Neuropsychiatric Symptoms Predict Functional Status in Alzheimer's Disease

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.

Prevalence of mild behavioural impairment and its association with cognitive and functional impairment in normal cognition, mild cognitive impairment, and mild Alzheimer's dementia

BACKGROUND

Mild behavioural impairment (MBI) is an emergent and persistent neuropsychiatric symptom (NPS) in subjects aged 50 and older who are at risk for cognitive decline. We examined the prevalence of MBI across the spectrum from cognitively normal (CN), mild cognitive impairment (MCI), to dementia, and further investigated the association between the MBI domain and cognitive and functional impairment.

METHOD

MBI was assessed in 2337 elderly patients in the Alzheimer's Disease Neuroimaging Initiative database (mean age, 73.04 years; 52.8% male). Among the subjects, 868 (37.1%) had normal cognition, 1066 (45.6%) had MCI, and 403 (17.2%) had mild Alzheimer's dementia (AD). MBI was evaluated in accordance with the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment diagnostic criteria for MBI, utilising the Neuropsychiatric Inventory. We compared the prevalence of the MBI domain with CN using multinominal logistic regression analysis and further quantified the magnitude of the association between MCI/AD and the MBI domains by calculating the population attributable risk (PAR). We assessed the association between the MBI domains and cognitive and functional impairment using simultaneous linear regression analysis.

RESULTS

The most common MBI domains in each diagnostic group were affective dysregulation followed by impulse dyscontrol, decreased motivation, social inappropriateness, and abnormal perception or thought content. The PARs for MBI domains in subjects with MCI or AD were respectively: 16.60% and 24.34% for affective dysregulation; 3.72% and 18.06% for impulse dyscontrol; 4.78% and 14.13% for decreased motivation, 1.91% and 2.29% for social inappropriateness; and 0.68% and 3.85% for abnormal perception or thought content. All MBI domains except for social inappropriateness were significantly associated with a higher 11-item Alzheimer's Disease Assessment Scale-Cognitive Subscale total score. All MBI domains were significantly associated with a higher Functional Activities Questionnaire total score.

CONCLUSION

Our findings show that MBI is highly prevalent across subjects with CN, MCI, and AD and is associated with cognitive and functional decline. MBI could be a crucial clinical phenotype relevant to the risk of cognitive and functional impairment, and provides a useful dimension pertinent to diagnostic approaches.

Alzheimer's disease detection using data fusion with a deep supervised encoder

Alzheimer's disease (AD) is affecting a growing number of individuals. As a result, there is a pressing need for accurate and early diagnosis methods. This study aims to achieve this goal by developing an optimal data analysis strategy to enhance computational diagnosis. Although various modalities of AD diagnostic data are collected, past research on computational methods of AD diagnosis has mainly focused on using single-modal inputs. We hypothesize that integrating, or "fusing," various data modalities as inputs to prediction models could enhance diagnostic accuracy by offering a more comprehensive view of an individual's health profile. However, a potential challenge arises as this fusion of multiple modalities may result in significantly higher dimensional data. We hypothesize that employing suitable dimensionality reduction methods across heterogeneous modalities would not only help diagnosis models extract latent information but also enhance accuracy. Therefore, it is imperative to identify optimal strategies for both data fusion and dimensionality reduction. In this paper, we have conducted a comprehensive comparison of over 80 statistical machine learning methods, considering various classifiers, dimensionality reduction techniques, and data fusion strategies to assess our hypotheses. Specifically, we have explored three primary strategies: (1) Simple data fusion, which involves straightforward concatenation (fusion) of datasets before inputting them into a classifier; (2) Early data fusion, in which datasets are concatenated first, and then a dimensionality reduction technique is applied before feeding the resulting data into a classifier; and (3) Intermediate data fusion, in which dimensionality reduction methods are applied individually to each dataset before concatenating them to construct a classifier. For dimensionality reduction, we have explored several commonly-used techniques such as principal component analysis (PCA), autoencoder (AE), and LASSO. Additionally, we have implemented a new dimensionality-reduction method called the supervised encoder (SE), which involves slight modifications to standard deep neural networks. Our results show that SE substantially improves prediction accuracy compared to PCA, AE, and LASSO, especially in combination with intermediate fusion for multiclass diagnosis prediction.

Cortical Iron Accumulation as an Imaging Marker for Neurodegeneration in Clinical Cognitive Impairment Spectrum: A Quantitative Susceptibility Mapping Study

OBJECTIVE

Cortical iron deposition has recently been shown to occur in Alzheimer's disease (AD). In this study, we aimed to evaluate how cortical gray matter iron, measured using quantitative susceptibility mapping (QSM), differs in the clinical cognitive impairment spectrum.

MATERIALS AND METHODS

This retrospective study evaluated 73 participants (mean age ± standard deviation, 66.7 ± 7.6 years; 52 females and 21 males) with normal cognition (NC), 158 patients with mild cognitive impairment (MCI), and 48 patients with AD dementia. The participants underwent brain magnetic resonance imaging using a three-dimensional multi-dynamic multi-echo sequence on a 3-T scanner. We employed a deep neural network (QSMnet+) and used automatic segmentation software based on FreeSurfer v6.0 to extract anatomical labels and volumes of interest in the cortex. We used analysis of covariance to investigate the differences in susceptibility among the clinical diagnostic groups in each brain region. Multivariable linear regression analysis was performed to study the association between susceptibility values and cognitive scores including the Mini-Mental State Examination (MMSE).

RESULTS

Among the three groups, the frontal (P < 0.001), temporal (P = 0.004), parietal (P = 0.001), occipital (P < 0.001), and cingulate cortices (P < 0.001) showed a higher mean susceptibility in patients with MCI and AD than in NC subjects. In the combined MCI and AD group, the mean susceptibility in the cingulate cortex (β = -216.21, P = 0.019) and insular cortex (β = -276.65, P = 0.001) were significant independent predictors of MMSE scores after correcting for age, sex, education, regional volume, and APOE4 carrier status.

CONCLUSION

Iron deposition in the cortex, as measured by QSMnet+, was higher in patients with AD and MCI than in NC participants. Iron deposition in the cingulate and insular cortices may be an early imaging marker of cognitive impairment related neurodegeneration.

Specific neuropsychiatric symptoms are associated with functional decline trajectories in Alzheimer's disease and Lewy body dementia: a five-year follow-up study

Background

Neuropsychiatric symptoms (NPS) are often overlooked and under-identified symptoms associated with dementia, despite their significant impact on the prognosis of individuals living with the disease. The specific role of certain NPS in functional prognosis remains unclear.

Aims

To determine the association of different NPS with functional decline in people living with Alzheimer's disease (AD) or Lewy body dementia (LBD).

Methods

This is an analysis of data from the Dementia Study of Western Norway (DemVest) with 196 patients included of which 111 had AD and 85 LBD. The Neuropsychiatric Inventory (NPI) and the Rapid Disability Rating Scale (RDRS-2) for activities of daily living were administered annually for 5 years. NPI total score and individual items with RDRS-2 trajectories were analyzed with linear mixed models.

Results

The LBD group exhibited higher levels of functional impairment and a greater burden of NPS at baseline. Over the 5-year follow-up, hallucinations, aggression, depression, anxiety, apathy, disinhibition, aberrant motor behavior, nighttime behavior disturbances, and abnormal eating patterns were significantly associated with the decline in functional abilities in individuals with AD, as well as irritability and aberrant motor behavior in those with LBD.

Discussion

These results highlight the relevance of early detection and intervention of these particularly relevant NPS, due to its potential of also impacting physical function. Better detection and management of these NPS could improve functional prognosis in people living with dementia.

Conclusion

Specific NPS demonstrate relevant distinct associations with Longitudinal trajectories of functional decline in AD and LBD.

Alzheimer's Behavioral and Psychiatric Burden in Saudi Arabia: Validation of the Saudi Version of the Neuropsychiatric Inventory

BACKGROUND

The burden of behavioral and psychiatric symptoms in dementia (BPSD) has not been characterized in Saudi patients with Alzheimer disease (AD). Moreover, the Saudi version of the Neuropsychiatric Inventory (SNPI) has not been validated.

OBJECTIVES

The purpose of this study was to validate the SNPI and describe frequency and determinants of BPSD in Saudi AD patients.

METHODS

The SNPI and BEHAVE-AD instruments were administered to community-dwelling Saudi AD patients and their caregivers.

RESULTS

The sample size was 192. The first 59 constituted the validation cohort. Cronbach alpha of the SNPI and BEHAVE-AD were 0.91 and 0.79, respectively. There were significant correlations between: (1) the total SNPI and BEHAVE-AD scores ( r =0.84, P <0.001); (2) analogous SNPI and BEHAVE-AD symptom subscores ( P <0.05); (3) SNPI and BEHAVE-AD caregiver distress ( F =22.6, P <0.001). Inter-rater reliability of the SNPI was excellent (kappa=0.74). Ninety percent of patients experienced 4 SNPI symptoms or more. Patients with stroke and prior psychiatric history were most likely to experience BPSDs. The most common symptom was apathy (82%). Caregiver distress was determined by the total NPI score and impulsiveness subscale score.

CONCLUSIONS

The SNPI is valid and reliable for assessing BPSD in Saudi AD patients. Longitudinal studies of BPSDs in Saudi specialized dementia clinics are needed.

Macrostructural and Microstructural White Matter Alterations Are Associated with Apathy across the Clinical Alzheimer's Disease Spectrum

Apathy is the commonest neuropsychiatric symptom in Alzheimer's disease (AD). Previous findings suggest that apathy is caused by a communication breakdown between functional neural networks involved in motivational-affective processing. This study investigated the relationship between white matter (WM) damage and apathy in AD. Sixty-one patients with apathy (AP-PT) and 61 without apathy (NA-PT) were identified from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database and matched for cognitive status, age and education. Sixty-one cognitively unimpaired (CU) participants were also included as controls. Data on cognitive performance, cerebrospinal fluid biomarkers, brain/WM hyperintensity volumes and diffusion tensor imaging indices were compared across groups. No neurocognitive differences were found between patient groups, but the AP-PT group had more severe neuropsychiatric symptoms. Compared with CU participants, only apathetic patients had deficits on the Clock Drawing Test. AP-PT had increased WM damage, both macrostructurally, i.e., larger WM hyperintensity volume, and microstructurally, i.e., increased radial/axial diffusivity and reduced fractional anisotropy in the fornix, cingulum, anterior thalamic radiations and superior longitudinal and uncinate fasciculi. AP-PT showed signs of extensive WM damage, especially in associative tracts in the frontal lobes, fornix and cingulum. Disruption in structural connectivity might affect crucial functional inter-network communication, resulting in motivational deficits and worse cognitive decline.

Multiple Cognitive and Behavioral Factors Link Association Between Brain Structure and Functional Impairment of Daily Instrumental Activities in Older Adults

OBJECTIVE

Functional impairment in daily activity is a cornerstone in distinguishing the clinical progression of dementia. Multiple indicators based on neuroimaging and neuropsychological instruments are used to assess the levels of impairment and disease severity; however, it remains unclear how multivariate patterns of predictors uniquely predict the functional ability and how the relative importance of various predictors differs.

METHOD

In this study, 881 older adults with subjective cognitive complaints, mild cognitive impairment (MCI), and dementia with Alzheimer's type completed brain structural magnetic resonance imaging (MRI), neuropsychological assessment, and a survey of instrumental activities of daily living (IADL). We utilized the partial least square (PLS) method to identify latent components that are predictive of IADL.

RESULTS

The result showed distinct brain components (gray matter density of cerebellar, medial temporal, subcortical, limbic, and default network regions) and cognitive-behavioral components (general cognitive abilities, processing speed, and executive function, episodic memory, and neuropsychiatric symptoms) were predictive of IADL. Subsequent path analysis showed that the effect of brain structural components on IADL was largely mediated by cognitive and behavioral components. When comparing hierarchical regression models, the brain structural measures minimally added the explanatory power of cognitive and behavioral measures on IADL.

CONCLUSION

Our finding suggests that cerebellar structure and orbitofrontal cortex, alongside with medial temporal lobe, play an important role in the maintenance of functional status in older adults with or without dementia. Moreover, the significance of brain structural volume affects real-life functional activities via disruptions in multiple cognitive and behavioral functions.

A multicentric exploratory study of behavioral and psychological symptom characteristics of dementia

BACKGROUND

Behavioral and psychological symptoms (BPS) are usually the expected consequences of dementia. BPS increases morbidity and burden, affects the quality of life, and impacts care costs. However, the symptom characteristics, clinical correlations, and symptom-specific clusters aiding the diagnosis are less well studied, especially in the Indian population.

MATERIALS AND METHODS

The present study examined the BPS clusters based on various cognitive and neuropsychiatric profiles in patients with dementia under a multicentric study in India. We did a cross-sectional assessment using the Neuropsychiatric Inventory Questionnaire (NPI-Q) and cognitive functions by Montreal Cognitive Assessment (MoCA), and the severity of dementia using the Clinical Dementia Rating (CDR) scale. In addition, all of the participants were evaluated on a structured Clinical Interview for DSM-5 Research Version for past or current psychiatric disorder(s).

RESULTS

We describe the various BPS clusters uniquely associated with the severity of dementia. Further, on linear regression analysis, we predicted three symptom clusters (anxiety, irritability, aberrant motor) in mild, two symptom clusters (disinhibition, agitation/aggression) in moderate and three symptom clusters (delusion, euphoria/elation, disinhibition) in severe dementia.

CONCLUSION

The study provides insights into the various symptom characteristics and inter-relationship of BPS, which may benefit the clinician while assessing patients with dementia.

Cognitive Profile of Large-Vessel Vascular Dementia—An Observational Study from a Tertiary Care Center in Kolkata

Introduction  Vascular dementia is the second leading cause of dementia worldwide. Its heterogenous presentation along with potential for reversibility at earlier stages makes it unique among all dementias.

Objectives  We aimed to study the cognitive dysfunction in large-vessel vascular dementia. Second, we tried to study the cognitive dysfunction in large-vessel vascular dementia as per the arterial territory involvement. Additionally, we also tried to study the contribution of hemispheric involvement to the dementia severity as evidenced by clinical dementia rating (CDR) scale.

Materials and Methods  We recruited 28 patients of large-vessel vascular dementia and categorized them on the basis of the arterial territories and hemisphere involved. The groups were later studied for the type of cognitive and behavioral dysfunctions as well as the dementia severity.

Results  Among 28 patients of large-vessel vascular dementia, attention (100%), executive function (100%), and behavior (100%) were more impaired in anterior cerebral artery territory infarcts ( p  < 0.05). Language (53.8%) and memory (53.8%) were more impaired in middle cerebral artery territory infarcts, while visuoperceptual (33.3%) domains were more impaired in posterior cerebral artery territory infarcts ( p  > 0.05). The mean CDR was lower in patients of right-sided lesions (1.292) than in those with left-sided (1.750) or bilateral lesions (2.000).

Conclusion  Different arterial territory lesions have different patterns of cognitive impairment in large-vessel vascular dementia. The dementia severity is less in right-sided lesions when compared with left-sided or bilateral lesions.

How does carer management style influence the performance of activities of daily living in people with dementia?

INTRODUCTION

People with Dementia (PwD)'s performance of activities of daily living (ADLs) has been associated with apathy, cognitive deficits, carers' depression and burden. However, it is not known if the carers' management style affects ADL performance, particularly alongside PwD's cognitive deficits and apathy. Thus, the aim of this study was to explore the contribution of intrinsic (cognition, apathy) and extrinsic (carer management styles) dementia factors to ADL performance.

METHODS

PwD (n = 143) were assessed on global cognition (ACE-III); apathy (CBI-R); ADLs (Disability Assessment for Dementia-DAD). Carers' (n = 143) criticism, encouragement and active-management styles were assessed with the Dementia Management Strategy Scale (DMSS). Multiple linear regression analysis investigated contributions of carer styles, cognition, apathy (independent variables) on ADLs (dependent variable).

RESULTS

The best model explaining the variance of the DAD scores included cognition (β = 0.413, t₍₁₄₂₎  = 4.463, p = 0.001), apathy (β = -0.365, t₍₁₄₂₎  = -5.556, p = 0.001), carer criticism (β = -0.326, t₍₁₄₂₎  = -2.479, p = 0.014) and carer encouragement styles (β = 0.402, t₍₁₄₂₎  = 2.941, p = 0.004) accounting for 40% of the variance of the DAD scores.

CONCLUSIONS

This novel study demonstrated that PwD's level of apathy and the carer's use of criticism negatively affected ADL performance while PwD's cognitive abilities and carer encouragement style improved ADL performance. These findings have critical implications for the development of novel multi-component non-pharmacological interventions to maintain function and delay disease progression in dementia, as well as direct relevance to current carers and families.

Benzodiazepines and antidepressants: Effects on cognitive and functional decline in Alzheimer's disease and Lewy body dementia

OBJECTIVES

We aim to study the effects of the prescription of benzodiazepines and antidepressants on cognitive and functional decline in older adults living with Alzheimer's disease (AD) and Lewy body dementia (LBD) over a 5-year follow-up.

METHODS

This is a longitudinal analysis of a Norwegian cohort study entitled "The Dementia Study of Western Norway" (DemVest). We included 196 patients newly diagnosed with AD (n = 111) and LBD (n = 85), followed annually for 5 years. Three prescription groups were defined: only benzodiazepines (BZD), only antidepressants (ADep), and the combination of benzodiazepines and antidepressants (BZD-ADep). Linear mixed-effects models were conducted to analyze the effect of the defined groups on the outcomes. The outcomes were functional decline, measured by the Rapid Disability Rating Scale-2, and cognition measured with the Mini-Mental State Examination.

RESULTS

Prescription of the combination of benzodiazepines and antidepressants in LBD was associated with faster functional decline. In AD, the prescription of BZD and BZD-ADep was associated with greater functional deterioration. ADep alone did not show positive or negative significant associations with the studied outcomes.

CONCLUSIONS

BZD and especially the combination of BZD and ADep are associated with functional decline in AD and LBD and should be used cautiously.

Social cognition: Patterns of impairments in mild and moderate Alzheimer's disease

OBJECTIVE

Social cognition (SC) deficits in Alzheimer's Disease (AD) are commonly associated with the progression of the disease, and mainly as a result of global cognition deterioration. We aimed to investigate the relationship between SC, global cognition, and other clinical variables in mild and moderate people with AD and their caregivers. We also investigated the differences between self-reported SC and family caregivers' ratings of SC.

METHODS

We included 137 dyads of people with AD (87 mild and 50 moderate) and caregivers. We evaluated social cognition, global cognition, quality of life, dementia severity, mood, functionality, neuropsychiatric symptoms, and caregiver burden.

RESULTS

SC presented a specific pattern of impairment, especially when related to global cognition deficits. Although the moderate AD group showed significant worsening in cognition, functionality and neuropsychiatric symptoms, when compared to the mild group, SC did not present significant differences between the groups. The multivariate regression analysis showed that in the mild group, self-reported SC was related to age and years of education. In the moderate group, SC was related to gender. For caregivers, in the mild group, SC was related to functionality and quality of life, while in the moderate group, was associated with quality of life.

CONCLUSION

The pattern of impairment of SC may be more stable as it implies interaction with cognition, mainly in the mild stage, but also include subjective factors as a personal perception about oneself and others, values, and beliefs that evokes individual, social, cultural, and contextual factors.

Association between Daily Activities and Behavioral and Psychological Symptoms of Dementia in Community-Dwelling Older Adults with Memory Complaints by Their Families

It is important and useful to consider information provided by family members about individuals with memory complaints' instrumental activities of daily living (IADL). The purpose of this study was to clarify the characteristics and relevance of individuals with memory complaints' IADL and behavioral and psychological symptoms of dementia (BPSD) assessed from the perspective of the family members using the Process Analysis of Daily Activity for Dementia and short version Dementia Behavior Disturbance scale. A self-administered questionnaire was sent to 2000 randomly selected members of Consumer's Co-operative Kagoshima, and 621 responded. Of the returned responses, there were 159 participants who answered about individuals with memory complaints. The stepwise multiple regression analysis was used to examine the association between IADL and BPSD. The result showed that many IADL of the individuals with memory complaints were associated with BPSD of apathy, nocturnal wakefulness, and unwarranted accusations, adjusted for age, gender, and the observation list for early signs of dementia. In addition, each IADL was associated with BPSD of apathy, nocturnal wakefulness, and dresses inappropriately. Modifying lifestyle early on when families recognize these changes may help maintain and improve the long-term quality of life of the individuals with memory complaints and their family.

Neuropsychiatric symptoms and activities of daily living in Alzheimer's disease: ALSOVA 5-year follow-up study

BACKGROUND

Neuropsychiatric symptoms (NPSs) in Alzheimer's disease (AD) are related to activities of daily living (ADLs), but longitudinal studies are sparse.

OBJECTIVES

We investigated which NPSs were related to decline in instrumental ADLs (IADLs) and basic ADLs (BADLs) in a 5-year follow-up of individuals with AD.

METHODS

ALSOVA 5-year follow-up study data of 236 individuals with very mild or mild AD at baseline and their caregiver were analyzed. IADLs and BADLs were assessed with Alzheimer's Disease Cooperative Study ADL inventory, and NPSs with Neuropsychiatric Inventory at annual follow-up visits. Generalized estimating equations (GEEs) were used for longitudinal data analysis, and NPS-ADL networks were estimated to demonstrate symptom interactions.

RESULTS

Apathy [rate ratio (RR) 1.23, 95% CI 1.06-1.44, p = 0.007], aberrant motor behavior (RR 1.24, 95% CI 1.07-1.44, p = 0.005), and appetite disturbances (RR 1.22, 95% CI 1.06-1.41, p = 0.005) were related to impairment in BADLs, and the same symptoms (RR 1.13, 95% CI 1.07-1.21, p < 0.001; RR 1.13, 95% CI 1.07-1.20, p < 0.001; RR 1.14; 95% CI 1.08-1.21, p < 0.001, for apathy, aberrant motor behavior, and appetite disturbances, respectively), in addition to delusions (RR 1.09, 95% CI 1.03-1.15, p = 0.004), were related to IADL impairment. Symptom networks varied at different time points.

CONCLUSION

As AD progresses, common (apathy) and uncommon NPSs (aberrant motor behavior, appetite disturbances, delusions) seem to be related to ADLs through various symptom interactions. Previous literature suggests that frontal pathology could underlie these relationships.

Insula and Amygdala Atrophy Are Associated With Functional Impairment in Subjects With Presbycusis

Hearing loss is an important risk factor for dementia. However, the mechanisms that relate these disorders are still unknown. As a proxy of this relationship, we studied the structural brain changes associated with functional impairment in activities of daily living in subjects with age related hearing loss, or presbycusis. One hundred eleven independent, non-demented subjects older than 65 years recruited in the ANDES cohort were evaluated using a combined approach including (i) audiological tests: hearing thresholds and cochlear function measured by pure tone averages and the distortion product otoacoustic emissions respectively; (ii) behavioral variables: cognitive, neuropsychiatric, and functional impairment in activities of daily living measured by validated questionnaires; and (iii) structural brain imaging—assessed by magnetic resonance imaging at 3 Tesla. The mean age of the recruited subjects (69 females) was 73.95 ± 5.47 years (mean ± SD) with an average educational level of 9.44 ± 4.2 years of schooling. According to the audiometric hearing thresholds and presence of otoacoustic emissions, we studied three groups: controls with normal hearing (n = 36), presbycusis with preserved cochlear function (n = 33), and presbycusis with cochlear dysfunction (n = 38). We found a significant association (R²_D = 0.17) between the number of detected otoacoustic emissions and apathy symptoms. The presbycusis with cochlear dysfunction group had worse performance than controls in global cognition, language and executive functions, and severe apathy symptoms than the other groups. The neuropsychiatric symptoms and language deficits were the main determinants of functional impairment in both groups of subjects with presbycusis. Atrophy of insula, amygdala, and other temporal areas were related with functional impairment, apathy, and language deficits in the presbycusis with cochlear dysfunction group. We conclude that (i) the neuropsychiatric symptoms had a major effect on functional loss in subjects with presbycusis, (ii) cochlear dysfunction is relevant for the association between hearing loss and behavioral impairment, and (iii) atrophy of the insula and amygdala among other temporal areas are related with hearing loss and behavioral impairment.

Neuropsychiatric Symptoms in Alzheimer's Disease Are the Main Determinants of Functional Impairment in Advanced Everyday Activities

BACKGROUND

Neuropsychiatric symptoms and cognitive impairment are independent contributors of functional impairment in activities of daily living (ADL) in Alzheimer's disease (AD) patients. ADL could be divided according to its complexity in three subdomains: basic (BADL), instrumental (IADL), and advanced (a-ADL).

OBJECTIVE

Studying the cognitive and neuropsychiatric determinants of BADL, IADL, and a-ADL in normal cognitive elders and AD patients.

METHODS

144 subjects were graduated using the clinical dementia rating (CDR) in CDR = 0, n = 52 (control group) and 92 AD patients CDR = 0.5, n = 34 and CDR = 1&2, n = 58. They were assessed with measures of cognitive performance and neuropsychiatric symptoms that were included in regression models to measure the best predictors for each ADL subdomain at every CDR status.

RESULTS

AD patients were significantly older, and had significantly more severe functional impairment, neuropsychiatric symptoms, and cognitive decline than controls. The best predictors of functional impairment in controls and CDR = 0.5 AD patients were neuropsychiatric symptoms; in the CDR 0.5 patients, apathy severity was the most important determinant of IADL and a-ADL impairment. While in the CDR 1&2 AD patients, cognitive impairment was the principal determinant of functional impairment, being memory the best determinant of IADL and a-ADL impairment, while global cognition was of BADL impairment.

CONCLUSIONS

The contribution of cognitive impairment and neuropsychiatric symptoms varied according to the subdomain of ADL, and the CDR. In very mild AD and controls the neuropsychiatric symptoms are the best predictors of more complex ADL impairment, while cognitive impairment is more important at mild to moderate states of AD.

Association Between Neuropsychiatric Symptoms and Functional Change in Older Non-Demented Adults: Mayo Clinic Study of Aging

We examined the associations between baseline neuropsychiatric symptoms (NPS) and longitudinal changes in functional performance among 5,394 non-demented individuals aged ≥50 years (2,729 males; median age 74.2 years; 4,716 cognitively unimpaired, 678 mild cognitive impairment). After adjusting for age, sex, education, and medical comorbidities, NPS assessed by the Neuropsychiatric Inventory Questionnaire, clinical depression (Beck Depression Inventory score ≥13) and anxiety (Beck Anxiety Inventory score ≥10) were significantly associated with an increase in the Functional Activities Questionnaire score, indicating functional decline over time. This association may vary depending on the degree of cognitive impairment at baseline.

Animal Models of Psychosis in Alzheimer Disease

Psychosis in Alzheimer Disease (AD) represents a distinct clinicopathologic variant associated with increased cognitive and functional morbidity and an accelerated disease course. To date, extant treatments offer modest benefits with significant risks. The development of new pharmacologic treatments for psychosis in AD would be facilitated by validated preclinical models with which to test candidate interventions. The current review provides a brief summary of the process of validating animal models of human disease together with a critical analysis of the challenges posed in attempting to apply those standards to AD-related behavioral models. An overview of phenotypic analogues of human cognitive and behavioral impairments, with an emphasis on those relevant to psychosis, in AD-related mouse models is provided, followed by an update on recent progress in efforts to translate findings in the pathophysiology of psychotic AD into novel models. Finally, some future directions are suggested to expand the catalogue of psychosis-relevant phenotypes that may provide a sturdier framework for model development and targets for preclinical treatment outcomes.

Why Do They Just Sit? Apathy as a Core Symptom of Alzheimer Disease

OBJECTIVE

Apathy is common in Alzheimer disease (AD) and has a far-reaching impact on patients' clinical course and management needs. However, it is unclear if apathy is an integral component of AD or a manifestation of depression in cognitive decline. This study aims to examine interrelationships between apathy, depression, and function.

METHODS

This was a cross-sectional study of well-characterized AD patients in the National Alzheimer's Coordinating Center Uniform Data Set with a Clinical Dementia Rating (CDR) between 0.5 and 2. Participants' function was measured using the Functional Assessment Questionnaire. Apathy and depression were measured using clinician judgment and informant-reported Neuropsychiatric Inventory-Questionnaire. Dementia severity was categorized by CDR.

RESULTS

Sample included 7,679 participants (55.7% men) with a mean (standard deviation) age of 74.9 (9.7) years; 3,197 (41.6%) had apathy based on clinician judgment. Among those with apathy, approximately half had no depression. Presence of apathy was associated with 21%, 10%, and 3% worsening in function compared with those without apathy in CDR 0.5, 1, and 2 groups, respectively. Depression was not independently associated with functional status. Results revealed no interaction between apathy and depression.

CONCLUSION

Apathy, but not depression, was significantly associated with worse function, with the strongest effects in mild dementia. Results emphasize the need for separate assessments of apathy and depression in the evaluation and treatment of patients with dementia. Understanding their independent effects on function will help identify patients who may benefit from more targeted management strategies.

Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia

Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent and represent a significant burden for patients and their caregivers. Early recognition and management of these symptoms is crucial as they are associated with increased risk of institutionalization, impairments in daily functioning, reduced quality of life, and more rapid progression to severe dementia. This chapter will discuss the pathophysiology, proposed diagnostic criteria, clinical features, and management of BPSD, including apathy, depression, agitation/aggression, psychosis, and sleep disturbances. Apathy and depression are the most common overall, and apathy is associated with high symptom severity likely because of its greater persistence. Symptoms such as agitation, aggression, hallucinations, and delusions may be especially distressing and dangerous to patients and caregivers. Nonpharmacologic management should be considered first-line therapy in most cases due to the modest and inconsistent evidence base for pharmacologic agents and greater risk of harm. However, the judicious use of pharmacologic agents may be warranted when symptoms are dangerous and/or severely distressing.

Apathy is associated with faster global cognitive decline and early nursing home admission in dementia with Lewy bodies

Background

Little is known about the consequences of apathy in dementia with Lewy bodies (DLB), because previous research on apathy in dementia focused mainly on Alzheimer’s disease (AD).

Methods

In this longitudinal study, we included patients with AD (n = 128) and patients with DLB (n = 81). At baseline, we analyzed the associations between apathy and cognition in the total sample and in AD and DLB separately. Generalized linear mixed models were used to investigate the association between apathy and Mini Mental State Examination (MMSE) over 4 years, and the Kaplan-Meier method was used to assess the association between apathy and survival or nursing home admission.

Results

In patients with DLB, apathy was associated with a faster global cognitive decline (MMSE) over 4 years. Patients with DLB and apathy had shorter time until nursing home admission than DLB patients without apathy and patients with AD, regardless of apathy. At baseline, patients with apathy had decreased performance on the Stroop color test and a composite executive function score. Neurocognition was unaffected by apathy in AD, but DLB patients with apathy had more verbal learning difficulties.

Conclusions

Apathy seems to be associated with more serious symptomatology in DLB than in AD. It is important to focus on apathy in dementia because it is one of the most prevalent and disturbing behavioral and psychological symptoms.

Apathy in Alzheimer's disease

Apathy is the most common neuropsychiatric symptom in patients with Alzheimer's disease (AD). The presence of apathy has been related to greater caregiver distress, decreased quality of life, and increased morbidity. Here we review the most recent studies on this neuropsychiatric syndrome, focusing on prevalence, impact on quality of life, behavioural and neuroimaging studies, and treatment options. The results of some investigations on the behavioural and neuroanatomical profile of apathy in AD point to a role of frontostriatal circuits, specifically involving the anterior cingulate cortex. However, small and heterogeneous samples, lack of control for disease severity, and non-specific apathy scales complicate interpretation of results. Future studies might benefit from studying multiple dimensions of apathy within conceptual frameworks which allow for a deconstruction of underlying mechanisms.

Melatonin for Sleep Disorders in Patients with Neurodegenerative Diseases

In patients with neurodegenerative diseases, sleep disorders are common; they impair the quality of life for patients and caregivers and are associated with poorer clinical outcomes. Melatonin has circadian, hypnotic, and free radical-scavenging effects, and preclinical data suggest benefits of melatonin on neurodegeneration. However, randomized, controlled trials of melatonin in patients with neurodegenerative diseases have not shown strong effects. Trials in Alzheimer's patients demonstrate a lack of benefit on sleep quantity. Subjective measures of sleep quality are mixed, with possible symptomatic improvements seen only on some measures or at some time points. Benefits on cognition have not been observed across several studies. In Parkinson's patients, there may be minimal benefit on objective sleep measures, but a suggestion of subjective benefit in few, small studies. Effective treatments for the sleep disorders associated with neurodegenerative diseases are urgently needed, but current data are insufficient to establish melatonin as such a treatment.