Management of dementia-related behavioral disturbances: a nonpharmacologic approach

Risk Factors Associated with Missing Incidents among Persons Living with Dementia: A Scoping Review

Worldwide, over 55-million people have dementia, and the number will triple by 2050. Persons living with dementia are exposed to risks secondary to cognitive challenges including getting lost. The adverse outcomes of going missing include injuries, death, and premature institutionalization. In this scoping review, we investigate risk factors associated with going missing among persons living with dementia. We searched and screened studies from four electronic databases (Medline, CINAHL, Embase, and Scopus), and extracted relevant data. We identified 3,376 articles, of which 73 met the inclusion criteria. Most studies used quantitative research methods. We identified 27 variables grouped into three risk factor domains: (a) demographics and personal characteristics, (b) health conditions and symptoms, and (c) environmental and contextual antecedents. Identification of risk factors associated with getting lost helps to anticipate missing incidents. Risk factors can be paired with proactive strategies to prevent incidents and inform policies to create safer communities.

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

OBJECTIVE

To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017.

METHODS

2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies.

RESULTS

Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01).

CONCLUSIONS AND IMPLICATIONS

Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.

The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?

OBJECTIVE

To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs.

METHODS

The 2011-2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N = 7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated.

RESULTS

The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors.

CONCLUSION

Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.

Falls in Synucleinopathies

Parkinson's disease (PD) and other synucleinopathies, namely dementia with Lewy bodies (DLB) and multiple system atrophy (MSA), are common degenerative neurological disorders that share synuclein pathology. Although certain cardinal features of parkinsonism, including bradykinesia and rigidity, respond well to levodopa, axial features, such as gait and balance impairment, are less reliably responsive to dopaminergic therapy and surgical interventions. Consequently, falls are common in PD and other synucleinopathies and are a major contributor toward injury and loss of independence. This underscores the need for appropriate fall risk assessment and implementation of preventative measures in all patients with parkinsonism. The aim of this review is therefore to explore modifiable and non-modifiable risk factors for falls in synucleinopathies. We next review and evaluate the evidence for pharmacological, nonpharmacological, and surgical approaches for fall prevention, and emphasize individualized and multifaceted approaches.

Psychiatric illness and resident assaults among veterans in long-term care facilities

This article describes a quality improvement program to reduce the prevalence of physical assaults in a university-affiliated, 234-bed Veterans Affairs (VA) long-term care (LTC) facility, which experienced a rise in the number of physical assaults to >4 per 1,000 bed days of care in four LTC units. Analysis of 55 events (29 patients) at this VA LTC site during 2007 revealed 19 resident assailants (8% total population), 10 victims, and 30% repeat events. Of the residents who exhibited assaultive behavior, 44% had dementia and 32% had schizophrenia as a major diagnosis. Following a process improvement plan, new occurrence assaultive behaviors declined from >4 to <1 per 1,000 bed days and remained low during 5-year follow up.

Improving safety and operational efficiency in residential care settings with WiFi-based localization

OBJECTIVES

To assess the effectiveness of a wireless network (WiFi-based) localization system (devices mounted on resident wheelchairs) in decreasing caretaker time spent searching for residents and providing alerts of residents going outdoors in a skilled nursing facility.

DESIGN

A controlled study over two 2-month periods approved by the institutional review board.

SETTING

A long-term skilled nursing facility in Massachusetts specializing in multiple sclerosis previously instrumented with wireless network infrastructure.

PARTICIPANTS

Nineteen residents and 9 staff members at the facility for the first 2-month period; 9 residents and 3 staff members at the facility for the second 2-month period.

INTERVENTION

Software was installed on 4 staff computers to display the locations of residents enrolled in the study. This software was made available to enrolled staff for the second half of the first 2-month period and the entirety of the second 2-month study. In the second 2-month study, the software was modified to provide alerts if any 1 of 9 participating "high-risk"' residents went outdoors, and the accuracy of the alert system was evaluated.

MEASUREMENTS

In the first 2-month study, 9 staff members recorded the amount of time it took them to locate participating residents (as and when needed during the course of their daily activities). In the second 2-month study, 3 staff members recorded whether outdoor-alerts correctly identified a resident leaving the building or if it was a false alarm.

RESULTS

In both phases, participating staff members made frequent use of the system (44 searches and 215 outdoor alerts). Overall, the localization information decreased the average time needed to find residents by about two-thirds (from 311.1 seconds to 110.9 seconds). For outdoor alerts, the system had a false-alarm rate of 9.1% (under normal facility operations); systematic tests of the outdoor-alert system carried out by the authors had a false-negative, or missed-alarm, rate of 1.7%.

CONCLUSION

Using timely resident location information can provide significant gains for both operational efficiency (finding residents) and enhanced resident safety (outdoor alerts). This approach may provide an inexpensive alternative for facilities that have sufficient wireless infrastructure; future work should assess its effectiveness in additional settings.

Central nervous system medication changes and falls in nursing home residents

We investigated the role of changes in 6 mutually exclusive medication categories on the risk of falling in nursing home residents. The 6 categories were: gastrointestinal, hypoglycemics, antibiotics, central nervous system (CNS) acting, cardiovascular disease agents, and analgesics. A change was defined as a new start, a dose change, an as-needed dose, or a discontinuation. Incident reports were used to determine the fall date and time. Medication records were abstracted to identify the date of changes before the date of each fall. The 158 residents who fell had 419 recorded falls during 2002 and 2003; they were on average 80.5 years old (SD 8.1; range 65-103), and 67% were men. Within 1-3 days of a change in any CNS medication (antipsychotic, sedative, antidepressant, or antiseizure), the fall risk (odds ratio) increased 3.4-fold (95% confidence interval 1.2-9.5) using 7-9 days prior as comparable control days. No changes in other medication categories had a significant effect on fall risk. These data suggest that the risk of falls among nursing home residents is significantly elevated within 3 days of a CNS medication change.

A framework for managing wandering and preventing elopement

PURPOSE OF THE STUDY

A framework aids choice of interventions to manage wandering and prevent elopement in consideration of associated risks and mobility needs of wanderers.

DESIGN AND METHODS

A literature review, together with research results, published wandering tools, clinical reports, author clinical experience, and consensus-based judgments was used to build a decision-making framework.

RESULTS

Referencing a published definition of wandering and originating a clinical description of problematic wandering, authors introduce a framework comprising (1) wandering and related behaviors; (2) goals of wandering-specific care, (3) interpersonally, technologically, and policy-mediated wandering interventions, and (4) estimates of relative frequencies of wandering behaviors, magnitudes of elopement risk, and restrictiveness of strategies.

IMPLICATIONS

Safeguarding wanderers from elopement risk is rendered person-centered and humane when goals of care guide intervention choice. Despite limitations, a reasoned, systematized approach to wandering management provides a basis for tailoring a specialized program of care. The need for framework refinement and related research is emphasized.

Late life psychosis: assessment and general treatment strategies

With the increased number of elderly patients suffering from mental illness, an increased incidence of psychiatric conditions including psychotic disorders is also expected. When psychosis occurs in the elderly, its assessment and treatment may pose a challenge for primary care clinicians and caregivers. This article will review the assessment and treatment of late life psychosis.

Dementia with Lewy bodies

The advent of new immunostains have improved the ability to detect limbic and cortical Lewy bodies, and it is evident that dementia with Lewy bodies (DLB) is the second most common neurodegenerative dementia, after Alzheimer's disease (AD). Distinguishing DLB from AD has important implications for treatment, in terms of substances that may worsen symptoms and those that may improve them. Neurocognitive patterns, psychiatric features, extrapyramidal signs, and sleep disturbance are helpful in differentiating DLB from AD early in the disease course. Differences in the severity of cholinergic depletion and type/distribution of neuropathology contribute to these clinical differences.

Psychiatric Emergencies in the Elderly Population

This article reviews the most common behavioral emergencies in the geriatric population. Psychiatric emergencies are seen frequently by emergency physicians who face the challenge of assessing and managing patients presenting with psychosis, severe depression, agitation, suicidal intent, and substance abuse in the emergency department. The evaluation is frequently complicated by the necessity to investigate numerous domains such as underlying medical conditions, prior psychiatric disorders and substance abuse, as well as psychosocial factors. It is crucial to rule out organic causes for what appears to be psychiatric disease in the elderly. The assessment might be further complicated by the patient's limited ability to recall pertinent aspects of the history due to either cognitive impairment or acute distress. Emergency department personnel might have inadequate expertise in assessing emergencies in elderly persons, further impeding the ability to appropriately manage behavioral complications in geriatric patients. Availability of high-quality emergency care and tight collaboration with primary care providers, psychiatric consultants, and social services is crucial to optimal outcomes from acute psychiatric decompensations in the elderly.

Behavior problems in demented nursing home residents: a multifaceted approach to assessment and management

Behavior disturbances are common among dementia patients. Management of behavioral problems begins with the assessment of psychiatric, medical, and environmental etiologies. Treatment plans based upon behavioral or pharmacologic interventions can substantially reduce problematic behaviors.

Correlates of behavioral disturbances and pattern of psychotropic medication use in five skilled nursing facilities

There are several treatment options for behavioral disturbances (BDs) in dementia. However, the choice of a specific psychotropic agent is directed by personal preferences and local community practice patterns. We examined the relationship between common clusters of BDs and the use of different classes of psychotropic agents in our community. A cross-sectional study of 430 long-term care residents from 5 nursing homes was undertaken. The Behavior Measurement Scale (BMS) was used to measure the frequency of BDs grouped in 4 categories. Residents with > 4 BD episodes in at least one category during a 2-week observation period were the behavior group and were considered to have clinically significant BDs. A sample of patients who had < 4 BDs in all BMS categories during the same observation period defined the nonbehavior group. A BD cluster was defined as > 4 BDs occurring in one or more BMS categories during the 2-week observation. Data on functional status, comorbidity, use of benzodiazepines, antidepressants, and neuroleptic agents were collected with chart review. The chi-square test was used to examine the correlation between variables. Clinically significant BDs were identified in 27.2% (117/430) of the residents in the sample. Five of 15 behavior clusters accounted for 73% of all clinically significant BDs. The 5 clusters were verbally nonaggressive behaviors (cluster 1, 20.5%), behaviors from all 4 categories (cluster 2, 17.9%), verbally and physically nonaggressive behaviors (cluster 3, 14.5%), physically nonaggressive behaviors (cluster 4, 12.8%), and verbally aggressive and nonaggressive behaviors (cluster 5, 7.7%). Cluster 5 had a negative correlation with functional impairment (P = .009). There was a significant correlation between cluster 2 and benzodiazepine use (P = .014). No other significant correlation was found between any of the 5 clusters and demographic variables, comorbidity status, and use of antidepressant or neuroleptic medications. Residents in the behavior group had higher impairment in self-feeding (P = .036) and bathing (P < .001) and were more likely to be treated with benzodiazepines (P = .004) and neuroleptic agents (P = .009) than residents in the nonbehavior group (n = 116). The higher use of neuroleptics and benzodiazepines in the behavior group compared with the nonbehavior group indicates that BDs are being identified for treatment, but the medications used may not be efficacious. The lack of association between specific classes of psychotropic medications and distinct behavior clusters indicates that clinicians are not using a standardized approach to target the neurochemical abnormalities that may underlie certain behavior clusters. Some behavior clusters correlate with impairment in specific activities of daily living categories such as bathing and feeding, making room for nonpharmacologic interventions.

Calming music and hand massage with agitated elderly

BACKGROUND

Agitated behavior is a widespread problem that adversely affects the health of nursing home residents and increases the cost of their care.

OBJECTIVE

To examine whether modifying environmental stimuli by the use of calming music and hand massage affects agitated behavior in persons with dementia.

METHOD

A four group, repeated measures experimental design was used to test the effect of a 10-minute exposure to either calming music, hand massage, or calming music and hand massage simultaneously, or no intervention (control) on the frequency and type of agitated behaviors in nursing home residents with dementia (N = 68). A modified version of the Cohen-Mansfield Agitation Inventory was used to record agitated behaviors.

RESULTS

Each of the experimental interventions reduced agitation more than no intervention. The benefit was sustained and increased up to one hour following the intervention (F = 6.47, p<.01). The increase in benefit over time was similar for each intervention group. When types of agitated behaviors were examined separately, none of the interventions significantly reduced physically aggressive behaviors (F = 1.93, p=.09), while physically nonaggressive behaviors decreased during each of the interventions (F = 3.78, p< 01). No additive benefit resulted from simultaneous exposure to calming music and hand massage. At one hour following any intervention, verbally agitated behavior decreased more than no intervention.

CONCLUSION

Calming music and hand massage alter the immediate environment of agitated nursing home residents to a calm structured surrounding, offsetting disturbing stimuli, but no additive benefit was found by combining interventions simultaneously.

Nonpharmacologic treatment of behavioral disturbance in dementia

This article provides an overview of the current literature on non-pharmacologic treatment of behavioral problems in patients with dementia, and offers practical guidelines for healthcare professionals interested in using this approach with their patients. Because effective treatment begins with accurate assessment, we provide a brief discussion of the state-of-the-art in assessment of behavioral problems. The article discusses current trends in clinical care along with specific strategies for treating and preventing some of the most common and debilitating behavioral problems of dementia patients: depression, agitation/aggression, wandering, and sleep disturbance. Because caregivers are essential informants and participants in patient care, we conclude by addressing the role of the caregiver in nonpharmacologic treatment.

Current management of sleep disturbances in dementia

The management of sleep disturbances in patients with dementia is a complicated and enormously important clinical and societal problem. In this review, we present one approach to the diagnosis and management of such sleep disturbances. Most disturbances can be categorized into four primary symptoms: insomnia, hypersomnia, excessive nocturnal motor activity, and hallucinations or behavioral problems. We describe how each symptom may relate to the dementing illnesses themselves, which primary sleep disorders may be at play, which medications employed for dementia may impact on the symptom, the role of depression in that symptom, and how circadian dysrhythmias can underlie that symptom. Although few well-designed studies have been conducted, we present management strategies for several sleep disturbances based on the literature and our clinical experience. Considering the impact on patient and caregiver quality of life, and the potential for delaying institutionalization with appropriate therapy, further research is clearly warranted to optimize the diagnosis and management of sleep disturbances in the cognitively impaired elderly population.

Does behavioral improvement with haloperidol or trazodone treatment depend on psychosis or mood symptoms in patients with dementia?

OBJECTIVES

Several previous studies have examined the effects of pharmacological interventions for agitated behavior in patients with dementia. However, the choice of medication in clinical practice continues to be directed largely by local pharmacotherapy culture rather than empirical treatment guidelines. We examined the relationship between behavioral improvement and co-occurring delusions and mood symptoms in patients with dementia who were treated with haloperidol, an antipsychotic medication, or trazodone, a serotonergic antidepressant.

DESIGN

Randomized, double-blind, parallel-group, 9-week treatment trial.

SETTING

Inpatient geropsychiatry unit.

PARTICIPANTS

Twenty-eight patients with dementia and agitated or aggressive behaviors.

INTERVENTION

Haloperidol 1 to 5 mg/day or trazodone 50 to 250 mg/day.

MEASUREMENTS

Cohen-Mansfield Agitation Inventory (CMAI), Hamilton Depression Rating Scale (Ham-D), and delusional thoughts subscale and hallucinations subscale of the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD).

RESULTS

CMAI scores improved in each treatment group over the 9 weeks of treatment (P < .001 in each group). Within the haloperidol treatment group, CMAI improvement was not associated with baseline delusional thoughts score or with change in delusional thoughts score over the course of treatment. Within the trazodone treatment group, CMAI improvement was associated with baseline score on total Ham-D (r = -0.60, P = .02), Ham-D items measuring subjective mood symptoms (r = -0.50, P = .07), and Ham-D items measuring neurovegetative signs (r = -0.49, P = .08). CMAI improvement was also associated with improvement in Ham-D total score over the course of treatment (r = 0.62, P = .02).

CONCLUSIONS

Mild depressive symptoms in patients with dementia and agitated behavior are associated with greater behavioral improvement by trazodone-treated patients. In contrast, the presence of delusions in concert with behavioral disturbance does not necessarily predict greater behavioral improvement with haloperidol treatment than in subjects without signs of psychosis.

Actions seen as demanding in patients with severe dementia during one year of intervention. Comparison with controls

Behaviours, viewed by nurses as demanding, performed by patients with severe dementia were investigated during one year of intervention. Supervised implementation of individually planned care and systematic clinical supervision were implemented on one experimental ward (EW) while another ward (CW) served as control. Each ward had 11 patients. At baseline and after 6 and 12 months of intervention structured interviews with the patients' assigned nurses were conducted based on the Demanding Behaviour Assessment Scale and Multi Dimensional Dementia Assessment Scale. At the EW there was a decreased frequency (p=0.000) and a reduced occurrence of physical behaviours (p=0.008), a decreased frequency (p=0.029) and a reduced occurrence of vocal behaviours (p=0.002). No significant changes were seen at the CW. Bearing the small sample size in mind, the findings indicate that individually planned care and systematic clinical supervision could be a means of reducing the frequency, and/or effect the nurses' attitude and interpretation of the patients' behaviour as demanding. The findings, however, can only be seen as indications for further research, but point to the importance of including effect variables related to patients when intervening in nursing care.

Assessment and management of behavioral disturbances in nursing home patients with dementia

Behavioral disturbances among nursing home patients with dementia are common and substantially affect patients and caregivers. Assessing the environmental, medical, and psychiatric causes of problematic behaviors and implementing a plan of behavioral, medical, and psychiatric management can reduce difficult target behaviors. This article presents a multifaceted approach to assessing patients with dementia who have behavioral problems, reviews medical and pharmacological management of these problems, and presents a multidisciplinary approach to developing treatment plans aimed at reducing such behaviors among nursing home patients with dementia.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part 2--Interventions

Delirium, a disorder of consciousness that may afflict over one-half of elderly surgical orthopaedic patients is a common sequela of surgery in the elderly. Agitation, either as an element of the delirium or dimension of a preexisting dementia, is another common behavioral problem that can confront the orthopaedic nurse in acute care. It is time now to tear down the barriers to intelligent and compassionate care of patients with agitation and delirium, including late or missed recognition and diagnosis, biases about what is "normal" and acceptable behavior in the elderly, and lack of familiarity with pharmacologic strategies. In Part 1 (Jan/Feb issue), current thinking about the phenomena was presented, including hypotheses about causation and pathophysiology. That foundation is intended to serve as the basis for the current discussion. The triad of interventions available to manage disorganized behavior in elderly orthopaedic patients is presented in Part 2. They include an extensive selection of pharmacologic options, a discussion of therapeutic use of self and environmental-organizational issues to address and consider on a case-by-case basis. Though it may be impossible to prevent behavioral decompensation during an acute orthopaedic admission, it is certainly possible to improve our performance to date, using a compassionate, intelligent, and inclusive approach with every patient.

Assessment and management of behavioral disturbances in Alzheimer disease

This article provides an update and review of strategies for assessing and treating behavioral changes in patients with Alzheimer disease. It discusses the impact of behavioral disturbances on patients, presents guidelines for identifying and monitoring behavioral changes, and presents behavioral treatment approaches.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part I--Theoretical aspects

Managing behavioral disorders such as delirium and agitation while simultaneously attending to the acute needs of elderly patients is a challenge that confronts orthopaedic nurses on a daily basis. This will only increase in frequency and complexity as the new century dawns. Delirium and agitation affect morbidity, mortality, length of stay, and costs--in short, outcomes. To manage and care for these patients, orthopaedic nurses must first update their knowledge of acute disorders that can disrupt mental status and behavior, and the effects of systemic events on brain function. With the knowledge of the pathophysiology of delirium and agitation, nurses then need to refine their assessment and intervention skills. This article describes the phenomena of agitation and delirium in the elderly acute orthopaedic patient, outlines current perceptions regarding pathophysiology, and offers guidelines for prevention and intervention. An algorithm has been developed that can assist with the identification of at-risk individuals, causes of delirium, and early assessments in the acute care setting.

Functional analysis of challenging behaviour in dementia: the role of superstition

BACKGROUND

Intervention for challenging behaviour of residents living in care homes is a neglected area of research. Pharmacological methods of management are widespread, although support for their efficacy is, on the whole, poor.

AIMS

There is little research on non-pharmacological methods of management and the present study aimed to add to the small literature in this area, by examining the meaning of behaviour for a given resident, within a functional analytic experimental framework.

METHODS

The study involved a systematic manipulation of specific trigger situations to evaluate their influence on challenging behaviour, using a single case experimental design.

RESULTS

Five residents with agitated and aggressive behaviour were successfully managed. The difficulties in engaging staff in the use of non-pharmacological, rather than pharmacological, methods and the scope for future randomised trials using psychological and environmental interventions to manage challenging behaviour, are discussed.

Leisure or therapeutics? Snoezelen and the care of older persons with dementia

Snoezelen is the registered tradename for a multisensory environment approach initially established for purposes of leisure or therapeutics in the special education arena, but now expanding into a variety of client groups and settings, most notably in the care of older persons. Snoezelen is making its way into Australia at a rapid rate despite a lack of evidence-based research. This paper looks at the Snoezelen phenomenon and searches the literature to review the history and contemporary use of this multisensory environmental work. While most articles indicate positive outcomes Snoezelen is not without its critics, some of whom focus on the lack of rigorous research while others critique the artificiality. As a leisure approach Snoezelen appears to add quality to the culture of the care environment.

Neuropsychiatric aspects of Alzheimer's disease

The increase in research studies focusing on neuropsychiatric symptoms over the last decade has greatly increased our knowledge base, particularly with regard to the frequency of these symptoms and their impact on both patients and carers. We still have a poor understanding of the natural course of these symptoms and their biologic correlates, however, and more specific treatment studies are needed to inform clinical management.

Beyond the Folstein: dementia in primary care

As the population of elderly patients continues to increase world-wide, the importance of identifying patients with dementia in primary care practices will increase. Our ability to see patients for an extended period of time may enable primary care physicians to identify patients with dementia early in their disease process. This enables patients, families, and caregivers to initiate treatment early, with the hope that future research will identify successful treatment modalities. This article discusses the identification of dementing syndromes, the importance of identifying familial needs and coping strategies, and the importance of caregiver stress.

Who are older adults? Demographics and major health problems

The care of older patients is a challenging and often rewarding experience. Elderly people can be helped to fulfill their needs and realize their goals with a sensitive and comprehensive evaluation, a positive and supportive attitude and an emphasis on illness rather than disease. Health care providers can contribute greatly to improved function and enhanced quality of life through an understanding of and respect for the individual qualities and aspirations of their older patients.

Symptomatic treatment of elderly patients with early Alzheimer's disease at a memory clinic

It is widely accepted that excess disability (treatable coexisting physical disorders and psychiatric phenomena) is common in demented patients, and should be looked for carefully and treated properly, as it may result in improvement. This idea, however, does not state what investigations should be performed and what kind of improvement can be expected. Therefore, we studied prospectively in elderly outpatients with early Alzheimer's disease the prevalence of excess disability, the results of medication treatment, and the added value of investigations for diagnosis, treatment, and outcome after clinical examination. Outcome was assessed clinically and clinimetrically (using instruments with regard to cognition, disability in daily functioning, behavior, and caregiver burden). Excess disability was present in 66% of patients. Medication treatment was effective with regard to target symptoms, but (partial) reversal of dementia did not occur. Only blood tests produced unexpected results with consequences for treatment and outcome. Positive treatment effects often resulted from clinical examination only. We recommend blood tests in all patients; other investigations can be performed on clinical indication.