Premorbid personality and behavioral and psychological symptoms in probable Alzheimer disease

Revised Temperament and Character Inventory factors predict neuropsychiatric symptoms and aging-related cognitive decline across 25 years

Introduction

Personality traits and neuropsychiatric symptoms such as neuroticism and depression share genetic overlap and have both been identified as risks factors for development of aging-related neurocognitive decline and Alzheimer's disease (AD). This study aimed to examine revised personality factors derived from the Temperament and Character Inventory, previously shown to be associated with psychiatric disorders, as predictors of neuropsychiatric, cognitive, and brain trajectories of participants from a population-based aging study.

Methods

Mixed-effect linear regression analyses were conducted on data for the full sample (Nmax = 1,286), and a healthy subsample not converting to AD-dementia during 25-year follow-up (Nmax = 1,145), complemented with Cox proportional regression models to determine risk factors for conversion to clinical AD.

Results

Two personality factors, Closeness to Experience (CE: avoidance of new stimuli, high anxiety, pessimistic anticipation, low reward seeking) and Tendence to Liabilities (TL: inability to change, low autonomy, unaware of the value of their existence) were associated with higher levels of depressive symptoms, stress (CE), sleep disturbance (TL), as well as greater decline in memory, vocabulary and verbal fluency in the full sample. Higher CE was additionally associated with greater memory decline across 25 years in the healthy subsample, and faster right hippocampal volume reduction across 8 years in a neuroimaging subsample (N = 216). Most, but not all, personality-cognition associations persisted after controlling for diabetes, hypertension and cardiovascular disease. Concerning risks for conversion to AD, higher age, and APOE-ε4, but none of the personality measures, were significant predictors.

Conclusion

The results indicate that personality traits associated with psychiatric symptoms predict accelerated age-related neurocognitive declines even in the absence of neurodegenerative disease. The attenuation of some personality effects on cognition after adjustment for health indicators suggests that those effects may be partly mediated by somatic health. Taken together, the results further emphasize the importance of personality traits in neurocognitive aging and underscore the need for an integrative (biopsychosocial) perspective of normal and pathological age-related cognitive decline.

The role of maladaptive personality in behavioural and psychological symptoms in dementia

BACKGROUND

Although research demonstrated a significant link between premorbid normative personality traits and the severity of behavioural and psychological symptoms in dementia (BPSD) and associated emotional distress of the caregiver, little is known about the relationship of BPSD symptoms and associated distress with maladaptive traits.

METHOD

Informants (N = 182) of Dutch nursing home residents with dementia aged 65+, completed the Neuropsychiatric Inventory Questionnaire to assess the severity of BPSD and associated emotional distress. Premorbid maladaptive personality traits were evaluated using informant versions of a brief version of the Personality Inventory for Diagnostic and Statistical manual of Mental Disorders-5 (PID-5-BF), and two age-specific personality measures, the Informant Personality Questionnaire (HAP), and Gerontological Personality disorder Scale. Relationships between premorbid personality and BPSD were investigated with correlational and ordinal regression analyses.

RESULTS

BPSD severity and distress were associated with medium sized correlations to Negative Affectivity, Antagonism and indications of personality disorder presence. The emotional distress also correlated with a medium effect with Detachment. Higher scores on maladaptive personality traits increased the odds of higher BPSD severity and distress.

CONCLUSION

Results found with age-specific personality measures were in line with results found with other measures of (mal)adaptive traits. Several maladaptive personality traits had a significant relationship with the BPSD severity and associated emotional distress. We therefore encourage to implement personality assessment within BPSD treatment strategies. This way care becomes more person-focused and more tailored to the specific needs of patients and caregivers.

Neuropsychiatric Inventory domains cluster into neuropsychiatric syndromes in Alzheimer's disease: A systematic review and meta-analysis

BACKGROUND

Studies of patients with Alzheimer's disease (AD) have observed that neuropsychiatric symptoms (NPS) tend to co-occur as neuropsychiatric syndromes and have generally shown mixed results regarding the number and composition of syndromes. We systematically reviewed how neuropsychiatric syndromes in AD have been defined and compared the different published definitions in a pooled sample of AD patients using meta-analytic structural equation modeling (MASEM).

METHODS

Studies examining the factor structure of the Neuropsychiatric Inventory (NPI) and published from 1994 to 2021 were included. We contacted the corresponding authors of eligible studies for correlation coefficients between NPI items. We pooled correlations under a random effects MASEM model and fitted and compared measurement models from published studies to identify a best-fitting model.

RESULTS

Twenty-five studies were included in the systematic review, and correlations were obtained from seven studies for MASEM. For the NPI-10 (seven studies, n = 5185), a five-factor structure was found to have a good fit to the data. For the NPI-12 (four studies, n = 2397), we were unable to identify a factor structure that displayed a good model fit.

CONCLUSION

This systematic review and meta-analysis contribute to the development of a theoretical model of neuropsychiatric syndromes in AD and reveals the barriers that accompany MASEM methodology.

Risk factors for apathy in Alzheimer's disease: A systematic review of longitudinal evidence

BACKGROUND

Apathy is frequent and persistent in Alzheimer's disease (AD), associated with poor prognosis and carer distress; yet our knowledge of risk factors remains limited.

AIMS

To identify risk factors associated with apathy incidence and progression in AD over time.

METHODS

We systematically reviewed evidence based on longitudinal studies assessing risk factors for apathy in AD up to June 2021. Two authors independently assessed article eligibility and rated quality.

RESULTS

13,280 articles were screened, of which 13 met inclusion criteria. Studies had a mean follow-up of 2.7 years reporting on a total of 2012 participants. Most findings were based on single studies of moderate quality evidence. Risk factors increasing apathy onset were: being a carrier of the T allele of the PRND gene polymorphism, and having high levels of the IL-6 and TNFα cytokines at baseline. Risk factors for apathy worsening were: reduced inferior-temporal cortical thickness, taking antidepressants, being an ApoE ε4 carrier, living longer with AD, lower cognitive test scores, higher baseline apathy, premorbid personality traits (lower agreeableness, higher neuroticism), and higher midlife motivational abilities.

CONCLUSIONS

Although results are limited by the small number of studies, this review identified specific genetic, neurobiological, AD specific, and dispositional factors that may increase risk of apathy onset and worsening in AD.

Agitation in Dementia: Real-World Impact and Burden on Patients and the Healthcare System

Background:

At least 90%of patients with dementia experience behavioral or neuropsychiatric symptoms including agitation, psychotic symptoms, apathy, depression, and sleep disturbances. Agitation has been reported to be experienced by 60%of patients with mild cognitive impairment and 76%of patients with Alzheimer’s disease.

Objective:

We aimed to assess the impact of agitation in patients with dementia on healthcare resource utilization (HCRU) and healthcare costs.

Methods:

This was a retrospective analysis of physician-reported patient data from a point-in-time survey. Patients included were aged≥50 years, with early cognitive impairment or dementia. Agitated and non-agitated patients were compared. Regression analyses assessed the relationship of agitation score (calculated from number/severity of agitation symptoms) with outcomes, with covariates including age and Mini-Mental State Examination score. Sensitivity analyses compared patients with 0 and≥2 agitation symptoms following propensity score matching on the base-case covariates.

Results:

Data were included for 1,349 patients (agitated, n = 693; non-agitated, n = 656). Based on regression analyses, agitation score was correlated with proportion of patients with professional caregivers (p < 0.01), institutionalized (p < 0.01), hospitalized in a psychiatric ward (p < 0.05), and receiving an antipsychotic/antidepressant (both p < 0.001); number of consultations with a healthcare professional (HCP), psychiatrist, or psycho-geriatrician; number and cost of hospitalizations (p < 0.01); cost of HCP consultations (p < 0.001); and total direct healthcare costs (p < 0.001). Sensitivity analyses generally supported the base-case analysis.

Conclusion:

Agitation in dementia is associated with increased HCRU and healthcare costs. Effective therapies are needed to address agitation in dementia, with the potential to alleviate patient impact, HCRU, and healthcare costs.

CSF metabolites associate with CSF tau and improve prediction of Alzheimer's disease status

INTRODUCTION

Cerebrospinal fluid (CSF) total tau (t-tau) and phosphorylated tau (p-tau) are biomarkers of Alzheimer's disease (AD), yet much is unknown about AD-associated changes in tau metabolism and tau tangle etiology.

METHODS

We assessed the variation of t-tau and p-tau explained by 38 previously identified CSF metabolites using linear regression models in middle-age controls from the Wisconsin Alzheimer's Disease Research Center, and predicted AD/mild cognitive impairment (MCI) versus an independent set of older controls using metabolites selected by the least absolute shrinkage and selection operator (LASSO).

RESULTS

The 38 CSF metabolites explained 70.3% and 75.7% of the variance in t-tau and p-tau, respectively. Of these, seven LASSO-selected metabolites improved the prediction ability of AD/MCI versus older controls (area under the curve score increased from 0.92 to 0.97 and 0.78 to 0.93) compared to the base model.

DISCUSSION

These tau-correlated CSF metabolites increase AD/MCI prediction accuracy and may provide insight into tau tangle etiology.

Does Personality Predict Behavioral and Psychological Symptoms of Dementia? Results from PACO Prospective Study

BACKGROUND

Premorbid personality could play a role in the onset of behavioral and psychological symptoms (BPS) in Alzheimer's disease (AD) but prospective studies are lacking.

OBJECTIVE

The present study aimed at prospectively assessing the influence of premorbid personality traits on BPS evolution in a population of patients with prodromal or mild AD.

METHODS

We used a multicenter prospective cohort study of 237 patients followed-up for 18 months. The influence of personality traits on BPS evolution, measured with Neuropsychiatric Inventory (NPI), was assessed using linear mixed-effect models.

RESULTS

A principal components analysis of the 12 NPI behavioral domains yielded five factors labelled as psychotic symptoms, affective symptoms, behavioral dyscontrol, apathy/appetite symptoms, and sleep disorders. During the follow-up, higher neuroticism was significantly associated with a higher progression of affective symptoms (p < 0.0001), apathy/appetite symptoms (p = 0.002), sleep disorders (p = 0.001) as well as global NPI scores (p < 0.0001). Greater conscientiousness was related to a lower evolution of psychotic (p = 0.002), affective (p = 0.02) and apathy/appetite symptoms (p = 0.02), and global NPI score (p < 0.0001). Higher openness was associated with lower affective symptoms evolution (p = 0.01). A significant relationship was found between higher extraversion, lower affective symptoms (p = 0.02), and higher behavioral dyscontrol (p = 0.04).

CONCLUSION

The present analysis suggests that premorbid personality may influence the evolution of BPS in prodromal or mild AD. Given these results, it seems important to give more importance to personality assessment in early AD, in order to better identify and manage patients at risk of adverse behavioral changes.

Irritability Disorders in Adults: Diagnostic Categories Missing in Plain Sight?

Research into irritability has focused largely on its developmental and child-adolescent manifestations. Although irritability appears to be as elemental an experience as anxiety or depression, diagnoses highlighting irritability as the focal ingredient have yet to be delineated for adults. Instead, irritability-related diagnoses in adults have largely emphasized externalizing behaviors, depressed mood, and personality. Consequently, patients complaining of irritability are sometimes shoehorned into diagnostic categories that they do not experience as authentic representations of their lived experiences. This article proposes that the symptom of irritability might be productively reenvisioned as a focal point, analogous to anxiety and depression, around which irritability-related syndromes and disorders in adults might coalesce. If anxiety, depressive, insomnia, and pain disorders, why not irritability disorders? Both state and trait characteristics of irritability can lend themselves to DSM diagnostic frames. Based on clinical observations, specific irritability disorders in adults can be envisioned, modeled as Irritability Disorder of Adulthood, Irritability Disorder Secondary to Another Medical Condition, Substance-Induced Irritability Disorder, Adjustment Disorder With Irritable Mood, and the like. Further delineation of irritability phenomena, syndromes, and possible disorders in adults is warranted to advance investigation, guide assessment, and improve treatment.

Neuroticism-Withdrawal and Neuroticism-Volatility Differently Influence the Risk of Neuropsychiatric Symptoms in Alzheimer's Disease

BACKGROUND

Neuroticism is recognized as the personality domain that is most strongly associated with behavioral and psychological symptoms (BPS) of Alzheimer's disease (AD). Two sub-components of neuroticism have been recently isolated. Neuroticism-withdrawal (N-withdrawal) refers to the tendency to internalize negative emotion, whereas neuroticism-volatility (N-volatility) reflect the predisposition to externalize negative emotions.

OBJECTIVE

The objective of the current study was to investigate the specific influence of these two sub-components of neuroticism on BPS.

METHODS

One hundred eighty-seven patients with prodromal or mild AD were drawn from the PACO study (Personalité Alzheimer COmportement). Neuroticism and its facets were assessed at baseline using the NEO-PI-R inventory. N-withdrawal and N-volatility were isolated using a principal component analysis led on the six facets composing neuroticism. BPS were measured with the short version of Neuropsychiatric Inventory (NPI-Q) and collected at baseline, then every 6 months over an 18-month follow-up. Linear mixed-effect analyses were conducted to investigate the association between N-withdrawal, N-volatility, and the severity of BPS over the follow-up.

RESULTS

Mean age of the participant was 79.2±6.5; 59% were female; mean MMSE was 24.5±2.5. Both N-volatility and N-withdrawal were related with the NPI-Q (p < 0.001; p = 0,004). N-withdrawal was positively associated with anxiety (p = 0.001) and depression (p = 0.002), while N-volatility was positively related to delusions (p = 0.004), agitation/aggression (p < 0.001), irritability/volatility (p = 0.037), and apathy (p = 0.021).

CONCLUSION

The present study demonstrates that N-volatility and N-withdrawal influence the risk of developing BPS in a different way. These results highlight the relevance of considering sub-components of neuroticism when studying links between personality and BPS.

Personality and the risk factors for developing behavioral and psychological symptoms of dementia: a narrative review

Premorbid personality traits have been implicated as risk factors for the development of behavioral and psychological symptoms of dementia (BPSD), although there is a paucity of studies investigating this relationship. In this narrative review, a number of studies found that premorbid neuroticism has consistently been observed to have a significant association with the development of BPSD symptoms while premorbid conscientiousness, extraversion, openness and agreeableness may be protective factors against future BPSD symptoms. In conclusion, premorbid personality traits appear to affect the risk of BPSD symptoms among individuals with dementia.

Personality Changes With Dementia From the Informant Perspective: New Data and Meta-Analysis

OBJECTIVE

To examine changes in personality in individuals with mild cognitive impairment (MCI) or dementia as observed by family members using both new data and a meta-analysis with the published literature.

DESIGN

Current and retrospective personality assessments of individuals with dementia by family informants. PubMed was searched for studies with a similar design and a forward citation tracking was conducted using Google Scholar in June 2018. Results from a new sample and from published studies were combined in a random effect meta-analysis.

SETTING AND PARTICIPANTS

Family members of older adults with MCI or dementia.

MEASURES

The 5 major dimensions (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and facets of personality were assessed with NEO Personality Inventory questionnaires.

RESULTS

The new sample (n = 50) and meta-analysis (18 samples; n = 542) found consistent shifts in personality from the premorbid to current state in patients with cognitive impairment. The largest changes (>1 standard deviation) were declines in conscientiousness (particularly for the facets of self-discipline and competence) and extraversion (decreased energy and assertiveness), as well as increases in neuroticism (increased vulnerability to stress). The new sample suggested that personality changes were larger in individuals taking cognition-enhancing medications (cholinesterase inhibitors or memantine). More recent studies and those that examined individuals with MCI found smaller effects.

CONCLUSIONS AND IMPLICATIONS

Consistent with the clinical criteria for the diagnosis of dementia, the new study and meta-analysis found replicable evidence for large changes in personality among individuals with dementia. Future research should examine whether there are different patterns of personality changes across etiologies of dementia to inform differential diagnosis and treatments. Prospective, repeated assessments of personality using both self- and informant-reports are essential to clarify the temporal evolution of personality change across the preclinical, prodromal, and clinical phases of dementia.

[Premorbid personality as a risk factor in the appearance of psychological and behavioural symptoms of dementia: Systematic review]

The aetiology of behavioural and psychological symptoms of dementia (BPSD) is defined by a diversity of factors, and recent studies suggest that premorbid personality could be a risk factor for BPSD. This study aimed to review studies on the relationship between premorbid personality and BPSD. Studies were identified using PsycInfo, MedLine, and PubMed. The searches combined terms for premorbid personality, dementia and BPSD. Ten studies have been included in this review. Eight out of ten studies show a relationship between premorbid personality and BPSD. Neuroticism is associated with behavioural disturbances and anxiety. Extraversion is associated with wandering. Low agreeableness is associated with affective disturbance and aggression-related behaviours and high agreeableness is associated with wandering. The studies found no congruent results for openness and conscientiousness. In conclusion, premorbid personality may increase the risk of developing BPSD during the course of the disease. Even so, the relationship between personality and BPSD is complex due to multifactorial aetiology.

Frequency and subgroups of neuropsychiatric symptoms in mild cognitive impairment and different stages of dementia in Alzheimer's disease

BACKGROUND

Neuropsychiatric symptoms (NPS), such as depression, apathy, agitation, and psychotic symptoms are common in mild cognitive impairment (MCI) and dementia in Alzheimer's disease (AD). Subgroups of NPS have been reported. Yet the relationship of NPS and their subgroups to different stages of cognitive impairment is unclear. Most previous studies are based on small sample sizes and show conflicting results. We sought to examine the frequency of NPS and their subgroups in MCI and different stages of dementia in AD.

METHODS

This was a cross-sectional study using data from a Norwegian national registry of memory clinics. From a total sample of 4,571 patients, we included those with MCI or AD (MCI 817, mild AD 883, moderate-severe AD 441). To compare variables across groups ANOVA or χ 2-test was applied. We used factor analysis of Neuropsychiatric Inventory Questionnaire (NPI-Q) items to identify subgroups of NPS.

RESULTS

The frequency of any NPS was 87.2% (AD 91.2%, MCI 79.5%; p < 0.001) and increased with increasing severity of cognitive decline. The most frequent NPS in MCI was depression. Apathy was the most frequent NPS in AD across different stages of severity. The factor analysis identified three subgroups in MCI and mild AD, and a fourth one in moderate-severe AD. We labelled the subgroups "depression," "agitation," "psychosis," and "elation."

CONCLUSIONS

The frequency of NPS is high in MCI and AD and increases with the severity of cognitive decline. The subgroups of NPS were relatively consistent from MCI to moderate-severe AD. The subgroup elation appeared only in moderate-severe AD.

Psychosocial or clinico-demographic factors related to neuropsychiatric symptoms in patients with Alzheimer's disease needing interventional treatment: analysis of the CATIE-AD study

OBJECTIVE

This study sought to determine psychosocial and clinico-demographic factors related to each symptomatic cluster (i.e., aggressiveness, psychosis, apathy/eating problems, and emotion/disinhibition) of neuropsychiatric symptoms (NPSs) in patients with Alzheimer's disease (AD) needing interventional treatment against their agitation or psychotic symptoms. These clusters were classified from 12 Neuropsychiatric Inventory (NPI) subscores in our previous study using the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease (CATIE-AD) dataset.

METHODS

Based on clinical data from 421 AD outpatients with agitation or psychotic symptoms needed interventional treatment enrolled in the CATIE-AD, we conducted logistic regression analyses to examine the relationships between each symptomatic cluster and three psychosocial (marital status, residence, and caregivers' burden) and nine clinico-demographic (age, gender, education year, general cognition, activity of daily living [ADL], general medical health, race, and intake of anti-dementia drugs or psychotropics) factors.

RESULTS

While no factor contributed to aggressiveness, psychosis was associated with several clinico-demographic factors: female gender, non-Caucasian race, and lower cognitive function. Apathy/eating problems was associated with more severe caregiver burden, living in one's own home, lower ADL level, and male gender, while emotion/disinhibition was predicted by more severe caregiver burden, lower education level, not-married status, and younger age.

CONCLUSIONS

Among the four NPS clusters, apathy/eating problems and emotion/disinhibition were associated with psychosocial as well as clinico-demographic factors in AD patients with psychotic symptoms or agitation needed interventional treatment. Copyright © 2016 John Wiley & Sons, Ltd.

Association of premorbid personality with behavioral and psychological symptoms in dementia with Lewy bodies: Comparison with Alzheimer's disease patients

AIM

The aim of this study was to elucidate the relation between premorbid personality traits and behavioral and psychological symptoms in dementia (BPSD) in dementia with Lewy bodies (DLB) and Alzheimer's disease (AD) patients.

METHODS

Forty-one DLB patients and 98 AD patients were assessed for BPSD using the Neuropsychiatric Inventory (NPI). Each patient's midlife personality traits were rated by a family member using the NEO Five-Factor Inventory (NEO-FFI) questionnaire.

RESULTS

In multiple regression analyses for DLB patients, NPI total score and anxiety were significantly associated with premorbid openness, delusion with premorbid agreeableness, and agitation with premorbid conscientiousness. In AD patients, depression was significantly associated with premorbid neuroticism, and agitation, apathy, and irritability with premorbid agreeableness.

CONCLUSION

Premorbid personalities affected BPSD differently in DLB and AD. Given the differences in the effects of premorbid personalities on BPSD, additional studies are needed to develop interventions to reduce these symptoms.

Neuroticism, depression, and anxiety traits exacerbate the state of cognitive impairment and hippocampal vulnerability to Alzheimer's disease

Introduction

Certain personality traits are associated with higher risk of Alzheimer's disease, similar to cognitive impairment. The identification of biological markers associated with personality in mild cognitive impairment could advance the early detection of Alzheimer's disease.

Methods

We used hierarchical multivariate linear models to quantify the interaction between personality traits, state of cognitive impairment, and MRI biomarkers (gray matter brain volume, gray matter mean water diffusion) in the medial temporal lobe (MTL).

Results

Over and above a main effect of cognitive state, the multivariate linear model showed significant interaction between cognitive state and personality traits predicting MTL abnormality. The interaction effect was mainly driven by neuroticism and its facets (anxiety, depression, and stress) and was associated with right-left asymmetry and an anterior to posterior gradient in the MTL.

Discussion

Our results support the hypothesis that personality traits can alter the vulnerability and pathoplasticity of disease and therefore modulate related biomarker expression.

Interaction between personality traits and cerebrospinal fluid biomarkers of Alzheimer's disease pathology modulates cognitive performance

Background

During adulthood, personality characteristics may contribute to the individual capacity to compensate the impact of developing cerebral Alzheimer’s disease (AD) pathology on cognitive impairment in later life. In this study we aimed to investigate whether and how premorbid personality traits interact with cerebrospinal fluid (CSF) markers of AD pathology to predict cognitive performance in subjects with mild cognitive impairment or mild AD dementia and in participants with normal cognition.

Methods

One hundred and ten subjects, of whom 66 were patients with mild cognitive impairment or mild AD dementia and 44 were healthy controls, had a comprehensive medical and neuropsychological examination as well as lumbar puncture to measure CSF biomarkers of AD pathology (amyloid beta_1–42, phosphorylated tau and total-tau). Participants’ proxies completed the Revised NEO Personality Inventory, Form R to retrospectively assess subjects’ premorbid personality.

Results

In hierarchical multivariate regression analyses, including age, gender, education, APOEε4 status and cognitive level, premorbid neuroticism, conscientiousness and agreeableness modulated the effect of CSF biomarkers on cognitive performance. Low premorbid openness independently predicted lower levels of cognitive functioning after controlling for biomarker concentrations.

Conclusion

Our findings suggest that specific premorbid personality traits are associated with cerebral AD pathology and modulate its impact on cognitive performance. Considering personality characteristics may help to appraise a person’s cognitive reserve and the risk of cognitive decline in later life.

Are premorbid abnormal personality traits associated with behavioural and psychological symptoms in dementia?

OBJECTIVE

The study aims to investigate associations between behavioural and psychological symptoms of dementia (BPSD) and abnormal premorbid personality traits.

METHODS

Data were obtained from 217 patients with a diagnosis of probable Alzheimer's disease. Behavioural and psychological symptoms of late-onset dementia were assessed with the Neuropsychiatric Inventory. Premorbid personality traits were assessed using the Standardised Assessment of Personality. Abnormal premorbid personality traits were categorised with Diagnostic and Statistical Manual of Mental Disorders fourth edition and International Statistical Classification of Diseases and Related Health Problems-10 diagnostic criteria for personality disorders.

RESULTS

Abnormal premorbid personality traits were associated with increased behavioural and psychological symptoms in dementia. Cluster A (solitary/paranoid) premorbid personality traits were associated with anxiety, depression and hallucinations. Cluster C (anxious/dependent) traits were associated with a syndrome of depression.

CONCLUSIONS

The presence of Clusters A (solitary/paranoid) and C (anxious/dependent) abnormal premorbid personality traits seems to affect the expression of certain behavioural and psychological symptoms in dementia, depression in particular. Copyright © 2016 John Wiley & Sons, Ltd.

Personality, Alzheimer's disease and behavioural and cognitive symptoms of dementia: the PACO prospective cohort study protocol

Background

Alzheimer’s disease is characterised by a loss of cognitive function and behavioural problems as set out in the term “Behavioural and Psychological Symptoms of Dementia”. These behavioural symptoms have heavy consequences for the patients and their families.

A greater understanding of behavioural symptoms risk factors would allow better detection of those patients, a better understanding of crisis situations and better management of these patients. Some retrospective studies or simple observations suggested that personality could play a role in the occurrence of behavioural symptoms. Finally, performance in social cognition like facial recognition and perspective taking could be linked to certain personality traits and the subsequent risks of behavioural symptoms.

We propose to clarify this through a prospective, multicentre, multidisciplinary study.

Main Objective:

- To assess the effect of personality and life events on the risk of developing behavioural symptoms.

Secondary Objectives:

- To evaluate, at the time of inclusion, the connection between personality and performance in social cognition tests;

- To evaluate the correlation between performance in social cognition at inclusion and the risks of occurrence of behavioural symptoms;

- To evaluate the correlation between regional cerebral atrophy, using brain Magnetic Resonance Imaging at baseline, and the risk of behavioural symptoms.

Methods/Design

Study type and Population: Prospective multicentre cohort study with 252 patients with Alzheimer’s disease at prodromal or mild dementia stage.

The inclusion period will be of 18 months and the patients will be followed during 18 months. The initial evaluation will include: a clinical and neuropsychological examination, collection of behavioural symptoms data (Neuropsychiatric-Inventory scale) and their risk factors, a personality study using both a dimensional (personality traits) and categorical approach, an inventory of life events, social cognition tests and an Magnetic Resonance Imaging. Patients will be followed every 6 months (clinical examination and collection of behavioural symptoms data and risk factors) during 18 months.

Discussion

This study aims at better identifying the patients with Alzheimer’s disease at high risk of developing behavioural symptoms, to anticipate, detect and quickly treat these disorders and so, prevent serious consequences for the patient and his caregivers.

Trial registration

ClincalTrials.gov: NCT01297140

Atherosclerosis decreases the impact of neuroticism in late-life depression: hypothesis of vascular apathy

OBJECTIVE

To examine the interplay between subclinical atherosclerotic disease and neuroticism in explaining variance in late-life depressive symptoms.

METHODS

This study was part of the Nijmegen Biomedical Study, a population-based survey; 1,517 participants aged 50-70 years were included. Depressive symptoms were measured by the Beck Depression Inventory (BDI). Principal components analysis of the BDI items yielded two factors, representing a cognitive-affective symptom cluster and a somatic-affective symptom cluster. Atherosclerotic disease was measured by the intima media thickness (IMT) of the carotid arteries and neuroticism by the revised Eysenck Personality Questionnaire.

RESULTS

Multiple linear regression analyses using different measures of depressive symptoms as the dependent variable showed that neuroticism was strongly and significantly associated with the sum score of the BDI and with the two depressive symptom clusters. IMT, however, was only significantly associated with the somatic-affective symptom cluster but not with the cognitive-affective symptom cluster. Interestingly, we found a significant negative interaction between neuroticism and IMT in explaining the severity of the cognitive-affective symptom cluster but not with respect to the somatic-affective symptom cluster.

CONCLUSION

The negative interaction between neuroticism and atherosclerosis indicates that neuroticism is less strongly associated with cognitive-depressive symptoms in the presence of more severe atherosclerosis. This may be explained by apathy due to cerebrovascular disease and fits with a hypothesis of vascular apathy.

Grouping of behavioural and psychological symptoms of dementia

OBJECTIVE

A wide range of behavioural and psychological symptoms (BPSD) are common in dementia, and it has been suggested that groups of correlated symptoms should be studied together. Here, we describe the groups of BPSD that have been identified in the literature and how they have been used to study associations, burden, treatment and underlying biology.

METHODS

The literature database PubMed was searched for articles that identified clusters or factors of BPSD or used previously defined symptom groups.

RESULTS

Sixty-two studies were included. Generally, the following symptom groups were suggested: affective symptoms, including depression and anxiety; psychosis, including delusions and hallucinations; hyperactivity, including irritability and aggression; and euphoria. Symptoms that did not show consistent results include apathy, eating disturbances, night-time behaviour disturbances, disinhibition and aberrant motor behaviour. Symptom groups differed in their associations, treatment and biology.

CONCLUSIONS

Studies investigating symptom groups show relatively consistent results. Studying symptom groups allows similar symptoms to be studied together, which might strengthen results and may point to differences in their aetiology and treatment. However, a large amount of the individual variability of the symptoms could not be explained by the factors, and authors should carefully address their research question and hypotheses to decide if symptoms should be studied in groups or individually. Clinicians need to consider each symptom in its own right and also to be aware of the interrelations between them when assessing patients and developing strategies for treatment.

Neuropsychiatric aspects of dementia

Dementia affects approximately 6.5% of people over the age of 65. Whilst cognitive impairment is central to the dementia concept, neuropsychiatric symptoms are invariably present at some stage of the illness. Neuropsychiatric symptoms result in a number of negative outcomes for the individual and their caregivers and are associated with higher rates of institutionalization and mortality. A number of factors have been associated with neuropsychiatric symptoms including neurobiological changes, dementia type, and illness severity and duration. Specific patient, caregiver and environmental factors are also important. Neuropsychiatric symptoms can be broadly divided into four clusters: psychotic symptoms, mood/affective symptoms, apathy, and agitation/aggression. Neuropsychiatric symptoms tend to persist over time although differing symptom profiles exist at various stages of the illness. Assessment should take into account the presenting symptoms together with an appreciation of the myriad of likely underlying causes for the symptoms. A structured assessment/rating tool can be helpful. Management should focus on non-pharmacological measures initially with pharmacological approaches reserved for more troubling symptoms. Pharmacological approaches should target specific symptoms although the evidence-base for pharmacological management is quite modest. Any medication trial should include an adequate appreciation of the risk-benefit profile in individual patients and discussion of these with both the individual and their caregiver.

Vascular risk factors and neuropsychiatric symptoms in Alzheimer's disease: the Cache County Study

OBJECTIVE

Knowledge of potentially modifiable risk factors for neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) is important. This study longitudinally explores modifiable vascular risk factors for NPS in AD.

METHODS

Participants enrolled in the Cache County Study on Memory in Aging with no dementia at baseline were subsequently assessed over three additional waves, and those with incident (new onset) dementia were invited to join the Dementia Progression Study for longitudinal follow-up. A total of 327 participants with incident AD were identified and assessed for the following vascular factors: atrial fibrillation, hypertension, diabetes mellitus, angina, coronary artery bypass surgery, myocardial infarction, cerebrovascular accident, and use of antihypertensive or diabetes medicines. A vascular index (VI) was also calculated. NPS were assessed over time using the Neuropsychiatric Inventory (NPI). Affective and Psychotic symptom clusters were assessed separately. The association between vascular factors and change in NPI total score was analyzed using linear mixed model and in symptom clusters using a random effects model.

RESULTS

No individual vascular risk factors or the VI significantly predicted change in any individual NPS. The use of antihypertensive medications more than four times per week was associated with higher total NPI and Affective cluster scores.

CONCLUSIONS

Use of antihypertensive medication was associated with higher total NPI and Affective cluster scores. The results of this study do not otherwise support vascular risk factors as modifiers of longitudinal change in NPS in AD.

Behavioral and psychological subsyndromes in Alzheimer's disease using the Neuropsychiatric Inventory

OBJECTIVE

Behavioral and psychological symptoms of dementia represent common clinical features of dementias, contributing to the heterogeneous phenotypic expression of Alzheimer's disease (AD). During the last two decades, several studies explored the possible presence of neuropsychiatric subsyndromes in dementia by examining the internal structure of the Neuropsychiatric Inventory (NPI). The aim of the present review is to present available evidence coming from studies adopting factor analysis to explore the NPI and describe neuropsychiatric clusters of symptoms in AD.

DESIGN

A systematic review of literature was performed concerning available studies describing neuropsychiatric subsyndromes in AD by adopting the NPI.

RESULTS

Overall, our analysis showed a relatively low concordance among available evidence for what concerns the definition and composition of NPI clusters, possibly due (at least in part) to the heterogeneity of the sample populations recruited in the studies. However, we also observed some consistent associations of specific symptoms across studies, defining potential subsyndromes in AD. More consistent results were obtained by studies evaluating the 10-item version of the NPI rather than the more recent 12-item one.

CONCLUSIONS

This review represents the first attempt to systematically evaluate evidence coming from factor analyses exploring the internal structure of the NPI in order to facilitate the identification of neuropsychiatric syndromes in AD patients. The NPI may support the definition of behavioral subsyndromes in AD. The evaluation of neuropsychiatric subsyndromes should always take into account the main potential confounders, such as age, severity of disease, and concomitant pharmacological treatment.

Noncontingent reinforcement of disruptive behaviors in personal care home settings

The purpose of this case study was to examine the potential of using noncontingent reinforcement (NCR) to reduce the frequency of disruptive behaviors of three elderly persons in personal care home (PCH) settings. Assessment indicated that participants were engaging in the disruptive behaviors to obtain social attention from PCH staff. Social attention, up to 1 min of staff making eye contact with the participant and directing positive verbal statements toward the participant, was given on a fixed time interval (from morning through early evening) beginning every 20 min and fading to every 30 min. Results indicate that NCR reduced the frequency of the disruptive behaviors.

The frequency and correlates of anxiety in patients with first-time diagnosed mild dementia

BACKGROUND

Anxiety in persons with dementia has received little attention despite its severe consequences. In this observational cross-sectional study, we investigated the frequency of anxiety and associations between anxiety and socio-demographic and clinical variables in an outpatient sample with first-time diagnosed mild dementia.

METHODS

The study sample (n = 169) comprised participants recruited from clinics in geriatric medicine and old age psychiatry for a longitudinal dementia study. Symptoms of anxiety were rated by a caregiver on the Neuropsychiatric Inventory (NPI) and by the patient on the anxiety tension item on the Montgomery and Åsberg Depression Rating Scale. Measures of caregiver stress, dementia-related impairment (Clinical Dementia Rating (CDR) scale), and cognitive functioning were also included.

RESULTS

According to caregiver reports, 19.5% had clinically significant anxiety and an additional 22.5% had subclinical anxiety. Half of the patients reported experiencing anxiety from time to time. Patients with Lewy-body dementia reported anxiety more often compared to patients with Alzheimer's disease. Anxiety was associated with depression, higher caregiver stress, and more dementia-related impairment, but not with cognitive test performance. Caregiver stress and higher CDR score increased the odds for anxiety significantly, even when controlling for depression.

CONCLUSION

Anxiety is common in patients with mild dementia, and seems to be associated not so much with cognitive test performance than with caregiver distress and the patient's ability to function in daily life. Anxiety should be taken into account when assessing dementia, as well as screened for when examining patients with known dementia.

National Taiwan University Irritability Scale: Evaluating Irritability in Patients With Traumatic Brain Injury

Irritability is not uncommon after traumatic brain injury (TBI). Unfortunately, no instruments are available to directly measure this clinical feature. This study thus aimed to develop a specific scale to evaluate the irritability for patients with TBI. A total of 144 participants, which include 80 healthy participants and 64 patients suffering from TBI, were recruited. Irritability was assessed by the National Taiwan University Irritability Scale (NTUIS). Our results showed the NTUIS has good reliability. The factor analysis further revealed 2 different components: annoyance, and verbal aggression. Moreover, both self-reported and family-reported irritability postinjury were significantly higher than the irritability reported by the healthy participants. Indeed patients with TBI have significant problems with irritability after injuries, and thus a more specific assessment tool to carefully evaluate patients' irritability should be used.

Profile of nursing home residents with dementia who require assistance with mouth care

The majority of nursing home residents require assistance with activities of daily living, including oral care. Poor oral health is common in the nursing home because residents are not given appropriate assistance to support this aspect of their care. The purpose of this study was to describe the demographic, functional, and behavioral profile of nursing home residents with dementia who require verbal or physical assistance with mouth care. Residents who required verbal support to complete mouth care exhibited higher levels of physical function, higher levels of cognitive functioning in the domains of language and executive function, lower levels of passivity, and higher scores for the personality trait of openness than residents who required physical assistance. Best practices for implementing verbal and physical assistance during mouth care to persons with dementia are presented on the basis of these profiles.

Self and next of kin's assessment of personality and sense of coherence in elderly people: Implications for dementia care

Nurses sometimes fail to understand the behaviour of individuals with severe dementia. Information from a next of kin may help to bridge this communicative gap. One factor that influences a person's reaction to a disease is their personality and ability to cope with stress. The aim of this study was to evaluate the inter-rater agreement between healthy elderly people's self-assessment and the assessment made by a next of kin concerning personality and sense of coherence. The participants ( n = 154) answered questions from the Eysenck Personality Inventory (EPI) and the Antonovsky Sense of Coherence (SOC) scale. The study shows high or moderate agreement in ratings when analysed by means of an intra-class correlation coefficient (range between r = .57 and r = .72) and the results indicate that in general a close relative is able to report on the personality of a next of kin. The inter-rater agreement was high on SOC and extraversion and somewhat lower on neuroticism. For neuroticism, length of time in the relationship increased the odds for a good inter-rater agreement. Thus, seemingly a next of kin is a reliable informant for the elderly in general and is probably also able to add information useful in the nursing care of people with dementia.

Midlife motivational abilities predict apathy and depression in Alzheimer disease: the aging, demographics, and memory study

Apathy and depression are the most common neuropsychiatric symptoms in mild cognitive impairment (MCI) and Alzheimer disease (AD). This study was the first to explore midlife motivational abilities as a predictor of the progression of apathy and depression in MCI and AD. It used a subsample of the Aging, Demographics, and Memory Study (N = 137). Participants, aged over 70, were categorized according to baseline clinical diagnosis (normal cognition, MCI, or AD). Assessments were conducted at an 18-month interval. Neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory. Midlife motivational abilities were estimated on the basis of the main occupation using the Occupational Information Network (O*NET) database, which provides detailed information on worker abilities. Repeated measures analysis of covariance was used. Apathy and depression were found to be particularly high in participants with AD and high motivational abilities. Apathy, but not depression, increased over time in those with AD and high motivational abilities. It would appear that holding on to unattainable goals with strong motivational efforts when faced with severe cognitive loss might lead to unproductive persistence, depressive reaction, and more apathetic behavior.

The interaction between cerebrovascular disease and neuroticism in late-life depression: a cross-sectional study

OBJECTIVE

Vascular disease and neuroticism are both risk factors for late-life depression. In this study we examined the interaction between vascular disease and neuroticism as determinants of clinically relevant depressive symptoms (CRDS) in late-life.

METHODS

Multivariate logistic regression in a survey of 1396 population-dwelling people aged ≥70 years. CRDS were defined as scoring ≥16 on the CES-D. Vascular disease was categorised into four levels: none, ≥2 vascular risk factors, cardiac disease or stroke.

RESULTS

Neuroticism was strongly associated with CRDS in women (OR: 1.6, 95% CI: 1.4-1.8). In men vascular disease interacted negatively but significantly with neuroticism (cardiac disease by neuroticism: OR: 0.8, 95% CI: 0.6-0.9; stroke by neuroticism: OR: 0.8, 95% CI: 0.6-0.96) when predicting CRDS.

CONCLUSIONS

In men vascular disease attenuates the predictive value of neuroticism in CRDS, which might be mediated by apathy caused by cerebrovascular disease.

Neuropsychiatric symptoms and quality of life in patients with very mild and mild Alzheimer's disease

BACKGROUND

Neuropsychiatric symptoms (NPS) are common manifestations of Alzheimer' s disease (AD).

OBJECTIVE

To examine the prevalence and significance of NPS in very mild and mild AD patients with emphasis on their influence on the well-being of the patients and their caregivers.

METHODS

The participants were 240 patient-caregiver dyads who participated in a prospective, controlled rehabilitation study (ALSOVA). Three Quality of Life (QoL) instruments were used; generic 15D, disease-specific QoL-AD and Visual Analog Scale (VAS). The disease-specific QoL-AD was both self-rated and caregiver rated. Other scales used were Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), ADCS-ADL, Neuropsychiatric Inventory (NPI) and Beck Depression Inventory (BDI).

RESULTS

NPS were present in 76.5% of patients with very mild AD (CDR 0.5) and in 84.9% of patients with mild to moderate AD (CDR 1). The most frequent symptoms were apathy, depression, irritability, and agitation. The strongest predictor of self-reported QoL-AD scores was depressive symptoms whereas functional decline and presence of NPS predicted poor caregiver ratings of patients' QoL. However, caregiver depression also influenced significantly their ratings.

CONCLUSION

NPS are common even in the early stages of AD. NPS were significantly associated with caregiver assessment of the patient's QoL but not with patients' self-assessed QoL. Depression decreases QoL, but may remain unrecognized in AD patients, emphasizing the need for careful and structured assessment of NPS before deciding on the appropriate treatment.

A psychosocial model of parent fixation in people with dementia: the role of personality and attachment

This study replicates and extends research into the occurrence of parent fixation in people with dementia by exploring the relationship between demographic, cognitive and psychological factors. Fifty-one people with dementia, living both in the community and in residential/nursing home settings, were interviewed about their parents and a relative of each completed measures assessing the person with dementia's demographic details, level of cognitive impairment/executive functioning, behavioural consequences of parent fixation and pre-morbid personality and attachment style. Results indicated that parent fixation can be viewed as a psychosocial phenomenon arising from the environment, pre-morbid personality and attachment style and that the behavioural consequences of parent fixation are maintained by the individual's level of executive functioning and gender. Findings and clinical implications are discussed in relation to Miesen's (1992, 1993, 1999) theoretical assumption that dementia is a loss process that activates the experience of feeling unsafe and the emotional need for the security of an attachment figure.

The relationship between pre-morbid personality and challenging behaviour in people with dementia: A systematic review

It has been suggested that challenging behaviour in people with dementia reflects a person's pre-morbid personality traits and a number of studies have explored this hypothesis. However, inconsistencies in outcome between studies suggest a need to review the available evidence systematically. As a result, major bibliographic databases were searched for studies examining the relationship between pre-morbid personality and challenging behaviour in order to conduct a systematic review. We included all English language studies published in referenced journals that assessed pre-morbid personality via a valid comprehensive personality measure, and also explored a relationship with challenging behaviour in people with dementia. A total of 18 studies were identified that covered a wide range of challenging behaviours including 'wandering', affective states, aggression, anxiety and delusions/hallucinations. Studies were assessed for their methodological quality and statistical findings. Studies lacked representative samples, were affected by confounding variables and suffered from small sample sizes. However, 72% of the studies reported significant relationships between pre-morbid personality and behaviour. In terms of specific relationships, the strongest evidence was found for a positive relationship between pre-morbid neuroticism and mood, and aggression and overall behavioural acts, thus supporting the inclusion of personality as one factor in the formulation of behaviour (Ballard, C., O'Brien, J., James, I., & Swann, A. (2001). Dementia: Management of Behavioural and Psychological Symptoms. Oxford: Oxford University Press; Kitwood, T. (1993). Person and process in dementia: Editorial. International Journal of Geriatric Psychiatry, 1, 541-545).

Nursing home structure and association with agitation and use of psychotropic drugs in nursing home residents in three countries: Norway, Austria and England

BACKGROUND

Understanding the underlying mechanisms and risk factors leading to agitation is crucial to reduce the severity of agitation and increase quality of life. International comparative studies offer special advantages in elucidating environmental risk factors by providing a wider diversity of environmental exposures such as nursing home structures, health care systems and genetic diversity.

METHODS

Baseline data for three different intervention studies in Austria (n = 38), England (n = 302) and Norway (n = 163) were combined posthoc. Patients were grouped according to their dementia severity using the global deterioration scale (GDS), functional assessment staging (FAST) and clinical dementia rating (CDR) scales. For the measurement of agitation, the Cohen-Mansfield Agitation Inventory (CMAI) was used. Data analysis was performed using one-way ANOVA, multivariate and linear regression analysis.

RESULTS

CMAI scores were available for 503 subjects with dementia. There were significant differences between the nursing home residents in the three countries regarding age, gender and dementia severity (all p values < 0.001). In the multivariate analyses, the level of agitation differed with higher mean scores in the Austrian (mean (SD) score 51.9(21.8)) compared to UK (43.3(16.1)) and Norwegian (41.6(13.2)) nursing homes (p = 0.002). Similarly, the use of psychotropic drugs differed significantly, with a higher proportion of neuroleptics in UK (48%, p < 0.001) and Austrian (52.6%; p = 0.001) compared to Norwegian (19%) nursing homes.

CONCLUSION

We found differences in agitation and antipsychotic drug use which are likely related to structural and cultural differences in nursing homes in three European countries. These findings suggest that structural changes can improve quality of care and quality of life for nursing home residents.

[Premorbid personality and aggressive behavior: a study with residents of psychogeriatric nursing homes]

From experimental research it appears that personality plays a role in causes and onset of aggressive behavior in adults. However, studies about the influence of premorbid personality on aggressive behavior of older persons with dementia show contradictory results. In this study we gathered data on personality and behavior of 166 residents of psychogeriatric nursing homes. Nursing staff filled out the Cohen-Mansfield Agitation Inventory (Dutch version, CMAI-D). Proxy family members completed the Hetero Anamnestic Personality questionnaire (HAP). Results showed that on the CMAI-D aggression could be distinguished from other forms of agitation. Four subscales of the HAP showed significant positive correlations with aggression as measured with the CMAI-D. These subscales were: Antagonism, Whimsical and impulsive behavior, Rigid behavior, and Being vulnerable in social interactions. Although the influence of personality decreased with increasing cognitive impairment, it was still present in stage 6 of the Reisberg Global Deterioration Scale. In depth analysis items of the HAP revealed a first profile of the aggression prone personality.

Management of behavioral problems in Alzheimer's disease

Alzheimer's disease (AD) is a complex progressive brain degenerative disorder that has effects on multiple cerebral systems. In addition to cognitive and functional decline, diverse behavioral changes manifest with increasing severity over time, presenting significant management challenges for caregivers and health care professionals. Almost all patients with AD are affected by neuropsychiatric symptoms at some point during their illness; in some cases, symptoms occur prior to diagnosis of the dementia syndrome. Further, behavioral factors have been identified, which may have their origins in particular neurobiological processes, and respond to particular management strategies. Improved clarification of causes, triggers, and presentation of neuropsychiatric symptoms will guide both research and clinical decision-making. Measurement of neuropsychiatric symptoms in AD is most commonly by means of the Neuropsychiatric Inventory; its utility and future development are discussed, as are the limitations and difficulties encountered when quantifying behavioral responses in clinical trials. Evidence from clinical trials of both non-pharmacological and pharmacological treatments, and from neurobiological studies, provides a range of management options that can be tailored to individual needs. We suggest that non-pharmacological interventions (including psychosocial/psychological counseling, interpersonal management and environmental management) should be attempted first, followed by the least harmful medication for the shortest time possible. Pharmacological treatment options, such as antipsychotics, antidepressants, anticonvulsants, cholinesterase inhibitors and memantine, need careful consideration of the benefits and limitations of each drug class.

Do people become more apathetic as they grow older? A longitudinal study in healthy individuals

BACKGROUND

The aim of this study was to determine levels, rates and progression of apathy in healthy older persons and to investigate factors associated with its progression.

METHODS

Seventy-six healthy elderly subjects, aged 58-85 years (mean 69.9), who were recruited by general advertisement and through local community groups, participated as a control group for a longitudinal study of stroke patients. Data were collected on demographic, psychological, neuropsychological and neuroimaging (MRI) variables and apathy was rated by informants on the Apathy Evaluation Scale (AES).

RESULTS

Apathy scores and rates increased over 5 years, especially in men. Change of apathy was associated with informant ratings of cognitive decline in the years prior to baseline assessment but not to subsequent neuropsychological, neuroimaging or functional changes.

CONCLUSIONS

Apathy increases with age in otherwise healthy community-dwelling individuals, particularly in men.

Premorbid personality traits are associated with post-stroke behavioral and psychological symptoms: a three-month follow-up study in Perth, Western Australia

BACKGROUND

Previous research has found an association between post-stroke depressive symptoms and premorbid personality. This study sought to investigate further the relationship between premorbid personality and a number of common post-stroke behavioral and psychological symptoms in a three-month follow-up study.

METHODS

This prospective study was conducted between May 2003 and January 2005 in a Perth metropolitan teaching hospital. The pre-stroke personality of stroke survivors was assessed by interviewing a close family member (informant) within four weeks of the index stroke using the NEO Personality Inventory-Revised. Three months after the stroke, patients were followed up and assessed with the Cambridge Cognitive examination and Hospital Anxiety and Depression Scale, and their informants completed the Neuropsychiatric Inventory-carer distress version (NPI) and instrumental activities of daily living scale.

RESULTS

Depressive symptoms were the most commonly reported post-stroke symptom (45.1%). Spearman's correlations showed that high neuroticism was positively correlated with NPI total scores (rho = 0.37, p = 0.007), NPI total distress scores (rho = 0.47, p = 0.001), and specifically with agitation and irritability NPI composite scores. Agreeableness was inversely correlated with agitation (rho = -0.40, p = 0.004) and irritability (rho = -0.37, p = 0.007) composite scores.

CONCLUSIONS

Premorbid personality traits of high neuroticism and low agreeableness are associated with the presence of post-stroke agitation, irritability, and carer distress. This knowledge may contribute to the development of strategies designed to identify patients and families who require more intense supervision and support during post-stroke rehabilitation.

Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia

BACKGROUND

Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimer's disease. However, there has been little previous study of the outcomes associated with discontinuing these medications.

OBJECTIVE

The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy.

METHODS

This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged > or =60 years with a diagnosis of Alzheimer's disease or non-Alzheimer's dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS.

RESULTS

The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged > or =85 years, and the sample was predominantly female. A diagnosis of Alzheimer's disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (-0.01; 95% CI, -0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, -0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (-0.26; 95% CI, -0.50 to -0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65).

CONCLUSION

Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.

Depression and anxiety symptoms are associated with cerebral FDDNP-PET binding in middle-aged and older nondemented adults

OBJECTIVES

Amyloid senile plaques and tau neurofibrillary tangles are neuropathologic hallmarks of Alzheimer disease, which may be associated with mild cognitive impairment (MCI) or mood and anxiety symptoms years before the dementia diagnosis. To address this issue, the authors obtained positron emission tomography (PET) scans after intravenous injections of 2-(1-{6-[(2-[fluorine-18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile (FDDNP), a molecule that binds to amyloid plaques and neurofibrillary tangles, to determine whether symptoms of depression and anxiety in nondemented subjects were associated with increased FDDNP-PET binding values.

METHODS

Forty-three middle-aged and elderly volunteers received clinical and FDDNP-PET assessments. Subjects were nondemented--23 of them were diagnosed with MCI and 20 were cognitively normal. Subjects with a diagnosis of major depression or an anxiety disorder were excluded. Correlations between standardized measures of depressive and anxiety symptoms and regional FDDNP binding values were calculated.

RESULTS

The MCI and comparison subjects did not differ by the depression and anxiety scores. In the MCI group, depression scores correlated with lateral temporal and trait anxiety scores correlated with posterior cingulate FDDNP binding. In the comparison group, depression scores correlated with medial temporal, and trait anxiety scores correlated with medial temporal and frontal FDDNP binding.

DISCUSSION

This is the first report to demonstrate a relationship between the severity of depression and anxiety symptoms and FDDNP binding values in nondemented middle age and older individuals. The results suggest a relationship between relatively mild mood symptoms and biomarkers of cerebral amyloid and tau deposition and vary according to degree of cognitive impairment. The presence of MCI may signify different pathophysiological mechanisms underlying mood and anxiety symptoms.

Factors associated with aggressive behavior among nursing home residents with dementia

PURPOSE

In an attempt to more thoroughly describe aggressive behavior in nursing home residents with dementia, we examined background and proximal factors as guided by the Need-Driven Dementia-Compromised Behavior model.

DESIGN AND METHODS

We used a multivariate cross-sectional survey with repeated measures; participants resided in nine randomly selected nursing homes within four midwestern counties. The Minimum Data Set (with verification by caregivers) identified participants. We used a disproportionate probability sample of 107 participants (51% with a history of aggressive behavior) to ensure variability. Videotaped care events included four of direct care (shower baths, meals, dressing, and undressing) and two of nondirect care (two randomly selected 20-minute time periods in the afternoon and evening). The majority of participants (75%) received three shower baths, for a total of 282 videotaped baths.

RESULTS

Because the shower bath was the only care event significantly related to aggressive behavior (F = 6.9, p < .001), only those data are presented. Multilevel statistical modeling identified background factors (gender, mental status score, and lifelong history of less agreeableness) and a proximal factor (amount of nighttime sleep) as significant predictors (p < .05) of aggressive behavior during the shower bath. We found significant correlations between aggressive behavior and negative subject affect (r = .27) during the bath, and aggressive behavior and lifetime agreeableness level (r = -.192). We also found significant correlations between mental status and the amount of education (r = .212), and between negative caregiver affect and negative participant affect (r = .321).

IMPLICATIONS

We identified three background and one proximal factor as significant risk factors for aggressive behavior in dementia. Data identify not only those persons most at risk for aggressive behavior during care, but also the care event most associated with aggressive behavior. Together these data inform both caregiving for persons with dementia as well as the design of intervention studies for aggressive behavior in dementia.