Assessment of Behavioural and Psychological Symptoms Associated with Dementia

The Effect of Agomelatine in Behavioral and Psychological Symptoms of Dementia

OBJECTIVE

Moderate and severe behavioral and psychological symptoms of dementia (BPSD) often need medical treatment to improve symptoms. Agomelatine is a selective melatonergic (MT1/MT2) agonist that has normalizing effects on disturbed circadian rhythms and disrupted sleep-wake cycles. Its activity of 5HT-2C receptor antagonism is associated with lessening depression and anxiety and increasing slow-wave sleep. Based on past clinical records and current findings it suggests that agomelatine can improve BPSD for patients. This retrospective cohort study was designed to compare the BPSD before and after using agomelatine.

METHODS

Records of dementia cases who had ever received agomelatine treatment for BPSD in a general hospital setting during the past 2.5 years were identified and reviewed. Scores from before and after 3 months of treatment with agomelatine were collected for Neuropsychiatric Inventory (NPI), Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impression (CGI) to compare and analyze the difference of psychological and behavioral symptoms pre- and post-agomelatine used.

RESULTS

Records of 144 cases of dementia with BPSD who had ever used agomelatine from January 2015 to June 2017 were collected. All of the 112 cases had BPRS and CGI scores, of which 75 cases had additional NPI scores. Among these 112 cases, the BPRS and CGI scores were significantly improved in all types of dementia. NPI scores indicated that the use of agomelatine alleviated obvious symptoms and decreased overall distress, especially in the depression/poor mood, anxiety, and sleep/night behavior.

CONCLUSION

It is consistent with an effective result of agomelatine in improving BPSD.

To Turn or Not to Turn: Exploring Nurses' Decision-Making Processes Concerning Regular Turning of Nursing Home Residents

Background: Nursing home (NH) residents are at high-risk for pressure injuries (PrIs), and those living with Alzheimer's Disease and Related Dementias (ADRD) are at even greater risk. Understanding how nursing staff approach repositioning remains critical. Methods: As part of an ongoing clinical trial, this mixed-method prospective, exploratory, descriptive study examined repositioning efforts for PrI prevention. An investigator-developed checklist guided researcher observations, and focus groups revealed staff perspective on resident behaviors and corresponding repositioning approaches. Focus group transcripts were analyzed using the constant comparative coding method. Results: Repositioning observations were conducted for 88 residents. Resident behaviors and nursing approaches were similar between the ADRD (n = 62, 70%) and non-ADRD (n = 26, 30%) groups. Thirty-six staff participated in one of six focus group sessions. A conceptual model was developed to depict the repositioning process. Staff revealed care is guided by clinical frameworks and guidelines, along with resident preferences and behaviors. Conclusions: Protocol-driven, standardized PrI prevention care may limit the capacity to honor repositioning preferences. Insights from the focus groups highlight the importance of being cognizant of competing factors that may interfere with successful repositioning. Approaches by staff may be protocol-driven or an integrated method of care.

Rehabilitation in Dementia

Dementia is an eurodegenerative disorder, which causes significant disability, especially among the elderly population worldwide. The affected person shows a progressive cognitive decline, which interferes with the independence in performing the activities of daily living. Other than the cognitive domain, the patient tends to have neuropsychiatric, behavioral, sensorimotor, speech, and language-related issues. It is expected that the global burden of the disease will rise with more people entering the geriatric age group. By 2050 close, to 140 million people will be living with one or the other type of dementia. Alzheimer's disease contributes to more than 60% of cases worldwide, followed by vascular dementia. Pharmacotherapy has a limited role to play in the treatment, and at present, no drug is available, which can halt or reverse the progress of the disease. World Health Organization has mandated rehabilitation as a core recommendation in the global action plan on the public health response to dementia. Rehabilitation services are widely recognized as a practical framework to maximize independence and community participation in dementia care. The rehabilitation program is customized to achieve the desired goals, as each person has different experiences, preferences, motivations, strengths, and requirements based on type, course, and severity of the illness. It is an interdisciplinary-team approach with the involvement of several health care professionals. This article reviews the existing literature and outlines the effective rehabilitation strategies concisely in dementia care.

Effects of COVID-19 Pandemic Confinement in Patients With Cognitive Impairment

Introduction: State of emergency caused by COVID-19 pandemic and subsequent lockdown hit Spain on 14th March 2020 and lasted until 21st June 2020. Social isolation measures were applied. Medical attention was focused on COVID-19. Primary and social care were mainly performed by telephone. This exceptional situation may affect especially vulnerable patients such as people living with dementia. Our aim was to describe the influence of restrictive measures on patients living with mild cognitive decline and dementia evaluating SARS-CoV2 infection, changes in routines, cognitive decline stage, neuropsychiatric symptoms, delirium, falls, caregiver stress, and access to sanitary care.

Materials and Methods: We gathered MCI and dementia patients with clinical follow-up before and after confinement from DegMar registry (Hospital del Mar). A telephone ad-hoc questionnaire was administered. Global status was assessed using CDR scale. Changes in neuropsychiatric symptoms were assessed by Neuropsychiatric Inventory (NPI) and retrospective interview for pre-confinement base characteristics.

Results: We contacted a total of 60 patients, age 75.4 years ± 5,192. 53.3% were women. Alzheimer's Disease (41.7%) and Mild Cognitive Impairment (25%) were the most prevalent diagnosis. Remaining cases included different dementia disorders. A total of 10% of patients had been diagnosed with SARS-CoV-2. During confinement 70% of patients abandoned previous daily activities, 60% had cognitive worsening reported by relatives/caretakers, 15% presented delirium episodes, and 13% suffered increased incidence of falls. Caregivers reported an increased burden in 41% cases and burnout in 11% cases. 16% reported difficulties accessing medical care, 33% received medical phone assistance, 20% needed emergency care and 21% had changes in psychopharmacological therapies. Neuropsychiatric profile globally worsened (p < 0.000), also in particular items like agitation (p = 0.003), depression (p < 0.000), anxiety (p < 0.000) and changes in appetite (p = 0.004).

Conclusion: SARS-CoV2-related lockdown resulted in an important effect over social and cognitive spheres and worsening of neuropsychiatric traits in patients living with mild cognitive decline and dementia. Although the uncertainty regarding the evolution of the pandemic makes strategy difficult, we need to reach patients and caregivers and develop adequate strategies to reinforce and adapt social and health care.

Pathways Connecting Late-Life Depression and Dementia

Late-life depression is associated with significant cognitive impairment. Meta-analyses showed that depression is associated with an increased risk for Alzheimer’s disease (AD) and it might be an etiological factor for AD. Since late-life depression is often connected with cognitive impairment and dementia is usually associated with depressive symptoms, a simple diagnostic approach to distinguish between the disorders is challenging. Several overlapping pathophysiological substrates might explain the comorbidity of both syndromes. Firstly, a stress syndrome, i.e., elevated cortisol levels, has been observed in up to 70% of depressed patients and also in AD pathology. Stress conditions can cause hippocampal neuronal damage as well as cognitive impairment. Secondly, the development of a depression and dementia after the onset of vascular diseases, the profile of cerebrovascular risk factors in both disorders and the impairments depending on the location of cerebrovascular lesions, speak in favor of a vascular hypothesis as a common factor for both disorders. Thirdly, neuroinflammatory processes play a key role in the etiology of depression as well as in dementia. Increased activation of microglia, changes in Transforming-Growth-Factor beta1 (TGF-beta1) signaling, production of pro-inflammatory cytokines as well as reduction of anti-inflammatory molecules are examples of common pathways impaired in dementia and depression. Fourthly, the neurotrophin BDNF is highly expressed in the central nervous system, especially in the hippocampus, where it plays a key role in the proliferation, differentiation and the maintenance of neuronal integrity throughout lifespan. It has been associated not only with antidepressant properties but also a reduction of cognitive impairment and therefore could be involved also in AD. Another etiologic factor is amyloid accumulation, as plasma amyloid beta-42 independently predicts both late-onset depression and AD. Higher plasma amyloid beta-42 predicts the development of late onset depression and conversion to possible AD. However, clinical trials with antibodies against beta amyloid recently failed, i.e., Solanezumab, Aducanumab, and Crenezumab. An overproduction of amyloid-beta might simply reflect a form of synaptic plasticity to compensate for neuronal dysfunction in different kind of neurological and psychiatric diseases of multiple etiologies. The tau hypothesis, sex/gender specific differences, epigenetics and the gut microbiota-brain axis imply other potential common pathways connecting late-life depression and dementia. In conclusion, different potential pathophysiological links between dementia and depression highlight several specific synergistic and multifaceted treatment possibilities, depending on the individual risk profile of the patient.

Living with a well-known stranger: Voices of family members to older persons with frontotemporal dementia

AIM

To describe family members' experiences of living with persons with neuropsychiatric symptoms (NPS) related to frontotemporal dementia (FTD).

BACKGROUND

The majority of persons with dementia during the disease trajectory develop NPS. Persons with FTD are likely to develop greater levels of NPS than persons with other types of dementias. Research-based knowledge regarding family members' experiences of living with persons with FTD and NPS is limited.

METHODS

Nine family members of persons with FTD were interviewed. Interviews commenced with completion of the Neuropsychiatric Inventory (NPI). Upon completion of the NPI, questions were posed from an interview guide where study participants provided in-depth information about NPS identified. Interview data were analysed using qualitative content analysis.

RESULTS

Interviewed family members highlighted that persons with FTD had developed between four and eight co-existing NPS. Irritability and disinhibition were the most common NPS, with variations in severity, frequency and distress. From the interview data, two themes emerged: Living with a well-known stranger and Coping and overstepping social norms.

CONCLUSIONS

Living with a well-known stranger depicted a new co-existence with a loved one with changes in personality and behaviour, which were not inherent to the person or predictable any more. The presence of NPS can threaten the safety of the person with FTD and their family in real world and on social media. Support offered should focus on the person's physical and psychological needs, not on a diagnosis.

IMPLICATIONS FOR PRACTICE

From a health care perspective it is important to see the person with FTD and their family as unique individuals with specific needs.

The Hyperactivity-Impulsivity-Irritiability-Disinhibition-Aggression-Agitation Domain in Alzheimer's Disease: Current Management and Future Directions

Behavioral and psychological symptoms of dementia (BPSD) afflict the vast majority of patients with dementia, especially those with Alzheimer's disease (AD). In clinical settings, patients with BPSD most often do not present with just one symptom. Rather, clusters of symptoms commonly co-occur and can, thus, be grouped into behavioral domains that may ultimately be the result of disruptions in overarching neural circuits. One major BPSD domain routinely identified across patients with AD is the hyperactivity-impulsivity-irritiability-disinhibition-aggression-agitation (HIDA) domain. The HIDA domain represents one of the most difficult sets of symptoms to manage in AD and accounts for much of the burden for caregivers and hospital staff. Although many studies recommend non-pharmacological treatments for HIDA domain symptoms as first-line, they demonstrate little consensus as to what these treatments should be and are often difficult to implement clinically. Certain symptoms within the HIDA domain also do not respond adequately to these treatments, putting patients at risk and necessitating adjunct pharmacological intervention. In this review, we summarize the current literature regarding non-pharmacological and pharmacological interventions for the HIDA domain and provide suggestions for improving treatment. As epigenetic changes due to both aging and AD cause dysfunction in drug-targeted receptors, we propose that HIDA domain treatments could be enhanced by adjunct strategies that modify these epigenetic alterations and, thus, increase efficacy and reduce side effects. To improve the implementation of non-pharmacological approaches in clinical settings, we suggest that issues regarding inadequate resources and guidance for implementation should be addressed. Finally, we propose that increased monitoring of symptom and treatment progression via novel sensor technology and the "DICE" (describe, investigate, create, and evaluate) approach may enhance both pharmacological and non-pharmacological interventions for the HIDA domain.

Assessing BPSD with the support of the NPI-NH: a discourse analysis of clinical reasoning

ABSTRACTBackground:The ability of nursing staff to assess and evaluate behavioral and psychological symptoms of dementia (BPSD) to determine when intervention is needed is essential. In order to assist with the assessment process, the current use of the Neuropsychiatric Inventory Nursing Home version (NPI-NH) is internationally accepted. Even though the NPI-NH is thoroughly validated and has several advantages, there are also various challenges when implementing this system in practice. Thus, the aim of this study was to explore clinical reasoning employed by assistant nurses when utilizing the NPI-NH as a tool to assess frequency and severity of BPSD in individuals with advanced dementia.

METHOD

Twenty structured assessment sessions in which assistant nurses used the NPI-NH were audio recorded and analyzed with a discourse analysis focusing on the activities in the communication.

RESULTS

Four categories were identified to convey assistant nurses' clinical reasoning when assessing and evaluating BPSD using the NPI-NH: considering deteriorations in ability and awareness, incorporating individual and contextual factors, overcoming variations in behaviors and ambiguous formulations in the instrument, and sense-making interactions with colleagues.

CONCLUSION

The NPI-NH served as a supportive frame and structure for the clinical reasoning performed during the assessment. The clinical reasoning employed by assistant nurses became a way to reach a consensual and broader understanding of the individual with dementia, with the support of NPI-NH as an important framework.

Different apathy clinical profile and neural correlates in behavioral variant frontotemporal dementia and Alzheimer's disease

OBJECTIVES

Apathy is one of the most common and disabling syndromes of dementia. Clinical apathy expression and neuroanatomical basis of apathy seem to differ between behavioral variant frontotemporal dementia (bvFTD) and Alzheimer's disease (AD), although evidence is scarce and poorly understood. Our main purposes were to compare the clinical apathy profile from patients with bvFTD and AD and analyze the relationship between apathy and brain metabolism measured using positron emission tomography imaging with ¹⁸ F fluorodeoxyglucose (FDG-PET).

METHODS

Forty-two bvFTD, 42 AD, and 30 healthy volunteers without cognitive or behavioral complaints were included. Apathy was defined using Robert's 2009 diagnostic criteria, and specific apathy characteristics were assessed with the Lille Apathy Rating Scale. All participants underwent FDG-PET brain scan to provide data for voxel-based morphometric analysis.

RESULTS

Multivariate analysis showed that subjects affected by bvFTD displayed greater impairment of emotional apathy and self-awareness in comparison with AD sample. Additionally, FDG-PET imaging analyses revealed that apathy was associated with different neuroanatomical substrates in each dementia group: left lateral prefrontal, medial frontal/anterior cingulate, lateral orbitofrontal and anterior insular cortices in bvFTD, and right anterior cingulate in AD.

CONCLUSIONS

These results support that apathy is a complex syndrome, with different clinical expressions across different pathological conditions. Those differences in qualitative aspects of apathy seem to be associated with differences in the damage sites, as shown by our FDG-PET imaging analysis. Our findings provide a better knowledge about pathophysiology of apathy in dementia, which could have practical implications for therapeutic management. Copyright © 2017 John Wiley & Sons, Ltd.

The relationship of specific items on the Neuropsychiatric Inventory to caregiver burden in dementia: a systematic review

OBJECTIVE

Neuropsychiatric symptoms (NPSs) are common in dementia, and they have been identified as important care-recipient variables in terms of their impact on caregiver burden. The aim of this review was to describe how individual NPSs in dementia, assessed using the Neuropsychiatric Inventory, are associated with caregiver burden.

METHODS

We performed a systematic review of English language, peer-reviewed articles retrieved from MEDLINE, PSYCINFO, and EMBASE.

RESULTS

A total of 13 studies met the inclusion criteria. Four studies examined the association between individual NPSs and caregiver burden using the Spearman rank correlation test, while three used Pearson's correlation test. Of the remaining studies, five used multiple regression analyses and one the chi-squared test. The majority of included studies did not differentiate between dementia subtypes in the analysis or mainly included only caregivers of people with Alzheimer's disease. The Clinical Dementia Rating score and mean Mini-Mental State Examination score indicate mild to moderate dementia. The majority of caregivers were women, most of whom were children (53.8%) or spouses (36%). The data indicated that irritability, followed by agitation, sleep disturbances, anxiety, apathy, and delusion seem to impact caregiver burden the most.

CONCLUSION

Our principal finding is that irritability, agitation, sleep disturbances, anxiety, apathy, and delusion seem to exert the most impact on caregiver burden. Heterogeneity in the measures and statistical analyses used, however, makes it difficult to make conclusive interpretations. Future research in this field would benefit from standardization of the scientific methodology in use. Copyright © 2017 John Wiley & Sons, Ltd.

Validation of the Lille's Apathy Rating Scale in Very Mild to Moderate Dementia

OBJECTIVE

Apathy is one of the most common and disabling syndromes of dementia and presents at all stages of the disease. Comprehensive and structured methods to assess apathy in dementia are still needed. Lille's Apathy Rating Scale (LARS) has shown good psychometric properties for apathy evaluation in Parkinson disease but has not been validated in dementia. The aim of this study was to validate the LARS in a cohort of patients with very mild to moderate dementia.

METHODS

101 patients with cognitive impairment (Clinical Dementia Rating ≤ 2) and 50 healthy subjects were recruited. Patient diagnoses included 43 individuals with Alzheimer disease, 41 frontotemporal dementia, and 17 primary progressive aphasia. In addition to LARS, the following assessments were administered: Clinical Dementia Rating, Interview for Deterioration in Daily Living Activities in Dementia, Functional Activities Questionnaire, Frontal Behavioral Inventory, Neuropsychiatric Inventory (NPI), and Hamilton Depression Rating Scale.

RESULTS

Internal consistency for LARS (Cronbach's alpha) was 0.940. Test-retest intraclass correlation coefficient (ICC) was 0.940 and inter-rater ICC was 0.987. The correlation among LARS and NPI apathy scores (concurrent validity) was 0.834. Receiver operating characteristic analysis estimated an area under the curve of 0.987. The optimal cutoff point was -10. Although total LARS score was influenced by the presence of depression, this disorder was independent with respect to apathy.

CONCLUSION

LARS is reliable and valid for detecting and quantifying apathy in patients with dementia, even in very early stages of the disease.

Quantitative EEG Neurometric Analysis-Guided Neurofeedback Treatment in Dementia: 20 Cases. How Neurometric Analysis Is Important for the Treatment of Dementia and as a Biomarker?

Dementia is a debilitating degenerative disorder where the sufferer's cognitive abilities decline over time, depending on the type of dementia. The more common types of dementia include Alzheimer's disease and vascular or multi-infarct dementia. In this study, 20 subjects with dementia (9 of Alzheimer's type, and 11 with vascular dementia) were treated using qEEG-guided neurofeedback training. The Mini Mental Status Examination (MMSE) was used as the primary outcome measure. The results showed an increase of the MMSE scores for all subjects regardless of dementia type with an average MMSE score increase of 6 points, which was found to be significant. To our knowledge this is the first time the same modality was shown to be beneficial in both dementia groups.

Validity of the Brazilian version of the Neuropsychiatric Inventory Questionnaire (NPI-Q)

The NPI-Q (Neuropsychiatry Inventory-Questionnaire) was developed to facilitate the evaluation of neuropsychiatric symptoms. This study evaluated the internal consistency, the test-retest reliability of the Brazilian NPI-Q version and its convergent validity with the original NPI.MethodThe NPI-Q and the NPI were administered to 64 caregivers of dementia patients. Thirteen informants were asked to complete a second NPI-Q form.ResultsThe internal consistency of the Brazilian NPI-Q version was 0.67 for the severity scale and 0.81 for the distress scale. The test-retest reliability of the total NPI-Q severity and the distress scales were 0.97 and 0.92, respectively (p < 0.001). There were significant correlations between the total NPI-Q severity score and the NPI (r = 0.75) and between the total NPI-Q distress score and the total NPI standard distress (r = 0.74).ConclusionThe Brazilian NPI-Q version showed evidence of good psychometric properties and can be used in general clinical practice.

Assessing neuropsychiatric symptoms in people with dementia: a systematic review of measures

BACKGROUND

Neuropsychiatric symptoms (NPS) occur in people with dementia throughout disease course and across etiologies. NPS are associated with significant morbidities and hastened disease processes. Nevertheless, people with dementia are not systematically assessed for NPS in clinical settings. We review existing NPS measures for clinical and/or research purposes, and identify measurement gaps.

METHODS

We conducted a computerized search of peer-reviewed published studies of measures (January 1, 1980-December 1, 2013) using multiple search terms. Measures selected for review were in English, had adequate psychometric properties, and were developed for or used with people with dementia. Papers describing measures were evaluated by three coders along seven characteristics: behavioral domains, number of items, method of administration, response categories, targeted population, setting, and psychometric properties.

RESULTS

Overall, 2,233 papers were identified through search terms, and 36 papers from manual searches of references. From 2,269 papers, 85 measures were identified of which 45 (52.9%) had adequate psychometric properties and were developed or used with dementia populations. Of these, 16 (35.6%) were general measures that included a wide range of behaviors; 29 (64.4%) targeted specific behaviors (e.g. agitation). Measures differed widely as to behaviors assessed and measurement properties.

CONCLUSIONS

A robust set of diverse measures exists for assessing NPS in different settings. No measures identify risk factors for behaviors or enable an evaluation of the context in which behaviors occur. To improve clinical efforts, research is needed to evaluate concordance of behavioral ratings between formal and informal caregivers, and to develop and test measures that can identify known risks for behaviors and the circumstances under which behaviors occur.

The merits and problems of Neuropsychiatric Inventory as an assessment tool in people with dementia and other neurological disorders

Objective

The Neuropsychiatric Inventory (NPI) is one of the most commonly used assessment scales for assessing symptoms in people with dementia and other neurological disorders. This paper analyzes its conceptual framework, measurement mode, psychometric properties, and merits and problems.

Method

All articles discussing the psychometric properties and factor structure of the NPI were searched for in Medline via Ovid. The abstracts of these papers were read to determine their relevance to the purpose of this paper. If deemed appropriate, a full paper was then obtained and read.

Results

The NPI has reasonably good content validity and internal consistency, and good test–retest and interrater reliability. There is limited information about its sensitivity, specificity, positive and negative predictive values, and, in particular, responsiveness. Merits of the NPI include being comprehensive, avoiding symptom overlap, ease of use, and flexibility. It has problems in scoring (no multiples of 5, 7, and 11) and, therefore, analysis using parametric tests may not be appropriate. The use of individual subscales also warrants further investigation.

Conclusion

In terms of its content and concurrent validity, intra- and interrater reliability, test–retest reliability, and internal consistency, the NPI can be considered as valid and reliable, and can be used across different ethnic groups. The tool is most likely unable to deliver as good a performance in terms of discriminating between different disorders. More studies are required to further evaluate its psychometric properties, particularly in the areas of factor structure and responsiveness. The clinical utility of the NPI also needs to be further explored.

A case-control study regarding relative factors for behavioural and psychological symptoms of dementia at a Canadian regional long-term extended care facility: a preliminary report

BACKGROUND

Behavioural and psychological symptoms of dementia (BPSD) are prevalent and have an impact on the care of persons with dementia. Previous studies regarding predisposing factors have included pharmacotherapy, but other factors may not have been sufficiently studied. We hypothesized that psychotropic medications, past history, comorbid psychiatric disorders and other factors may be relevant factors related to BPSD.

METHODS

Data were collected from patients' medical charts at an extended care facility over a 2-year period from 1 May 2008 to 30 April 2010. Information obtained included the presence of BPSD, gender, age, marital status, past history, comorbid psychiatric disorder and medication use. Patients were divided into two groups: a group with BPSD (n = 29) and a group without BPSD (n = 10). A binomial logistic regression analysis was performed for the above factors.

RESULTS

Comorbid major depression was linked to BPSD (odds ratio = 12.57, 95% confidence interval: 1.31-120.74) as well as to the use of antidepressants (odds ratio = 6.49, 95% confidence interval: 1.02-41.25). There was a trend towards statistical significance in the relationship between greater use of antidepressants for the patients with comorbid major depression and the presence of BPSD. Past history of depression (Fisher's exact test; P = 0.03) and cerebral vascular accident (degrees of freedom = 1, χ(2) = 4.44, P = 0.04) were linked to the presence of BPSD and comorbid major depression.

CONCLUSION

Accurate evaluation and treatment of comorbid major depression may affect BPSD. In order to reduce the burden of BPSD on patients and caregivers, there should be a careful and thoughtful diagnosis of comorbid major depression in patients with dementia.

EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia

BACKGROUND AND OBJECTIVES

The last version of the EFNS dementia guidelines is from 2007. In 2010, the revised guidelines for Alzheimer's disease (AD) were published. The current guidelines involve the revision of the dementia syndromes outside of AD, notably vascular cognitive impairment, frontotemporal lobar degeneration, dementia with Lewy bodies, corticobasal syndrome, progressive supranuclear palsy, Parkinson's disease dementia, Huntington's disease, prion diseases, normal-pressure hydrocephalus, limbic encephalitis and other toxic and metabolic disorders. The aim is to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists and other specialist physicians responsible for the care of patients with dementing disorders. It represents a statement of minimum desirable standards for practice guidance.

METHODS

The task force working group reviewed evidence from original research articles, meta-analyses and systematic reviews, published by June 2011. The evidence was classified (I, II, III, IV) and consensus recommendations graded (A, B, or C) according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided.

RESULTS AND CONCLUSIONS

New recommendations and good practice points are made for clinical diagnosis, blood tests, neuropsychology, neuroimaging, electroencephalography, cerebrospinal fluid (CSF) analysis, genetic testing, disclosure of diagnosis, treatment of behavioural and psychological symptoms in dementia, legal issues, counselling and support for caregivers. All recommendations were revised as compared with the previous EFNS guidelines. The specialist neurologist together with primary care physicians play an important role in the assessment, interpretation and treatment of symptoms, disability and needs of dementia patients.

Nursing interventions in cases of agitation and dementia

This study had two objectives: firstly, to assess and compare the frequency and circumstances of agitation and, secondly, to generate decision-making aids for the treatment of agitation patients by applying a nursing intervention in cases of dementia and agitation. For that purpose, 1002 measurements of open nursing interventions in cases of agitation were obtained over a period of 11 weeks in two nursing homes in the city of Zurich and in the nursing home Sonnweid. Before, during and after two intervention periods of four weeks each, data were collected for 60 persons suffering from severe dementia. The results show that two-thirds of the residents were never agitated, one-quarter was moderately agitated and only very few suffered from medium-to-severe agitation. In almost half the cases, agitation occurred while the person was alone (46%), followed by cases of agitation as a constant state (26%). There was rarely any agitation while the residents were engaged in activities. After analysing 433 documented cases, it turned out that the most successful care interventions were avoiding noise, accompanying the person to the toilet, communication/validation, walking about/movement and administering beverages. Being based on newly translated observational methods and a unique longitudinal study design with combined intervention, this study provides important insights into how agitation in dementia can be influenced within the care context, as well as a practical evaluation of interventions specific to different institutions.

Farsi version of the Neuropsychiatric Inventory: validity and reliability study among Iranian elderly with dementia

BACKGROUND

This study aimed to validate the Farsi version of Neuropsychiatric Inventory (F-NPI), with the aim of promoting clinical assessment and local research on evaluation of neuropsychiatric symptom profiles of individuals with dementia in Iran.

METHODS

In this cross-sectional, psychometric study, 100 patients with dementia in the age range of 60–90 years participated. Two trained psychiatrists interviewed the study subjects. Positive and Negative Symptoms Scale (PANSS) and Geriatric Depression Scale (GDS) were used to determine the concurrent validity. Testretest,inter-rater reliability and internal consistency were calculated. Discrimination validity was determined,using a matched control group consisting of 49 participants without dementia. Cronbach’s α and Pearson’ scorrelation coefficients were used to analyze the data.

RESULTS

The internal consistency (Cronbach’s α = 0.9) was excellent. The inter-rater reliability varied between 0.6 and 0.98 for frequency, severity and total scale of the F-NPI, and test-retest reliability was between 0.4 and 0.96. Concurrent validity varied between 0.3 and 0.9 (P < 0.05). The most prevalent symptom was “apathy” and the least prevalent was “euphoria”.

CONCLUSION

The Farsi version of NPI has satisfactory psychometric indexes and is applicable for clinical and study works in Iranian community.

Assessment and treatment of behavior problems in dementia in nursing home residents: a comparison of the approaches of physicians, psychologists, and nurse practitioners

OBJECTIVE

To compare physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) regarding their approach to dementia-associated behavior problems in nursing home residents.

METHODS

A web-based questionnaire solicited information about symptoms, assessment methods, suspected etiologies, and interventions with respect to the last resident treated for dementia-associated behavior problems.

RESULTS

Responses were obtained from 108 MDs, 38 PhDs, and 100 NPs. All groups relied similarly on information from the nursing staff, speaking with nursing assistants, and care team meetings in assessment; NPs were more likely to consult with family members. A standard assessment instrument was used most frequently by PhDs (50%), but this generally assessed cognitive status rather than problem behaviors. PhDs most frequently noted depression in residents. Groups were similar in attributing the behavioral symptoms to dementia and to underlying medical conditions, but PhDs were more likely to indicate depression, loneliness/boredom, staff-resident communication, and insufficient activities as etiologies. Use of pharmacological and nonpharmacological interventions of MDs and NPs were similar. PhDs reported least satisfaction with treatment.

CONCLUSION

Awareness of similarities and differences in the approaches of different health professionals can facilitate interdisciplinary interaction in providing care for dementia-associated behavior problems in nursing home residents.

EFNS guidelines for the diagnosis and management of Alzheimer's disease

BACKGROUND AND OBJECTIVES

In 2008 a task force was set up to develop a revision of the European Federation of the Neurological Societies (EFNS) guideline for the diagnosis and management of Alzheimer's disease (AD) and other disorders associated with dementia, published in early 2007. The aim of this revised international guideline was to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists, and other specialist physicians responsible for the care of patients with AD. Mild cognitive impairment and non-Alzheimer dementias are not included in this guideline.

METHODS

The task force working group reviewed evidence from original research articles, meta-analysis, and systematic reviews, published before May 2009. The evidence was classified and consensus recommendations graded (A, B, or C) according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided.

RESULTS

The recommendations for clinical diagnosis, blood tests, neuropsychology, neuroimaging, electroencephalography, cerebrospinal fluid (CSF) analysis, genetic testing, disclosure of diagnosis, treatment of AD, behavioural and psychological symptoms in dementia, legal issues, counselling and support for caregivers were all revised as compared with the previous EFNS guideline.

CONCLUSION

A number of new recommendations and good practice points are made, namely in CSF, neuropsychology, neuroimaging and reviewing non-evidence based therapies. The assessment, interpretation, and treatment of symptoms, disability, needs, and caregiver stress during the course of AD require the contribution of many different professionals. These professionals should adhere to these guideline to improve the diagnosis and management of AD.

Managing the patient with dementia in long-term care

The majority of residents in a nursing home have some degree of dementia. The prevalence is commonly from 70% to 80% of residents. This article covers the following topics on caring for patients with dementia in long-term care: (1) the efficacy of cholinesterase inhibitors and memantine, (2) the optimal environment for maintenance of function in moderate dementia, (3) the treatment of depression and agitation, and (4) the evaluation and management of eating problems.

The implementation of the serial trial intervention for pain and challenging behaviour in advanced dementia patients (STA OP!): a clustered randomized controlled trial

Background

Pain (physical discomfort) and challenging behaviour are highly prevalent in nursing home residents with dementia: at any given time 45-80% of nursing home residents are in pain and up to 80% have challenging behaviour. In the USA Christine Kovach developed the serial trial intervention (STI) and established that this protocol leads to less discomfort and fewer behavioural symptoms in moderate to severe dementia patients. The present study will provide insight into the effects of implementation of the Dutch version of the STI-protocol (STA OP!) in comparison with a control intervention, not only on behavioural symptoms, but also on pain, depression, and quality of life. This article outlines the study protocol.

Methods/Design

The study is a cluster randomized controlled trial in 168 older people (aged >65 years) with mild or moderate dementia living in nursing homes. The clusters, Dutch nursing homes, are randomly assigned to either the intervention condition (training and implementation of the STA OP!-protocol) or the control condition (general training focusing on challenging behaviour and pain, but without the step-wise approach). Measurements take place at baseline, after 3 months (end of the STA OP! training period) and after 6 months.

Primary outcome measures are symptoms of challenging behaviour (measured with the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and pain (measure with the Dutch version of the Pain Assessment Checklist for Seniors (PACSLAC-D) and the Minimum Data Set of the Resident Assessment Instrument (MDS-RAI) pain scale). Secondary outcome measures include symptoms of depression (Cornell and MDS-RAI depression scale), Quality of Live (Qualidem), changes in prescriptions of analgesics and psychotropic drugs, and the use of non-pharmacological comfort interventions (e.g. snoezelen, reminiscence therapy).

Discussion

The transfer from the American design to the Dutch design involved several changes due to the different organisation of healthcare systems. Specific strengths and limitations of the study are discussed.

Trial registration

Netherlands Trial Register (NTR): NTR1967

Potential Antidepressant Role of Neurotransmitter CART: Implications for Mental Disorders

Depression is one of the most prevalent and debilitating public health concerns. Although no single cause of depression has been identified, it appears that interaction among genetic, epigenetic, biochemical, environmental, and psychosocial factors may explain its etiology. Further, only a fraction of depressed patients show full remission while using current antidepressants. Therefore, identifying common pathways of the disorder and using that knowledge to develop more effective pharmacological treatments are two primary targets of research in this field. Brain-enriched neurotransmitter CART (cocaine- and amphetamine-regulated transcript) has multiple functions related to emotions. It is a potential neurotrophic factor and is involved in the regulation of hypothalamic-pituitary-adrenal axis and stress response as well as in energy homeostasis. CART is also highly expressed in limbic system, which is considered to have an important role in regulating mood. Notably, adolescents carrying a missense mutation in the CART gene exhibit increased depression and anxiety. Hence, CART peptide may be a novel promising antidepressant agent. In this paper, we summarize recent progress in depression and CART. In particular, we emphasize a new antidepressant function for CART.

Validity and Reliability of the Zarit Burden Interview in Assessing Caregiving Burden

Introduction: This study aims to validate the Zarit Burden Interview as an instrument to measure the level of burden experienced by caregivers of patients with dementia (PWD) in Singapore. Materials and Methods: Adult family caregivers of PWD were recruited from the ambulatory dementia clinic of a tertiary hospital and the Alzheimer’s Disease Association. All subjects completed a battery of questionnaires which consisted of demographic questions and the following instruments: the Zarit Burden Interview (ZBI), Burden Assessment Scale (BAS), General Health Questionnaire (GHQ-28), Dementia Management Strategies Scale (DMSS), and the Revised Memory and Behaviour Problems Checklist (RMBPC). A subgroup of subjects also completed the ZBI for the second time 2 weeks after the fi rst survey. Results: A total of 238 subjects completed the survey. As hypothesised, the Zarit burden score was strongly correlated with BAS, GHQ-28, DMSS, and RMBPC scores (Pearson’s correlation coefficient: 0.53 to 0.73); caregivers who undertook the major role in caregiving, had spent >1 year in caregiving, or experienced financial problems had higher Zarit burden scores than those who were not main carers, with ≤1 year of caregiving, or reported no/minimal financial problems, respectively. The Cronbach’s alpha value for the ZBI items was 0.93; the intra-class correlation coefficient for the test-retest reliability of the Zarit burden score was 0.89 (n = 149). Conclusion: The results in this study demonstrated that the Zarit Burden Interview is a valid and reliable instrument for measuring the burden of caregivers of PWD in Singapore. Key words: Caregiver, Dementia, Scale, Validation

Apple juice improved behavioral but not cognitive symptoms in moderate-to-late stage Alzheimer's disease in an open-label pilot study

Preclinical studies demonstrate that apple juice exerts multiple beneficial effects including reduction of central nervous system oxidative damage, suppression of Alzheimer's disease (AD) hallmarks, improved cognitive performance, and organized synaptic signaling. Herein, we initiated an open-label clinical trial in which 21 institutionalized individuals with moderate-to-severe AD consumed 2 4-oz glasses of apple juice daily for 1 month. Participants demonstrated no change in the Dementia Rating Scale, and institutional caregivers reported no change in Alzheimer's Disease Cooperative Study (ADCS)-Activities of Daily Living (ADL) in this brief study. However, caregivers reported an approximate 27% (P < .01) improvement in behavioral and psychotic symptoms associated with dementia as quantified by the Neuropsychiatric Inventory, with the largest changes in anxiety, agitation, and delusion. This pilot study suggests that apple juice may be a useful supplement, perhaps to augment pharmacological approaches, for attenuating the decline in mood that accompanies progression of AD, which may also reduce caregiver burden.

Efficacy of integrated interventions combining psychiatric care and nursing home care for nursing home residents: a review of the literature

BACKGROUND

Nursing home residents needing both psychiatric care and nursing home care for either somatic illness or dementia combined with psychiatric disorders or severe behavioural problems are referred to as Double Care Demanding patients, or DCD patients. Integrated models of care seem to be necessary in order to improve the well-being of these residents.

OBJECTIVES

Two research questions were addressed. First, which integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are described in the research literature? And second, which outcomes of integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are reported in the literature?

METHOD

A critical review of studies was done that involved integrated interventions combining both psychiatric care and nursing home care on psychiatric disorders and severe behavioural problems in nursing home patients. A systematic literature search was performed in a number of international databases.

RESULTS

Eight intervention trials, including four RCTs (2b level of evidence), were identified as relevant studies for the purpose of this review. Seven studies, three of which were RCTs, showed beneficial effects of a comprehensive, integrated multidisciplinary approach combining medical, psychiatric and nursing interventions on severe behavioural problems in DCD nursing home patients.

CONCLUSIONS

Important elements of a successful treatment strategy for DCD nursing home patients include a thorough assessment of psychiatric, medical and environmental causes as well as programmes for teaching behavioural management skills to nurses. DCD nursing home patients were found to benefit from short-term mental hospital admission.This review underlines the need for more rigorously designed studies to assess the effects of a comprehensive, integrated multidisciplinary approach towards DCD nursing home residents.

Assessing depression outcome in patients with moderate dementia: sensitivity of the HoNOS65+ scale

To date, there is no widely accepted clinical scale to monitor the evolution of depressive symptoms in demented patients. We assessed the sensitivity to treatment of a validated French version of the Health of the Nation Outcome Scale (HoNOS) 65+ compared to five routinely used scales. Thirty elderly inpatients with ICD-10 diagnosis of dementia and depression were evaluated at admission and discharge using paired t-test. Using the Brief Psychiatric Rating Scale (BPRS) "depressive mood" item as gold standard, a receiver operating characteristic curve (ROC) analysis assessed the validity of HoNOS65+F "depressive symptoms" item score changes. Unlike Geriatric Depression Scale, Mini Mental State Examination and Activities of Daily Living scores, BPRS scores decreased and Global Assessment Functioning Scale score increased significantly from admission to discharge. Amongst HoNOS65+F items, "behavioural disturbance", "depressive symptoms", "activities of daily life" and "drug management" items showed highly significant changes between the first and last day of hospitalization. The ROC analysis revealed that changes in the HoNOS65+F "depressive symptoms" item correctly classified 93% of the cases with good sensitivity (0.95) and specificity (0.88) values. These data suggest that the HoNOS65+F "depressive symptoms" item may provide a valid assessment of the evolution of depressive symptoms in demented patients.

Efficacy of a vitamin/nutriceutical formulation for moderate-stage to later-stage Alzheimer's disease: a placebo-controlled pilot study

Recent studies demonstrated efficacy of a vitamin/ nutriceutical formulation (folate, vitamin B12, alpha-tocopherol, S-adenosyl methionine, N-acetyl cysteine, and acetyl-L-carnitine) for mild to moderate Alzheimer's disease. Herein, we tested the efficacy of this formulation in a small cohort of 12 institutionalized patients diagnosed with moderate-stage to later-stage Alzheimer's disease. Participants were randomly separated into treatment of placebo groups. Participants receiving the formulation demonstrated a clinically significant delay in decline in the Dementia Rating Scale and clock-drawing test as compared to those receiving placebo. Institutional caregivers reported approximately 30% improvement in the Neuropyschiatric Inventory and maintenance of performance in the Alzheimer's Disease Cooperative Study-Activities of Daily Living for more than 9 months. This formulation holds promise for delaying the decline in cognition, mood, and daily function that accompanies the progression of Alzheimer's disease, and may be particularly useful as a supplement for pharmacological approaches during later stages of this disorder. A larger trial is warranted.

Efficacy of a vitamin/nutriceutical formulation for early-stage Alzheimer's disease: a 1-year, open-label pilot study with an 16-month caregiver extension

We examined the efficacy of a vitamin/nutriceutical formulation (folate, vitamin B6, alpha-tocopherol, S-adenosyl methionine, N-acetyl cysteine, and acetyl-L-carnitine) in a 12-month, open-label trial with 14 community-dwelling individuals with early-stage Alzheimer's disease. Participants improved in the Dementia Rating Scale and Clock-drawing tests (Clox 1 and 2). Family caregivers reported improvement in multiple domains of the Neuropsychiatric Inventory (NPI) and maintenance of performance in the Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADL). Sustained performance was reported by caregivers for those participants who continued in an 16-month extension. Performance on the NPI was equivalent to published findings at 3 to 6 months for donepezil and exceeded that of galantamine and their historical placebos. Participants demonstrated superior performance for more than 12 months in NPI and ADL versus those receiving naproxen and rofecoxib or their placebo group. This formulation holds promise for treatment of early-stage Alzheimer's disease prior to and/or as a supplement for pharmacological approaches. A larger, placebo-controlled trial is warranted.

Importance of circadian rhythmicity in the cholinergic treatment of Alzheimer's disease: focus on galantamine*

OBJECTIVE AND SCOPE: This review article used data from an extensive literature search (including MEDLINE database searches) to explore the relationships between sleep, memory and Alzheimer's disease (AD). The importance of taking into account circadian rhythmicity and acetylcholine (ACh) levels when considering acetylcholinesterase inhibitors, galantamine in particular, in the treatment of patients with AD is discussed.

REVIEW FINDINGS

Moderate changes of circadian rhythms may occur as part of the normal ageing process, but patients with AD exhibit circadian rhythm disturbances extending beyond those observed in non-demented elderly and this may lead to severe disruption of the sleep-wake cycle. Indeed, ACh plays an active role in maintaining a normal sleep pattern, which is important for memory consolidation. Low levels of ACh during slow-wave sleep compared with wakefulness have been shown to be critical for the consolidation of declarative memory. This suggests the existence of a circadian rhythm in central cholinergic transmission which modulates memory processes, with high ACh levels during wakefulness and reduced levels during slow-wave sleep. When using cholinesterase inhibitors to stimulate central cholinergic transmission in AD, respecting the natural circadian fluctuations of central cholinergic transmission may therefore be an important factor for patient improvement. Interfering with nocturnal cholinergic activity can add to memory problems and induce sleep disorders. Available data suggest that the type of cholinesterase inhibitor used and the time of administration may be critical with regard to the possible development of such disturbances. Plasma levels of galantamine, for example, are high during the waking day and lower at night, supporting a cholinergic stimulation that mirrors the physiological circadian rhythm of cholinergic activity. This may have beneficial implications with regard to sleep and memory.

CONCLUSIONS

The pharmacokinetic properties of cholinesterase inhibitors may need to be taken into account to avoid interference with sleep architecture and to achieve optimum benefits from treatment on cognitive processes.

Verhaltenssymptome bei Demenz in Pflegeeinrichtungen

In fortgeschrittenen Stadien von Demenzerkrankungen treten neben Depression vermehrt Verhaltenssymptome auf, zu denen Unruhe, Aggressivität und Halluzinationen zählen. In Pflegeeinrichtungen betrifft dies bis zu drei Viertel aller Bewohner. Diese Symptome sind für Pflegende belastend, ziehen erhöhte Versorgungskosten, eine vermehrte Verschreibung von Psychopharmaka, sowie häufigere Krankenhausaufenthalte nach sich. Im Jahr 2003 haben die Amerikanischen Gesellschaften für Gerontopsychiatrie und Geriatrie Leitlinien zur Behandlung von Depressionen und Verhaltenssymptomen in Pflegeeinrichtungen vorgestellt. Vergleichbare Leitlinien der deutschen Fachgesellschaften liegen bislang nicht vor. Die amerikanischen Leitlinien geben neben einem standardisierten Assessment Therapiealgorhythmen vor. In unserem Projekt werden diese Leitlinien in acht Pflegeinrichtungen in Berlin eingeführt und die Ausprägung von Verhaltenssymptomen, die Verschreibung von Psychopharmaka, die Anzahl der Krankenhauseinweisungen und die Belastung der Pflegenden mit einer Kontrollstichprobe von acht vergleichbaren Pflegeeinrichtungen ohne Leitlinienbehandlung über einen Zeitraum von 12 Monaten verglichen. Wir erwarten eine Verminderung der Ausprägung von Verhaltenssymptomen, sowie der Psychopharmakaverschreibungen, der Hospitalisierungsrate und der subjektiven Belastung für Pflegende.

Assessment and treatment approaches for behavioral disturbances associated with dementia in the nursing home: self-reports of physicians' practices

OBJECTIVES

Behavior problems are common in dementia, yet little is known about how physicians deal with these problems in practice. This article reports on a survey asking physicians to describe, with respect to the last nursing home resident with dementia they treated for behavior problems, the behaviors observed, assessment methods used, suspected etiology of the problem, types of intervention, and their reaction to the intervention process.

DESIGN

This is a descriptive study presenting responses to a Web-based questionnaire.

PARTICIPANTS

Participants were 110 physicians providing services to nursing home residents.

MEASUREMENTS

Physicians answered a close-ended questionnaire with open-ended "other" options concerning symptoms, methods of assessment, suspected etiological factors, and interventions to describe the last nursing home resident they treated for behavior problems associated with dementia.

RESULTS

Resisting care was the most frequently reported symptom (71%). Physicians were most likely to attribute the behavior problems to the indirect effects of dementia on the ability to remember, communicate, and comprehend (67%). Most (87%) reported using more than one method for treating these problems. Rate of reported use of psychotropic drugs (80%) was slightly higher than that for nonpharmacological methods (75%), with the majority (61%) reporting use of both of these methods. Standardized instruments were not used in assessment. Forty percent of the participants reported feeling satisfied or very satisfied with the intervention they provided, and close to a third (32%) reported feeling frustrated with the intervention process.

CONCLUSION

The data underscore the complexity in the treatment of behavior problems. Despite federal regulations limiting their use, the potential for side effects, and ambivalence toward such treatment, psychotropic drugs are still used for the majority of nursing home residents with behavior problems associated with dementia. On the other hand, physicians report employing nonpharmacological methods to a closely similar extent, although their role in the implementation of these treatments is less clear. Further work is needed to clarify physicians' involvement in and decision to use nonpharmacological interventions.