Behavioral and psychological symptoms of dementia: A study of symptomatology

SENSE-Cog Asia: A Feasibility Study of a Hearing Intervention to Improve Outcomes in People With Dementia

Background: There are few evidence-based non-pharmacological interventions adapted for people with dementia (PwD) in lower- and middle-income countries (LMIC). Thus, there is value in culturally adapting existing interventions from other settings. One such intervention for PwD involves hearing rehabilitation, which may improve dementia-related outcomes.

Objective: To culturally adapt and evaluate the feasibility and acceptability of a multi-faceted hearing support intervention to enhance quality of life in PwD for a LMIC setting, Pakistan.

Design: This was a study in three phases: (1) training and capacity building to deliver the study, including Patient and Public Involvement (PPI); (2) cultural adaptation of the intervention; and (3) delivery of a single-group feasibility study with a pre-test post-test design.

Setting: Home-based intervention, in two cities of Pakistan.

Participants: Adults aged ≥ 60 with mild-moderate dementia and uncorrected or partially corrected hearing impairment, and their study partners (n = 14).

Intervention: An adapted hearing support intervention (HSI) comprising a full assessment of hearing function, fitting of hearing aids, and home-based support from a “hearing support practitioner.”

Outcomes: Ratings of the feasibility of the study procedures, and acceptability/tolerability of the adapted intervention were ascertained through questionnaires, participant diaries, therapist logbooks and semi-structured interviews. A signal of effectiveness of the intervention was also explored using a battery of dementia-related outcome measures.

Results: Following cultural adaptation and capacity building for study conduct and delivery, we successfully implemented all intervention components in most participants, which were well-received and enacted by participant dyads. Acceptability (i.e., understanding, motivation, sense of achievement) and tolerability (i.e., effort, fatigue) ratings and safety of the intervention were within a priori target ranges. Recruitment and retention targets required improvement, due to the COVID-19 pandemic outbreak, as well as the lack of a clear clinical diagnostic pathway for dementia in both sites. Areas for future modification were clearly identified, including: the assessment/delivery logistics circuit; procedures for arranging visits; communication among referring clinicians and the study team.

Conclusion: This is the first study in a LMIC of sensory enhancement to improve dementia outcomes. Positive feasibility, acceptability and tolerability findings suggest that a full-scale effectiveness trial, with certain modifications is warranted.

Behavioural and Psychological Symptoms of Dementia: Correlates and Impact on Caregiver Distress

Aims

To evaluate the behavioural and psychological symptoms of dementia (BPSD), to determine their correlation with types and stages of dementia and patient demographics, and to assess the impact on caregiver distress.

Methods

This cross-sectional study recruited consecutive dementia patients and caregivers who attended our cognitive clinic. Standard criteria were used to classify types of dementia. BPSD were assessed with the Neuropsychiatric Inventory, and its distress scale was used for caregiver distress.

Results

Of a total 107 patients, nearly all (99.1%) had at least one BPSD; 71% had ≥4 symptoms. Most frequent were apathy and agitation, followed by irritability, sleep and appetite disorders, and mood disorders; disinhibition and euphoria were least frequent. BPSD were less prominent with increasing age; males showed more agitation. Apathy and eating disorders were more prevalent in the rural community. BPSD were highest in frontotemporal dementia (FTD), followed by dementia with Lewy bodies (DLB), and least in vascular dementia. Hallucinations were more common in DLB, aberrant motor behaviour in FTD. All domains of BPSD, except for anxiety and euphoria, were more prominent with increasing severity of dementia. Increasing BPSD (except for euphoria) caused higher caregiver distress.

Conclusion

BPSD are universally present, bear correlates with dementia type and severity, and cause significant caregiver distress.

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.

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.

Caregiver burden of behavioral and psychological symptoms of dementia among Indian patients with Alzheimer's disease

Behavioral and psychological symptoms of dementia (BPSD) are common in Alzheimer's disease (AD) and can potentially contribute to disease burden among caregivers. In this letter, an attempt is reported to establish if disease burden was higher among those with BPSD compared to those without it.

Analysis of caregiver perceptions of "hallucinations" in people with dementia in institutional settings

This study investigated the meanings and etiologies of hallucinations in persons with dementia. Participants were 74 nursing home residents aged ≥ 65 diagnosed with dementia. Most of the reported visual and auditory hallucinations involved talking to persons who are not present, a phenomenon described as either a visual or auditory hallucination, or both. All participants who were reported to experience a hallucination had poor vision. Current results suggest that hallucination was a term staff caregivers used for the phenomena they could not easily explain, demonstrating their lack of understanding of the resident and/or the phenomena they termed hallucination. The classification of hallucinations into subtypes may not be meaningful, and most visual and auditory hallucinations were not associated with negative affect. Some hallucinations occurred out of boredom, which exacerbated the sensory deprivation experienced by these persons, thereby increasing the likelihood of hallucinations.

The meanings of delusions in dementia: a preliminary study

One of the common symptoms of dementia is delusions. Due to a biological conceptualization of the behaviors represented as delusions, these are classified as psychotic symptoms. This is a qualitative and quantitative study aiming to describe the delusions experienced by older persons with dementia and the context of occurrence, and to elucidate their etiology. Participants were 74 nursing home residents aged 65 and over, diagnosed with dementia, from nine nursing homes in Israel. Participants with delusions were found to have significantly more difficulties in performing ADLs, and poorer vision and hearing. Based on assessment using the BEHAVE-AD, six categories of delusions were examined: 1. One's house is not one's home, 2. Theft, 3. Danger, 4. Abandonment, 5. Misidentification, and 6. Other non-paranoid. Common themes appeared across delusions including reality, disorientation, re-experience of past events, loneliness and insecurity, boredom, and trigger. Current results suggest that delusions may not represent psychotic symptoms for most participants, because they sometimes represented reality, or were neither firm nor incontrovertible. Thus, utilizing the term delusion relegates the person's behavior to the domain of severe psychiatric phenomena and precludes understanding its true meaning.

Anxiety, anxiety symptoms, and associations among older people with dementia in assisted-living facilities

Anxiety is a major cause for distress among older people with dementia, and it impedes care. In order to develop interventions to treat anxiety and identify who might be most likely to benefit, mental health nurses need to understand what clinical and demographic factors are associated with anxiety in dementia. This cross-sectional study is a detailed assessment of anxiety in people living in assisted-living facilities using the Rating Anxiety in Dementia (RAID) scale and the Clinical Anxiety Scale (CAS). One hundred and forty-eight people, with a mean age of 86.2 years, were recruited from 19 assisted-living facilities in the USA. Prevalence rates for anxiety were 11% and 18%, as measured on the RAID and CAS, respectively. One or more symptoms of anxiety were exhibited for 49% (RAID) and 48% (CAS) of participants. Behavioural symptoms and the presence of depression strongly predicted anxiety, as did staff's reaction to behavioural symptoms and their sense of competence to care. These findings demonstrate that anxiety is prominent enough to warrant further investigation and treatment, and that anxiety in older people with dementia is closely associated with staff skill. This study has also identified areas for mental health nurses to target interventions.

Indian research on aging and dementia

All the articles published in the Indian Journal of Psychiatry (IJP) from 1958 to 2009 on aging, dementia and other mental health issues of late life were systematically reviewed. There were only a limited number of research articles on dementia in the IJP. Most of the Indian studies on dementia were published elsewhere. People above the age of 60 years constitute about 5% of patients seen in tertiary care settings. High prevalence of psychiatric morbidity was reported among community resident older people. Depression was the commonest mental health problem in late life. We need to develop community-based interventions for management of common conditions like depression in late life. The effectiveness of these interventions needs to be established. It is important to identify risk factors for depression and dementia in our population. We could then try and modify these factors to reduce the prevalence of these conditions.

An overview of Indian research in depression

Depression as a disorder has always been a focus of attention of researchers in India. Over the last 50-60 years, large number of studies has been published from India addressing various aspects of this commonly prevalent disorder. The various aspects studied included epidemiology, demographic and psychosocial risk factor, neurobiology, symptomatology, comorbidity, assessment and diagnosis, impact of depression, treatment related issues and prevention of depression in addition to the efficacy and tolerability of various antidepressants. Here, we review data on various aspects of depression, originating from India.