A comparison of psychiatric symptoms in vascular dementia and Alzheimer's disease

Neuropsychological differential diagnosis of Alzheimer's disease and vascular dementia: a systematic review with meta-regressions

Introduction

Diagnostic classification systems and guidelines posit distinguishing patterns of impairment in Alzheimer's (AD) and vascular dementia (VaD). In our study, we aim to identify which diagnostic instruments distinguish them.

Methods

We searched PubMed and PsychInfo for empirical studies published until December 2020, which investigated differences in cognitive, behavioral, psychiatric, and functional measures in patients older than 64 years and reported information on VaD subtype, age, education, dementia severity, and proportion of women. We systematically reviewed these studies and conducted Bayesian hierarchical meta-regressions to quantify the evidence for differences using the Bayes factor (BF). The risk of bias was assessed using the Newcastle-Ottawa-Scale and funnel plots.

Results

We identified 122 studies with 17,850 AD and 5,247 VaD patients. Methodological limitations of the included studies are low comparability of patient groups and an untransparent patient selection process. In the digit span backward task, AD patients were nine times more probable (BF = 9.38) to outperform VaD patients (β g = 0.33, 95% ETI = 0.12, 0.52). In the phonemic fluency task, AD patients outperformed subcortical VaD (sVaD) patients (β g = 0.51, 95% ETI = 0.22, 0.77, BF = 42.36). VaD patients, in contrast, outperformed AD patients in verbal (β g = -0.61, 95% ETI = -0.97, -0.26, BF = 22.71) and visual (β g = -0.85, 95% ETI = -1.29, -0.32, BF = 13.67) delayed recall. We found the greatest difference in verbal memory, showing that sVaD patients outperform AD patients (β g = -0.64, 95% ETI = -0.88, -0.36, BF = 72.97). Finally, AD patients performed worse than sVaD patients in recognition memory tasks (β g = -0.76, 95% ETI = -1.26, -0.26, BF = 11.50).

Conclusion

Our findings show inferior performance of AD in episodic memory and superior performance in working memory. We found little support for other differences proposed by diagnostic systems and diagnostic guidelines. The utility of cognitive, behavioral, psychiatric, and functional measures in differential diagnosis is limited and should be complemented by other information. Finally, we identify research areas and avenues, which could significantly improve the diagnostic value of cognitive measures.

Is Living with Persons with Dementia and Depression Correlated to Impacts on Caregivers? A Scoping Review

Caregivers of persons with dementia and depression experience adverse effects associated with their role. The aim of this scoping review was to identify the challenges faced by caregivers of people with dementia and depression, along with interventions to support them. The MEDLINE®, Embase and PsycINFO databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. Grey literature was assessed using the Canadian Agency for Drugs and Technologies in Health's Gray Matter tool.The population consisted of caregivers of people with dementia and depression; the concept was to identify the negative impacts that caregivers experience and whether there are interventions to reduce them; the context was any study design targeting family or friends who were caregivers. A total of 12,835 citations were identified; 139 studies were included. Dementia and depression have variable impacts on outcomes experienced by caregivers, including burden/strain (n = 52), depression (n = 27), distress (n = 53), quality of life (n = 5) and health/well-being (n = 9). Pharmacological and non-pharmacological interventions have mixed effects. This study is important considering that depression in people with dementia is associated with caregiver distress. The use of a variety of non-pharmacological interventions could be beneficial to the latter.

Revisiting Preclinical Observations of Several Histamine H3 Receptor Antagonists/Inverse Agonists in Cognitive Impairment, Anxiety, Depression, and Sleep-Wake Cycle Disorder

A relationship appears to exist between dysfunction of brain histamine (HA) and various neuropsychiatric brain disorders. The possible involvement of brain HA in neuropathology has gained attention recently, and its role in many (patho)physiological brain functions including memory, cognition, and sleep-wake cycle paved the way for further research on the etiology of several brain disorders. Histamine H3 receptor (H3R) evidenced in the brains of rodents and humans remains of special interest, given its unique position as a pre- and postsynaptic receptor, controlling the synthesis and release of HA as well as different other neurotransmitters in different brain regions, respectively. Despite several disappointing outcomes for several H3R antagonists/inverse agonists in clinical studies addressing their effectiveness in Alzheimer's disease (AD), Parkinson's disease (PD), and schizophrenia (SCH), numerous H3R antagonists/inverse agonists showed great potentials in modulating memory and cognition, mood, and sleep-wake cycle, thus suggesting its potential role in neurocognitive and neurodegenerative diseases such as AD, PD, SCH, narcolepsy, and major depression in preclinical rodent models. In this review, we present preclinical applications of selected H3R antagonists/inverse agonists and their pharmacological effects on cognitive impairment, anxiety, depression, and sleep-wake cycle disorders. Collectively, the current review highlights the behavioral impact of developments of H3R antagonists/inverse agonists, aiming to further encourage researchers in the preclinical drug development field to profile the potential therapeutic role of novel antagonists/inverse agonists targeting histamine H3Rs.

Association between Ultraviolet B Exposure Levels and Depression in Taiwanese Adults: A Nested Case-Control Study

Depression is a common mental disorder that affects more than 264 million people worldwide. Anxiety, diabetes, Alzheimer's disease, myocardial infarction, and cancer, among other disorders, are known to increase the risk of depression. Exposure to ultraviolet B (UVB) can cause human serotonin levels to increase. The vitamin D pathway is one mechanism through which ultraviolet light absorbed through the skin can affect mood; however, UVB exposure is known to increase the risk of cancer. In this study, we explored the effects of prolonged exposure to UVB on depression. Data were retrieved from the Taiwan National Health Insurance Research Database for 2008 to 2013. Each patient with depression was matched 1:4 with a comparison patient by sex and age (±5 years); thus, the study included 23,579 patients with depression and 94,316 healthy controls for comparison. The patients had been exposed to UVB for at least 1 year to observe the cumulative effect of UVB exposure. Based on the World Health Organization UV index, we divided the observation period data into five UV levels: low, moderate, high, very high, and extreme. A multivariate Poisson regression model was used to assess the risk of depression according to UVB exposure level, adjusting for sex, age, income, urbanization level, month, and comorbidities. The results revealed that the incidence rate ratio (IRR) for patients with depression was 0.889 for moderate levels (95% CI 0.835-0.947), 1.134 for high levels (95% CI: 1.022-1.260), 1.711 for very high levels (95% CI: 1.505-1.945), and 2.785 for extreme levels (95% CI: 2.439-3.180) when compared to low levels. Moderate levels of UVB lowered the risk of depression, while high levels of UVB gradually increased the risk. We propose that UVB at normal concentrations can effectively improve depression. However, exposure to high concentrations of UVB damage DNA results in physical diseases such as skin cancer, which increase the risk of depression.

Potential biomarkers: differentially expressed proteins of the extrinsic coagulation pathway in plasma samples from patients with depression

Depression is a severe disabling psychiatric illness and the pathophysiological mechanisms remain unknown. In previous work, we found the changes in extrinsic coagulation (EC) pathway proteins in depressed patients compared with healthy subjects were significant. In this study, we screened differentially expressed proteins (DEPs) in the EC pathway, and explored the molecular mechanism by constructing a protein-protein interaction (PPI) network. The DEPs of the EC pathwaywere initially screened by isobaric tags for relative and absolute quantification (iTRAQ) in plasma samples obtained from 20 depression patients and 20 healthy controls, and were then identified by Enzyme-linked immunosorbent assays (ELISAs). Ingenuity Pathway Analysis (IPA) software was used to analyse pathway. The differentially expressed genes (DEGs) were identified by analyzing the GSE98793 microarray data from the Gene Expression Omnibus database using the Significance Analysis for Microarrays (SAM, version 4.1) statistical method. Cytoscape version 3.4.0 software was used to construct and visualize PPI networks. The results show that Fibrinogen alpha chain (FGA), Fibrinogen beta chain (FGB), Fibrinogen gamma chain (FGG) and Coagulation factor VII (FVII) were screened in the EC pathway from depression patient samples. FGA, FGB, and FGG were significantly up-regulated, and FVII was down-regulated. Thirteen DEGs related to depression and EC pathways were identified from the microarray database. Among them NF-κB Inhibitor Beta (NFKBIB) and Heat shock protein family B (small) member 1 (HSPB1) were highly correlated with EC pathway. We conclude that EC pathway is associated with depression, which provided clues for the biomarker development and the pathogenesis of depression.

Distress in neurocognitive disorders due to Alzheimer's disease and stroke

Patients with neurocognitive disorders experience subjectively the concept of quality of life; this is the reason why researchers avoid approaching this concept and prefer to focus attention on the emotional profile of the caregivers. Many studies highlight the efforts both emotional and financial made by caregivers in case of patients diagnosed with neurocognitive disorders. The present study shows the differences between the patients diagnosed with neurocognitive disorder due to Alzheimer's disease and patients diagnosed with stroke, as well as the Romanian norms for the short form of Geriatric Depression Scale. The study group consisted of the clinical population (N=45), selected according to the inclusion/exclusion criteria, following the principles of Helsinki Declaration for Ethical Medical Research. The study was conducted at the Neuropsychiatry section of the Municipal Clinical Hospital, Dr Gavril Curteanu, Oradea, Romania. The results showed significant differences between the two types of patients in terms of quality of life, t(43)=-7.99, P=0.001, affective distress, t(43)=5.10, P=0.001 and perceived stress, t(43)=3.81, P=0.001. The internal consistency of the scale is high, the coefficient KR-20 being 0.86.

Neuropsychiatric Symptoms in Dementia: Considerations for Pharmacotherapy in the USA

Dementia affects all domains of cognition. The relentless progression of the disease after diagnosis is associated with a 98% incidence of neuropsychiatric symptoms (NPS) at some point in the disease, including depression, psychosis, agitation, aggression, apathy, sleep disturbances, and disinhibition. These symptoms can be severe and lead to excess morbidity and mortality. The purpose of this article was to describe current literature on the medication management of NPS of dementia and highlight approaches to and concerns about the pharmacological treatment of NPS in the USA. Guidelines and expert opinion favor nonpharmacologic management of NPS as first-line management. Unfortunately, lack of adequate caregiver training and a high failure rate eventually result in the use of psychotropic agents in patients with dementia. Various psychotropic medications have been studied, although how they should be used in the management of NPS remains unclear. A systematic approach to evaluation, treatment, and monitoring, along with careful documentation and evidenced-based agent and dose selection, is likely to reduce risk and improve patient outcomes. Considerations should be given to the NPS presentation, including type, frequency, and severity, when weighing the risks and benefits of initiating, continuing, or discontinuing psychotropic management. Use of antidepressants, sedative/hypnotics, antipsychotics, and antiepileptic agents should include a clear and documented analysis of risk and benefit in a given patient with dementia.

A Multimodal Imaging Study in a Case of Bilateral Thalamic Damage With Multidomain Cognitive Impairment

Severe thalamic injury can determine a particular type of vascular dementia affecting multiple network dysfunctions, considered the central role of thalamus as a hub for afferent and efferent stimuli. A 67-year-old male patient with bilateral thalamic stroke was studied with positron emission tomography, magnetic resonance imaging, and cognitive assessment, performed at baseline and at two follow-up evaluations. A pattern primarily involving thalamo-frontal connections was observed by both PET and tractography analyses. All significant differences between the patient and controls involved the anterior thalamic radiation, one of the major fiber tracts in the fronto-thalamic circuitry. In particular, altered tractography indices of higher radial diffusivity and apparent diffusion coefficient and reduced fractional anisotropy values for the anterior thalamic radiation were reported. In accordance with imaging findings, neuropsychological evaluation demonstrated a multidomain impairment including memory, executive functions, and attention. Additionally, the patients displayed behavioral symptoms, in absence of mood alterations. Multimodal imaging assessment, revealing the metabolic and microstructural alterations that attend to multidomain neuropsychological impairment, demonstrated multiple levels of adaptations to bilateral vascular thalamic injury.

Behavioral Disturbances in Dementia and Beyond: Time for a New Conceptual Frame?

Alzheimer’s disease and vascular dementia are estimated to be the most common causes of dementia, although mixed dementia could represent the most prevalent form of dementia in older adults aged more than 80 years. Behavioral disturbances are common in the natural history of dementia. However, so far, there is a paucity of studies that investigated the causal association between behavioral psychological symptoms of dementia and dementia sub-types, due to the high heterogeneity of methodology, study design and type of clinical assessment. To understand the scant evidence on such a relevant clinical issue, it could be hypothesized that a new shifting paradigm could result in a better identification of the relationship between behavioral disturbances and dementia. This narrative review provides an update of evidence on the behavioral patterns associated with different dementia sub-types and offers a potential future perspective as common ground for the development of new translational studies in the field of behavioral disturbances in dementia and the appropriateness of psychoactive treatments.

High Occurrence of Psychiatric Disorders and Suicidal Behavior Across Dementia Subtypes

OBJECTIVE

To compare occurrence of clinically diagnosed psychiatric disorders and suicidal behavior (mental health disorders) across dementia subtypes in the largest healthcare system in the United States.

METHODS

We aggregated two national databases (Department of Veterans Affairs [VA] National Patient Care Database, National Suicide Prevention Applications Network [SPAN]) and estimated 2-year prevalence of mental health disorders across five dementia subtypes during fiscal years 2012-2013. Using VA healthcare systems throughout the United States, the sample included 56,296 older patients (≥50 years) with Alzheimer's disease (AD; n = 30,578), vascular dementia (VD; n = 17,924), frontotemporal dementia (FTD; n = 1,181), Lewy body dementia (LBD; n = 3,194), and mixed dementia (MD; n = 3,419). Mental health disorders were determined by International Classification of Diseases, Ninth Revision, Clinical Modification codes and the National SPAN.

RESULTS

Roughly 25% of patients had at least one mental health disorder, with 2-year prevalence reaching 30%-45% in FTD, VD, LBD, and MD. Compared with other subtypes, patients with FTD had the highest prevalence of mood (19%), anxiety (20%), and substance use (19%) disorders, as well as suicidal behavior (4%), with nearly 0.5% with a suicidal plan/attempt. Those with VD also showed a high prevalence of these disorders (14%-17%). Although patients with LBD and MD had a slightly lower prevalence of mood and anxiety disorders (12%-15%), they had a much lower prevalence of substance use disorders (9%) and suicidal behavior (2%). Patients with AD had the lowest 2-year prevalence of all mental health disorders (<7%).

CONCLUSION

Occurrence of mental health disorders is high and differs across dementia subtypes, highlighting the importance of reducing the burden of mental health disorders in dementia subtypes.

Effect of a Positive Photo Appreciation Program on Depressive Mood in Older Adults: A Pilot Randomized Controlled Trial

Safer and more effective programs are required to cope with an increasing number of older people with depression. Hence, we developed the Positive Photo Appreciation (PPA) program. A three-month pilot randomized controlled trial was conducted with healthy Japanese individuals aged 65⁻84 years, assigned to a PPA group (n = 28) or Photo Correspondence Education (PCE) (control group) (n = 27). We used the Center for Epidemiologic Studies Depression Scale (CES-D) score as the primary outcome measure. Secondary outcome measures, among others, were cognitive function and positive emotion. Data collected at baseline and post-intervention were analyzed using a linear mixed-effect model. Over 80% of the participants in the PPA group completed and were satisfied with the program. Compared with the PCE group, the CES-D score in the PPA group significantly improved (main effect of group: t = -4.30, p < 0.001; interaction effect of group by time: t = 4.39, p < 0.001), with an effect size of d = 1.23. Additionally, a positive significant interaction effect of group by time was found in the Positive and Negative Affect Schedule (t = -2.33, p = 0.024). The PPA program might be promising for mitigating depressive mood in older adults.

Comparison of neuropsychiatric symptoms and diffusion tensor imaging correlates among patients with subcortical ischemic vascular disease and Alzheimer's disease

BACKGROUND

The causes of behavioral and psychological symptoms of dementia (BPSD) vary according to the dementia subtype and associated neuropathology. The present study aimed to (i) compare BPSD between patients with subcortical ischemic vascular disease (SIVD) and Alzheimer's disease (AD) across stages, and (ii) explore the associations with diffusion tensor imaging (DTI) in the corpus callosum (CC) and other major fibers.

METHODS

Twenty-four patients with SIVD and 32 with AD were recruited. Four domains of the Neuropsychiatric Inventory (NPI) (hyperactivity, psychosis, affective, and apathy) and two DTI parameters [fractional anisotropy (FA) and mean diffusivity (MD)] within the genu, body (BCC), and splenium (SCC) of the CC and other major fibers were assessed.

RESULTS

Overall, the patients with clinical dementia rating (CDR) 1 ~ 2 had higher scores in apathy domain than those with CDR0.5. Among those with CDR1 ~ 2, SIVD had higher scores in apathy domain than AD. MD values in the BCC/SCC were positively correlated with total NPI score and psychosis, hyperactivity, and apathy domains. FA values in the SCC were inversely correlated with total NPI score and psychosis domain. The correlations were modified by age, the CASI, and CDR scores. Stepwise linear regression models suggested that FA value within the left superior longitudinal fasciculus predicted the hyperactivity domain. MD value within the SCC/left uncinate fasciculus and FA value within the GCC/left forceps major predicted the psychosis domain. MD value within the right superior longitudinal fasciculus and CDR predicted the apathy domain. Further analysis suggested distinct patterns of regression models between SIVD and AD patients.

CONCLUSION

White matter integrity within the BCC/SCC had associations with multi-domains of BPSD. Our study also identified important roles of regions other than the CC to individual domain of BPSD, including the left superior longitudinal fasciculus to the hyperactivity domain, the left uncinate fasciculus/forceps major to the psychosis domain, and the right superior longitudinal fasciculus to the apathy domain. The neuronal substrates in predicting BPSD were different between SIVD and AD patients. Of note, apathy, which was more profound in SIVD, was associated with corresponding fiber disconnection in line with dementia severity and global cognition decline.

Expressive Suppression Depletes Executive Functioning in Older Adulthood

OBJECTIVES

Accurate detection of executive dysfunction in neuropsychological assessments is complicated by the fact that executive functioning (EF) is vulnerable to temporary disruption (i.e., lapses), with more frequent lapses in older adulthood. Effortful regulation of affect (i.e., expressive suppression) is a well-known source of executive lapses in younger adults, but the generalizability of this depleting effect to older adults is unknown. The purpose of this study was to (1) determine whether EF is subject to depletion via expressive suppression and (2) to examine whether this effect is unique to EF, or whether it also applies to lower-order component processes in older adults.

METHODS

Ninety-seven non-demented, community-dwelling older adults were randomly assigned to either an expressive suppression group or control group. We compared performance of the groups on a battery of tests measuring EF and component processes both before and after exposure to emotionally evocative stimuli.

RESULTS

Consistent with the hypothesized depletion effect, suppressing participants showed an attenuated practice effect on post-manipulation EF relative to controls, while performance on lower-order component processes was unaffected by suppression.

CONCLUSIONS

These results suggest that depletion contributes to executive lapses in older adulthood. (JINS, 2017, 23, 341-351).

[The characteristics of a comprehensive geriatric assessment in patients with mild cognitive impairment with a cerebral white matter lesion]

AIM

Vascular dementia may be referred to as "treatable dementia" because its development and progress can be inhibited by intervention in the early stage. In particular, cerebral white matter lesions are readily encountered the clinical setting. In this study, we aimed to clarify the phenomenon and symptoms of patients with mild cognitive impairment (MCI) with cerebral white matter lesions prior to the onset of dementia.

METHODS

The subjects included 181 cases diagnosed with MCI among 643 consecutive new patients of the Center for Comprehensive Care on Memory Disorder at Kyorin University Hospital from January 1, 2013 to January 31, 2014. Patients with particular diseases were excluded. An interview, physical examination, comprehensive geriatric assessment, brain MRI and SPECT were performed for all subjects. The cerebral white matter lesions were evaluated using the modified Fazekas scale. We defined Grades 0 and 1 as the group without apparent cerebral white matter lesions and Grades 2 and 3 as the group with apparent cerebral white matter lesions. We compared the laboratory findings and outcomes of these two groups.

RESULTS

The age of the group with apparent cerebral white matter lesions was significantly higher than the group without apparent cerebral white matter lesions (P<0.05). No significant difference was observed regarding gender, MMSE, or "vegetable" term retrieval. A significant difference was observed in the total score and the subordinate component of the 21-item fall risk index and geriatric depression scale between the groups (P<0.05). Additionally, a significant difference was observed regarding the subordinate component of the instrumental ADL, the Dementia Behavior Disturbance Scale and the Zarit Care Burden Scale between the groups (P<0.05).

CONCLUSIONS

Our results suggest that the presence of white matter lesions at the stage of MCI has a significant relationship to care burden due to the deterioration of ADL, risk of falling, and the presence of depression and behavior disorders. We speculate that our results are useful for the explanation of the characteristics of MCI with white matter lesion to the patients and the care givers. Furthermore, these results may lead to improvements in the appropriate approach, intervention and appropriate nursing of such patients.

Mental health issues and Alzheimer's disease

As the prevalence of Alzheimer's disease (AD) increases, concerns have been voiced regarding how to best maintain and treat those affected. Psychiatric symptoms may be a prominent and influencing factor in decisions regarding the most appropriate level of care. The behavioral manifestations of AD, particularly agitation, may present dilemmas for formal and informal caregivers. The most significant dilemmas surrounding appropriate care for individuals manifesting psychiatric symptoms and negative behaviors may include the safety of caregivers as well as the safety of the diagnosed individual. These dilemmas may be compounded when there is not adequate psychiatric/psychotherapeutic intervention. This paper will seek to examine the psychopathology associated with AD as well as some intensive and restrictive interventions available to formal and informal caregivers when less intensive and less restrictive interventions fail. The intensive and restrictive interventions discussed include institutionalization, physical and chemical restraints, and psychiatric hospitalization.

Dementia and Comorbidities: An Overview of Diagnosis and Management

The term “dementia” describes various neurodegenerative disorders that effect cognition, including Alzheimer disease, vascular dementia, and others. This article reviews the diagnosis and management of common types of dementia and comorbidities. Dementias are differentiated clinically by history, symptom presentation, and exclusion of other causes through laboratory and imaging studies. Cholinesterase inhibitors are useful but may not be effective for all types of dementia and provide only modest benefits. Certain medical comorbidities may increase the risk of dementia, although genetics are also important in its etiology. Psychiatric comorbidities in dementia include delirium, which is treated primarily by addressing underlying medical disorders, but antipsychotics can be useful for symptom management and patient comfort. Nonpharmacologic interventions are first-line treatments for other psychiatric comorbidities, although drug therapy may be useful in some cases. The management of patients with dementia presents many challenges and will continue to do so unless agents with pronounced disease-modifying capabilities are developed.

Divalproex Sodium Therapy in Elderly with Dementia-Related Agitation

OBJECTIVE:

To review available literature regarding the use of divalproex sodium in the treatment of agitation in elderly patients with dementia.

DATA SOURCES:

Clinical trials and review articles were identified by MEDLINE search (1966 — March 2002).

DATA SYNTHESIS:

The literature provides information regarding the potential benefits and tolerability of divalproex sodium in the treatment of dementia-related agitation. This article analyzes 7 studies to better understand the role of divalproex sodium in the treatment of dementia.

CONCLUSIONS:

Divalproex sodium may offer a slight benefit to elderly patients suffering from dementia-related agitation. Until better-controlled trials demonstrate statistical significance and comparisons with established treatments are performed, practitioners should use divalproex sodium cautiously.

Neuropsychiatric symptoms in patients with vascular dementia in mainland China

Background

Neuropsychiatric deficits can induce marked disability in patients with dementia and increase caregiver distress. Several studies have found that neuropsychiatric symptoms are common both in patients with Alzheimer’s disease (AD) and patients with vascular dementia (VaD). However, there are few studies of the neuropsychiatric disturbances in large clinical samples of patients with mixed (cortical - subcortical) VaD from mainland China. This study aimed to investigate the neuropsychiatric symptoms in VaD patients in mainland China.

Methods

Eighty patients with mixed VaD for over 6 months duration, and their caregivers (VaD group), were recruited for interview in Zhongnan Hospital of Wuhan University, from June 2010 to June 2012. Eighty age- and sex-matched normal volunteers (control group) were interviewed at the same time. The Mini Mental State Examination (MMSE) and the Neuropsychiatric Inventory (NPI) were administered to the VaD patients, their caregivers, and normal volunteers. Group differences were analyzed using the unpaired t-test.

Results

The total mean scores of the NPI in the VaD group were higher than in the control group (P < 0.01). The subscale scores of NPI, including delusions, hallucinations, depression, apathy, irritability, agitation, aberrant motor behavior, and change in appetite were significantly higher in the VaD group than in the control group (P < 0.05–0.01). Compared with the mild VaD subgroup, the NPI subscale scores of apathy, irritability and total scores were significantly higher in the moderate VaD subgroup (P < 0.05–0.01); the NPI subscale scores of anxiety, apathy, irritability, and total scores were significantly higher in the severe VaD subgroup (P < 0.01). Compared with the moderate VaD subgroup, the NPI subscale scores of anxiety and apathy were significantly higher in the severe VaD subgroup (P < 0.05–0.01).

Conclusions

Neuropsychiatric symptoms, such as hallucination, anxiety, apathy, irritability and aberrant action behavior, are common in patients with mixed VaD from mainland China; anxiety and apathy were more pronounced in the subgroup of severe VaD patients.

Neuropsychiatric profiles in patients with Alzheimer's disease and vascular dementia

Background/Aims:

The aim of the following study is to compare the behavioral and psychological symptoms of dementia (BPSD) in patients of Alzheimer disease (AD) and vascular dementia (VaD).

Materials and Methods:

We used National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for diagnosing AD and National Institute of Neurological Disorders and Stroke-Association International pour la Recherche et l’Enseignement en Neurosciences Criteria for diagnosing VaD. VaD cohort was further subcategorized into small vessel and large vessel disease. The severity of cognitive impairment and the BPSD were studied by means of the Clinical Dementia Rating Scale (CDR) and the Neuropsychiatric Inventory respectively.

Results:

We studied 50 AD and 50 VaD patients of whom 38 were small vessels and 12 were large vessels VaD. The severity of dementia was comparable in both groups. The agitation/aggression, depression/dysphoria, anxiety, apathy/indifference, irritability, aberrant motor behavior, appetite and eating behavior and night-time behaviors occurred significantly more frequently in patients with VaD than AD. We found a weak positive correlation between the CDR score and the number of neuropsychiatric symptoms per patient in both cohorts. Elation/euphoria, agitation/aggression was significantly more frequent in patients with large vessel in comparison to small vessel VaD.

Conclusions:

BPSD are common in both types of dementia and they are more severe in VaD than AD when the groups have similar levels of cognitive impairment.

Psychological treatments for depression and anxiety in dementia and mild cognitive impairment

BACKGROUND

Experiencing anxiety and depression is very common in people with dementia and mild cognitive impairment (MCI). Psychological interventions have been suggested as a potential treatment for these populations. Current research suggests that people with dementia and MCI have limited opportunities for psychological treatments aimed at improving their well-being. A systematic review of the evidence on their effectiveness is likely to be useful in terms of improving outcomes for patients and for future recommendations for practice.

OBJECTIVES

The main objective of this review was to assess the effectiveness of psychological interventions in reducing anxiety and depression in people with dementia or mild cognitive impairment (MCI).

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group Specialized Register and additional sources for both published and unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing a psychological intervention with usual care or a placebo intervention (social contact control) in people with dementia or MCI.

DATA COLLECTION AND ANALYSIS

Two review authors worked independently to select trials, extract data and assess studies for risk of bias, using a data extraction form. We contacted authors when further information was not available from the published articles.

MAIN RESULTS

Six RCTs involving 439 participants with dementia were included in the review, but no studies of participants with MCI were identified. The studies included people with dementia living in the community or in nursing home care and were carried out in several countries. Only one of the studies was classified as low risk of bias. Five studies were at unclear or high risk of bias due to uncertainties around randomisation, blinding and selective reporting of results. The studies used the different psychological approaches of cognitive behavioural therapy (CBT), interpersonal therapy and counselling. Two studies were of multimodal interventions including a specific psychological therapy. The comparison groups received either usual care, attention-control educational programs, diagnostic feedback or services slightly above usual care.Meta-analysis showed a positive effect of psychological treatments on depression (6 trials, 439 participants, standardised mean difference (SMD) -0.22; 95% confidence interval (CI) -0.41 to -0.03, moderate quality evidence) and on clinician-rated anxiety (2 trials, 65 participants, mean difference (MD) -4.57; 95% CI -7.81 to -1.32, low quality evidence), but not on self-rated anxiety (2 trials, SMD 0.05; 95% CI -0.44 to 0.54) or carer-rated anxiety (1 trial, MD -2.40; 95% CI -4.96 to 0.16). Results were compatible with both benefit and harm on the secondary outcomes of patient quality of life, activities of daily living (ADLs), neuropsychiatric symptoms and cognition, or on carers' self-rated depressive symptoms, but most of the studies did not measure these outcomes. There were no reports of adverse events.

AUTHORS' CONCLUSIONS

We found evidence that psychological interventions added to usual care can reduce symptoms of depression and clinician-rated anxiety for people with dementia. We conclude that psychological interventions have the potential to improve patient well-being. Further high quality studies are needed to investigate which treatments are most effective and to evaluate the effect of psychological interventions in people with MCI.

Key neuropsychiatric symptoms in common dementias: prevalence and implications for caregivers, clinicians, and health systems

The purpose of this study was to compare neuropsychiatric symptoms (NPS) among people with common dementias and equip interdisciplinary clinicians and health services planners with large-sample data necessary to plan care for patients and families. We analyzed selected variables from baseline assessments of older adults with dementia of one or more etiologies (N = 3,768) from the National Alzheimer's Coordinating Center data repository. Dementias included Alzheimer's disease (AD), Lewy body dementia (DLB), behavioral variant frontotemporal dementia (bvFTD), and vascular dementia (VaD). We compared the prevalence of four NPS clusters (agitation/aggression, depression/dysphoria, anxiety, irritability/lability) across dementia etiologies and stages using logistic regression and AD as the reference group. NPS profiles differed significantly across dementia types and stages. Compared with primary AD, DLB was associated with greater odds of depression/dysphoria (OR = 1.68, 95% confidence interval [CI] 1.28, 2.20) and anxiety (OR = 1.80, 95% CI 1.37, 2.36), with similar findings when DLB was diagnosed in combination with AD (depression/dysphoria: OR = 1.79, 95% CI 1.11, 2.89; anxiety: OR = 1.88, 95% CI 1.17, 3.02). Primary bvFTD was associated with greater odds of agitation/aggression (OR = 1.59, 95% CI 1.17, 2.18). The prevalence of anxiety and irritability/lability was highest in moderate stages of dementia, and agitation/aggression was most prevalent in severe dementia. Differential diagnosis and staging of dementias and inclusion of single and overlapping etiologies is important for planning and implementing appropriate strategies to anticipate, report, and intervene with key NPS that complicate home and health care.

Neuropsychiatric predictors of conversion to dementia both in patients with amnestic mild cognitive impairment and those with subcortical vascular MCI

OBJECTIVE

The aim of this study was to investigate whether specific neuropsychiatric domains could predict a conversion to dementia in those patients either with amnestic subtype of mild MCI (aMCI) or subcortical vascular MCI (svMCI).

METHODS

At baseline, all subjects underwent neuropsychological tests, Neuropsychiatric Inventory (NPI), and MRI. We compared the baseline NPI scores between converters (CV) and non-converters (NCV) both in the aMCI and svMCI groups.

RESULTS

The mean follow-up duration was 16.74±8.02 months (range: 4.2-43.9). At the second time point, about 30% of aMCI and svMCI patients converted to dementia with 7.5% of aMCI patients exhibiting improvement to normal cognitive state. In female aMCI patients, those who later improved to normal cognition exhibited higher baseline depression scores than the CV group. However, baseline depression scores were higher in the CV group than the NCV group in svMCI patients, and this difference was significant only in males.

CONCLUSION

Our results suggest that depression might serve as a predictive marker of conversion to dementia in patients with svMCI, albeit only in males. On the other hand, patients who later improved to normal cognition showed higher scores of depression at baseline in female aMCI patients, suggesting that longer follow-ups are warranted in female patients with aMCI and depression.

A comparison of the E-BEHAVE-AD, NBRS, and NPI in quantifying clinical improvement in the treatment of agitation and psychosis associated with dementia

OBJECTIVES

The aim of this study is to compare the Empirical Behavioral Rating Scale (E-BEHAVE-AD), Neurobehavioral Rating Scale (NBRS), and Neuropsychiatric Interview (NPI) in detecting behavioral disturbance and psychotic symptoms in dementia and characterizing changes in response to treatment.

DESIGN

Eighty-seven subjects in the randomized controlled trial "Continuation Pharmacotherapy for Agitation of Dementia" were included in this analysis. We compared the detection in, and changes of, both agitation and psychosis, using these three instruments. A receiver operating characteristic analysis was performed to compare the performance of the three instruments in detecting global improvement.

RESULTS

The instruments were equally likely to detect agitation. The NBRS was most likely to detect psychosis. Although the NPI best detected improvement in agitation, the instruments were equal for detecting improvement in psychosis. In the receiver operating characteristic analysis for overall clinical improvement in response to treatment, there were no differences in the areas under the correlated curves for the three instruments, but they demonstrated different sensitivity and specificity at different cutoff points for target symptom reduction. The E-BEHAVE-AD performed best at a cut point of 30% target symptom reduction and the NBRS and NPI both performed best at 50%.

CONCLUSION

The E-BEHAVE-AD, NBRS, and NPI were more similar than different in characterizing symptoms but differed in detecting response to treatment. Differences in sensitivity and specificity may lead clinicians to prefer a specific instrument, depending on their goal and the expected magnitude of response to any specific intervention.

Vascular depression: a new view of late-onset depression

We have suggested that cerebrovascular disease may predispose, precipitate, or perpetuate some late-life depressive syndromes. The mechanisms of "vascular depression" include disruption of cortico-striato-pallido-thalamo-cortical (CSPTC) pathways or their modulating systems. This view is supported by the presentation of vascular depression, which consists of depressive symptoms, cognitive abnormalities, as well as neuroimaging findings that may result from CSPTC impairment. Moreover, clinical and electrophysiological evidence of CSPTC impairment, an abnormality frequently found in patients with vascular depression, appears to be associated with poor response to antidepressant treatment and early relapse and recurrence. The vascular depression hypothesis provides the conceptual background for studies that may have clinical and theoretical impact. Agents influencing dopamine, acetylcholine, and opioid neurotransmitters may be studied in vascular depression, since these are essential neurotransmitters of the frontostriatal circuitry. Drugs used for prevention and treatment of cerebrovascular disease may be shown to reduce the risk for vascular depression or improve its outcomes. The choice of antidepressants in vascular depression may depend on their effect on neurological recovery from ischemic lesions. Finally, identification of specific relationships between specific symptoms, cognitive deficits, and disability may lead to interventions that target the patients' deficits as well as their interactions with psychosocial factors known to contribute to depression. Research can clarify the pathways to vascular depression by focusing on the site of lesion, the resultant brain dysfunction, the presentation of depression and time of onset, and the contribution of nonbiological factors.

Neuropsychiatric profiles in dementia

We compared patterns of neuropsychiatric symptoms across 4 dementia types [Alzheimer disease (AD), vascular dementia (VAD), dementia with Lewy bodies (DLB), and Parkinson disease dementia], and 2 mixed groups (AD/VAD and AD/DLB) in sample of 2,963 individuals from the National Alzheimer's Coordinating Center Uniform Data Set between September 2005 and June 2008. We used confirmatory factor analysis to compare neuropsychiatric symptom severity ratings made by collateral sources on the Neuropsychiatric Inventory Questionnaire for people with Clinical Dementia Rating scores of 1 or higher. A 3-factor model of psychiatric symptoms (mood, psychotic, and frontal) was shared across all dementia types. Between-group comparisons revealed unique neuropsychiatric profiles by dementia type. The AD group had moderate levels of mood, psychotic, and frontal symptoms whereas VAD exhibited the highest levels and Parkinson disease dementia had the lowest levels. DLB and the mixed dementias had more complex symptom profiles. Depressed mood was the dominant symptom in people with mild diagnoses. Differing psychiatric symptom profiles provide useful information regarding the noncognitive symptoms of dementia.

Behavioral disturbance in dementia

Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.

Distinguishing Alzheimer's disease from other major forms of dementia

Alzheimer's disease (AD) is the most common and most studied cause of dementia. Significant advances have been made since the first set of clinical criteria for AD were put forth in 1984 that are now captured in the new criteria for AD published in 2011. Key features include recognition of a broad AD spectrum (from preclinical to mild cognitive impairment to AD dementia) and requirement of AD biomarkers for diagnosis. Correctly diagnosing dementia type is increasingly important in an era when potential disease-modifying agents are soon to be marketed. The typical AD dementia syndrome has at its core, an amnestic syndrome of the hippocampal type, followed by associated deficits in word-finding, spatial cognition, executive functions and neuropsychiatric changes. Atypical presentations of AD have also been identified that are presumed to have a different disease course. It can be difficult to distinguish between the various dementia syndromes given the overlap in many common clinical features across the dementias. The clinical difficulty in diagnosis may reflect the underlying pathology, as AD often co-occurs with other pathologies at autopsy, such as cerebrovascular disease or Lewy bodies. Neuropsychological evaluation has provided clinicians and researchers with profiles of cognitive strengths and weaknesses that help to define the dementias. There is yet no single behavioral marker that can reliably discriminate AD from the other dementias. The combined investigation of cognitive and neurobehavioral symptoms coupled with imaging markers could provide a more accurate approach for differentiating between AD and other major dementia syndromes in the future.

Apolipoprotein E genotypes and neuropsychiatric symptoms and syndromes in late-onset Alzheimer's disease

Neuropsychiatric symptoms (NPS) in dementia, previously denominated as behavioural and psychological symptoms of dementia, are often more distressing, impairing, and costly than cognitive symptoms, representing a major health burden for older adults. These symptoms are common features of Alzheimer's disease (AD), and are one of the major risk factors for institutionalization. There is a high prevalence of neuropsychiatric disturbances in patients with AD, including depression, anxiety, apathy, psychosis, aggression, and agitation. At present, the role of the apolipoprotein E (APOE) genotypes in the development of NPS or neuropsychiatric syndromes/endophenotypes in AD patients is unclear. In this article, we summarized the findings of the studies of NPS and neuropsychiatric syndromes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between the APOE polymorphism and NPS in late-onset AD, other studies reported a significant association between the APOE ɛ4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. However, current cumulative evidence coming from the few existing longitudinal studies shows no association of APOE genotypes with NPS as a whole in AD. Some negative studies that focused on the distribution of APOE genotypes between AD patients with or without NPS further emphasized the importance of sub-grouping NPS in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, possible lack of statistical power to detect associations in the negative studies, and small sample sizes generating false positives that cannot be consistently replicated. Finally, many reviewed studies were cross-sectional, whereas it would be of paramount importance to evaluate the risk for incident NPS in relation to the APOE genotype in prospectively followed cohorts of AD patients. In fact, identifying predisposing genetic risk factors may allow us to understand the pathophysiological features of neuropsychiatric syndromes or symptoms in AD, so optimizing possible therapeutic options.

Impact of the life review program on elders with dementia: a preliminary study at a day care center in southern Taiwan

BACKGROUND

: Life review, a type of reminiscence therapy, assists participants to seek personal value in order to enhance social status and maintain a high quality of life (QOL).

PURPOSE

: This study aimed to examine the impact of an adaptive life review program (LRP) on perceived QOL in elders with mild to moderate dementia at a day care center and assess the effect, if any, of different cognitive impairment levels on intervention outcome.

METHODS

: This pre-experimental design used a single group of seven subjects for pretest and posttest and purposive sampling at a 2-week interval. Researchers administered to each subject a 10-day therapeutic recreation program modified from Tabourne's (1991) LRP.

RESULTS

: Posttest results found no statistically significant improvements. However, subjects reported higher mean scores of perceived QOL as measured by the 36-Item Short Form Health Survey. This finding indicated a trend of improving physical and mental health after the intervention. In addition, subjects with moderate cognitive impairment reported a higher improvement in physical health perception than did subjects with mild cognitive impairment.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

: Future research should include a larger sample size and a longer period of intervention and adopt multiple dimensions of QOL measurements to increase research rigor. Suggestions from this study can be used to improve the LRP.

The complex relationship between depression and dementia

Dementia and depression are mental health problems that are commonly encountered in neuropsychiatric practice in the elderly. Approximately, half of the patients with late-onset depression have cognitive impairment. The prevalence of depression in dementias has been reported to be between 9 and 68%. Depression has been both proposed to be a risk factor for dementia as well as a prodrome of dementia. This article is a selective literature review of the complex relationship between the two conditions covering definitions, epidemiology, related concepts, treatment, and emerging biomarkers. The methodological issues and the mechanisms underlying the relationship are also highlighted. The relationship between the two disorders is far from conclusive.

[Early onset dementia]

BACKGROUND

It is estimated that 1,200 people under the age of 65 have been diagnosed with dementia in Norway. This article provides an overview of the types of dementia frequently seen in younger patients.

MATERIAL AND METHODS

The article is based on a non-systematic search in PubMed, as well as the authors' own clinical and research experience.

RESULTS

Alzheimer's disease, frontotemporal dementia, vascular dementia and dementia with Lewy bodies, are the most common types of dementia occurring more often in younger than in older patients. The cognitive symptoms are more variable in younger patients than in older. Only a small percentage of early onset dementia is caused by genetic factors. There are few diagnostic tools available for this age group and it takes considerable time to reach a correct diagnosis. Early diagnosis allows the patient and carer to plan for the future.

INTERPRETATION

Physicians should be aware that dementia can occur in younger people, and more diagnostic assessments should be developed for this patient group. Better coordination from the public health authority and municipalities is needed to provide respite care for early onset dementia patients and their carers.

Neuropsychiatric correlates of white matter hyperintensities in Alzheimer's disease

OBJECTIVE

To investigate the association of behavioral and psychological symptoms of dementia (BPSD) in Alzheimer's disease (AD) and magnetic resonance imaging (MRI) measures of brain atrophy and white matter hyperintensities (WMH).

METHODS

Thirty-seven patients with probable AD received the Neuropsychiatric Inventory (NPI), the Mini Mental Status Exam (MMSE), and an MRI scan as part of their initial evaluation at the Outpatient Memory Diagnostic Clinic at McLean Hospital. MRI-based volumetric measurements of whole brain atrophy, hippocampal volumes, and WMH were obtained. Analysis of covariance models, using age as a covariate and the presence of specific BPSD as independent variables, were used to test for differences in whole brain volumes, hippocampal volumes and WMH volumes.

RESULTS

Increased WMH were associated with symptoms of anxiety, aberrant motor behavior, and night time disturbance, while symptoms of disinhibition were linked to lower WMH volume. No associations were found for whole brain or hippocampal volumes and BPSD.

CONCLUSIONS

These findings suggest that white matter changes are associated with the presence of BPSD in AD.

Subtypes of depression among patients with Alzheimer's disease and other dementias

OBJECTIVES

We compared the prevalence of subtypes of depression in patients with Alzheimer's disease (AD), vascular dementia (VaD), and unspecified dementia (UD).

METHODS

Using the Integrated Healthcare Information Services database, we conducted an analysis of subtypes of depression (major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder; depressive psychosis, and adjustment disorder depressive) among patients with AD, VaD, and UD. Six thousand four hundred and forty patients aged 60 years or older with dementia (2947 with AD, 725 with VaD, and 2768 with UD) were identified from January 1 to December 31, 2001. Both subtypes of depression and dementia subgroups were diagnosed using criteria from the International Classification of Diseases, 9th version.

RESULTS

The overall prevalence of depressive disorders was 27.41%. The prevalence of depressive disorders was significantly higher in VaD (44.14%) and UD (32.48%) patients compared with AD (18.53%, P < .0001) patients. The AD patients had the lowest prevalence of all subtypes of depression. The VaD patients, compared with both AD and UD (P < .005), had a significantly higher prevalence of: 1) depressive disorder not otherwise specified, 2) major depressive disorder, and 3) dysthymic disorder. Adjustment disorder with depressive symptoms was more common in the UD subgroup, whereas the rate of depressive psychosis was similar in all dementia subgroups

CONCLUSIONS

This study supports the view that depressive disorders are more prevalent in VaD compared with UD and AD, and provides indicators to the clinician for further evaluation of depression in dementia subgroups.

Behavioral and psychological symptoms associated with dementia subtype and severity

BACKGROUND

There is a growing body of research exploring differences in behavioral and psychological symptoms of dementia (BPSD) between Alzheimer's disease (AD) and vascular dementia (VaD), yet these differences are inconsistent and it is uncertain whether this inconsistency might be due to the confounding effect of differing severities of dementia.

METHODS

BPSD, measured with the Behavior Problems Check List (BPCL) and Revised Memory and Behavior Problems Check List (RMBPCL) and CDR-measured severity of dementia were examined using archival data of individuals with AD (N = 377) or VaD (including multi-infarct and other vascular causes; N = 74) presenting to a Sydney memory disorders clinic over a 20-year period.

RESULTS

There was no significant difference in scores for AD and VaD patients on the BPCL or on the RMBPCL when controlling for sex and severity of dementia. However, severity of BPSD increased with increasing severity of dementia.

CONCLUSIONS

BPSD severity is no different in AD and VaD at the time of initial assessment in a memory disorders clinic population of mild to moderate dementia. However, BPSD increases with severity of dementia in this group.

The neuropsychiatric inventory scores change across the mini mental state examination ranges in patients with Alzheimer's disease: a multicenter study in Turkey

OBJECTIVE

To investigate neuropsychiatric manifestations in patients at various stages of Alzheimer's disease (AD).

BACKGROUND

Several earlier studies reported high prevalence of neuropsychiatric symptoms in patients with AD; to date, no such study has been conducted in Turkey.

METHOD

We evaluated 217 patients with AD from 18 referral centers across Turkey using a web-based dementia data registry. The Mini Mental State Examination and the Neuropsychiatric Inventory (NPI) were used to evaluate the global cognitive function, and assessment of neuropsychiatric symptoms, respectively. We classified the patients into mild, moderate, and severe stages on the basis of their Mini Mental State Examination scores. We assessed group differences and correlations between the degree of AD severity and NPI values.

RESULTS

The highest NPI scores were seen in patients with severe AD. The mean composite scores for apathy, anxiety, and depression were the highest. The prevalence of any behavioral symptom was 86%. There was no difference in the behavioral domain between the groups or between the referral centers. Moderate correlation was found between the severity of AD and the total NPI score. The caregivers' NPI distress scores varied among referral centers.

CONCLUSIONS

The prevalence of behavioral disturbance in AD is high and similar to earlier studies, yet regional differences are seen in caregivers' reactions to behavioral symptoms.

Prevalence of depression among older Americans: the Aging, Demographics and Memory Study

BACKGROUND

Previous studies have attempted to provide estimates of depression prevalence in older adults. The Aging, Demographics and Memory Study (ADAMS) is a population-representative study that included a depression assessment, providing an opportunity to estimate the prevalence of depression in late life in the U.S.A.

METHODS

The ADAMS sample was drawn from the larger Health and Retirement Study. A total of 851 of 856 ADAMS participants aged 71 and older had available depression data. Depression was measured using the Composite International Diagnostic Interview - Short Form (CIDI-SF) and the informant depression section of the Neuropsychiatric Inventory (NPI). We estimated the national prevalence of depression, stratified by age, race, sex, and cognitive status. Logistic regression analyses were performed to examine the association of depression and previously reported risk factors for the condition.

RESULTS

When combining symptoms of major or minor depression with reported treatment for depression, we found an overall depression prevalence of 11.19%. Prevalence was similar for men (10.19%) and women (11.44%). Whites and Hispanics had nearly three times the prevalence of depression found in African-Americans. Dementia diagnosis and pain severity were associated with increased depression prevalence, while black race was associated with lower rates of depression.

CONCLUSIONS

The finding of similar prevalence estimates for depression in men and women was not consistent with prior research that has shown a female predominance. Given the population-representativeness of our sample, similar depression rates between the sexes in ADAMS may result from racial, ethnic and socioeconomic diversity.

Neuropsychiatric profiles of patients with Alzheimer's disease and vascular dementia in Taiwan

BACKGROUND

Previous studies have reported several conflicting findings regarding neuropsychiatric symptoms when comparing patients with Alzheimer's disease (AD) and patients with vascular dementia (VaD).

OBJECTIVES

The purpose was to: (1) compare the prevalence of neuropsychiatric symptoms among patients with AD and VaD after controlling for demographic characteristics in difference setting and (2) rank and contrast the severity the common symptoms between the two groups in north of Taiwan.

METHODS

This study was a cross-sectional comparative design. Data were collected from clinical interviews using three instruments: the Mini-Mental Status Examination (MMSE), the Clinical Dementia Rating Scale (CDR), and the Neuropsychiatric Inventory (NPI).

RESULTS

A total of 154 subjects participated in this study. The male subjects with VaD from the outpatient setting had lower NPI scores. In the OPD, the subjects with AD had more nighttime behavior than subjects with VAD. In the nursing home setting, the subjects with VaD had higher prevalence of depression, irritability, and appetite changes than subjects with AD. The subjects with AD had more euphoria and nighttime behavior than subjects with VaD. The average of total NPI scores for people with AD and VaD from the nursing home setting indicate higher scores. In the nursing home group, the VaD subjects evidenced significantly higher irritability scores than the AD subjects.

CONCLUSIONS

This was first care unit based study in north Taiwan. Our results showed the significant differences between AD and VaD groups of NPI symptoms. Understanding those differences may aid differential diagnosis of dementia subtypes and help develop proper interventions.

Structural differences within negative and depressive syndrome dimensions in schizophrenia, organic brain disease, and major depression: A confirmatory factor analysis of the positive and negative syndrome scale

OBJECTIVE

The emerging dimensional approach to classification and treatment of psychiatric disorders calls for better understanding of diagnosis-related variations in psychiatric syndromes and for proper validation of psychometric scales used for the evaluation of those syndromes. This study tested the hypothesis that negative and depressive syndromes as measured by the Positive and Negative Syndrome Scale (PANSS) are consistent across different diagnoses.

METHOD

We administered the PANSS to subjects with schizophrenia (n = 305), organic brain disease (OBD, n = 66) and major depressive disorder (MDD, n = 75). Confirmatory factor analysis (CFA) was used to establish if the PANSS items for negative symptoms and for depression fit the hypothesized factor structure and if the item factor loadings were similar among the diagnostic groups.

RESULTS

The negative and depressive symptom subscales fit well according to a variety of fit indexes for all groups individually after some modest model modification. However, multisample modeling procedures indicated that the pattern of factor loadings was significantly different among the groups in most cases.

CONCLUSION

The results of this study indicate diagnosis-related variations in the negative and depressive syndrome dimensions in schizophrenia, OBD and MDD. These results also validate limited use of the PANSS for evaluation of negative and depressive syndromes in disorders other than schizophrenia. Larger studies are warranted to further evaluate clinical and nosologic significance of diagnostic categories, dimensions and structures of psychiatric syndromes.

Anxiety in dementia: a critical review

Until recently, little attention has been paid to anxiety symptoms in dementia. However, anxiety is common in this population, and associated with poor outcome and quality of life. The current review examines the existing literature around three major themes: the definition of anxiety in dementia, the properties of available instruments for assessment, and the clinical characteristics of anxiety in this population. Defining anxiety in individuals with dementia is complicated by the overlap between symptoms of anxiety, depression and dementia, and by the influence of the source of information. Several instruments are available to assess anxiety in this population, including general neuropsychiatric instruments and two scales designed specifically for this purpose. The reliability of these instruments is acceptable, but their validity has not been sufficiently examined, and they may discriminate poorly between anxiety and depression. Anxiety may be higher in vascular dementia than in Alzheimer's Disease, and it decreases in the severe stages of dementia. It is associated with poor quality of life and behavioral disturbances, even after controlling for depression. Little is known, however, about its social and environmental correlates. Limitations of the existing literature and key directions for future research are discussed.

Screening instruments for older adult depressive disorders: updating the evidence-based toolbox

The prevalence of clinically significant depressive disorders in persons 65 years of age or older in the United States has been estimated to be approximately 15%, increasing the risk for functional decline, morbidity, and mortality. Utilization of a well-chosen screening instrument has been shown to improve the rates of recognition of depressive disorders in older adults. This paper presents a targeted review of the most commonly accepted tools for case-finding of depressive disorders in older adults. After a review of the benefits and shortcomings of screening tools, the strengths, weaknesses, and utility of selected depression scales in geriatric clinical settings are discussed.

Neuropsychiatric symptoms in dementia: importance and treatment considerations

Neuropsychiatric symptoms are frequent in people with dementia, result in distress for the people experiencing them and their caregivers, and are a common precipitant of institutional care. The safe and effective treatment of these symptoms is a key clinical priority, but is a long way from being achieved. Psychological interventions are recommended as the first line treatment strategy in most good practice guidelines, and there is emerging evidence of efficacy for agitation and depression. Neuroleptics remain the mainstay of pharmacological treatment, although meta-analyses indicate that they are mainly of benefit for the short-term (up to 12 weeks) treatment of aggression in people with Alzheimer's disease, and there have been increasing concerns about serious adverse effects including mortality. The evidence is limited for other pharmacological approaches for the treatment of agitation, and psychosis in people with Alzheimer's disease is limited, but post-hoc analyses do indicate that memantine may be a promising therapy and aromatherapy may be a useful alternative. Autopsy studies indicate that the adrenergic system may be an important therapeutic target. Clinical experience suggests that antidepressants are effective in people with severe depression in the context of dementia, but the evidence base regarding the broader value of antidepressants is far from clear. There are very few trials specifically focusing upon the treatment of neuropsychiatric symptoms in common non-Alzheimer dementias, which is a major limitation and urgently needs to be addressed to provide an evidence base to enable the safe and effective treatment of these individuals.

Separating mood disturbance from mild cognitive impairment in geriatric depression

Disentangling depression from dementia remains one of the most difficult clinical challenges for psychiatrists caring for older adults. The relationship between geriatric depression and dementia is complex for several reasons. First, cognitive impairment is often a prominent feature of depression in the elderly. Cognition may improve with successful treatment of depression but it may not normalize. Indeed, marked memory impairment in older depressed individuals may indicate a prodromal state of dementia. This review will examine issues related to depression and cognitive disorder in the elderly. The author will provide an evidence-based approach to separate mood disorder from cognitive disorder among older adults.

Geriatric depression and cognitive impairment

Cognitive impairment is common in geriatric depression, and depressed individuals with co-morbid cognitive impairment are at increased risk for a number of adverse medical, psychiatric and cognitive outcomes. This review focuses on clinical issues surrounding the co-occurrence of these two conditions within the context of current research. We (1) review the clinical criteria and prevalence of depression, as well as co-morbid cognitive impairment, (2) discuss factors associated with persistent cognitive impairment in depression, including dementia, and (3) review research relevant to the assessment and treatment of cognitive impairment and dementia in the context of depression. We conclude that current research on depression and cognition can inform clinical decisions that reduce the occurrence of adverse outcomes. Clinicians are encouraged to develop proactive approaches for treatment, which may include combinations of pharmacological and psychotherapeutic interventions.