Psychiatric symptoms in cases of clinically diagnosed Alzheimer's disease

Neuropsychiatric symptom patterns in hospice-eligible nursing home residents with advanced dementia

OBJECTIVE

The purpose of this study was to determine whether specific neuropsychiatric symptom patterns could be identified in a cohort of hospice-eligible nursing home residents with advanced dementia.

METHODS

Surrogate decision makers gave informed consent to enroll 123 residents from 3 nursing homes. All participating residents met criteria for hospice eligibility and were determined by direct examination at the time of study enrollment to have advanced dementia. Retrospective medical record review was used to collect data on residents' demographics, diagnoses, and the presence of any neuropsychiatric symptoms during the 6 months prior to study enrollment. Latent class analysis (LCA) was used to classify residents based on neuropsychiatric symptom patterns.

RESULTS

Overall, 85% of residents exhibited one or more neuropsychiatric symptoms. LCA revealed that these individuals could be classified into 3 groups: one with low symptom frequencies (36%) considered to be the normative class, one characterized by psychosis and agitation or aggression (23%), and a third characterized by withdrawal or lethargy (41%).

CONCLUSIONS

These results add to the growing understanding of neuropsychiatric symptom patterns in advanced dementia and have implications for more dimensional classification and treatment approaches.

Mild cognitive impairment is associated with characteristic neuropsychiatric symptoms

Mild cognitive impairment (MCI) has emerged as an identifiable condition and in many cases is a transitional state preceding diagnosable Alzheimer disease (AD). Neurobiological and neuroimaging characteristics of amnestic-type MCI have been investigated, but few comprehensive neuropsychiatric studies have been reported. The aim of this preliminary study was to define the neuropsychiatric features of the amnestic-type MCI and compare them with those of mild AD and normal controls. The Neuropsychiatric Inventory (NPI) was used to assess the neuropsychiatric symptoms in three age and education comparable groups, i.e., 28 MCI, 124 mild AD, and 50 normal subjects. Individual subscores of the 10 NPI symptoms and total NPI scores were compared between the MCI patients and the other 2 groups. The results of this preliminary investigation showed that MCI patients frequently manifested neuropsychiatric symptoms. The most common symptoms in the MCI group were dysphoria (39%), apathy (39%), irritability (29%), and anxiety (25%). There were significant differences in apathy, dysphoria, irritability, anxiety, agitation, and aberrant motor behavior between the MCI and control groups; in contrast, only delusions were significantly less common in MCI compared with mild AD. There was a significant difference between the MCI and control groups on total NPI scores (p = 0.001), but not between the MCI and mild AD groups (p = 0.304). Amnestic MCI is associated with significant neuropsychiatric symptoms, especially mood disturbances and apathy. Psychotic symptoms are significantly more common in the early stage of AD than in MCI. These results are derived from a limited clinical sample and require confirmation in longitudinal community-based investigations.

Symptômes comportementaux et psychologiques dans la maladied' Alzheimer : résultats de l'étude REAL.FR

Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) are important manifestations of Alzheimer's Disease (AD) and other forms of dementia, because they are associate with care-giver distress, increase the likelihood of institutionalization, and may be associated with more rapid cognitive decline In this study (REAL.FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Neuropsychiatric Inventory NPI to examine BPSD. 255 AD patients with a Mini-Mental State Examination (MMSE) score between 11 and 20 and 244 AD patients with a MMSE between 21 and 30 were examined. Factor analysis was carried out leading to three different syndromes according to the level of cognitive impairment. BPSD were detected in 92.5% of the patients with a MMSE between 11 and 20, and in 84% of the patients with a MMSE between 21 and 30. Apathy was the most common abnormality, followed by anxiety and dysphoria. These results in a French cohort of patients with AD underline the importance of the evaluation and finally of the treatment of BPSD.

Déambulation et maladie de type Alzheimer. Étude descriptive.Programme de recherche REAL.FR sur la maladie d'Alzheimer et les filières de soins

PURPOSE

Wandering is a common problem among patients with Alzheimer's disease. Few studies have examined this problematic behaviour in the community. The aim of the present study was to increase our understanding of wandering during Alzheimer's disease in subjects living in the community.

METHODS

We studied 571 patients with Alzheimer's disease living in the community. Objective cognitive status was assessed using a series of standardized neuropsychological tests. Nutritional assessment, risk of fall, autonomy were assessed as well as the burden of their family. The behavioural abnormalities of patients were assessed with their caregiver using the Neuro-Psychiatric Inventory. Patients with or without wandering were described.

RESULTS

Prevalence of wandering was 12.6%. Patients with wandering appeared to have more severe cognitive impairment, less autonomy and were undernourished. Behavioural and psychological signs significantly associated with wandering were delirium, aggressiveness, irritability, depression, anxiety, euphoria, apathy, desinhibition and eating behaviour disorder. Subtype of Alzheimer's disease patients seemed to have frontal release behaviour.

CONCLUSION

Wandering is a common behaviour in Alzheimer's disease patients living in the community. Special care must be organized to help those frail patients and their caregivers.

Recognition and Management of Behavioral Disturbances in Dementia

Behavioral disturbances are seen in most patients with dementia at some point in their course. They cause immense patient suffering and are responsible for caregiver stress, institutionalization, and hospitalization. Identification of predisposing and precipitating factors is very important. The approach to the management of behavioral disturbances in dementia patients should be structured and thorough. Ensuring the safety of the patient and others should be paramount. Addressing the causes of behavioral disturbances such as comorbid medical illnesses, polypharmacy, pain, personal need, environmental factors, etc. is critical to a successful outcome. Many behavioral disturbances such as wandering and hoarding are not amenable to pharmacotherapy. Nonpharmacologic interventions are the mainstay of managing behavioral disturbances. Success of pharmacologic interventions will depend on accurate identification of specific syndromes, e.g., depression-anxiety and psychosis and severity of symptoms. Response to pharmacologic interventions is usually modest and may be associated with significant symptom resolution. Many behavioral disturbances can be prevented by avoiding inappropriate medications and educating patient, family, caregivers, and health care providers. Hospitalization can be avoided and institutionalization delayed by early recognition and treatment of behavioral disturbances. Leadership from physicians to implement preventive measures is recommended. Research to clarify the biological underpinnings of behavioral disturbances and to address cost-effectiveness of currently identified interventions is needed.

Wandering. A dementia-compromised behavior

The wandering behavior of individuals with dementia is a puzzling behavior, and strategies for responding to it often are poorly grounded. However, advances in the understanding of neuro-cognitive factors contributing to wandering now may provide important clues for designing nursing approaches. In this article, such advances are summarized, and implications and strategies for practice are delineated.

Family boundary ambiguity predicts Alzheimer's outcomes

This study examines caregiver and patient relationship characteristics in the etiology of behavior problems in Alzheimer's disease. Seventy-two caregivers and patients were assessed twice, 12 months apart. Cross lag panel analysis was used to test for one-way or reciprocal causal links among caregiver variables, patient impairment measures, and patient behavior problems. Caregiver distancing from patients (closeout) predicted increases in the frequency of behavior problems, including activity disturbances, paranoia, and anxiety. These behaviors in turn led to increased closeout of the patient by the caregiver. The reciprocal causal associations found in this study suggest that dysfunctional family interactions may underlie patient behavior problems and caregiver distress.

A small exploratory study of the reaction of older people to an episode of delirium

Delirium or an acute confusional state, occurs as a result of disease or physiological imbalance secondary to impaired brain function. One of its main clinical features is widespread cognitive impairment, which causes patients to become disconnected from their immediate surroundings and misinterpret reality. It has a sudden onset and its duration is relatively brief. Some authors take the view that delirium might be interpreted as a precursor to dementia. The aim of the study was to retrospectively explore older peoples' experience of an episode of delirium. In particular, whether they knew what had caused and cured it; and whether it had left them with any unresolved feelings of anxiety. A cross sectional design using grounded theory methodology was chosen, as being the most appropriate method for exploring this issue. A sample of 19 patients was selected using predetermined criteria, and engaged in a semi-structured interview with the researcher, in the ward environment. The interviews were audiotaped, transcribed, and analysed using the constant comparison method. Those interviewees who had illusions and hallucinations, were often able to describe their experiences in detail. They ranged from being pleasant and entertaining, to horrible and frightening. They were also able to remember short verbal commands from nurses during the episode of altered perception. Others remembered, or chose not to remember, very little. Few interviewees appeared to know exactly what had caused and cured the delirium, although some were able to tentatively connect the experience to their present medical condition. There also appeared to be little evidence of therapeutic communication with nursing staff once the episode of delirium had resolved. Although no one connected the experience with dementia, there did seem to be some evidence of mildly disturbed feelings, on reflecting back over the episode. As interviewees were generally willing to discuss their experiences with the researcher, it suggests that it would be helpful for nurses to provide opportunities to do so. Nevertheless, interviewees appeared to regard the episode simply as a transitory event in the overall context of illness, admission to hospital and their future welfare. The latter was of prime concern; yet again it appeared that they did not always receive the information they required to maintain control over their personal destinies.

[Psychiatric manifestations in dementia: phenomenologic perspectives]

The study of psychiatric manifestations in dementia has long been overshadowed by the more classical manifestations of the disease, such as memory loss and other cognitive deficits. In recent years, however, psychiatric symptoms as part of the demential process have attracted interest and research has become more specific. Clinicians are faced with diagnostic, treatment and management difficulties related to affective or psychotic symptoms, which account for much distress and morbidity. Several studies indicate that the prevalence of psychiatric manifestations in clinical populations of patients suffering from dementia is high: 15% to 30% for hallucinations, 15% to 30% for delusions, ten percent to 20% for major depression and 40% to 50% for depressed mood. These figures tend to confirm the hypothesis that psychiatric features in dementia are neither infrequent nor atypical. Thus, researchers have sought to link psychotic or depressive symptomatology with several clinical characteristics of dementia, namely stage, severity, prognosis or cognitive dysfunction. Some recent studies involving extensive neuropsychological evaluations indicate that subgroups of patients can be defined according to psychiatric criteria, as well as cognitive or neurological criteria. Unfortunately, results are inconsistent. Some of the contradictions in the literature are related to poorly defined terms and symptoms, a lack of reliable operational criteria, absence of validation of instruments and scales and heterogeneity of the populations studied. Ambiguous syndromes, such as pseudodementia, while illustrative of certain clinical situations, have not been helpful in categorizing demented patients. The author suggests that research focused on specific and clearly defined psychiatric symptoms in dementia will better serve our comprehension of mixed syndromes.