Prevalence of neuropsychiatric symptoms in elderly patients with dementia in Mungialde County (Basque Country, Spain)

Predicting neurodegeneration from sleep related biofluid changes

Sleep-wake disturbances are common in neurodegenerative diseases and may occur years before the clinical diagnosis, potentially either representing an early stage of the disease itself or acting as a pathophysiological driver. Therefore, discovering biomarkers that identify individuals with sleep-wake disturbances who are at risk of developing neurodegenerative diseases will allow early diagnosis and intervention. Given the association between sleep and neurodegeneration, the most frequently analyzed fluid biomarkers in people with sleep-wake disturbances to date include those directly associated with neurodegeneration itself, such as neurofilament light chain, phosphorylated tau, amyloid-beta and alpha-synuclein. Abnormalities in these biomarkers in patients with sleep-wake disturbances are considered as evidence of an underlying neurodegenerative process. Levels of hormonal sleep-related biomarkers such as melatonin, cortisol and orexin are often abnormal in patients with clinical neurodegenerative diseases, but their relationships with the more standard neurodegenerative biomarkers remain unclear. Similarly, it is unclear whether other chronobiological/circadian biomarkers, such as disrupted clock gene expression, are causal factors or a consequence of neurodegeneration. Current data would suggest that a combination of fluid biomarkers may identify sleep-wake disturbances that are most predictive for the risk of developing neurodegenerative disease with more optimal sensitivity and specificity.

A systematic review of the prevalence of depression, anxiety, and apathy in frontotemporal dementia, atypical and young-onset Alzheimer's disease, and inherited dementia

OBJECTIVES

Depression, anxiety, and apathy are the most commonly reported neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD). Understanding their prevalence in rarer dementias such as frontotemporal dementia (FTD), primary progressive aphasia (PPA), posterior cortical atrophy (PCA), young-onset AD (YOAD), and inherited dementias has implications for both clinical practice and research. In this study, we aimed to examine the current state of knowledge of the prevalence of these three NPS in less prevalent dementias.

DESIGN

We conducted a systematic review based on searches of EMBASE, PsycINFO, and PubMed up to September 2019.

RESULTS

47 articles meeting inclusion criteria were identified. Depression, anxiety, and apathy were commonly reported across the phenotypes studied but their prevalence showed large variation between studies. Apathy showed the highest reported frequency in FTD (50-100% across studies), behavioral variant frontotemporal dementia (bvFTD) (73-100%), and YOAD (44-100%). Anxiety was frequently reported in FTD (0-100%) and bvFTD (19-63%). Depression showed the highest prevalence in FTD (7-69%) and YOAD (11-55%). Among the three variants of PPA, sv-PPA is the one most investigated (seven articles). Three or fewer articles were identified examining NPS in the remaining PPA variants, PCA, familial AD, and familial FTD. Inconsistency in the tools used to measure symptoms and small sample sizes were common methodological limitations.

CONCLUSIONS

Future studies should consider the inclusion of larger sample sizes (e.g. through multicenter collaborations) and the use of harmonized protocols that include the combination of caregiver and patient-derived measures and symptom-specific questionnaires. More research is needed on the phenotype-specific barriers and facilitators for people living with dementia to successfully engage in self-reports of NPS.

Neuropsychiatric features in a multi-ethnic population with Alzheimer disease and mild cognitive impairment

BACKGROUND

Alzheimer disease (AD) is more prevalent in African American (AA) and Hispanic White (HIW) compared to Non-Hispanic White (NHW) individuals. Similarly, neuropsychiatric symptoms (NPS) vary by population in AD. This is likely the result of both sociocultural and genetic ancestral differences. However, the impact of these NPS on AD in different groups is not well understood.

METHODS

Self-declared AA, HIW, and NHW individuals were ascertained as part of ongoing AD genetics studies. Participants who scored higher than 0.5 on the Clinical Dementia Rating (CDR) Scale (CDR) were included. Group similarities and differences on Neuropsychiatric Inventory Questionnaire (NPI-Q) outcomes (NPI-Q total score, NPI-Q items) were evaluated using univariate ANOVAs and post hoc comparisons after controlling for sex and CDR stage.

RESULTS

Our sample consisted of 498 participants (26% AA; 30% HIW; 44% NHW). Overall, NPI-Q total scores differed significantly between our groups, with HIW having the highest NPI-Q total scores, and by AD stage as measured by CDR. We found no significant difference in NPI-Q total score by sex. There were six NPI-Q items with comparable prevalence in all groups and six items that significantly differed between the groups (Anxiety, Apathy, Depression, Disinhibition, Elation, and Irritability). Further, within the HIW group, differences were found between Puerto Rican and Cuban American Hispanics across several NPI-Q items. Finally, Six NPI-Q items were more prevalent in the later stages of AD including Agitation, Appetite, Hallucinations, Irritability, Motor Disturbance, and Nighttime Behavior.

CONCLUSIONS

We identified differences in NPS among HIW, AA, and NHW individuals. Most striking was the high burden of NPS in HIW, particularly for mood and anxiety symptoms. We suggest that NPS differences may represent the impact of sociocultural influences on symptom presentation as well as potential genetic factors rooted in ancestral background. Given the complex relationship between AD and NPS it is crucial to discern the presence of NPS to ensure appropriate interventions.

Prevalence of sleep disturbances in people with dementia living in the community: A systematic review and meta-analysis

This study aimed to systematically review and meta-analyse the prevalence of sleep disturbances in people with dementia and examine demographic predictors and whether overall prevalence has changed over time. We searched Embase, MEDLINE and PsycINFO for studies reporting the prevalence of sleep disturbances in people with dementia living at home. We meta-analysed the data and calculated the pooled prevalence of sleep disturbances in people with dementia overall and in dementia subtypes. We used meta-regressions to investigate the effects of study characteristics, publication dates and participant demographics. Eleven studies fulfilled the inclusion criteria. The pooled prevalence of any symptoms of sleep disturbance was 26 % (95 % confidence intervals, CI: 23-30 %; n = 2719) and of clinically significant sleep disturbance 19 % (13-25 %; n = 2753). The pooled prevalence of sleep disturbance symptoms was significantly lower among people with Alzheimer's disease (24 %; 16-33 %, n = 310) than Lewy body dementia (49 %; 37-61 %, n = 65). Meta-regression analysis did not find that publication year, participant's age, sex and study quality predicted prevalence. Sleep disturbances are common among people with dementia living in the community, especially in Lewy body dementia. There was no change in prevalence according to publication dates, suggesting treatment has not improved over time.

The Relationship of Anxiety with Alzheimer's Disease: A Narrative Review

BACKGROUND

There is an increased effort to better understand neuropsychiatric symptoms of Alzheimer's Disease (AD) as an important feature of symptomatic burden as well as potential modifiable factors of the disease process. Anxiety is one of the most common neuropsychiatric symptoms in Alzheimer's Disease (AD). A growing body of work has emerged that addresses the epidemiology and biological correlations of anxiety in AD.

METHODS

Here, we review human studies in research and clinical cohorts that examined anxiety in AD. We focused on work related to prevalence across AD stages, correlation with established biomarkers, relationship with AD neuropathology and genetic risk factors, and impact on progression.

RESULTS

Anxiety is prominent in the early stages and increases across the spectrum of functional stages. Biomarker relationships are strongest at the level of FDG-PET and amyloid measured via PET or cerebrospinal fluid analysis. Neuropathologically, anxiety emerges with early Braak stage tau pathology. The presence of the apolipoprotein E e4 allele is associated with increased anxiety at all stages, most notably at mild cognitive impairment. Anxiety portended a faster progression at all predementia stages.

CONCLUSION

This body of work suggests a close biological relationship between anxiety and AD that begins in early stages and influences functional decline. As such, we discuss future work that would improve our understanding of this relationship and test the validity of anxiolytic treatment as disease modifying therapy for AD.

Apathy and risk of probable incident dementia among community-dwelling older adults

OBJECTIVE

To evaluate the association between baseline apathy and probable incident dementia in a population-based sample of community-dwelling older adults.

METHODS

We studied 2,018 white and black community-dwelling older adults from the Health, Aging, and Body Composition (Health ABC) study. We measured apathy at year 6 (our study baseline) with the modified Apathy Evaluation Scale and divided participants into tertiles based on low, moderate, or severe apathy symptoms. Incident dementia was ascertained over 9 years by dementia medication use, hospital records, or clinically relevant cognitive decline on global cognition. We examined the association between apathy and probable incident dementia using a Cox proportional hazards model adjusting for demographics, cardiovascular risk factors, APOE4 status, and depressed mood. We also evaluated the association between the apathy group and cognitive change (as measured by the modified Mini-Mental State Examination and Digit Symbol Substitution Test over 5 years) using linear mixed effects models.

RESULTS

Over 9 years of follow-up, 381 participants developed probable dementia. Severe apathy was associated with an increased risk of dementia compared to low apathy (25% vs 14%) in unadjusted (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.5-2.5) and adjusted models (HR 1.7, 95% CI 1.3-2.2). Greater apathy was associated with worse cognitive score at baseline, but not rate of change over time.

CONCLUSION

In a diverse cohort of community-dwelling adults, apathy was associated with increased risk of developing probable dementia. This study provides novel evidence for apathy as a prodrome of dementia.

Agitation in patients with dementia: a systematic review of epidemiology and association with severity and course

OBJECTIVES

More than 90% of individuals with Alzheimer's disease (AD) experience behavioral and neuropsychiatric symptoms (NPS), such as agitation. However, little is known regarding the specific burden of agitation for Alzheimer's patients.

DESIGN

A global systematic literature review was conducted in MEDLINE and Embase for studies of clinical, humanistic, and economic burden of agitation in AD/dementia published from 2006-2016. References of identified papers and related literature reviews were examined. Studies meeting predetermined inclusion criteria for burden of agitation/NPS were summarized.

RESULTS

Eighty papers met the inclusion criteria for burden of agitation in dementia. Wide ranges of agitation prevalence were reported, but few papers provided information on incidence. The association of agitation with AD severity was presented in multiple studies; a few suggested positive association of agitation with mortality.

CONCLUSIONS

High prevalence of agitation is consistent with earlier reports, but several gaps in understanding of agitation in AD need further exploration.

Symptoms of Anxiety in Older Adults with Depression, Dementia, or Psychosis: A Principal Component Analysis of the Geriatric Anxiety Inventory

AIMS

The primary aim of this study was to examine anxiety symptoms as measured by the Geriatric Anxiety Inventory (GAI) in older patients with depression, dementia, or psychotic disorders. The secondary aim was to conduct a principal component analysis (PCA) of the GAI and to examine whether its subscales differ between the 3 disorders.

METHODS

We included data from 428 patients who were admitted to a department of geriatric psychiatry and examined according to a standardized protocol. The GAI was used to measure current anxiety symptoms.

RESULTS

The GAI symptoms occurred more frequently in the group with depression than in the other 2 groups. The PCA of the GAI with oblimin rotation resulted in a 2-component solution, labelled as "worries" (explained variance 46.3%, Cronbach's α 0.92) and "physical symptoms" (explained variance 7.1%, Cronbach's α 0.85).

CONCLUSION

The results indicate that in old age, anxiety is especially prevalent in depression. The 2-component solution indicates that the GAI measures 2 different aspects of anxiety with different symptomatology.

Sleep Disturbances in Frontotemporal Dementia

Sleep disorders appear to be frequent comorbidities in patients with frontotemporal dementia (FTD). Insomnia and excessive daytime sleepiness commonly occur in patients with FTD and significantly contribute to caregiver burden and burnout. Sleep is severely fragmented in FTD patients, likely secondary to behavioral disturbances, other primary sleep disorders such as sleep disordered breathing and restless leg syndrome, and neurodegeneration of nuclei involved in sleep and wakefulness. Treatment of primary sleep disorders may improve excessive daytime sleepiness and sleep quality and may improve daytime cognitive functioning. Rapid eye movement (REM) sleep behavior disorder is rare in FTD and may be confused with excessive nocturnal activity due to disturbed circadian rhythm. The relationship between FTD, sleep quality, and sleep disorders requires further study to better understand the contribution of disturbed sleep to daytime neurocognitive functioning and quality of life in FTD. Further, future studies should focus on comparing sleep disturbances between different FTD syndromes, especially behavioral variant FTD and primary progressive aphasia. Comorbid sleep disorders should be promptly sought and treated in patients with FTD to improve patient and caregiver quality of life.

"Sundowning" as a biological phenomenon: current understandings and future directions: an update

The clinical phenomenon of early evening disruptive behavior also called "Sundowning" in elderly patients has been largely reported in the medical literature without a consistent diagnosis and criteria to define this phenomenon. The current understandings of sundowning are incomplete and current treatment strategies have relied heavily on use of antipsychotic medications, despite side effects and limited evidence to justify their use. A comprehensive understanding of the biogenesis of this phenomenon and mechanistic changes from oxidative pathways may provide novel information on completing the sundowning puzzle. Future studies could examine the utility of natural factors in reviving neuronal energy loss and altering the oxidative pathways might be safe and additional options in development of treatment models for this behavioral disorder.

The prevalence of neuropsychiatric symptoms in Alzheimer's disease: Systematic review and meta-analysis

BACKGROUND

Neuropsychiatric symptoms (NPS) are being increasingly recognized as common serious problems in Alzheimer's disease (AD). However, published data on the prevalence of NPS in persons with AD are conflicting. This meta-analysis aimed to estimate the prevalence of NPS in persons with AD.

METHODS

Studies published from 1964 to September 30, 2014, were identified from PubMed and Embase database, reference lists and conference abstracts. We calculated prevalence rates and conducted meta-regression analysis with random-effects model, according to study characteristics, population demographics or condition information.

RESULTS

We identified 48 eligible articles, which provided data for 12 NPS reported in Neuropsychiatric Inventory (NPI). The most frequent NPS was apathy, with an overall prevalence of 49% (95% CI 41-57%), followed by depression, aggression, anxiety and sleep disorder, the pooled prevalence estimates of which were 42% (95% CI 37-46%), 40% (95% CI 33-46%), 39% (95% CI 32-46%) and 39% (95% CI 30-47%), respectively. The less prevalent NPS were irritability (36%, 31-41%), appetite disorder (34%, 27-41%), aberrant motor behavior (32%, 25-38%), delusion (31%, 27-35%), disinhibition (17%, 12-21%) and hallucination (16%, 13-18%). Least common was euphoria, with an overall prevalence of 7% (95% CI 5-9%).

LIMITATIONS

Several aspects, such as the quality of included studies were not always optimal and there was significant heterogeneity of prevalence estimate across studies.

CONCLUSIONS

NPS were observed to be highly prevalent in AD patients. Disease duration, age, education level, population origin and the severity of cognitive impairment had influence on the prevalence of some NPS.

The prevalence of depressive symptoms in frontotemporal dementia: a meta-analysis

BACKGROUND

Depression is common in Alzheimer's and vascular dementia and is associated with poorer outcomes; however, less is known about the impact of depression on frontotemporal dementia (FTD). Here, we conducted a meta-analysis of diagnostic methods and the prevalence of depressive symptoms in FTD.

METHODS

PubMed, EMBASE and PsychINFO were queried for 'depression' and/or 'depressive mood' in behavioral- and language-variant FTD. The prevalence and diagnosis of depressive symptoms were extracted from relevant studies and the results pooled using a random-effects model.

RESULTS

We included 29 studies in this meta-analysis, with sample sizes ranging from 3 to 73 (n = 870). The omnibus estimated event rate of depressed mood was 0.334 (33%; 95% CI: 0.268-0.407). Symptoms were most commonly assessed via standardized neuropsychiatric rating scales, with other methods including subjective caregiver reports and chart reviews. The study results were heterogeneous due to the variability in diagnostic methods.

CONCLUSIONS

Depressive symptoms similar to those in other dementias are commonly detected in FTD. However, the diagnostic methods are heterogeneous, and symptoms of depression often overlap with manifestations of FTD. Having a standardized diagnostic approach to depression in FTD will greatly facilitate future research in this area.

The prevalence and burden of behavioural and psychological symptoms of dementia in rural Tanzania

OBJECTIVES

Behavioural and psychological symptoms (BPS) in dementia are common in high-income countries, but there are few data from sub-Saharan Africa. Our aim was to estimate the prevalence and pattern of BPS and associated caregiver distress in rural Tanzania.

METHODS

Prevalent cases of dementia (aged 70 and over) were identified during a community-based door-to-door study in six rural villages in Tanzania. Following cognitive screening, a stratified sample (over-sampled for people with dementia) of cases underwent a detailed clinical assessment including the brief 12 item neuropsychiatric inventory (NPI-Q), which assesses BPS and associated caregiver distress over the preceding 30 days.

RESULTS

Of 78 people with dementia, at least one current BPS was reported by 69 (88.4%), with 40 (51.3%) reporting 3 or more symptoms. In 172 people with no cognitive impairment, 110 (64.0%) reported at least one symptom and 48 (27.9%) reported 3 or more. In dementia cases, the most frequent symptoms reported were anxiety (47.4%), agitation/aggression (38.5%), night-time behavioural disturbance (34.6%), irritability (33.3%) and depression (33.3%).

CONCLUSION

The frequency of BPS in dementia in this rural Tanzanian population is high and comparable to that reported in prevalence studies from high income countries. Symptoms were also common, although to a lesser degree, amongst cognitively intact subjects. BPS are likely to have a significant impact on quality of life for elderly persons and their carers in low-income settings. Low-cost interventions, such as community-based therapy and education, are needed.

Dementia, neuropsychiatric symptoms, and the use of psychotropic drugs among older people who receive domiciliary care: a cross-sectional study

BACKGROUND

The objective of this study was to (a) determine the prevalence of cognitive impairment, dementia, and neuropsychiatric symptoms (NPSs) among home-dwelling people, 70 years and older (70+ years), who receive domiciliary care, and (b) describe their use of psychotropic drugs. Few studies have investigated dementia among people receiving in-home care.

METHODS

A sample (N = 1,000) representative of people aged 70+ years receiving domiciliary care was randomly recruited for participation. A standardized interview with the participants and their next of kin were performed using well-established assessment scales. Two clinical experts independently diagnosed dementia according to ICD-10 criteria.

RESULTS

Of the 415 participants (41.5%) with dementia according to ICD-10 criteria, 19.5% had a dementia diagnosis known to the patient themselves, their caregiver, or health workers in the domiciliary care service. In the previous month, 72.1% exhibited NPSs (21.1% rated as clinically significant), with depression (47.5%), apathy (33.7%), anxiety (33.0%), and irritability (31.1%) being the most common. Psychotropic drugs were regularly used by 40.1% of the sample. Antidepressants (p = 0.001) and cognitive enhancers (p < 0.001) were more often given to people with dementia than to those without dementia.

CONCLUSIONS

Dementia and NPSs are highly prevalent among people who receive domiciliary care, and diagnostic disclosure is low. People with dementia constitute a distinct group with respect to NPSs and psychotropic drug use. Early detection and correct diagnosis might increase the understanding of their everyday challenges and enable families to alleviate consequences of dementia and NPSs.

The prevalence and incidence of dementia with Lewy bodies: a systematic review of population and clinical studies

BACKGROUND

Dementia with Lewy bodies (DLB) is increasingly recognized as a common cause of dementia in older people. However, its true frequency remains unclear, with previous studies reporting a prevalence range from zero to 22.8% of all dementia cases. This review aimed to establish the population prevalence and incidence for DLB and to compare this to its prevalence in secondary care settings.

METHOD

A literature review of all relevant population and clinical studies was conducted using PubMed. Additional references from papers found during that process were added to this.

RESULTS

DLB accounted for 4.2% of all diagnosed dementias in the community. In secondary care this increased to 7.5%. The incidence of DLB was 3.8% of new dementia cases. There was a significant increase in DLB diagnoses when using the revised (2005) International Consensus Criteria (ICC) for DLB compared to the original (1996) criteria.

CONCLUSIONS

DLB currently accounts for around one in 25 dementia cases diagnosed in the community and one in 13 cases in secondary care. The significantly higher rates of DLB in secondary care may reflect enhanced diagnostic accuracy in specialist settings and/or the increased morbidity and carer burden of the DLB syndrome compared to other dementias. However, the true prevalence is likely to be much higher because DLB diagnoses are often missed, although there is evidence that new criteria aid case identification.

Neuropsychiatric symptoms in elderly inpatients: a multicenter cross-sectional study

BACKGROUND/AIMS

We determined the prevalence of neuropsychiatric symptoms in geriatric rehabilitation patients to compare neuropsychiatric symptoms between patients with and without dementia, and to evaluate associations linking severity of cognitive impairment and neuropsychiatric symptoms.

METHODS

In February 2009, we studied patients aged 75 years or older who had been admitted to four geriatric rehabilitation units in the Paris area. The twelve Neuropsychiatric Inventory items and four neuropsychiatric subsyndromes defined by the European Alzheimer's Disease Consortium were evaluated.

RESULTS

Of the 194 patients, 149 (76.8%) had dementia, and 154 (79.4%) had exhibited at least one neuropsychiatric symptom during the past week. Agitation was the most common neuropsychiatric symptom in the group with dementia (36.9%) and depression in the group without dementia (35.6%). The dementia group had significantly higher prevalences of hyperactivity (p < 0.001) and delusions (p = 0.01) than the non-dementia group. In the dementia group, severity of cognitive impairment was associated with hyperactivity (p = 0.01) and psychosis (p = 0.02).

CONCLUSION

The prevalence of neuropsychiatric symptoms among geriatric rehabilitation patients was high but not higher than in elderly outpatients.

Neuropsychiatric symptom clusters of Alzheimer's disease in Hong Kong Chinese: prevalence and confirmatory factor analysis of the Neuropsychiatric Inventory

BACKGROUND

The aim of this study was to investigate the clustering of symptoms on the Neuropsychiatric Inventory (NPI) and the relative prevalence of symptom clusters in mild and moderate Alzheimer's disease (AD).

METHODS

Confirmatory factor analysis (CFA) was performed on the polychoric correlation matrix of 12 NPI items (scored yes or no) using the weighted least squares with mean and variance adjustment (WLSMV) estimator in Mplus (N = 224 community-dwelling Chinese persons with mild/moderate AD). Severity of AD was determined by Clinical Dementia Rating scores. The relative model fit of three competing measurement models (also known as factor structures) was tested using a modified χ2 difference test. Prevalence rates across mild and moderate stages were compared using χ2 tests. Furthermore, the measurement model of choice was cross-validated in an independent sample of 181 community-dwelling persons with dementia.

RESULTS

CFA supported a four-factor model, namely behavioral problems (agitation/aggressiveness, disinhibition, irritability, and aberrant motor behavior), psychosis (delusions and hallucinations), mood disturbance (depression, anxiety, sleep, appetite, and apathy), and euphoria (a stand-alone item that is equivalent to the factor). The most prevalent symptom clusters were behavioral (72%) and mood (69%) disturbances, followed by psychosis (45%). Euphoria was rare (6%). All syndromes were more prevalent in moderate than in mild stage, except for euphoria. In addition, the four-factor model was replicated in the cross-validation sample.

CONCLUSIONS

The four syndromes provide a parsimonious conceptualization of neuropsychiatric symptoms corresponding to clinical observations and neurochemical changes of the disease. The independent replication in the second sample supports generalization of the four-factor model in Chinese persons with AD.

Serotonergic function and treatment of behavioral and psychological symptoms of frontotemporal dementia

OBJECTIVES

The purposes of this study were first, to evaluate the effectiveness of citalopram in treating behavioral disturbances in frontotemporal dementia (FTD) subjects and second, to determine whether an association exists between serotonergic function, as determined by a neuroendocrine challenge, and treatment response.

DESIGN

Single-dose citalopram (30 mg per os) challenge followed by a 6-week open-label study.

SETTING

Outpatients referred to memory clinics.

PARTICIPANTS

Fifteen patients suffering from FTD with severe behavioral and psychological symptoms of dementia.

INTERVENTION

Following citalopram challenge, all patients were treated with citalopram titrated to a target dose of 40 mg once daily.

MEASUREMENTS

Behavioral disturbances, using the Neuropsychiatric Inventory (NPI) (primary outcome) and Frontal Behavioural Inventory (secondary outcome), were assessed. Change in prolactin concentration following citalopram challenge was used as an index of central serotonergic response.

RESULTS

Citalopram treatment was effective in treating behavioral symptoms, with significant decreases in NPI total score (F[2, 28] = 6.644, p = 0.004), disinhibition (F[2, 28] = 4.030, p = 0.029), irritability (F[2, 28] = 7.497, p = 0.003) and depression (F[2, 28] = 3.467, p = 0.045) scores over the 6 weeks. Significant improvement in Frontal Behavioural Inventory scores suggested that citalopram was also effective in the treatment ofbehaviors specific to FTD. A lower change score in concentration of prolactin was significantly positively correlated with greater improvement in the total NPI score from baseline to endpoint (r = 0.687, p = 0.005). A blunted response to a citalopram challenge, implying a dysfunctional serotonergic system, predicted a more positive treatment outcome.

CONCLUSIONS

The results suggest that despite the endogenous serotonin deficiency of FTD, citalopram treatment may be effective in targeting the behavioral disturbances characteristic of FTD.

Behavioral and psychological symptoms of dementia

Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, represent a heterogeneous group of non-cognitive symptoms and behaviors occurring in subjects with dementia. BPSD constitute a major component of the dementia syndrome irrespective of its subtype. They are as clinically relevant as cognitive symptoms as they strongly correlate with the degree of functional and cognitive impairment. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. It is estimated that BPSD affect up to 90% of all dementia subjects over the course of their illness, and is independently associated with poor outcomes, including distress among patients and caregivers, long-term hospitalization, misuse of medication, and increased health care costs. Although these symptoms can be present individually it is more common that various psychopathological features co-occur simultaneously in the same patient. Thus, categorization of BPSD in clusters taking into account their natural course, prognosis, and treatment response may be useful in the clinical practice. The pathogenesis of BPSD has not been clearly delineated but it is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD. A high degree of clinical expertise is crucial to appropriately recognize and manage the neuropsychiatric symptoms in a patient with dementia. Combination of non-pharmacological and careful use of pharmacological interventions is the recommended therapeutic for managing BPSD. Given the modest efficacy of current strategies, there is an urgent need to identify novel pharmacological targets and develop new non-pharmacological approaches to improve the adverse outcomes associated with BPSD.

Comparison of polysomnographic variables and their relationship to cognitive impairment in patients with Alzheimer's disease and frontotemporal dementia

Polysomnograhic (PSG) studies in Alzheimer's disease (AD) show REM sleep abnormalities, which may be indicative for the deterioration of cholinergic pathways and probably closely linked to declarative memory impairment. To clarify the specificity of the association between sleep and cognitive impairment in dementia, we compared AD patients with patients suffering from frontotemporal dementia (FTD) with regard to PSG and neuropsychological variables. 15 AD and 6 FTD patients underwent polysomonography and a neuropsychological battery (CERAD-NB). Group differences (age: AD > FTD; education level: AD < FTD) were considered as covariates. Polysomnography revealed a trend towards increased REM latency and reduced REM sleep in AD, as well as a decrease of stage 2 sleep, however, at least partly due to effects of age. Declarative memory was more impaired in AD than in FTD, but this difference disappeared when adjusted for covariates. While no relationship was found between REM sleep and CERAD-NB parameters, strong positive correlations between stage 2 sleep and declarative memory measures were observed, which were also detectable when analyzing both groups separately. Based on these results we conclude that REM sleep alterations may be specific for AD, distinguishable from other dementia diagnoses, whereas NonREM stage 2 sleep may be related to declarative memory formation in dementia independent of subtype.

Sleep-wake changes and cognition in neurodegenerative disease

With the increasing aging population, neurodegenerative disorders will become more common in clinical practice. These disorders involve multiple pathophysiological mechanisms that differentially affect cognition, mood, and physical functions. Possibly due to the involvement of common underlying neurobiological circuits, sleep and/or circadian (sleep-wake) changes are also common in this disease group. Of significance, sleep-wake changes are often a prodromal feature and are predictive of cognitive decline, psychiatric symptoms, quality of life, need for institutional care, and caregiver burden. Unfortunately, in neurodegenerative disease, few studies have included detailed polysomnography or neuropsychological assessments although some data indicate that sleep and neurocognitive features are related. Further studies are also required to address the effects of pharmacological and nonpharmacological treatments on cognitive functioning. Such research will hopefully lead to targeted early intervention approaches for cognitive decline in older people.

Temporoparietal hypometabolism in frontotemporal lobar degeneration and associated imaging diagnostic errors

OBJECTIVE

To evaluate the cause of diagnostic errors in the visual interpretation of positron emission tomographic scans with fludeoxyglucose F 18 (FDG-PET) in patients with frontotemporal lobar degeneration (FTLD) and patients with Alzheimer disease (AD).

DESIGN

Twelve trained raters unaware of clinical and autopsy information independently reviewed FDG-PET scans and provided their diagnostic impression and confidence of either FTLD or AD. Six of these raters also recorded whether metabolism appeared normal or abnormal in 5 predefined brain regions in each hemisphere-frontal cortex, anterior cingulate cortex, anterior temporal cortex, temporoparietal cortex, and posterior cingulate cortex. Results were compared with neuropathological diagnoses.

SETTING

Academic medical centers.

PATIENTS

Forty-five patients with pathologically confirmed FTLD (n=14) or AD (n=31).

RESULTS

Raters had a high degree of diagnostic accuracy in the interpretation of FDG-PET scans; however, raters consistently found some scans more difficult to interpret than others. Unanimity of diagnosis among the raters was more frequent in patients with AD (27 of 31 patients [87%]) than in patients with FTLD (7 of 14 patients [50%]) (P=.02). Disagreements in interpretation of scans in patients with FTLD largely occurred when there was temporoparietal hypometabolism, which was present in 7 of the 14 FTLD scans and 6 of the 7 scans lacking unanimity. Hypometabolism of anterior cingulate and anterior temporal regions had higher specificities and positive likelihood ratios for FTLD than temporoparietal hypometabolism had for AD.

CONCLUSIONS

Temporoparietal hypometabolism in FTLD is common and may cause inaccurate interpretation of FDG-PET scans. An interpretation paradigm that focuses on the absence of hypometabolism in regions typically affected in AD before considering FTLD is likely to misclassify a significant portion of FTLD scans. Anterior cingulate and/or anterior temporal hypometabolism indicates a high likelihood of FTLD, even when temporoparietal hypometabolism is present. Ultimately, the accurate interpretation of FDG-PET scans in patients with dementia cannot rest on the presence or absence of a single region of hypometabolism but rather must take into account the relative hypometabolism of all brain regions.

Behavioural symptoms in patients with Alzheimer's disease and their association with cognitive impairment

Background

Behavioural and psychological symptoms of dementia (BPSD) are non-cognitive symptoms commonly associated to Alzheimer's disease (AD). The characterization of the clinical profile of AD patients might help to better understand disease evolution and to improve diagnosis and treatment. Thus, the aim of the present study is to describe the clinical profile of AD patients, and to correlate the presence of BPSD with the severity of the disease.

Methods

A cross-sectional, observational and multicenter study was conducted at 115 centres in Spain. Patients suffering from AD with higher and lower BPSD scores (ADAS-Noncog score 26-50 and ≤25, respectively) were included. Demographic and clinical data were collected, and dementia severity was assessed by the Mini Mental State Examination (MMSE) [mild 27-21, moderate 20-11, severe ≤10]. The use of ADAS-Noncog in clinical practice was also explored.

Results

A total of 1014 patients (463 with higher and 551 with lower BPSD scores) were included (mean age 77 ± 7 years, 65% women). Almost all patients (90%) had BPSD at inclusion, 17% of which reported psychotic outbreaks. The most prevalent symptoms were lack of concentration (56%), tremors (56%), depression (44%), lack of cooperation (36%), and delusions (32%). Patients with higher BPSD scores showed a significantly higher prevalence of psychotic symptoms (delusions, hallucinations, and delirium) and tremors, while emotional symptoms (tearfulness and apathy) predominated in patients with lower BPSD scores. MMSE and ADAS-Noncog scores were negatively associated (p = 0.0284), suggesting a correlation between cognitive impairment and BPSD. Lack of concentration and appetite change significantly correlated with MMSE (p = 0.0472 and p = 0.0346, respectively). Rivastigmine and donepezil were the first choice therapies in mild to moderate dementia. ADAS-Noncog was generally considered better or similar to other scales (82%), and 68% of the investigators were willing to use it in the future.

Conclusions

Our study shows that patients with AD have a high prevalence of noncognitive symptoms, and that cognitive impairment and BPSD are correlated. Therefore, ADAS-Noncog is a useful evaluation tool.

Risk factors for dementia in the epidemiological study of Munguialde County (Basque Country-Spain)

BACKGROUND

Prevalence of degenerative dementias and dementias associated with cerebrovascular disease is increasing. Dementia is one of the most significant public health problem. In recent years, the role of vascular risk factors (hypertension, diabetes mellitus and hypercholesterolemia) and depression has been evaluated.The incidence of dementia and risk factors has not been fully investigated in Spain. The aim of this study was to identify the risk factors for dementia, Alzheimer's disease (AD) and vascular dementia (VD) in elderly people in Munguialde County (Spain).

METHODS

A two phase, door-to-door populational study was performed. Demographic variables and the presence of vascular risk factors and depression were recorded. The MMSE, the DSM-IV and the conventional criteria for AD and VD were used in the evaluation. The odds ratio for each risk factor was calculated by logistic regression analysis.

RESULTS

1756 healthy subjects and 175 patients with dementia participated in the study. Of these, 133 had AD, 15 VD and the remainder other dementias. The risk factors for dementia and AD were female sex (OR = 1.67 and 1.97, respectively); age (OR = 1.14 and 1.15); stroke (OR = 7.84 and 3); and depression (OR = 53.08 and 3.19). Stroke was the only risk factor for VD (OR = 119).

CONCLUSION

Greater age, female sex, stroke and depression increase the risk of suffering dementia, AD and VD. The relationship between depression, vascular risk factors and dementia has clear public health implications. Prevention and early treatment of vascular risk factors and depression may have an important impact in lowering the risk of dementia and could modify the natural history of the disease.