime types and incidences were compared between disorders and the general population.

PARTICIPANTS

All Finnish individuals diagnosed with AD, LBD, or FTD (n = 92 189) during 1998-2015.

MEASUREMENTS

Types of crimes and incidences, the standardized criminality ratio (SCR, number of actual crimes per number of expected crimes), numbers of observed cases, and person-years at risk counted in 5-year age groups and for both sexes and yearly.

RESULTS

Among men, at least one crime was committed by 2.8% of AD, 7.2% of FTD, and 4.8% of LBD patients. Among women, the corresponding figures were 0.4%, 2.0%, and 2.1%. The most frequent type of crime was traffic offence, followed by property crime. After age adjustment, the relative number of crimes between groups did not differ, except that men with FTD and LBD committed more crimes than those with AD. The SCR (95% CI) among men were 0.40 (0.38-0.42) in AD, 0.45 (0.33-0.60) in FTD, and 0.52 (0.48-0.56) in LBD. Among women, these were 0.34 (0.30-0.38), 0.68 (0.39-1.09), and 0.59 (0.51-0.68).

CONCLUSIONS

The diagnosis of a neurocognitive disorder does not increase criminal behavior, but rather reduces it by up to 50%. Differences in crime activity are present between different neurocognitive disorders and between the sexes.

Culpability for offenses in frontotemporal dementia and other brain disorders

The responsibility of persons with brain disorders who commit offenses may depend on how their disorders alter brain mechanisms for culpability. Criminal behavior can result from brain disorders that alter social cognition including a neuromoral system of intuitive moral emotions that are absolute (deontological) normative codes and that includes an emotion-mediated evaluation of intentionality. This neuromoral system has its hub in the ventromedial prefrontal cortex (VMPFC) with other frontal, anterior temporal-amygdalar, insular, and right temporoparietal connections. Among brain disorders, investigators report offenses in persons with brain tumors, epilepsy, and traumatic brain injury, but it is those with a form of dementia with VMPFC pathology, behavioral variant frontotemporal dementia (bvFTD), who are most prone to criminal behavior. This review presents four new patients with bvFTD who were interviewed after committing offenses. These patients knew the nature of their acts and the wrongness of the type of action but lacked substantial capacity to experience the criminality of their conduct at the intuitive, deontological, moral emotional level. Disease in VMPFC and its amygdalar connections may impair moral emotions in these patients. These findings recommend evaluation for the experience of moral emotions and VMPFC-amygdala dysfunction among persons with antisocial behavior, with or without brain disease.

Do patients diagnosed with a neurological disease present increased risk of suicide?

INTRODUCTION

Neurological diseases are the leading cause of disability and the second leading cause of death worldwide. Physical and psychological pain, despair, and disconnection with the environment are observed after the diagnosis of numerous neurological processes, particularly neurodegenerative diseases.

DEVELOPMENT

A higher risk of suicide is observed in patients with such common neurological diseases as epilepsy, migraine, and multiple sclerosis, as well as in those with such degenerative disorders as Alzheimer disease, Huntington disease, amyotrophic lateral sclerosis, and Parkinson's disease. In most cases, suicidal ideation appears in the early stages after diagnosis, in the presence of disabling symptoms, and/or in patients with psychiatric comorbidities (often associated with these neurological diseases).

CONCLUSIONS

Effective suicide prevention in this population group requires assessment of the risk of suicide mainly in newly diagnosed patients, in patients showing unmistakable despair or disabling symptoms, and in patients presenting psychiatric comorbidities (especially depressive symptoms). It is essential to train specialists to detect warning signs in order that they may adopt a suitable approach and determine when psychiatric assessment is required.

The risk of criminal behavior in the elderly and patients with neurodegenerative disease

Behavioral changes are commonly observed in patients with dementia and can lead to criminal offenses, even without a history of criminal or antisocial behavior. Due to the growth of the aging population, this poses a rising problem to deal with for the criminal justice system and in general for society. Criminal behavior may include minor crimes such as theft or traffic violations, but also serious crimes such as physical abuse, sexual offense, or murder. In the assessment of criminal behavior among elderly (first-time) offenders, it is important to be aware of possible neurodegenerative diseases at the time of the crime. This book chapter provides an overview on criminal behavior in the elderly and specifically discusses existing literature on patients suffering from a neurodegenerative disease, including Alzheimer disease, vascular dementia, frontotemporal dementia, Parkinson disease, and Huntington disease. Each section is introduced by a true case to illustrate how the presence of a neurodegenerative disease may affect the criminal judgment. The chapter ends with a summary, multifactorial model of crime risk, future perspectives, and concluding remarks.

Behavioral Variant Frontotemporal Dementia and Social and Criminal Transgressions

OBJECTIVE

Behavioral variant frontotemporal dementia (bvFTD) is associated with social and criminal transgressions; studies from countries around the world have documented such behavior in persons with this condition. An overview and analysis of social and criminal transgressions in bvFTD and their potential neurobiological mechanisms can provide a window for understanding the relationship of antisocial behavior and the brain.

METHODS

This review evaluated the literature on the frequency of social and criminal transgressions in bvFTD and the neurobiological disturbances that underlie them.

RESULTS

There is a high frequency of transgressions among patients with bvFTD due to impairments in neurocognition, such as social perception, behavioral regulation, and theory of mind, and impairments in social emotions, such as self-conscious emotions and empathy. Additionally, there is significant evidence for a specific impairment in an innate sense of morality. Alterations in these neurobiological processes result from predominantly right-hemisphere pathology in frontal (ventromedial, orbitofrontal, inferolateral frontal), anterior temporal (amygdala, temporal pole), limbic (anterior cingulate, amygdala), and insular regions.

CONCLUSIONS

Overlapping disturbances in neurocognition, social emotions, and moral reasoning result from disease in the mostly mesial and right-sided frontotemporal network necessary for responding emotionally to others and for behavioral control. With increased sophistication in neurobiological interventions, future goals may be the routine evaluation of these processes among individuals with bvFTD who engage in social and criminal transgressions and the targeting of these neurobiological mechanisms with behavioral, pharmacological, and other interventions.

A comparison of older and younger offenders with delusional jealousy

We sought to determine whether or not there were differences in medical, criminological and legal factors between older and younger offenders with diagnoses of delusional jealousy by undertaking a retrospective case-file search of Australian legal databases. Our results demonstrate that older offenders were more likely to have comorbid dementia whereas younger offenders were more likely to have comorbid substance use and chronic psychotic conditions. A history of domestic violence frequently predated the index offence but we were unable to determine if this was due to psychosis or a pre-existing tendency for violence. Despite a common diagnosis, the older offenders were more likely to be made forensic patients rather than sentenced prisoners when compared with the younger offenders. Consequently, different factors might mediate the pathway to violence in older and younger people suffering from delusional jealousy and could be additional targets for clinical intervention.

Determinants of violence towards care workers working in the home setting: A systematic review

BACKGROUND

Home care is a rapidly growing industry. Violence towards home care workers is common, while also likely underreported. This violence adversely affects the physical and mental health of both workers and care recipients. The current study aims to identify and appraise recent evidence on the determinants of violence towards care workers working in the home setting.

METHODS

Six electronic databases: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Informit, Medline, PsycINFO, and Web of Science, were systematically searched. A systematic review was conducted in accordance with the Joanna Briggs Institute manual for evidence synthesis.

RESULTS

A total of 18 papers met the inclusion criteria. All were cross-sectional surveys. The majority of studies were from the United States. The most commonly investigated associations were those between the medical history of clients, workers' apprehension of violence, worker-client relationship, or care plans, and any form of violence or verbal abuse.

CONCLUSION

Violence was common in clients with cognitive disorders, substance abuse disorder, and limited mobility; toward workers who feared that violence might happen; toward those who had very close or very distant worker-client relationships; and when care plans were not inclusive of clients' needs. The current review highlights a gap in evidence on determinants of violence towards care workers working in the home setting, and suggests potential areas to be addressed to reduce such violence.

Homicide and Dementia: A Systematic Review

BACKGROUND

Homicide by older offenders is rare and devastating. It likely occurs due to a complex interaction of personal, social, and environmental factors. Dementia is a progressive neurological condition which may amplify behavioural disturbances such as aggression. This systematic review aims to evaluate the factors associated with homicide committed by people with dementia in order to inform clinical practice.

SUMMARY

MEDLINE, PsychINFO, Embase, and PubMed databases were searched in accordance with PRISMA guidelines for empirical studies examining the characteristics and circumstances of people with dementia who committed homicides. Data on factors associated with the homicide were extracted and the quality of each study rated using standardized criteria. A total of 499 papers were screened and thirteen studies met the inclusion criteria. Study design included case reports (seven studies), case series (four studies), and two retrospective cohort studies, indicative of low levels of evidence. Sample sizes were 1-70. Study findings were predominantly descriptive. Quality ratings ranged from 50 to 100%. Factors associated with disinhibition such as dysexecutive syndrome, alcohol use, and delirium may predispose to severe impulsive aggression. Psychosis and personality pathology appeared to influence targeted assaults resulting in homicide by people with dementia. Victim vulnerability was also a key element.

KEY MESSAGES

The current evidence examining risk factors for homicide committed by people with dementia is limited. However, there are common characteristics reported in these descriptive studies including psychiatric factors and cognitive states causing disinhibition. Recommendations for clinical practice include early assessment of older people with dementia and changed behaviours to allow management of comorbidities and reversible risk factors, alongside education, and advice to carers (who may be targets of aggression). Specialized geriatric forensic psychiatry services and care settings should be developed.

Criminal Behavior in the Four Years Preceding Diagnosis of Neurocognitive Disorder: A Nationwide Register Study in Finland

OBJECTIVE

To explore the criminality of patients with subsequent diagnosis of Alzheimer's disease (AD), frontotemporal dementia (FTD), or Lewy body dementias (LBD) in the four years preceding diagnosis.

DESIGN

Nationwide register study.

SETTING

Data on Finnish patients were collected from the discharge register and data on criminal offending from the police register. Research findings were compared with the same-aged general population.

PARTICIPANTS

A total of 92,191 patients who had received a diagnosis of AD (N = 80,540), FTD (N = 1,060), and LBD (N = 10,591) between 1998 and 2015.

MEASUREMENTS

Incidences and types of crimes, the standardized criminality ratio (number of actual crimes per number of expected crimes), and the numbers of observed cases and person-years at risk counted in five-year age groups and separately for both genders and yearly.

RESULTS

At least one crime was committed by 1.6% of AD women and 12.8% of AD men, with corresponding figures of 5.3% and 23.5% in FTD, and 3.0% and 11.8% in LBD. The first crime was committed on average 2.7 (standard deviation 1.1) years before the diagnosis. The standardized criminality ratio was 1.85 (95% confidence interval [CI] 1.43-2.37) in FTD women and 1.75 (95% CI 1.54-1.98) in FTD men, and in AD 1.11 (95% CI 1.04-1.17) and 1.23 (95% CI 1.20-1.27), respectively. Traffic offences and crimes against property constituted 94% of all offences.

CONCLUSION

Criminal acts may occur several years prior to the diagnosis of dementia. If novel criminality occurs later in life, it may be associated with neurocognitive disorder.

[Criminal behavior in frontotemporal dementia and Alzheimer's disease]

Seniorenkriminalität ist insgesamt ein seltenes Phänomen. Bei älteren Straftätern hat es die Justiz in hohem Maß mit Ersttätern zu tun, die mehrheitlich männlichen Geschlechts sind. Eine mögliche Ursache von Erstkriminalität im höheren Lebensalter stellen Demenzerkrankungen dar. Es ist jedoch wenig dazu bekannt, wie häufig Demenzerkrankungen tatsächlich Ursache delinquenten Verhaltens im höheren Lebensalter sind. Die Demenzprävalenz in Studien mit forensischen Kohorten älterer Straftäter ist sehr heterogen, was vor allem studienmethodisch begründet ist. Längsschnittlich begehen etwa 50 % aller Patienten mit frontotemporaler Demenz und etwa 10 % aller Patienten mit Alzheimer-Demenz Delikte im Erkrankungsverlauf. Die neurobiologischen Entstehungsmechanismen von Delinquenzverhalten im Rahmen von Demenzen sind unvollständig verstanden. Nach aktuellen Erkenntnissen wird davon ausgegangen, dass Erstdelinquenz im Rahmen von Demenzerkrankungen als Folge von Beeinträchtigungen der sozialen Kognition, Empathiefähigkeit und der Verhaltenskontrolle zu verstehen ist. Bedeutsam sind insbesondere frontale und anteriore temporale Hirnstrukturen. Demenzerkrankungen können zu Beeinträchtigungen der Schuldfähigkeit führen, weshalb forensisch-psychiatrische Sachverständige auch mit Demenzerkranken konfrontiert sind. Hierbei müssen ätiologiespezifische Besonderheiten berücksichtigt werden. Insbesondere Erstdelikte im Rahmen wesensuntypischer Persönlichkeitsänderungen nach dem 50. Lebensjahr sollten an eine neurodegenerative Ätiologie denken lassen. Insbesondere frontotemporale Demenzerkrankungen, wie die behaviorale Variante einer frontotemporalen Demenz (bvFTD), aber auch die semantische Demenz (svPPA), prädisponieren zu delinquentem Verhalten.Diese Arbeit fasst aktuelle Erkenntnisse zu dieser forensisch-psychiatrisch, aber auch klinisch relevanten Thematik zusammen.

Do patients diagnosed with a neurological disease present increased risk of suicide?

INTRODUCTION

Neurological diseases are the leading cause of disability and the second leading cause of death worldwide. Physical and psychological pain, despair, and disconnection with the environment are observed after the diagnosis of numerous neurological processes, particularly neurodegenerative diseases.

DEVELOPMENT

A higher risk of suicide is observed in patients with such common neurological diseases as epilepsy, migraine, and multiple sclerosis, as well as in those with such degenerative disorders as Alzheimer disease, Huntington disease, amyotrophic lateral sclerosis, and Parkinson's disease. In most cases, suicidal ideation appears in the early stages after diagnosis, in the presence of disabling symptoms, and/or in patients with psychiatric comorbidities (often associated with these neurological diseases).

CONCLUSIONS

Effective suicide prevention in this population group requires assessment of the risk of suicide mainly in newly diagnosed patients, in patients showing unmistakable despair or disabling symptoms, and in patients presenting psychiatric comorbidities (especially depressive symptoms). It is essential to train specialists to detect warning signs in order that they may adopt a suitable approach and determine when psychiatric assessment is required.

Violence In Older Adults: Scope, Impact, Challenges, And Strategies For Prevention

Although often perceived to be a problem of the young, violence commonly affects older adults, a rapidly growing segment of the population. Violence can be directed toward older adults (elder abuse and intimate partner violence), self-directed (suicide), or perpetrated by older adults against others (intimate partner violence and violence in dementia). Across forms of violence, firearm access increases lethality, and veterans may be a particularly high-risk population. The forms of violence in older adults have some common risk factors (such as medical or psychiatric illness) and common challenges for prevention (such as balancing autonomy and well-being in vulnerable adults). The integration of prevention strategies across the life span, disciplines, and forms of violence offers promise for promoting older adult health and well-being. Looking forward, key areas for attention will include raising awareness about these topics and prioritizing funding for the implementation and evaluation of violence prevention interventions in health care settings and the community.

Euthanasia and other end of life in patients suffering from dementia

Medicine aims to relieve patient suffering and cure illness. To relieve suffering is the heart of what doctors do. However, respect for individual autonomy and self-determination are fundamental principles in Western medical ethics and decision-making, often expressed as a desire for control over the timing and manner of death. Patients who become demented often formulate advance euthanasia and assisted suicide directives. Dealing with such request is quite complex because of the specific medical and conflicting ethical questions they raise. Some specific medical and ethical issues arise regarding these substantive requirements when evaluating the euthanasia request of a person suffering from dementia. In jurisdictions that allow euthanasia, the most fundamental prerequisite for a person to make autonomous decisions is capacity. Whether anyone with moderate or severe dementia, and even some with mild dementia, could be deemed to be competent by these criteria is debatable, but during the course of their disease people with dementia sooner or later lose their capacity to make self-determined decisions.

'I am dead': Cotard syndrome and dementia

Background: Cotard syndrome is a rare condition whose main feature is a nihilistic delusion ranging from the denial of body parts to that of the existence of one's own life or even the entire universe. Objectives: The aim of this article is to review the nosological significance of Cotard syndrome and to explore the disorder among patients with dementia. Methods: Medline and Google Scholar searches were conducted for relevant articles, chapters and books published before 2018. Search terms used included Cotard delusion, Cotard syndrome and dementia, nihilistic delusion. Publications found through this indexed search were reviewed for further relevant references. Results and conclusion: In this narrative review we emphasise the fact that cases of Cotard syndrome involving patients with dementia are reported quite infrequently. Published studies are limited to very short series or isolated cases. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent in this condition. Keypoints Cotard syndrome is a rare condition characterised by nihilistic delusions that may range from negation of existence of parts of the body to delusion of being dead. The prevalence and incidence of this rare syndrome are not known. Since Cotard's syndrome is conceptualised as part of an underlying disorder, several psychiatric and somatic diseases have been associated with the syndrome. The syndrome may occur in patients suffering from dementia.

A Contagious Disorder: Folie à Deux and Dementia

BACKGROUND

Folie à deux is a clinical condition that was first described in 19th century. It is a psychotic disorder in which two closely associated individuals share a similar delusional system.

OBJECTIVES

The aim of this article is to review the nosological significance of folie à deux and to explore the disorder among patients with dementia.

METHODS

Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2017. Search terms used included dementia, folie à deux, induced delusional disorder, neurocognitive disorders, shared psychotic disorder. Publications found through this indexed search were reviewed for further relevant references.

RESULTS AND CONCLUSION

Cases of Folie à deux involving patients with dementia are reported quite infrequently. Most of the studies on the topic consist in case reports. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent this psychotic syndrome.

Armed and Aging: Dementia and Firearms Do Not Mix !

The possibility that persons with dementia possess firearms is cause for concern, but only a limited number of research studies have been conducted on such a topic, usually in the form of case reports. Reducing the occurrence of the firearm-related violence requires effectively identifying dangerous individuals and keeping firearms out of their hands. The health care professionals, i.e. the social workers and the physicians, need to work together and to produce a suitable evaluation of patients with dementia to prevent firearm-related injuries and serious and irreparable damage to persons.

Old and dangerous: Prison and dementia

Older prisoners are the fastest growing group of prisoners in many countries. The purpose of this study is to explore the phenomenon of detention of persons suffering from dementia. Medline searches were conducted for relevant articles, chapters and books published until August 2016. Search terms included dementia, elderly, prison and criminal. Publications found through this indexed search were reviewed for further relevant references. As results, there is a lack of data about elderly with dementia in prisons. Given the rise in the average age, it is reasonable to hypothesize that the number of older prisoners is growing. Moreover, some elderly are imprisoned with a concomitant cognitive impairment or psychiatric disorder while others will develop such diseases once incarcerated. At the present time, legal and social systems seem unprepared to handle the phenomenon of dementia in prison. As proposal, health assessments for older first time offenders should become a practice inside the correctional facilities and include an evaluation for specific health issues, such as psychiatric comorbidity and cognitive impairment.

Voices of Spouses Living with Partners with Neuropsychiatric Symptoms Related to Dementia

Persons with dementia, who reside in their own homes, are often cared for by family members. The presence of a family career is said to have a protective effect, postponing admissions to residential care. The majority of persons with dementia develop behavioural and personality changes during the disease trajectory also known as neuropsychiatric symptoms. Quality of life for both the person with neuropsychiatric symptoms and their careers are affected, increasing suffering and risk for hospitalisation and admission to long-term residential care. Family careers to persons with dementia have identified behavioural changes as more distressing than cognitive impairment leading to increased burden of care and admissions to residential care. Knowledge gaps exist regarding how family careers living with persons with dementia experience neuropsychiatric symptoms in a community setting. The aim was to describe spouses' experiences of living with partners who have developed neuropsychiatric symptoms related to dementia in a community setting. Semi-structured interviews were carried out with 14 spouses of partners with dementia. The interviews included completion of the neuropsychiatric inventory. Interview data were analysed using a content analysis approach. The results showed that spouses identified in the neuropsychiatric inventory that partners with dementia had on average five to eight co-existing symptoms. Frequency, severity and distress varied. From the narrative data, the theme living on the edge lacking support and time for self, emerged. The findings of this study suggest that support offered to persons with dementia and their spouses should have a person-centred approach meeting individual needs. Safety and welfare of persons with dementia and their spouses residing in their own homes may be jeopardised in the presence of neuropsychiatric symptoms. A greater awareness is required in the community regarding the well-being of these persons.

Chronic disease self-management support for persons with dementia, in a clinical setting

The burden of chronic disease is greater in individuals with dementia, a patient group that is growing as the population is aging. The cornerstone of optimal management of chronic disease requires effective patient self-management. However, this is particularly challenging in older persons with a comorbid diagnosis of dementia. The impact of dementia on a person’s ability to self-manage his/her chronic disease (eg, diabetes mellitus or heart failure) varies according to the cognitive domain(s) affected, severity of impairment and complexity of self-care tasks. A framework is presented that describes how impairment in cognitive domains (attention and information processing, language, visuospatial ability and praxis, learning and memory and executive function) impacts on the five key processes of chronic disease self-management. Recognizing the presence of dementia in a patient with chronic disease may lead to better outcomes. Patients with dementia require individually tailored strategies that accommodate and adjust to the individual and the cognitive domains that are impaired, to optimize their capacity for self-management. Management strategies for clinicians to counter poor self-management due to differentially impaired cognitive domains are also detailed in the presented framework. Clinicians should work in collaboration with patients and care givers to assess a patient’s current capabilities, identify potential barriers to successful self-management and make efforts to adjust the provision of information according to the patient’s skill set. The increasing prevalence of age-related chronic illness along with a decline in the availability of informal caregivers calls for innovative programs to support self-management at a primary care level.

Inappropriate behaviors and hypersexuality in individuals with dementia: An overview of a neglected issue

Behavioral and psychological symptoms of dementia are very common in patients affected by dementia, and are associated with high rates of institutionalization. Behavioral and psychological symptoms of dementia consist of aggressive behavior, delusions, hallucinations, depression, apathy, wandering, stereotyped and inappropriate sexual behavior. Interestingly, the latter has been reported to be relatively uncommon, but causing immense distress to patients and their caregivers. The genesis of inappropriate behavior is considered a combination of neurological, psychological and social factors. Although assessment is mainly carried out by clinical observation and interviews with caregivers, the most appropriate management of behavioral and psychological symptoms of dementia, including hypersexuality, is a combination of pharmacological and non-pharmacological interventions, according to specific symptoms, degree of cognitive dysfunction and subtype of dementia. The present narrative review will mainly focus on aggressiveness, disinhibition, aberrant motor, and sexually inappropriate behavior diagnostic work-up and treatment, in an attempt to provide both the patients and their caregivers with useful information to better manage these symptoms and improve their quality of life. Space is particularly dedicated to inappropriate sexual behavior, which is still considered a neglected issue. Geriatr Gerontol Int 2017; 17: 865-874.