Neuropsychiatric symptoms and subsyndromes in patients with different stages of dementia in primary care follow-up (NeDEM project): a cross-sectional study

Monoamine alterations in Alzheimer's disease and their implications in comorbid neuropsychiatric symptoms

Alzheimer's disease (AD) is a devastating neurodegenerative disorder characterized by relentless cognitive decline and the emergence of profoundly disruptive neuropsychiatric symptoms. As the disease progresses, it unveils a formidable array of neuropsychiatric manifestations, including debilitating depression, anxiety, agitation, and distressing episodes of psychosis. The intricate web of the monoaminergic system, governed by serotonin, dopamine, and norepinephrine, significantly influences our mood, cognition, and behavior. Emerging evidence suggests that dysregulation and degeneration of this system occur early in AD, leading to notable alterations in these critical neurotransmitters' levels, metabolism, and receptor function. However, how the degeneration of monoaminergic neurons and subsequent compensatory changes contribute to the presentation of neuropsychiatric symptoms observed in Alzheimer's disease remains elusive. This review synthesizes current findings on monoamine alterations in AD and explores how these changes contribute to the neuropsychiatric symptomatology of the disease. By elucidating the biological underpinnings of AD-related psychiatric symptoms, we aim to underscore the complexity and inform innovative approaches for treating neuropsychiatric symptoms in AD.

Dual 5-HT6/SERT ligands for mitigating neuropsychiatric symptoms of dementia exerting neuroprotection against amyloid-β toxicity, memory preservation, and antidepressant-like properties

In light of the biological targets alterations in dementia patients suffering from neuropsychiatric symptoms, particularly in the 5-HT6 receptor and SERT transporters, this study aimed to develop dual-acting molecules targeting both these targets. By combining a 5-substituted indole with piperazine scaffolds, we synthesized molecules with nanomolar affinities for these sites, avoiding interaction with off-targets detrimental to dementia patients. Preliminary pharmacodynamic and ADMET assays let the identification of compound 15 as a lead molecule. In vitro studies showed that 15 provided neuroprotection against Aβ toxicity and reduced the levels of proapoptotic enzymes: caspase 3 and 7. In vivo, 15 reversed MK-801-induced memory deficits and exhibited antidepressant-like effects. Further studies showed that acute administration of compound 15 at a dose of 5 mg/kg increased BDNF levels, which are crucial for supporting neuronal survival and potentially slowing cognitive decline in dementia. These findings suggest 15's potential as a therapeutic for behavioral and psychological symptoms of dementia (BPSD), warranting further investigation.

The Paradox in Positive and Negative Aspects of Emotional Functioning Among Older Adults with Early Stages of Cognitive Impairment

Introduction: Emotional functioning in older adults is influenced by normal aging and cognitive impairment, likely heterogeneous across positive versus negative aspects of emotional functioning. Little is known about positive emotional experiences at the early stages of cognitive impairment. Methods: We assessed different aspects of emotional functioning among 448 participants aged 65+ (Normal Control (NC) = 276, Mild Cognitive Impairment (MCI) = 103, and mild dementia of the Alzheimer type (mild DAT) = 69) and tested moderators. Results: Compared to NC, older adults with MCI and mild DAT have maintained many positive aspects of emotional functioning, despite higher levels of negative affect, sadness, and loneliness. Among the oldest-old, the mild DAT group experienced higher fear and lower self-efficacy. Discussion: Older adults at early stages of cognitive impairment can experience positive aspects of emotional functioning, such as positive affect, purpose, and life satisfaction, all of which are important buildable psychological resources for coping.

Neuropsychiatric Symptom Profile in Alzheimer's Disease and Their Relationship With Functional Decline

OBJECTIVE

Understanding the course of individual neuropsychiatric symptoms (NPS) and their relationship with function is important for planning targeted interventions for preventing and delaying functional decline. This study aims to disentangle relative contributions of individual NPS on functional decline.

METHODS

Longitudinal study of 9,358 well-characterized participants with baseline diagnoses of Mild Cognitive Impairment or AD in the National Alzheimer's Coordinating Center Uniform Data Set. Function was measured using the Functional Assessment Questionnaire (FAQ). Clinician judgment of seven common behavioral symptoms were examined simultaneously: apathy-withdrawal, depressed mood, visual or auditory hallucinations, delusions, disinhibition, irritability, and agitation.

RESULTS

Apathy was the most common NPS at baseline (33.7%) and throughout follow-up, endorsed by clinicians in 63.7% of visits. Apathy was the most persistent with 36.7% of participants having clinician-endorsed apathy in ≥50% of their visits. Apathy strongly correlated with faster rate of functional decline. Compared to those who never had apathy, baseline FAQ was worse in those with intermittent or persistent/always apathy (intermittent: estimated coefficient ±SE=1.228±0.210, 95% CI=[0.817, 1.639]; persistent/always: 2.354±0.244 (95% CI=[1.876, 2.832], both p <0.001). Over time, rate of functional decline was faster in those with intermittent and persistent/always apathy (intermittent: 0.454±0.091, 95% CI=[0.276, 0.632]; persistent/always: 0.635±0.102, 95% CI=[0.436, 0.835], both p <0.001). Worse agitation, delusions, and hallucinations also correlated with functional decline, but magnitudes of the estimates were smaller.

CONCLUSION

Individual NPS may be sensitive targets for tracking longitudinal change in function. The study raises awareness of the need for more comprehensive assessment of functional decline in AD patients with noncognitive symptoms.

Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy

OBJECTIVE

40-60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD.

METHODS

Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools.

RESULTS

6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI).

CONCLUSIONS

The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.

Progress in Pharmacologic Management of Neuropsychiatric Syndromes in Neurodegenerative Disorders: A Review

Importance

Neuropsychiatric syndromes (NPSs) are common in neurodegenerative disorders (NDDs); compromise the quality of life of patients and their care partners; and are associated with faster disease progression, earlier need for nursing home care, and poorer quality of life. Advances in translational pharmacology, clinical trial design and conduct, and understanding of the pathobiology of NDDs are bringing new therapies to clinical care.

Observations

Consensus definitions have evolved for psychosis, agitation, apathy, depression, and disinhibition in NDDs. Psychosocial interventions may reduce mild behavioral symptoms in patients with NDD, and pharmacotherapy is available for NPSs in NDDs. Brexpiprazole is approved for treatment of agitation associated with Alzheimer disease dementia, and pimavanserin is approved for treatment of delusions and hallucinations associated with psychosis of Parkinson disease. Trials are being conducted across several of the NDDs, and a variety of mechanisms of action are being assessed for their effect on NPSs.

Conclusions and Relevance

Detection and characterization of NPSs in patients with NDDs is the foundation for excellent care. New definitions for NPSs in NDDs may inform choices regarding clinical trial populations and translate into clinical practice. Psychosocial and pharmacologic therapies may reduce behavioral symptoms and improve quality of life for patients and caregivers. Approved agents may establish regulatory precedents, demonstrate successful trial strategies, and provide the foundation for further advances in treatment development.

Personal dignity in people with early-stage dementia: A longitudinal study

BACKGROUND

A psychosocial problem faced by people with early-stage dementia (PwESD) is the perception of threats to personal dignity. Insights into its dynamics are important for understanding how it changes as dementia advances and to develop suitable interventions. However, longitudinal studies on this change in PwESD are lacking.

AIMS

To determine how perceptions of dignity and selected clinical and social factors change over 1 year in home-dwelling PwESD and the predictors associated with changes in perceptions of dignity over 1 year.

RESEARCH DESIGN AND METHODS

A longitudinal study was conducted. The sample included 258 home-dwelling Czech PwESD. Data were collected using the Patient Dignity Inventory (PDI-CZ), Mini-Mental State Examination, Bristol Activities of Daily Living Scale, Geriatric Depression Scale and items related to social involvement. Questionnaires were completed by the PwESD at baseline and after 1 year.

ETHICAL CONSIDERATIONS

The study was approved by the ethics committee and informed consent was provided by the participants.

RESULTS

People with Early-Stage Dementia rated the threat to dignity as mild and the ratings did not change significantly after 1 year. Cognitive function, self-sufficiency, vision, and hearing worsened, and more PwESD lived with others rather than with a partner after 1 year. Worsened depression was the only predictor of change in perceived personal dignity after 1 year, both overall and in each of the PDI-CZ domains. Predictors of self-sufficiency and pain affected only some PDI-CZ domains.

CONCLUSIONS

Perceptions of threat to dignity were mild in PwESD after 1 year, although worsened clinical factors represented a potential threat to dignity. Our findings lead us to hypothesise that perceived threats to personal dignity are not directly influenced by health condition, but rather by the social context.

Influence of affective states on informant impression of neuropsychiatric symptoms in people living with MCI

Objectives: Alzheimer's disease (AD) and mild cognitive impairment (MCI) are often accompanied by neuropsychiatric symptoms (NPS; e.g. depression/apathy/irritability) causing challenges for people living with dementia/caregivers and predicting worse disease progression. Accurately assessing NPS is critical to research on AD/MCI. However, there are limitations to both self-reports and clinician evaluations; the field often relies on informants to assess NPS. Informants' perception of NPS are influenced by disease and caregiver factors that may lead to biased assessments. We aimed to assess the relationship between participants self-reported affective states (valence/arousal) and informant-reported NPS.Methods: Data from a double-blinded intervention design (primarily testing neurostimulation's effect on NPS) were used to examine the relationship between participant-reported affective states and informant-reported NPS over 1 month. Forty participants (24 females) with MCI and NPS (mean age = 71.7, SD = 7) were enrolled along with informants (primarily spouses/partners) who regularly interact with participants. NPS assessment occurred weekly and at pre- and post-intervention, and participant-reported affective states were assessed at 14 timepoints.Results: Generalized Estimating Equations showed that participant levels of arousal, but not valence, were significantly related to corresponding informant-reported NPS at weekly (arousal: B= -0.59, SE = 0.27, Wald's χ2 = 4.61, p=.032; valence: B = 0.17, SE = 0.19, Wald's χ2 = 0.80, p=.37) and pre-/post- (arousal: B= -4.00, SE = 1.58, Wald's χ2 = 6.42, p=.011; valence: B= -3.34, SE = 1.80, Wald's χ2 = 3.43, p=.06) assessments.Conclusion: The findings indicate that informant-reported NPS may be more strongly influenced by arousal, and informants may be less attuned to valence in people living with MCI.

Burden in caregivers of primary care patients with dementia: influence of neuropsychiatric symptoms according to disease stage (NeDEM project)

BACKGROUND

Caregiver burden is related to personal factors and patient characteristics and is greater when neuropsychiatric symptoms (NPSs) are present.

OBJECTIVE

Estimate the prevalence of burden among caregivers of dementia patients and its association with NPSs and identify NPSs causing greater caregiver distress according to dementia stage.

METHODS

A cross-sectional observational study in caregivers of noninstitutionalized dementia patients was conducted. Caregiver variables were sociodemographic, time of care, NPS-associated distress based on the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D) and burden based on the Zarit Burden Interview (ZBI). Patient variables were time since disease onset, Global Deterioration Scale (GDS) disease stage, functional assessment and NPS presence and intensity according to the Neuropsychiatric Inventory (NPI). The mean ZBI score, prevalence of burden and NPI-D score with 95% CIs at each dementia stage were estimated. Factors associated with burden were identified by multivariate analysis.

RESULTS

Of the 125 caregivers included, 77.6% were women, with a mean age of 60.7 (± 14.3) years; 78.4% (95%CI: 71.0; 86.0) experienced burden. The mean ZBI score was 12.3 (95%CI: 11.6; 12.9) and increased according to NPS number (p = 0.042). The NPSs causing the most burden were disinhibition (93.5%), irritability (87.3%) and agitation (86.1%). Agitation, apathy, and sleep disorders were the NPSs generating the greatest overall caregiver distress; depression (max NPI-D 1.9), hyperactivity (max NPI-D 2.1), and psychosis symptoms (max NPI-D 1.6) generated the greatest distress at stage GDS 3, stages GDS 4-5, and stages GDS 6-7, respectively. The NPI score (OR = 1.0, 95%CI 1.0; 1.1), intensity of irritability (OR = 1.2, 95%CI 1.0; 1.6), disinhibition (OR = 2.6, 95%CI 1.1; 5.8) and hyperactivity subsyndrome (OR = 1.1, 95%CI 1.0; 1.2) were associated with caregiver burden. Other associated factors were female gender (OR = 6.0, 95%CI 1.6; 22.8), ≥ 8 h daily care (OR = 5.6, 95%CI 1.4; 22.8), working outside the home (OR = 7.6, 95%CI 1.8; 31.8), living with the patient (OR = 4.5, 95%CI 1.1; 19.6), kinship (OR = 5.4, 95%CI 1.0; 28.2) and lower patient education (OR = 8.3, 95%CI 2.3; 30.3).

CONCLUSIONS

The burden on caregivers of dementia patients is high and associated with NPS presence and intensity. Disinhibition and irritability caused the highest burden. Depression, hyperactivity and psychosis produce more distress in mild, mild-moderate and severe dementia, respectively.

Case Management-based Collaborative Care Model Associated with improvement in neuropsychiatric outcomes in community-dwelling people living with dementia

BACKGROUND

This study aimed to explore the association between adherence of collaborative care model and short-term deterioration of BPSD after controlling patient and caregiver factors.

METHODS

This retrospective case-control study enrolled 276 participants who were newly diagnosed with dementia and BPSD. A dementia collaborative care team interviewed patients and caregivers to form a care plan and provided individualized education or social resource referrals. A multivariate logistic regression model with backward selection was used to test factors associated with BPSD deterioration, defined as worse neuropsychiatric inventory (NPI) scores 1 year after joining the care model.

RESULTS

Male sex (odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.25-0.84) and higher clinical dementia rating scale sum of boxes scores (CDR-SOB) (OR = 0.90; 95% CI = 0.83-0.98) were protective factors, whereas spouse caregivers and withdrawals from the care model (OR = 3.42; 95% CI = 1.28-9.15) were risk factors for BPSD deterioration.

CONCLUSIONS

Our study showed that both patient and caregiver factors were associated with deterioration of BPSD. The case manager-centered dementia collaborative care model is beneficial for the management of BPSD. Healthcare systems may consider implementing a case management model in clinical dementia care practice.

A review of current evidence for mild behavioral impairment as an early potential novel marker of Alzheimer's disease

Mild behavioral impairment (MBI) is a neurobehavioral syndrome that occurs in the absence of cognitive impairment later in life (≥50 years of age). MBI is widespread in the pre-dementia stage and is closely associated with the progression of cognitive impairment, reflecting the neurobehavioral axis of pre-dementia risk states and complementing the traditional neurocognitive axis. Despite being the most common type of dementia, Alzheimer's disease (AD) does not yet have an effective treatment; therefore, early recognition and intervention are crucial. The Mild Behavioral Impairment Checklist is an effective tool for identifying MBI cases and helps identify people at risk of developing dementia. However, because the concept of MBI is still quite new, the overall understanding of it is relatively insufficient, especially in AD. Therefore, this review examines the current evidence from cognitive function, neuroimaging, and neuropathology that suggests the potential use of MBI as a risk indicator in preclinical AD.

Association of Dementia Severity and Caregiver Support With Early Discharge From Home Health

INTRODUCTION

The objective of this study was to examine the relationship between dementia severity and early discharge from home health.

METHODS

This was a retrospective study of 100% national Medicare home health da ta files (2016-2017). Multilevel logistic regression was used to study the relationship of dementia severity, caregiver support, and medication assistance with early discharge from home health.

RESULTS

The final cohort consisted of 91 302 Medicare beneficiaries with an ADRD diagnosis. A pattern of early discharge rates across dementia severity levels was not demonstrated. The relative risk for early discharge was lower for individuals who needed assistance with medication and for those with unmet caregiver needs.

DISCUSSION

The findings of this study do not support the hypothesis that dementia severity contributes to early discharge from home health. Further research is needed to fully understand key factors contributing to early discharge from home health.