The Role of Sexual Disinhibition to Predict Caregiver Burden and Desire to Institutionalize Among Family Dementia Caregivers

Case report: Assessing criminal responsibility and recidivism risk in the behavioral variant of frontotemporal dementia

Frontotemporal dementia (FTD) affects the frontal and temporal lobes of the brain, leading to personality changes, language impairments, and behavioral disturbances, including impulsivity and disinhibition. Assessing responsibility and recidivism risk in forensic evaluations is challenging due to the evolving nature of FTD. Despite limited literature, we present a case of a 45-year-old man with no prior legal or medical history, who committed criminal acts due to behavioral changes linked to the behavioral variant of frontotemporal dementia (bvFTD). Initial assessment found him irresponsible, with a non-evaluable risk of recidivism. Subsequent evaluation showed a low recidivism risk based on clinical evolution. We discuss these findings considering existing literature and Swiss jurisprudence.

Neuropsychiatric Symptoms are Related to Blood-biomarkers in Major Neurocognitive Disorders

BACKGROUND

Neuropsychiatric symptoms (NPS) are highly prevalent among individuals with major neurocognitive disorders (MNCD).

OBJECTIVE

Here, we characterized blood biomarkers (metabolic, inflammatory, neurotrophic profiles and total antioxidant), body composition, physical fitness and quality of life (QoL) in individuals with MNCD according to NPS.

METHODS

The sample comprised 34 older adults (71.4% women; 74.06±6.03 yrs, with MNCD diagnosis) categorized according to 50th percentile [Low (≤12) or High (≥13)] for NPS (Neuropsychiatric Inventory Questionnaire). Sociodemographic, clinical data, body composition, anthropometric, cognitive assessment (ADAS-Cog), physical fitness (Senior Fitness Test), QoL (QoL-Alzheimer's Disease scale) were evaluated, and blood samples were collected for biochemical analysis.

RESULTS

Low compared to high NPS group showed higher levels of IL-6, IGF-1and neurotrophic zscore (composite of IGF-1, VEGF-1, BDNF). Additionally, low compared to high NPS group have higher QoL, aerobic fitness and upper body and lower body strength.

CONCLUSION

The severity of NPS seems to be related to modified neurotrophic and inflammatory outcomes, lower physical fitness, and poor QoL. Strategies to counteract NPS development may preserve the physical and mental health of individuals with MNCD.

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Prediction of 3-Year Survival in Patients with Cognitive Impairment Based on Demographics, Neuropsychological Data, and Comorbidities: A Prospective Cohort Study

OBJECTIVES

Based on readily available demographic data, neuropsychological assessment results, and comorbidity data, we aimed to develop and validate a 3-year survival prediction model for patients with cognitive impairment.

METHODS

In this prospective cohort study, 616 patients with cognitive impairment were included. Demographic information, data on comorbidities, and scores of the Mini-Mental State Examination (MMSE), Instrumental Activities of Daily Living (IADL) scale, and Neuropsychiatric Inventory Questionnaire were collected. Survival status was determined via telephone interviews and further verified in the official death register in the third year. A 7:3 ratio was used to divide patients into the training and validation sets. Variables with statistical significance (p < 0.05) in the single-factor analysis were incorporated into the binary logistic regression model. A nomogram was constructed according to multivariate analysis and validated.

RESULTS

The final cohort included 587 patients, of whom 525 (89.44%) survived and 62 (10.56%) died. Younger age, higher MMSE score, lower IADL score, absence of disinhibition, and Charlson comorbidity index score ≤ 1 were all associated with 3-year survival. These predictors yielded good discrimination with C-indices of 0.80 (0.73-0.87) and 0.85 (0.77-0.94) in the training and validation cohorts, respectively. According to the Hosmer-Lemeshow test results, neither cohort displayed any statistical significance, and calibration curves displayed a good match between predictions and results.

CONCLUSIONS

Our study provided further insight into the factors contributing to the survival of patients with cognitive impairment.

CLINICAL IMPLICATIONS

Our model showed good accuracy and discrimination ability, and it can be used at community hospitals or primary care facilities that lack sophisticated equipment.

The Experiences, Needs, and Solutions of Caregivers of Patients With Behavioral and Psychological Symptoms of Dementia Living in Residential and Long-Term Care Centers

Behavioral and psychological symptoms of dementia (BPSD) pose great challenges for the caregivers during the evolution of the disease with impacts on patients, caregivers, and healthcare providers. Caregivers often remain very present and involved once the difficult decision has been made to relocate the person to a residential and long-term care center (centre d'hébergement de soins de longue durée [CHSLD] in Quebec). The experience of caregivers about BPSD management in CHSLDs remains poorly understood. The aim of this study is to explore the needs and experience of caregivers of patients with BPSD living in CHSLDs, as well as the solutions they suggest to better manage BPSD in CHSLDs. We carried out this qualitative interpretive descriptive study with six focus groups, including 32 caregivers, in Quebec, Canada. Data analysis identified six themes: (1) the transition period between home and the CHSLD; (2) the lack of knowledge about BPSD; (3) the approach to BPSD by healthcare professionals; (4) the lack of communication; (5) defining the caregiver's role in the healthcare team; and (6) the caregiver's need for respite. These results offer relevant avenues to improve collaborative practices with caregivers in CHSLDs involved in the care of people with BPSD.

Comparing Behavioral and Psychological Symptoms of Dementia and Caregiver Distress Caused Between Older Adults With Dementia Living in the Community and in Nursing Homes

OBJECTIVES

To investigate differences in behavioral and psychological symptoms of dementia (BPSD) and caregiver distress caused between older adults with dementia living in the community and in nursing homes.

DESIGN

A comparative cross-sectional study.

SETTING AND PARTICIPANTS

Participants were recruited from outpatient clinics of a tertiary psychiatric hospital and dementia units of a nursing home in Guangzhou, China.

METHODS

Neuropsychiatric Inventory was used to assess symptoms and caregiver distress. Dementia severity was determined using the Clinical Dementia Rating.

RESULTS

This study included 157 community and 112 nursing home residents with dementia. Clinically significant symptoms (item score ≥ 4) were found in 88.5% of the former and 75% of the latter. Caregivers of 79.6% of the former and 26.8% of the latter reported that at least one of these caused them moderate-to-severe distress (distress score ≥ 3). Among the community patients, anxiety was the most frequent "very severe" symptom, while sleep disorders and agitation caused the most frequent "very severe" caregiver distress. After controlling for dementia severity and medication use, family caregiving remained an independent risk predictor for clinically significant symptoms and moderate-to-severe caregiver distress. The prediction of caregiver distress based on symptom scores varied across caregiver types and individual symptoms (R² 0.36-0.82). Group differences in clinically significant symptoms and moderate-to-severe caregiver distress showed at the stage of moderate-to-severe dementia.

CONCLUSIONS AND IMPLICATIONS

Tailored management strategies to relieve family caregivers' BPSD-induced distress are needed, especially at the stage of moderate-to-severe dementia. An effective service system should be established for supporting family caregivers to cope with BPSD.

Treatment and Management of Sexual Disinhibition in Elderly Patients With Neurocognitive Disorders

Sexual disinhibition is uncommon but challenging symptom to address in elderly patients with neurocognitive disorders. Due to the lack of large-scale studies, there is no gold standard treatment for sexual disinhibition, and treatment is largely left up to the discretion of the provider based on the severity and onset of the patient's symptoms. A review was conducted to investigate the non-pharmacological and pharmacological interventions for treating this condition. Articles that discussed treatments were screened for the type of treatment and possible side effects of medication if applicable. Thorough patient history should be taken prior to starting any drug therapy to rule out possible behavioral changes due to an existing medication side effect, delirium, or past mental or sexual health history. Non-pharmacological treatment has been generally recommended as first-line therapy over pharmacological treatment. Distraction/diversion of the patient when inappropriate sexual behaviors occur was the most common non-pharmacological intervention. Antidepressants were generally recommended as the first line of pharmacological treatment after attempting all possible non-pharmacological interventions. Several other categories of interventions are discussed as well in addition to the ethical implications of treating a patient for this condition.

Development of an assessment measure for sexual disinhibition in dementia

OBJECTIVE

Sexual disinhibition (SD), a neuropsychiatric symptom characterized by sexually inappropriate comments and/or behaviors, remains under identified in dementia, possibly due to a lack of standardized assessment methods. A recent systematic review of measures used to assess SD proposed four behavioral domains and identified the need for a population-specific measure. The present study addressed this by examining the underlying factor structure of SD to create a new caregiver-report measure.

METHODS

Dementia caregivers (n = 622) recruited online were randomly assigned to Initial Validation (n = 311) or Cross-Validation (n = 311) groups.

RESULTS

Initial Validation revealed five behavioral domains that served as provisional scales for cross-validation, leading to measure development.

CONCLUSIONS

The current study is the first to statistically evaluate the underlying factor structure of SD, resulting in a new measure that can help better characterize and identify SD.

Rehabilitation in Dementia

Dementia is an eurodegenerative disorder, which causes significant disability, especially among the elderly population worldwide. The affected person shows a progressive cognitive decline, which interferes with the independence in performing the activities of daily living. Other than the cognitive domain, the patient tends to have neuropsychiatric, behavioral, sensorimotor, speech, and language-related issues. It is expected that the global burden of the disease will rise with more people entering the geriatric age group. By 2050 close, to 140 million people will be living with one or the other type of dementia. Alzheimer's disease contributes to more than 60% of cases worldwide, followed by vascular dementia. Pharmacotherapy has a limited role to play in the treatment, and at present, no drug is available, which can halt or reverse the progress of the disease. World Health Organization has mandated rehabilitation as a core recommendation in the global action plan on the public health response to dementia. Rehabilitation services are widely recognized as a practical framework to maximize independence and community participation in dementia care. The rehabilitation program is customized to achieve the desired goals, as each person has different experiences, preferences, motivations, strengths, and requirements based on type, course, and severity of the illness. It is an interdisciplinary-team approach with the involvement of several health care professionals. This article reviews the existing literature and outlines the effective rehabilitation strategies concisely in dementia care.

Physical exercise for individuals with dementia: potential benefits perceived by formal caregivers

Background

The social and economic impact of dementia for the development of accessible and sustainable care for individuals with dementia (IwD). Physical exercise has been seen as a beneficial non-pharmacological therapy in the prevention and management of dementia, and possible benefits may not only impact on participants, but also indirectly on their caregivers. Thus, this quasi-experimental non-randomized study aimed to analyze the effects of an exercise intervention on functional capacity, behavioural and psychological symptoms in dementia (BPSD) and quality of life of institutionalized older adults with dementia, perceived by their formal caregivers.

Methods

Sixty-four institutionalized older adults (from both genders, aged 65–93 yrs. old), clinically diagnosed with dementia, were divided into two groups: control group (CG, continued with usual care, n = 26) and exercise group (EG, 6-month supervised multicomponent exercise intervention, n = 38). Nine caregivers (female, aged 28–47 yrs. old) from nine different nursing homes, reported about their distress related to BPSD and proxy-reported about participants’ functional capacity (Katz index), quality of life (QoL-AD), BPSD (NPI) before and after 6 months of an exercise intervention (aerobic, muscular resistance, flexibility and postural exercises).

Results

A two-way ANOVA, with repeated measures, revealed significant group and time interactions on Total Katz index and QoL-AD. The CG’s performance functional capacity and quality of life score worsen over time while in EG maintains these values after the exercise intervention. Moreover, formal caregiver’s distress triggered by apathy and disinhibition increased in CG while after 6 months of an exercise intervention no alterations were seen regarding these distress causes in EG. No significant main effects were observed for total NPI score or NPI distress.

Conclusions

Overall results show that after the exercise intervention, IwD from the EG, was capable of preserving the functional capacity, quality of life and neuropsychiatric symptoms were attenuate, contributing to a lower load of distress for the caregivers.

Trial registration

clinicaltrials.gov, NCT04095962. Retrospectively registered on 19 September 2019

Measurement of sexual disinhibition in dementia: A systematic review

Sexual disinhibition in dementia is correlated with multiple negative care recipient and caregiver outcomes but remains largely overlooked in the literature. Its prevalence is not well understood, with studies reporting between 1.8% and 25% presence of sexual disinhibition in dementia samples. One reason for the variability in the reported presence of sexual disinhibition may be lack of standardized methods for assessment. Several widely used measures for neuropsychiatric symptoms do not include items to assess sexual disinhibition. When measures do include sexual disinhibition, it is not addressed in a consistent manner. Inconsistency in how questions about sexual disinhibition are phrased is problematic, given that recent work shows it can differentially influence endorsement. Working toward a gold standard of sexual disinhibition measurement in dementia is needed. To this end, a systematic review of the literature to identify potentially appropriate instruments for measurement of sexual disinhibition in this population was conducted through the Web of Science and PubMed databases between January 2019 and February 2019. An overview of the 20 measures identified in this search is provided. Each measure is evaluated for appropriateness of use in dementia samples through broad examination of psychometric properties, structure, and format and the extent to which measure content overlaps with current conceptualizations of sexual disinhibition in dementia. Five common content domains were identified: hypersexuality, lewd/aberrant sexual behavior, inappropriate sexual advances, inappropriate sexual comments, and socially disruptive sexual behavior. No single measure addressed all content domains. Directions for future research are identified and discussed.