Repetitive and stereotypic phenomena and dementia

Defining repetitive behaviours in frontotemporal dementia

Repetitive behaviours are common manifestations of frontotemporal dementia (FTD). Patients with FTD exhibit various types of repetitive behaviours with unique behavioural and cognitive substrates, including compulsivity, lack of impulse control, stereotypy and hoarding. Other sources of repetitive behaviours, such as restrictive interests and insistence on sameness, may also be seen in FTD. Although repetitive behaviours are highly prevalent and potentially discriminatory in this population, their expression varies widely between patients, and the field lacks consensus about the classification of these behaviours. Terms used to describe repetitive behaviours in FTD are highly heterogeneous and may lack precise definitions. This lack of harmonization of the definitions for distinct forms of repetitive behaviour limits the ability to differentiate between pathological behaviours and impedes understanding of their underlying mechanisms. This review examines established definitions of well-characterized repetitive behaviours in other neuropsychiatric disorders and proposes operational definitions applicable to patients with FTD. Building on extant models of repetitive behaviours in non-human and lesion work and models of social behavioural changes in FTD, we describe the potential neurocognitive bases for the emergence of different types of repetitive behaviours in FTD and their potential perpetuation by a predisposition towards habit formation. Finally, examples of distinct therapeutic approaches for different forms of repetitive behaviours are highlighted, along with future directions to accurately classify, measure and treat these symptoms when they impair quality of life.

Occupational Therapy Interventions in Patients with Frontotemporal Dementia: A Systematic Review

Frontotemporal dementia (FTD) is a neurodegenerative disorder characterized by progressive impairments in behavior, executive function, and language, primarily affecting individuals under the age of 65. This disorder is associated with expressive and receptive anomia, word comprehension deficits, and behavioral symptoms such as apathy, loss of empathy, and disinhibition, all of which closely correlate with functional impairment in daily activities. Despite substantial efforts, research on occupational therapy (OT) interventions has yet to demonstrate clear benefits in managing the disease. The aim of this study is to investigate OT interventions and assess their efficacy, with a specific focus on individuals suffering from FTD. We systematically conducted searches on two databases, namely Medline and Science Direct, spanning a ten-year period from 2003 to 2023, in accordance with the PRISMA guidelines. Eleven studies met the inclusion criteria. OT interventions targeted both patients and caregivers and yielded significant positive improvements in their lives. A key focus of these interventions was to teach acceptable alternatives to the behaviors exhibited by FTD patients, as these behaviors are strongly influenced by the disease itself. OT contributes positively to enhancing the quality of life of FTD patients and alleviating the caregiving burden experienced by those providing long-term care to these patients.

Aging to 24 months increased C57BL/6J mouse social sniffing and hippocampal Neto1 levels, and impaired female spatial learning

Understanding how natural aging impacts rodent performance in translational behavior tests is critical to teasing apart impairments due to age-related decline from neurodegenerative disorder modeling. Reduced neuropilin and tolloid-like 1 (NETO1), an accessory protein of ionotropic glutamate receptors involved in synaptic plasticity, was associated with Alzheimer's disease, yet aging effects on Neto1 remain unclear. For these reasons, our goal was to characterize how Neto1 expression corresponded with social, repetitive, and spatial learning behaviors and stress response across the C57BL/6J mouse lifespan. We measured social preferences in three-chamber tests, and motor stereotypies by marble burying. Cognitive flexibility is typically assessed in the Morris water maze (MWM), wherein C57BL/6J mice exhibit deficits with age. However, fatigue or locomotor impairment may confound interpretation of MWM performance. Therefore, we used a less arduous water T-maze (WTM) to compare spatial learning flexibility in 2, 9-15, and 24-month-old male and female mice to test the hypothesis that deficits would emerge with age. In both sexes, 9-15-month-olds made more chamber entries during social preference tests, while 2-month-olds did less social sniffing than aged mice. No age or sex differences emerged in marble burying or serum corticosterone measurements. In 24-month-olds hippocampal Neto1was increased relative to 2-month-olds, and male cognitive flexibility was strong, while spatial learning and reversal learning of 24-month-old females was impaired in WTM irrespective of Neto1 expression. The WTM is a useful alternative assessment for cognitive flexibility deficits in aged mice, and the role of hippocampal Neto1 in promoting social sniffing is of interest.

The relationship between semantic and episodic memory: evidence from a case of severe anterograde amnesia

It is increasingly being recognized that new declarative, consciously accessible information can be learned in anterograde amnesia, but it is not clear whether this learning is supported by episodic or semantic memory. We report a case of a 55-year-old man who experienced severe amnesia after limited damage to the medial temporal lobe following neurosurgical complications. His general cognitive performance and knowledge of new French words and public events that occurred before and after the onset of amnesia were assessed. Performance remained satisfactory on post-morbid vocabulary and public events, with a drop in performance observed for very recent public events only, while knowledge of very recent vocabulary was comparable to that of the control subjects. The implications of these findings for our understanding of the underlying learning mechanisms are discussed. This is the first report of acquisition of consciously accessible postmorbid knowledge of public events in a patient with severe amnesia.

Relationship between engagement with the impossible task, cognitive testing, and cognitive questionnaires in a population of aging dogs

Introduction

The aim of this study was to evaluate the engagement of aging dogs with a cognitively challenging and potentially frustrating task (the impossible task). Based on previous observations, we predicted that dogs showing signs of cognitive impairment in other cognitive tests and owner-completed questionnaires would show reduced engagement with the task.

Methods

In this task, dogs were shown a piece of food in a clear container that they could not open; time spent interacting with the container and the experimenter was measured. While the impossible task has not been used as a measure of frustration, the parameters of the test design creates a potential frustrate state, making this assessment appropriate. Thirty-two dogs enrolled in a longitudinal aging study participated in the study. Owners were asked to complete two cognitive dysfunction screening questionnaires (Canine Dementia Scale [CADES] and Canine Cognitive Dysfunction Rating Scale [CCDR]) as well a questionnaire assessing general frustration. Dogs participated in multiple measures of cognitive function as well the impossible task.

Results

Latency to disengage from the impossible task was faster for dogs with higher total (more impaired) CADES (p = 0.02) and total CCDR (p = 0.04) scores. Latency to disengage also correlated with decreased performance in cognitive tests observing social cues (p = 0.01), working memory (p ≤ 0.001), spatial reasoning and reversal learning (p = 0.02), and sustained attention (p = 0.02).

Discussion

The high correlation with several cognitive measures and the ease of administration of this test makes it a useful tool in evaluating canine cognitive dysfunction syndrome, however it is unclear if increased frustration or other cognitive processes are contributing to the observed changes.

Repetitive Behaviors in Alzheimer's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Repetitive behaviors (RBs) are a well-known symptom of Alzheimer's disease (AD); however, they have been little studied and have not been the subject of any specific literature review.

OBJECTIVE

To conduct a systematic review of all studies to document RBs in AD.

METHODS

An extensive literature search combining five databases and a meta-analysis were conducted to investigate the frequency, nature, and cognitive correlates of RBs in AD.

RESULTS

Ten studies were included in the review. Seven studies out of ten investigated the frequency of RBs in patients with AD, which ranged from 52.3% to 87%. A meta-analysis showed an overall frequency of 66.3% (95% CI: 55.5; 77.1) of patients exhibiting RBs in AD, but important heterogeneity was observed between studies. Three studies investigated the predominant nature of RBs in AD. Verbal RBs, complex behavioral stereotypies, and simple motor stereotypies have been identified to different degrees depending on the level of dementia. Most verbal RBs are underpinned by episodic memory impairment, while simple motor stereotypies and complex behavioral stereotypies are mostly underpinned by executive dysfunction.

CONCLUSIONS

The current review seems to suggest that there are two types of mechanisms underpinning RBs involved in AD. The first is observed especially in the mild stages of the disease and is mediated by episodic memory impairment. The second occurs later and is mediated by executive impairment. Additional studies should be conducted to improve the knowledge about RBs in AD and thus improve their management.Systematic review registration number: PROSPERO 2022: CRD42022310027.

Sex-Dependent Signatures, Time Frames and Longitudinal Fine-Tuning of the Marble Burying Test in Normal and AD-Pathological Aging Mice

The marble burying (MB) test, a classical test based on the natural tendency of rodents to dig in diverse substrates and to bury small objects, is sensitive to some intrinsic and extrinsic factors. Here, under emerging neuroethological quantitative and qualitative analysis, the MB performance of 12-month-old male and female 3xTg-AD mice for Alzheimer’s disease and age-matched counterparts of gold-standard C57BL6 strain with normal aging unveiled sex-dependent signatures. In addition, three temporal analyses, through the (1) time course of the performance, and (2) a repeated test schedule, identified the optimal time frames and schedules to detect sex- and genotype-dependent differences. Besides, a (3) longitudinal design from 12 to 16 months of age monitored the changes in the performance with aging, worsening in AD-mice, and modulation through the repeated test. In summary, the present results allow us to conclude that (1) the marble burying test is responsive to genotype, sex, aging, and its interactions; (2) the male sex was more sensitive to showing the AD-phenotype; (3) longitudinal assessment shows a reduction in females with AD pathology; (4) burying remains stable in repeated testing; (5) the time-course of marbles burying is useful; and (6) burying behavior most likely represents perseverative and/or stereotyped-like behavior rather than anxiety-like behavior in 3xTg-AD mice.

When twice is better than once: increased liking of repeated items influences memory in younger and older adults

BACKGROUND

Numerous studies have reported that the repeated presentation of a stimulus leads to an increase in positive affect towards the stimulus itself (the so-called mere exposure effect). Here, we evaluate whether changes in liking due to repetition may have a differential impact on subsequent memories in younger and older adults.

METHOD

In two experiments, younger and older adults were asked to rate a series of nonwords (Experiment 1) or unfamiliar neutral faces (Experiment 2) in terms of how much they like them and then presented with a surprise yes-no recognition memory task. At study, items were repeated either consecutively (massed presentation) or with a lag of 6 intervening items (spaced presentation).

RESULTS

In both experiments, participants rated spaced repeated items more positively than massed items, i.e. they liked them most. Moreover, older adults remembered spaced stimuli that they liked most better than younger adults.

CONCLUSIONS

The findings are discussed in accordance with the mechanisms underlying positivity effects in memory and the effect of repetition on memory encoding.

A Comparative Study of the Behavioral Profile of the Behavioral Variant of Frontotemporal Dementia and Parkinson's Disease Dementia

BACKGROUND

Executive dysfunction is the common thread between pure cortical dementia like the behavioral variant of frontotemporal dementia (bvFTD) and subcortical dementia like Parkinson's disease dementia (PDD). Although there are clinical and cognitive features to differentiate cortical and subcortical dementia, the behavioral symptoms differentiating these 2 conditions are still not well known.

OBJECTIVE

To evaluate the behavioral profile of bvFTD and PDD and compare them to find out which behavioral symptoms can differentiate between the two.

METHODS

Twenty consecutive patients with bvFTD (>1 year after diagnosis) and 20 PDD patients were recruited according to standard diagnostic criteria. Behavioral symptoms were collected from the reliable caregiver by means of a set of questionnaires and then compared between the 2 groups.

RESULTS

bvFTD patients had more severe disease and more behavioral symptoms than PDD. bvFTD patients were different from PDD patients due to their significantly greater: loss of basic emotion (p < 0.001, odds ratio [OR] 44.33), loss of awareness of pain (p < 0.001, OR 44.33), disinhibition (p < 0.001, OR 35.29), utilization phenomenon (p = 0.008, OR 22.78), loss of taste discrimination (p < 0.001, OR 17), neglect of hygiene (p = 0.001, OR 13.22), loss of embarrassment (p = 0.003, OR 10.52), wandering (p = 0.004, OR 9.33), pacing (p = 0.014, OR 9), selfishness (p = 0.014, OR 9), increased smoking (p = 0.014, OR 9), increased alcohol consumption (p = 0.031, OR 7.36), social avoidance (p = 0.012, OR 6.93), mutism (p = 0.041, OR 5.67), and failure to recognize objects (p = 0.027, OR 4.33). The bvFTD patients were also significantly less suspicious (p = 0.001, OR 0.0295), less inclined to have a false belief that people were in their home (p = 0.014, OR 0.11) and had fewer visual illusions/hallucinations (p = 0.004, OR 0.107) than PDD patients.

CONCLUSION

Behavioral symptoms are helpful to distinguish bvFTD from PDD, and thus also cortical dementia with frontal-lobe dysfunction from subcortical dementia.

Daily functioning and dementia

Dementia is characterized by a decline in memory, language, problem-solving and in other cognitive domains that affect a person's ability to perform everyday activities and social functioning. It is consistently agreed that cognitive impairment is an important risk factor for developing functional disabilities in patients with dementia. Functional status can be conceptualized as the ability to perform self-care, self- maintenance and physical activity. A person with dementia usually requires help with more complex tasks, such as managing bills and finances, or simply maintaining a household. Good functional performance is fundamental for elderly people to maintain independency and avoid institutionalization. The purpose of this review is to describe functional changes in demented patients, evaluating the variability in subgroups of dementias.

Factors Influencing Family Surrogates' Intention with Regard to Do-Not-Resuscitate Directive for Patients with Dementia

Objective: To investigate the prevalence of family surrogates' do-not-resuscitate (DNR) intention for patients with dementia (PwD), and factors influencing family surrogates' decisions. Methods: This is a descriptive and cross-sectional study. Patients with dementia and their family surrogates from Dementia Outpatient Clinic of a teaching hospital in southern Taiwan were included. Data were collected using chart review and questionnaire survey. Influential factors were analyzed using multiple logistic regression. Results: One hundred and forty of the 223 participants (62.8%) have intention to sign DNR consents for their dementia relatives. Factors influencing the intention were: (1) Comorbid with musculoskeletal diseases or diabetes (p < .05); (2) psychological symptoms of repetitive wording and behavior (p < .05); (3) spouse (p < .05) and lineal relatives (p < .01); (4) previous discussion between families and patient about DNR directive (p = .001); (5) believers of Taiwan folk belief (Buddhism or Taoism) (p < .05). Conclusions: Advanced dementia patients cannot express intention about their end-of-life care and depend on family surrogates to decide for them. Our study showed that spouse and direct relatives, comorbidities of musculoskeletal disease or diabetes, psychological symptoms of repetitive wording and behavior, previous discussion about patients' intention, and believers of Taiwan folk belief are all positive influencing factors for surrogates to consent DNR directive for patients. Our findings are important in promoting DNR directive for PwD. Clinical implications: Our results may help to promote DNR decisions for dementia patients, especially in Chinese populations.

Uncommon and/or bizarre features of dementia: Part III

Clinical neurologists have long recognized that dementia can present as atypical or variant syndromes/symptoms. This study aimed at describing uncommon or bizarre symptoms/syndromes observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published before 2018. Search terms used included compulsion, dementia, extracampine hallucination, disordered gambling, humour, and obsession. Publications found through this indexed search were reviewed for further relevant references. The uncommon/bizarre feature of dementia was described as case reports and there were no systematic investigations.

Subthalamic nucleus pathology contributes to repetitive behavior expression and is reversed by environmental enrichment

Repetitive motor behaviors are common in neurodevelopmental, psychiatric and neurological disorders. Despite their prevalence in certain clinical populations, our understanding of the neurobiological cause of repetitive behavior is lacking. Likewise, not knowing the pathophysiology has precluded efforts to find effective drug treatments. Our comparisons between mouse strains that differ in their expression of repetitive behavior showed an important role of the subthalamic nucleus (STN). In mice with high rates of repetitive behavior, we found significant differences in dendritic spine density, gene expression and neuronal activation in the STN. Taken together, these data show a hypoglutamatergic state. Furthermore, by using environmental enrichment to reduce repetitive behavior, we found evidence of increased glutamatergic tone in the STN with our measures of spine density and gene expression. These results suggest the STN is a major contributor to repetitive behavior expression and highlight the potential of drugs that increase STN function to reduce repetitive behavior in clinical populations.

Distinctive effects between cognitive stimulation and reminiscence therapy on cognitive function and quality of life for different types of behavioural problems in dementia

BACKGROUND

Among the various complementary therapies for patients with dementia (PwD), cognitive stimulation therapy (CST) and reminiscence therapy (RT) are frequently used to improve cognitive function and quality of life. However, no studies have examined the use of complementary therapies applied to different types of behavioural and psychological symptoms of dementia in PwD.

AIMS

The purpose of this study was to investigate the distinctive effects of CST and RT on cognitive function and quality of life for PwD with three types of behavioural problems - the dispute, return and dissociate types.

METHODS

A quasi-experimental design was employed. A total of PwD residing in 10 long-term care institutions participated in the study and were divided into three groups. The CST and RT groups received 50-minute sessions of intervention therapy once a week for 10 continuous weeks, and the control group participated in regular activities. The pretest (week 1), post-test (week 12) and follow-up (week 24) data were collected using the Mini-Mental State Examination and Quality of Life-Alzheimer's Disease. Two-way analysis of variance was used for data analysis.

RESULTS

The results of our study revealed CST and RT interventions had positive effects on cognition and quality of life of PwD. For short-term effects on cognitive function, CST was the most positive intervention for the dispute type. With regard to short-term effects on quality of life, CST was greater than RT for PwD. For follow-up effects, CST and RT may have potentially sustained effects.

CONCLUSION

This study suggests that CST and RT could be applied to improve the cognitive function and quality of life for PwD, as well as contribute to the effectiveness of nonpharmacological approaches to PwD with certain types of behavioural problems.

Reversal learning in C58 mice: Modeling higher order repetitive behavior

Restricted, repetitive behaviors are diagnostic for autism and prevalent in other neurodevelopmental disorders. These behaviors cluster as repetitive sensory-motor behaviors and behaviors reflecting resistance to change. The C58 mouse strain is a promising model for these behaviors as it emits high rates of aberrant repetitive sensory-motor behaviors. The purpose of the present study was to extend characterization of the C58 model to resistance to change. This was done by comparing C58 to C57BL/6 mice on a reversal learning task under either a 100% or 80%/20% probabilistic reinforcement schedule. In addition, the effect of environmental enrichment on performance of this task was assessed as this rearing condition markedly reduces repetitive sensory-motor behavior in C58 mice. Little difference was observed between C58 and control mice under a 100% schedule of reinforcement. The 80%/20% probabilistic schedule of reinforcement generated substantial strain differences, however. Importantly, no strain difference was observed in acquisition, but C58 mice were markedly impaired in their ability to reverse their pattern of responding from the previously high density reinforcement side. Environmental enrichment did not impact acquisition under the probabilistic reinforcement schedule, but enriched C58 mice performed significantly better than standard housed C58 mice in reversal learning. Thus, C58 mice exhibit behaviors that reflect both repetitive sensory motor behaviors as well as behavior that reflects resistance to change. Moreover, both clusters of repetitive behavior were attenuated by environmental enrichment. Such findings, along with the reported social deficits in C58 mice, increase the translational value of this mouse model to autism.

Eating Behaviors and Dietary Changes in Patients With Dementia

BACKGROUND

Eating problems and dietary changes have been reported in patients with dementia.

OBJECTIVES

The aim of this article is to explore the generalized problems with nutrition, diet, feeding, and eating reported among patients with dementia.

METHODS

Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2016. Search terms used included behavioral and psychological symptoms of dementia, dementia, dietary changes, eating behavior. Publications found through this indexed search were reviewed for further relevant references.

RESULTS

Abnormal eating behaviors, eating problems, and dietary changes are present in most people with dementia, especially in the later stages of the condition.

CONCLUSION

Individuals with dementia frequently develop serious feeding difficulties and changes in eating and dietary habits. The changes may be secondary to cognitive impairment or apraxia, or the result of insufficient caregiving, or the consequence of metabolic or neurochemical abnormalities occurring as part of the dementing process.

A unique type of GSK-3 inhibitor brings new opportunities to the clinic

A substrate peptide that the kinase GSK-3 converts into its own inhibitor improves symptoms and cognitive function in an Alzheimer’s disease model.

Delusion of pregnancy: an unusual symptom in the context of dementia

BACKGROUND

Delusions can complicate practically all brain disorders. They may be dramatic and bizarre. An example is the so-called delusion of pregnancy.

OBJECTIVE

To identify the characteristic of a psychotic symptom, the phenomenon of delusion of pregnancy, in the context of dementia.

METHOD

MEDLINE and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2014. Search terms used included delusion of pregnancy, uncommon presentation, behavioral and psychological symptoms, dementia, Alzheimer's disease, and frontotemporal dementia (FTD). Publications found through this indexed search were reviewed for further relevant references. We included case reports that highlight the relationship and overlap between dementia presenting as schizophrenia-like psychosis and schizophrenia.

RESULTS

Literature on delusion of pregnancy in the course of dementia consists mostly of case reports and small samples of patients.

CONCLUSION

Psychotic phenomena such as delusion of pregnancy may be a feature in some cases of dementia. If this bizarre features of dementia appears as early presentation of FTD whose usual onset is in the presenium, it may be mistaken for schizophrenia.

Personality and dementia

Personality describes persistent human behavioral responses to broad classes of environmental stimuli. Change in personality may be an early sign of dementia. Our goal was to review scientific literature on the association between personality and dementia. Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published since 1980. Search terms used included personality, dementia, Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies. People with dementia commonly exhibit changes in personality that sometimes precede the other early clinical manifestations of the condition, such as cognitive impairment. Premorbid personality might be a determining factor so that caricature or exaggeration of original personality emerges as dementia progresses. Although it is generally accepted that these personality changes reflect the impact of progressive brain damage, there are several possible patterns of personality alterations with dementia. Early identification of personality modifications might assist with the timely diagnosis of dementia.

Uncommon and/or bizarre features of dementia

This study aimed at describing uncommon or bizarre symptoms observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published since 1967. Search terms used included uncommon presentation, behavioural and psychological symptoms, dementia, Alzheimer's disease, and fronto-temporal dementia. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms are described as case-reports and there are no systematic investigations. Bizarre behaviours arising late in life should be thoroughly investigated as symptoms of dementia.

Wandering and dementia

Wandering represents one of many behavioural problems occurring in people with dementia. To consider the phenomenon of wandering behaviour in demented patients, we conducted searches using Medline and Google Scholar to find relevant articles, chapters, and books published since 1975. Search terms used included 'wandering', 'behavioural and psychological symptoms', 'dementia', 'nursing', and 'elopements'. Publications found through this indexed search were reviewed for further relevant references. The term 'wandering' covers different types of behaviour, including aimless movement without a discernible purpose. It is associated with a variety of negatives outcomes. The aetiology of wandering is poorly understood and it remains an unsolved riddle. Wandering is an acutely distressing problem worldwide, both for the patients and caregivers, and it is a major reason for nursing home admission. Evidence on the effectiveness of pharmacological and non-pharmacological interventions is limited. It is possible that management of coexistent psychopathology would help to ameliorate this problematic behavioural disorder.