Serotoninergic treatment of screaming and banging in dementia

The spectrum of involuntary vocalizations in humans: A video atlas

In clinical practice, involuntary vocalizing behaviors are typically associated with Tourette syndrome and other tic disorders. However, they may also be encountered throughout the entire tenor of neuropsychiatry, movement disorders, and neurodevelopmental syndromes. Importantly, involuntary vocalizing behaviors may often constitute a predominant clinical sign, and, therefore, their early recognition and appropriate classification are necessary to guide diagnosis and treatment. Clinical literature and video-documented cases on the topic are surprisingly scarce. Here, we pooled data from 5 expert centers of movement disorders, with instructive video material to cover the entire range of involuntary vocalizations in humans. Medical literature was also reviewed to document the range of possible etiologies associated with the different types of vocalizing behaviors and to explore treatment options. We propose a phenomenological classification of involuntary vocalizations within different categorical domains, including (1) tics and tic-like vocalizations, (2) vocalizations as part of stereotypies, (3) vocalizations as part of dystonia or chorea, (4) continuous vocalizing behaviors such as groaning or grunting, (5) pathological laughter and crying, (6) vocalizations resembling physiological reflexes, and (7) other vocalizations, for example, those associated with exaggerated startle responses, as part of epilepsy and sleep-related phenomena. We provide comprehensive lists of their associated etiologies, including neurodevelopmental, neurodegenerative, neuroimmunological, and structural causes and clinical clues. We then expand on the pathophysiology of the different vocalizing behaviors and comment on available treatment options. Finally, we present an algorithmic approach that covers the wide range of involuntary vocalizations in humans, with the ultimate goal of improving diagnostic accuracy and guiding appropriate treatment. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

[Shouting in dementia]

Shouting in dementia is a frequent manifestation in institution and is often considered to be extremely disruptive. It remains the most misunderstood behavioral disorder. Shouting or screaming is not a necessarily pejorative qualifier as defined by public authorities and institutions. It can take a multitude of meanings and be characterized alternately as a "reflex", a "behavior", a "language", an "aggression". Shouting has a multifactorial causation. It can translate organic or somatic disorders, but also psychological, cognitive and/or environmental disturbances that clinicians should look for. The 5W method is a reliable and easy to use method in clinical practice to allow analysis of shouting in dementia. There is still too early and massive use of pharmacological approach in taking charge of the repetitive shouts in dementia. Instead, it is necessary to use a first-line non-pharmacological approach based on patient-centered, environment-centered and/or entourage-centered interventions after careful multidisciplinary assessment of this behaviour by the healthcare team.

Vocally disruptive behavior in the elderly: a systematic review

BACKGROUND

Vocally disruptive behavior (VDB) in the elderly is a common condition, especially in people with dementia, but difficult to treat. It may occur in as many as 40% of nursing home residents. This study is a review of the existing literature on this condition.

METHOD

The literature review was conducted using PubMed (particularly Medline and the Cochrane database) and reference lists from relevant publications in English, French, and German.

RESULTS

Most studies are small and no conclusive prevalence data are available. Many biological and psychosocial treatments have been advocated, but most studies are little more than anecdotal case reports. It is evident that VDB can have deleterious consequences on others and the patients themselves, although no studies specifically examine the range or the pervasiveness of VDB. Etiopathogenic research on VDB is still in its infancy.

CONCLUSIONS

Most aspects surrounding VDB are insufficiently understood. The heterogeneity and multiple contributive factors regarding VDB suggest quite convincingly that a panoply of different interventions tailored to the individual's needs will be required to overcome VDB and the suffering related to it.

Screaming in elderly persons with dementia

This article presents a critical review of empirical data to guide knowledge development of screaming in elderly persons with dementia. Many reasons have been identified for why humans and animals scream. Studies on elderly populations have focused mostly on factors associated with screaming. Also, a vast selection of interventions for elderly persons with dementia who scream has been tested, but there is little evidence of their efficacy. Better knowledge of screaming in this population is needed. In particular, the meaning of this behaviour must be determined and stronger evidence of the efficacy of interventions must be acquired. In order to develop helpful clinical interventions, it is suggested that diverse research methods be used and that the perspective of all actors involved be considered, including that of the elderly persons, their families and their professional caregivers.

The management of inappropriate vocalisation in dementia: a hierarchical approach

BACKGROUND

Patients with dementia can demonstrate noisy behaviours such as screaming, repetitive speech, moaning and singing. Such behaviours can be grouped under the title of "Inappropriate Vocalisation" which is used in this article to describe any noise making which impacts detrimentally upon patients, families or those in a caring role. Inappropriate vocalisation is notoriously difficult to treat and clinicians may have to rely on a "trial and error" approach when attempting to limit the distress it causes.

OBJECTIVES

This paper applies a hierarchical approach to Behavioural and Psychological Symptoms of Dementia (BPSD) in attempting to tackle inappropriate vocalisation systematically. Nine steps are ranked within three stages, with evidence for each intervention being considered sequentially in terms of the likelihood for success as the authors attempt to review the relevant literature.

METHODS

The authors performed a search of the medline database using the key words "screaming," "shouting," "persistent vocalisation" and "inappropriate vocalisation" combined with the key word "dementia". Further searches of the references of medline generated articles revealed a second group of articles of use in this review.

RESULTS

The search generated 53 reviews, research papers, case studies or letters, 36 of which are referenced in this article and the remaining references drawn from reading by the authors around the subject and related problems.

CONCLUSION

Interventions for inappropriate vocalisation in dementia are not limited to medication. Environmental factors and behavioural approaches are considered ahead of pharmacotherapy as the concepts of Underlying Illness, Hidden Meaning and Empirical Treatments are used to structure consideration of important, and sometimes overlooked, issues including pain, depression and overall level of stimulation.

Vocally disruptive behaviour in dementia: development of an evidence based practice guideline

Vocally Disruptive Behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests. It is one of the most challenging behaviours for nursing home staff, caregivers for people with dementia, and other nursing home residents. As with other behavioural disturbances, multiple causal factors have been identified in the literature and individual cases may have a number of interacting factors. There is a lack of consensus about how to treat VDB. Systematic treatment studies are few and there is a lack of empirical data supporting the effectiveness of specific interventions commonly used in clinical practice. This hinders clinicians and may result in the use of inappropriate treatments. Our aim was to systematically review the literature in order to develop a practice guideline for the assessment and management of VDB. The review will examine the typology, risk factors and management of VDB.

Trazodone for agitation in dementia

BACKGROUND

Behavioural and psychiatric disturbances affect at least 50% of people with Alzheimer's disease and other dementias. Neuroleptic drugs are extensively prescribed to treat behavioural manifestations of dementia in spite of only modest efficacy and a high frequency of adverse effects. There is clearly a need for safer and more effective remedies. Trazodone is a psychoactive compound with sedative and antidepressant properties, and with mixed serotonin agonist and antagonist effects. Functional serotonergic deficits may be related to the genesis of behavioural disturbances in dementia.

OBJECTIVES

To determine the clinical efficacy and safety of trazodone, for any type of behavioural or psychological cognition in people with dementia without an additional diagnosis of depression.

SEARCH STRATEGY

Trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 1 June 2004 using the terms trazodon*, beneficat, desirel, sideril, trazodil, trazalon. This register contains records from all major health care databases and many ongoing trials databases, and is updated regularly.

SELECTION CRITERIA

All unconfounded, double-blind, randomised controlled trials, comparing trazodone with placebo in managing behavioural and psychiatric symptoms (except depression) in any type of dementia.

DATA COLLECTION AND ANALYSIS

Available data for this analysis were extracted from the two included studies and odds ratios or average differences, with 95% confidence intervals, calculated. Intention-to-treat analysis was undertaken where possible.

MAIN RESULTS

Two studies were included, comprising 104 participants with dementia. The trials differed in design - one being a parallel-group study of patients with Alzheimer's disease (Teri 2000) and one being a cross-over study of patients with frontotemporal dementia (Lebert 2004). It was not possible to pool the data. The studies were respectively of 16 and 6 weeks duration, using trazodone from 50 to 300mg daily. Both trials examined global clinical state, behavioural disturbances and cognitive function. Teri 2000 also assessed activities of daily living and caregiver burden. Compared with placebo, the use of trazodone was not associated with statistically significant benefits for behavioural manifestations as measured by various rating scales (ABID, CERAD-BRSD,CMAI, NPI). Analysis of changes from baseline for clinical impression of change and for cognitive function did not produce statistically significant results in favour of trazodone. A variety of adverse effects were recorded with no significant differences between trazodone and placebo.

REVIEWERS' CONCLUSIONS

There is insufficient evidence to recommend the use of trazodone as a treatment for behavioural and psychological manifestations of dementia. In order to assess effectiveness and safety of trazodone, longer-term trials are needed, involving larger samples of participants with a wider variety of types and severities of dementia.

Confused and disturbed behavior in the elderly following silent frontal lobe infarction

It is unclear whether silent frontal lobe infarction is truly asymptomatic; frontal behavioral syndromes following strokes have rarely been reported. We studied 12 elderly patients with silent frontal lobe infarction who were exhibiting confused and disturbed behavior. Ten were male and two female; their ages ranged from 68 to 79 (mean 78). Three groups of symptom clusters emerged: changes in mood and emotional behavior, cognitive deterioration with minor psychiatric symptoms, and a confusional state. When related to the CT scan location, three regions were identified: predominantly orbitofrontal, deep white matter and caudate, and border-zones, respectively. These findings were related to what is known about the neuroanatomic location of the lesions and the role of the frontal subcortical circuitry in relation to behavior. The different manifestations could be explained by damage to the frontal lobe or interruption of the complex frontal subcortical circuits.

Screaming, shrieking and muttering: the noise-makers amongst dementia patients

We have described twelve dementia patients with noise making. We categorized noise making into (i) persistent screaming, (ii) perseverative vocalization, (iii) continuous chattering, muttering, singing or humming, and (iv) swearing, grunting and bizarre noise-making. The patients' ages ranged from 70 to 92 years with a mean of 78. There were four males and eight females. Five had Alzheimer's disease and the remaining seven vascular dementia. Five exhibited mild to moderate aggression while another five displayed severe aggression. All but one had motor restlessness and four had delusions or hallucinations. In ten patients the dementia was moderate to severe with five having total dissolution of speech. All but two were in the third stage of the illness and were totally dependent for basic self care. There was a wide network of anatomical structures involved in the twelve patients. The findings are related to what is known of the neuroanatomic location of the lesions and the role of frontal subcortical circuitry and neurotransmitter systems in relation to behavior. Noise-making could be explained by damage to the frontal lobe or interruption of the complex subcortical circuits and related brain chemistry. Treatment of patients with noise-making remains a challenge.

Clinical and economic factors in the treatment of behavioural and psychological symptoms of dementia

The prevalence of behavioural and psychological symptoms of dementia (BPSD) exceeds 50%. They cause distress to patients and caregivers, increase resource utilisation of various kinds, and form a high risk for accelerated psychiatric care through institutionalisation. Although evidence for current pharmacological treatment is not strong and the construct of BPSD is still not very clear, future aspects of treatment of BPSD may be positive. If we look at overall success rates of the antipsychotics, the traditional antipsychotics have the highest combined success rate of 63.1%, whereas the novel antipsychotics have an overall success rate of 56.1%. Haloperidol is the drug with the highest success rate of 65.4%, although this drug is associated with parkinsonian adverse drug reactions. Newer antipsychotics show promise in treating BPSD, but more convincing evidence (e.g. from randomised clinical trials) is required. We provide an overview of the clinical, epidemiological and economic aspects of BPSD and a review of the available literature on their pharmacological treatment. Although only 1 pharmacoeconomic study has been conducted on BPSD, it seems likely that these manifestations drastically increase the burden of dementia.

Citalopram for verbal agitation in patients with dementia

Various behaviors can be associated with dementing disorders. Management of these behaviors is often challenging to caregivers and clinicians. Verbal agitation such as talking constantly, screaming, and repeating phrases and noises is one of the most frequently encountered behaviors in the long-term care setting. We report two cases in which verbal agitation favorably responded to citalopram, a selective serotonin reuptake inhibitor. We also discuss some other factors possibly associated with this response. Nonetheless, citalopram appears to be an added option in the treatment of verbal agitation in demented patients.

Treatment of verbal agitation with a selective serotonin reuptake inhibitor

The objective of this study was to examine the safety and efficacy of paroxetine as an alternative to neuroleptic medications for the treatment of verbal agitation in demented patients. An open case series design was used, and the setting included two nursing homes and an outpatient geriatric clinic. Participants were eight consecutive nursing home residents and seven community-dwelling older adults diagnosed with dementia who exhibited verbal agitation in the form of repetitive questions or unwarranted request for attention. Patients received paroxetine orally in doses of 10 mg to 40 mg per day. The Cohen-Mansfield Agitation Inventory (CMAI) was used to rate the frequency of verbal agitation. A baseline score was obtained before starting paroxetine. Six scores were then obtained at 2-week intervals over a period of 3 months. All patients had reduction (2-4 points per item) in the CMAI scores at the end of the first month of treatment with paroxetine. Scores were further reduced (up to 5 points per item, 67%-71% reduction from baseline) in five patients at the end of the third month of treatment. Most patients tolerated paroxetine well. In this report, the use of paroxetine was associated with reduction in verbal agitation. This finding supports the possibility that verbal agitation in demented patients could be a manifestation of underlying depression.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Attitudes of registered nurses towards patients with severe dementia

Meeting the needs and wishes of people with severe dementia is difficult and demanding for carers, and a number of approaches can be used in encounters with dementia sufferers. The aim of this study was to explore how registered nurses in a northern Norwegian county thought about approaching people with severe dementia. A patient case was used as a vignette, followed by a questionnaire with 13 sets of statements, each set containing two alternative approaches (one reality orientation approach and one personhood focused approach). In 12 out of the 13 sets of statements the reality orientation alternative was usually chosen, but responses to the statement regarding the meaning of confusion tended more towards the personhood focused approach. RNs with more than the basic education and staff nurses working in a team nursing system, chose the personhood focused approach significantly more often than RNs with no post-basic education and nurses working in a primary nursing system. The article discusses how reflection on daily experiences can improve one's ability to reflect on one's own experiences and encourage a personhood focused approach. Working in a team means gaining opportunities to reflect together with coworkers, while working in a primary nursing care system might afford fewer such opportunities.

Clinical predictors of aggressive behaviour in Alzheimer's disease

OBJECTIVES

To examine the level and clinical correlates of aggressive behaviour in Alzheimer's disease (AD).

METHOD

Seventy patients with probable AD were rated using validated assessment instruments including the Rating Scale for Aggressive Behaviour in the Elderly (RAGE).

RESULTS

Thirty-one subjects were rated as at least mildly aggressive during the 3-day period prior to assessment. RAGE scores correlated significantly with delusions and activity disturbance scores. Aggressive behaviour was not associated with age, sex, dementia severity, hallucinations or depression.

CONCLUSIONS

Aggressive behaviour occurs frequently in patients with AD. Our results confirm the findings of previous studies that the presence of delusions increases the risk of aggression in this population.

Pharmacologic treatment of agitation in dementia: a comprehensive review

Agitated behaviors are a common and nearly universal occurrence among patients suffering from dementing illnesses. The pharmacologic treatments available for this troubling syndrome are varied, but treatment studies are limited. Clinicians are frequently faced with the challenging management of patients with disruptive behavior who fail to respond to trials with multiple agents. This review summarizes available treatment studies of agitation in dementia and offers a guide to therapy and management. Reports of therapies for agitation in dementia are limited by lack of controlled studies, variability of diagnostic criteria and outcome measures, and small sample size. The need for carefully designed, well-controlled studies of outcome in this growing population is formidable. It is imperative to identify effective and well-tolerated treatment strategies to reduce the morbidity of these distressing and burdensome symptoms.

Trazodone for aggression in an adolescent with hydrocephalus

A case of 19 year old male with hydrocephalus is reported whose aggressive self-injurious behaviors were resistant to conventional pharmacotherapy but successfully treated by trazodone. In addition to the self-injurious behaviors, this patient displayed withdrawal and eating refusal, which initially resulted in his admission to a psychiatric ward. Various conventional treatments with pharmacotherapy (e.g., tricyclic antidepressants, antipsychotics, anxiolytics and anticonvulsants) in combination with psychotherapy and family therapy proved not to be effective for 15 months. Neither was electroconvulsive therapy successful. Administration of trazodone for 5 months after tapering of the above agents improved his aggressive behaviors. A survey of previous cases with organic brain syndromes who had aggressive behaviors and responded well to trazodone revealed that most of the cases were aged individuals and that cases in adolescence are rare.

Psychiatric illnesses in the elderly: a review

Neuropsychiatric disorders in the elderly, such as dementia, depression, anxiety, and psychosis, may occur alone or in combination with neurologic or medical illness. Geriatricians must be familiar not only with diagnostic issues but also with treatment options and medication-induced alterations in mental status.

Pharmacotherapy of aggressive behavior

OBJECTIVE

To review the definition, clinical characteristics, prevalence, etiology, neurochemistry, and pharmacologic treatment of aggressive behavior, and provide recommendations regarding the use of specific pharmacologic agents for treating aggressive behavior.

DATA SOURCES

Data from the scientific literature were analyzed, interpreted, and summarized. An English-language MEDLINE search yielded clinical trials, case reports, letters, and review articles addressing the etiology and pharmacotherapy of aggression.

STUDY SELECTION

Because few well-controlled studies are available in aggression research, all literature addressing the pharmacologic treatment of aggressive behavior, as well as the neurochemistry and psychobiology of aggressive behavior, was reviewed.

DATA EXTRACTION

The literature was reviewed on the basis of the particular pharmacotherapy and the specific population used. A separate review of the treatment of aggressive behavior in the elderly was included.

DATA SYNTHESIS

The literature was assessed for applicability to clinical practice and usefulness to the general clinician. Recommendations were made from the primary literature in conjunction with trends in clinical practice. Pharmacotherapy is a primary mainstay of treatment for aggressive patients. In individuals for whom behavioral intervention alone is unsuccessful, drug therapy should be initiated along with continued nonpharmacologic intervention. Short-acting benzodiazepines and high-potency antipsychotic agents are effective in treating acute aggression on a short-term or as needed basis. Agents such as lithium, beta adrenergic blockers, carbamazepine, valproic acid, buspirone, trazodone, serotonin reuptake inhibitors, and clozapine may be useful in the chronic management of aggressive behavior. Every attempt should be made to streamline drug therapy in patients with chronic aggression and comorbid psychiatric disorders.

CONCLUSIONS

On the basis of available research and extensive clinical experience, lithium or propranolol should be considered as first-line antiaggressive agents in patients without comorbid psychiatric disorders. A minimum trial period for assessing drug efficacy should last at least 6-8 weeks at maximum tolerated dosages. Patients responding to pharmacotherapy should be reevaluated every 3-6 months, and periodic medication tapers and/or drug-free periods should be attempted.

Anticonvulsant and other non-neuroleptic treatment of agitation in dementia

Studies have shown that the vast majority of patients with dementia experience some psychopathologic symptoms during the course of their illness. Symptoms of this nature, which can include frightening hallucinations or anxiety of phobic proportions, are subjectively distressing and can lead both to unsafe or violent situations as well as to the preventable use of inappropriate medication, physical restraint, and frequently to institutionalization. These psychopathologic manifestations of dementia often prove to be a burden on family, caregivers, and the health care system as well. This article presents an overview of the assessment and management of agitation as it relates to the severity of dementia symptoms and cognitive deterioration. Specifically, the use of anticonvulsant and other non-neuroleptic therapies is examined.

Pharmacotherapy of cognitive impairment in Alzheimer's disease: a review

Experimental pharmacotherapy of cognitive impairment in Alzheimer's disease has seen a recent proliferation of drug trials involving a wide variety of drugs. Many of the earlier studies focused on cholinergic agents. However, subsequent advances in basic and biological sciences have broadened the scope of therapeutic strategies beyond the neurotransmitter approaches to include neurotrophic, metabolic-enhancing, membrane-modifying, and antitoxic agents, and have also provided rationale for developing antiamyloid and anti-infective therapies. For the clinician, it has not been easy to keep abreast of these developments. In this article, I present an overview of the cognition-enhancing drugs that have been used in the past, of those currently under investigation, and of new drugs and strategies that are likely to receive attention in the next few years.

Psychiatric aspects of progressive supranuclear palsy

Progressive supranuclear palsy (PSP) is characterized by supranuclear ophthalmoplegia mainly affecting vertical gaze, nuchal dystonia in extension, pseudobulbar palsy, and mental changes. The literature on PSP has been neurologically oriented whereas the psychiatric aspects have been relatively neglected. A review of the literature shows that psychiatric disturbance in PSP is common but with no characteristic pattern. Cognitive impairment, nonspecific affective and behavioral disturbances are commonly found, whereas frank psychosis or bipolar disorder are rare. Misdiagnoses with psychiatric disorders are common and a heightened awareness of the condition is necessary for early diagnosis.

Practical guidelines for the treatment of behavioural complications of dementia

A step-by-step approach to management of behavioural problems in dementia is outlined. Initial strategies include assessment of the underlying cause and consideration of non-pharmacological methods of treatment. If pharmacotherapy is required, the altered pharmacokinetics in the elderly and the variable efficacy of different psychotropic drugs should be kept in mind. Recommendations regarding drug dosage, monitoring and review are given.

The management of other psychiatric states. Hallucinations, delusions, and other disturbances

The behavioral disturbances that are most common in Alzheimer's disease are not those directly associated with the core characteristics of the disease; however, they often cause the most difficult problems of management. These disturbances include agitation, hallucinations, and delusions. This article reviews their prevalence, etiology, differential diagnosis, and management.

The use of psychotropic medication in the management of problem behaviors in the patient with Alzheimer's disease

Although a variety of potential alternatives to the neuroleptics in the management of agitated behavior in Alzheimer's disease exist, more large, well-controlled studies are needed. At present, neuroleptics remain the standard treatment for this problem. It is also important for the clinician to investigate thoroughly underlying instigators of behavior change in Alzheimer's patients, such as delirium, anxiety, depression, or environmental factors, and target treatment to these disorders.

A naturalistic study of trazodone in the treatment of behavioral complications of dementia

Altered serotonin transmission has been associated with behavioral complications of degenerative dementia. This study examined whether trazodone, a serotonergic antidepressant, may be useful in treating behavioral syndromes associated with dementia. Twenty-two dementia patients with behavioral problems were treated with trazodone (mean daily dose 172 ± 107 mg; mean duration 20 days). Seventy of cognitive impairment and behavioral symptoms were rated using the Mini-Mental State Examination (MMSE), the Global Assessment Scale, the Hamilton Rating Scale for Depression, and the Brief Psychiatric Rating Scale. A global assessment of improvement was made by chart review. Mean scores, with the exception of the MMSE, improved modestly but significantly between admission and discharge. Chart review of target symptoms revealed that 82% of the patients showed moderate-to-marked improvement on discharge, with most able to return to their preadmission residence. Trazodone was generally well tolerated except for occasional mild sedation effects. Results suggest that trazodone may be a useful alternative to neuroleptics or benzodiazepines in treating behavior problems in some demented patients.

Effects of Buspirone on Agitation Associated With Dementia

Ten patients with probable Alzheimer's disease participated in an open-label study of buspirone for agitation. The starting dose of 15 mg/day was increased by 5 mg every week until maximal improvement or 60 mg/day was reached. A significant decrease in agitation scores occurred at an average dose of 35 mg/day.

The Present Behavioural Examination (PBE): the development of an interview to measure current behavioural abnormalities

Behavioural problems are an important feature of dementia and other neuropsychiatric conditions. This paper describes the development and performance of an investigator-based interview (the PBE) for the detailed assessment of the behaviour of subjects over the preceding four weeks. The interview is designed to be administered to carers. A test-retest reliability study was carried out on the penultimate edition of this interview; and the inter-rater reliability of the final edition was measured. These studies show that the reliability of the PBE is comparable with that of other investigator-based interviews.

Screaming in nursing home residents

This article reports the results of two studies of screaming in the nursing home. The first was a survey study of 408 nursing home residents, which revealed that 25% of the residents screamed at least four times a week. Screaming was associated with cognitive impairment, depressed affect, social networks of poor quality, and severe impairment in the performance of activities of daily living. The second study was an in-depth observational study of five residents who screamed frequently. Residents screamed more often when they were alone in their rooms during the evening hours, suggesting that screaming may arise as a response to social isolation.

Staff interaction with vocally disruptive demented patients compared with demented controls

This study addressed the effect of social isolation on vocally disruptive demented patients (V); the results center on the amount of time patients spent in interactions, and the differences in type and time of staff-patient interaction (IA), compared to controls (C). Semi-structured observations were collected (1100 hours) for 37 vocally disruptive patients and 37 controls, all residents of psychogeriatric wards. Quantitative analysis revealed a low frequency of interactions, elicited mainly for procedural matters and short duration of most interaction episodes. Multiple regression analysis showed a significant difference in the type of interaction: there was more correction of undesired behaviour for vocally disruptive patients than for controls. The results show that social isolation is part of the institutionalized demented patients' life. The dominance of short interaction episodes could contribute to overstimulation. The only significant difference found was the frequency of corrective interactions in the group of vocally disruptive patients. We conclude that this is not the cause of their behaviour, but it may reinforce it. Other factors that might cause and maintain this behaviour require investigation.

Progressive supranuclear palsy with agitation: response to trazodone but not to thiothixine or carbamazepine

A 66-year-old man with progressive supranuclear palsy is described. Although generally apathetic, withdrawn, and spontaneous in speech and behavior, he had sudden episodes of agitation, during which he was verbally threatening and physically abusive. Treatment with thiothixine and then with carbamazepine was ineffective in controlling his violent behavior. He responded temporarily to trazodone, and a recurrence of aggressive behavior was suppressed by increasing the dose of trazodone; this response may be related to trazodone's putative effect on the serotonin system. Although both carbamazepine and trazodone have been advocated for the control of aggression in organically impaired patients, they were not equally effective in this case.

Reversible anorexia and rapid weight loss associated with neuroleptic administration in Alzheimer's disease

Weight loss and malnutrition despite adequate dietary intake has been reported to be part of the clinical course in advanced dementia of the Alzheimer type. We present a case of reversible weight loss associated with neuroleptic use in a patient with Alzheimer's disease and discuss a possible pathophysiological basis for the weight loss.