The Prevalence of Incontinence and Its Association With Urinary Tract Infections, Dermatitis, Slips and Falls, and Behavioral Disturbances Among Older Adults in Medicare Fee-for-Service

PURPOSE

The purpose of this study was to examine the prevalence of urinary (UI), fecal (FI), and dual incontinence (DI) in older adults and their association with urinary tract infections, dermatitis, slips and falls, and behavioral disturbances based on Medicare fee-for-service (FFS) claims data.

DESIGN

Retrospective analysis.

SUBJECTS AND SETTINGS

Data from administrative claims from the CMS Medicare Limited Data Set (5% sample) for all months in 2018 were reviewed. The analysis was limited to FFS Medicare beneficiaries, with minimum of 3-month enrollment in Parts A and B who were at least 65 years old. This cohort included 1.2 million beneficiaries in the United States.

METHODS

We used diagnosis codes to identify members with incontinence and grouped these members into 3 categories (UI only, FI only, and DI). We also divided claims based on 4 sites of care (nursing home, skilled nursing facility, home health, and self- or family care). We then determined the prevalence of (1) urinary tract infections (UTIs), (2) dermatitis, (3) slips and falls, and (4) behavioral disturbances for each type of incontinence.

RESULTS

We found that 11.2% of Medicare members had a claims-based diagnosis of incontinence in 2018. On average, those diagnosed with incontinence experienced 5 times more UTIs, 2 times as many dermatitis events, more than twice as many slips and falls, and 2.8 times more behavior disturbances compared to those without an incontinence diagnosis. For those with DI, the prevalence of the 4 outcomes was significantly higher (between 22% and 185%) compared to those with UI only.

CONCLUSIONS

Findings show that Medicare beneficiaries diagnosed as incontinent experience a much higher prevalence of UTIs, dermatitis, slips and falls, and behavioral disturbances compared to those without a diagnosis of incontinence. Our results suggest that incontinence may be an important indicator diagnosis for multiple other conditions and, if not well-managed, may challenge the desire for those who are incontinent to age at home.

Low-dose ketamine improves animals' locomotor activity and decreases brain oxidative stress and inflammation in ammonia-induced neurotoxicity

Ammonium ion (NH4 + ) is the major suspected molecule responsible for neurological complications of hepatic encephalopathy (HE). No specific pharmacological action for NH4 + -induced brain injury exists so far. Excitotoxicity is a well-known phenomenon in the brain of hyperammonemic cases. The hyperactivation of the N-Methyl- d-aspartate (NMDA) receptors by agents such as glutamate, an NH4 + metabolite, could cause excitotoxicity. Excitotoxicity is connected with events such as oxidative stress and neuroinflammation. Hence, utilizing NMDA receptor antagonists could prevent neurological complications of NH4 + neurotoxicity. In the current study, C57BL6/J mice received acetaminophen (APAP; 800 mg/kg, i.p) to induce HE. Hyperammonemic animals were treated with ketamine (0.25, 0.5, and 1 mg/kg, s.c) as an NMDA receptor antagonist. Animals' brain and plasma levels of NH4 + were dramatically high, and animals' locomotor activities were disturbed. Moreover, several markers of oxidative stress were significantly increased in the brain. A significant increase in brain tissue levels of TNF-α, IL-6, and IL-1β was also detected in hyperammonemic animals. It was found that ketamine significantly normalized animals' locomotor activity, improved biomarkers of oxidative stress, and decreased proinflammatory cytokines. The effects of ketamine on oxidative stress biomarkers and inflammation seem to play a key role in its neuroprotective mechanisms in the current study.

Specific neuropsychiatric symptoms are associated with functional decline trajectories in Alzheimer's disease and Lewy body dementia: a five-year follow-up study

Background

Neuropsychiatric symptoms (NPS) are often overlooked and under-identified symptoms associated with dementia, despite their significant impact on the prognosis of individuals living with the disease. The specific role of certain NPS in functional prognosis remains unclear.

Aims

To determine the association of different NPS with functional decline in people living with Alzheimer's disease (AD) or Lewy body dementia (LBD).

Methods

This is an analysis of data from the Dementia Study of Western Norway (DemVest) with 196 patients included of which 111 had AD and 85 LBD. The Neuropsychiatric Inventory (NPI) and the Rapid Disability Rating Scale (RDRS-2) for activities of daily living were administered annually for 5 years. NPI total score and individual items with RDRS-2 trajectories were analyzed with linear mixed models.

Results

The LBD group exhibited higher levels of functional impairment and a greater burden of NPS at baseline. Over the 5-year follow-up, hallucinations, aggression, depression, anxiety, apathy, disinhibition, aberrant motor behavior, nighttime behavior disturbances, and abnormal eating patterns were significantly associated with the decline in functional abilities in individuals with AD, as well as irritability and aberrant motor behavior in those with LBD.

Discussion

These results highlight the relevance of early detection and intervention of these particularly relevant NPS, due to its potential of also impacting physical function. Better detection and management of these NPS could improve functional prognosis in people living with dementia.

Conclusion

Specific NPS demonstrate relevant distinct associations with Longitudinal trajectories of functional decline in AD and LBD.

A PUS7 gene pathogenic variant causing self-injurious behavior, sleep disturbances, and developmental delay: A case report

PUS7 gene pathogenic variants cause a deficiency in an RNA-independent pseudouridine synthase, which results in a neurodevelopmental phenotype characterized by various degrees of psychomotor delay, acquired microcephaly, aggressive behavior, and intellectual disability. Since 2018, PUS7 deficiency has been described in 15 patients with different pathogenic variants but similar clinical phenotypes. We describe the case of a male infant with a homozygous truncating pathogenic variant in the PUS7 gene (c.329_332delCTGA; p.Thr110Argfs*4) who, in addition to the previously mentioned features, displays self-injurious behavior, sleep disturbances and motor stereotypies.

Association of Religious Service Attendance and Neuropsychiatric Symptoms, Cognitive Function, and Sleep Disturbances in All-Cause Dementia

Commonly reported in dementia, neuropsychiatric symptoms (NPS), cognitive decline, and sleep disturbances indicate dementia progression. With the growing dementia burden, identifying protective factors that may slow dementia progression is increasingly essential. Religion and spirituality are associated with better mental and physical health, yet few studies have been reported in older adults with dementia. This study examines associations between religious service attendance and symptoms of dementia progression. Using data from the Health and Retirement Study in 2000, 2006, and 2008 and the sub-study, Aging, Demographics, and Memory Study in 2001-2003, 2006-2007, and 2008-2009, we examined the association of religious attendance with neuropsychiatric symptoms, cognitive function, and sleep disturbances among U.S. older adults aged 70 years and older with all-cause dementia (N = 72) using Spearman's partial Rho correlation controlling for social interaction. Significant associations were identified for religious attendance and NPS (r_s (97) = -0.124, 95% CI [-0.129, -0.119], p < 0.0005); cognitive function, r_s (97) = -0.018, 95% CI [-0.023, -0.013], p < 0.001); and sleep disturbances, r_s (97) = -0.275, 95% CI [-0.280, -0.271], p < 0.0005). Beyond adjusting for social interaction, increased religious attendance was associated with lower NPS, better cognitive function, and fewer sleep disturbances. Clinical trials and longitudinal studies with a larger sample size examining religion and spirituality factors with dementia progression are warranted.

Aggression Towards Caregivers in Parkinson's Disease and Related Disorders: A Mixed Methods Study

Background

Aggression is one manifestation of behavioral disturbances in neurodegenerative disease with emerging literature suggesting a high prevalence in Parkinson's disease and related disorders (PDRD).

Objectives

Our aim was to describe characteristics, associated factors, and consequences of aggression towards caregivers in PDRD.

Methods

This is a convergent mixed methods study, leveraging data from 296 PDRD patient-caregiver dyads in a clinical trial of palliative care and semi-structured interviews with a subgroup of 14 caregivers who reported aggression. The primary outcome was baseline caregiver-reported aggression. Using multivariate linear regression, baseline dyad characteristics (eg, measures of disease, psychosocial issues, caregiver strain) were examined to identify factors associated with aggression. Thematic analysis of interviews was used to augment these findings.

Results

Associated variables included disease duration (r = 0.15, P < 0.05), patient grief (r = 0.22, P< 0.001), symptom burden (r = 0.18, r < 0.01), resistance to care (r = 0.40, P < 0.01), caregivers' depression (r = 0.16, P < 0.05), and caregiving burden (r = 0.34, P < 0.001). We identified five themes: (1) Aggressive behaviors range from verbal abuse to threats of physical violence; (2) Caregivers believe that aggressive behaviors result from the difficulty patients experience in coping with disease progression and related losses; (3) Caregivers' stress and mental health are worsened by aggressive behaviors; (4) Aggressive behaviors negatively affect patient-caregiver relationships; (5) Caregivers are ill-prepared to manage aggressive behaviors and cope with the consequences on their own.

Conclusions

Aggression in PDRD is driven by diverse factors (eg, grief, fluctuations in cognition) with serious consequences for caregivers. Neurologists and movement specialists should consider screening for aggression while prioritizing caregiver education and wellbeing.

Fifty years of experience with loxapine for the rapid non-coercive tranquilization of acute behavioral disturbances in schizophrenia patients, and beyond

INTRODUCTION

Acute behavioral disturbances in psychosis, including agitation, comprise a heterogeneous group of manifestations varying in intensity and duration they last for. They require rapid, non-coercive treatments ranging from verbal de-escalation to the calming effect of pharmacological agents. The treatment goals are reduction of patient suffering and prevention of disease deterioration. Stabilizing rather than sedating is preferred to ensure improved compliance and a stronger therapeutic alliance. Furthermore, animal pharmacology and clinical studies on agitation reveal the robust calming and anxiolytic properties of loxapine.

AREAS COVERED

This review covers the pharmacological and clinical history of loxapine along with research developments. It emphasizes the advantages of its multiple formulations ranging from injectable forms and tablets to orally inhaled forms to attain rapid and fine-tuned tranquilization.

EXPERT OPINION

Rapid tranquillization is achieved within 2-6 hours using liquid orally-consumed loxapine, and within an hour or less with its IM or orally inhaled forms. Loxapine has been adopted in the management of a wide range of acute disturbances, such as agitation in psychosis. In the context of personalized medicine, key cellular and molecular elements of the schizophrenia phenotype were recently shown to be improved with loxapine.

[The immediate impact of Covid-19 infection and the resulting lockdown on nursing home residents]

INTRODUCTION

Following the Covid-19 epidemic affecting 76 of the 97 residents (78.3 %) in a French nursing home, we assessed the impact of this cluster period on the physical and psycho-cognitive health of the residents, expecting in particular to observe effects that were dependent on their state of cognitive-behavioural dependence.

METHODS

We retained twenty-two variables, 5 relating to demographic data, 6 to the specific care linked to Covid-19 infection, 6 to somatic pathologies and psycho-behavioural disturbances before the epidemic and 5 to the period following it.

RESULTS

Eleven residents among those diagnosed positive died. Nine were transferred to a Covid unit, and 35 were asymptomatic. The main consequences of the period of infections were in particular behavioural, nutritional, and motor. A history of disruptive behaviours before the appearance of the cluster increased the risk of an aggravation of these behaviours by four (RR = 3.9, IC95 % = 1.38–11.02, p = 0.0042). Twenty per cent of the residents presented under-nutrition at the end of lockdown, but no specific risk factors could be identified. However, states of under-nutrition for the whole of 2020 were significantly more frequent than in 2019, in particular severe cases (χ² = 5.43, p = 0.02). A history of under-nutrition in the previous year increased twofold the likelihood of under-nutrition in the following year (RR = 2.07, IC95 % = 1.14–3.74, p = 0.02). The Covid cluster period also had an effect on the functional autonomy of certain patients.

CONCLUSION

Our main hypothesis relating to cognitive-behavioural dependence was not completely validated. The impact of the occurrence of the cluster remained moderate, in particular because of the care resources afforded by the nursing home. The advantages of a “medicalised” facility, and the problems associated with the restrictions of lockdown, are viewed in the light of ethical considerations.

The Frailty Puzzle: Searching for Immortality or for Knowledge Survival?

What is the value of assessing the biological age and frailty and predicting residual lifespan and health status? The benefit is obvious if we have means to alter the pace of aging and the development of frailty. So far, limited but increasing examples of interventions altering the predicted status indicate that, at least in some cases, this is possible through interventions spanning from the economic-social through drug treatments. Thus, why searching for biological markers, when some clinical and socio-economic indicators do already provide sufficiently accurate predictions? Indeed, the search of frailty biomarkers and of their biological clocks helps to build up a mechanistic frame that may orientate the design of interventions and the time window of their efficacy. Among the candidate biomarkers identified, several studies converge to indicate epigenetic clocks as a promising sensitive biomarker of the aging process. Moreover, it will help to establish the relationship between personal aging and health trajectories and to individuate the check points beyond which biological changes are irreversible.

Firearm access and dementia: A qualitative study of reported behavioral disturbances and responses

BACKGROUND

Cognitive impairment and behavioral changes associated with Alzheimer's disease and related dementias (ADRDs) can impair safe firearm handling ability, an issue that can be challenging for ADRD caregivers to address. In this qualitative analysis, we sought to explore behavioral disruptions that raise concerns about firearm access in dementia and how caregivers react and respond.

METHODS

Secondary qualitative analysis using data from semi-structured, one-on-one interviews originally conducted as part of a study to develop firearm safety educational materials for ADRD caregivers. Interviewees were English-speaking adults (≥18 years) from three stakeholder groups: ADRD caregivers (professional or informal), medical professionals (geriatricians, neurologists), and firearm professionals (retailers, range employees, instructors). For secondary analysis, transcripts of interviews were recoded and analyzed after an inductive-deductive thematic analysis process.

RESULTS

Among 24 participants, 17 (70%) were female and 20 (83%) white; 13 (54%) had personal or professional experience with ADRD caregiving; and 5 (21%) had a firearm affiliation. Major themes were: (1) behavioral disturbances that make caregivers concerned about firearm access; (2) caregiver emotional responses to and difficulties associated with these disturbances; and (3) caregiver actions (planned or actual) to limit firearms access.

CONCLUSION

Various behavioral disturbances and emotional burdens can trigger ADRD caregiver concern about firearms access, but strategies exist for restricting or safeguarding firearms in the home. Study findings suggest a need for caregiver support on this topic, including counseling by healthcare providers, advance planning for older firearm owners, and development of community resources.

Neuropsychiatric Symptoms in Patients with Neurocognitive Disorder and Their Performance Between Mild and Major Stages

BACKGROUND

The neuropsychiatric symptoms (NPS) in patients with neurocognitive disorders (NCD) increases the risk of exhibiting significant cognitive and functional decline. However, to the best of our knowledge, few studies have evaluated to what extent the presence of chronic and early NPS impacts cognition and functionality in patients with minor or major stages of NCD.

OBJECTIVE

We aimed to assess the interplay between early and chronic NPS and cognitive and functional presentation of patients with mild and major forms of NCD.

METHODS

We used two NPS tools tracking early and late NPS and assessed to what extent they determine cognitive and functional outcomes in patients with mild and major forms of NCD.

RESULTS

We found an inverse relationship between the presence of NPS, as measured by the Neuropsychiatric Inventory and Mild Behavioral Impairment Checklist (MBI-C), and cognitive and functional variables in major forms of NCD. In contrast, the minor stage of NCD was associated with increased MBI-C scores.

CONCLUSION

Our results revealed that NPS are associated with cognitive and functional outcomes in mild and chronic forms of NCD. Crucially our results suggest that NPS could be considered as a pathological marker of the clinical course of dementia. Additionally, our study calls to study early and late forms of NPS as both impact cognition and functionality of NCD.

Differentiating traits and states identifies the importance of chronic neuropsychiatric symptoms for cognitive prognosis in mild dementia

INTRODUCTION

Neuropsychiatric symptoms (NPS) in dementia are associated with poor cognitive outcomes in longitudinal studies. Whether this is due to differences in symptom burden between persons (BP) or changes within persons (WP) is unknown.

METHODS

Patients with mild Alzheimer's disease (AD, n = 111) and Lewy-body dementia (LBD, n = 85) were assessed annually for 8 years. We modelled the association between NPS assessed by the Neuropsychiatric Inventory (NPI) and Mini-Mental State Examinations (MMSE) using Tobit mixed-effects model with NPS as individual means over time (BP) and its deviance (WP).

RESULTS

The association between higher NPS and poorer cognitive outcomes was mostly due to BP differences for the NPI-total score, and in particular for delusions, hallucinations, agitation, aberrant motor behavior, and apathy scores.

DISCUSSION

The NPS trait (BP) effect on cognitive decline is considerably stronger than the state effect (WP). Clinically, long-term rather than episodic NPS better identifies patients with poor cognitive outcomes.

The Spectrum of Long-Term Behavioral Disturbances and Provided Care After Traumatic Brain Injury

Introduction: Behavioral disturbances are found in 50–60% of traumatic brain injury (TBI) survivors with an enormous impact on daily functioning and level of recovery. However, whether typical profiles can be distinguished and how these relate to provided care is unclear. The purpose of this study is to specify the characteristics of behavioral disturbances in patients with various severity of TBI and the impact on functional outcome. Furthermore, the pathways of care after hospital discharge for patients and their care givers are analyzed.

Methods: We performed a retrospective cohort study comprising 226 patients with mild TBI (mTBI; n = 107) and moderate-to-severe TBI (mod/sevTBI; n = 119) treated at the outpatient clinic and/or rehabilitation center of our university hospital between 2010 and 2015. Inclusion criteria were: behavioral disturbances as determined with the Differential Outcome Scale and age ≥16 years. Functional outcome was determined by the Glasgow Outcome Scale Extended and return to work (RTW) at six months to one year post-injury. Behavioral impairments and pathway of care were derived from medical files and scored according to predefined criteria.

Results: Overall 24% of patients showed serious behavioral disturbances; three times higher in mod/sevTBI (35%) compared to mTBI (13%). mTBI patients mostly showed irritation (82%) and anger (49%), while mod/sevTBI patients mostly showed irritation (65%) and disinhibition (55%). Most (92%) patients returned home, half of the patients did not RTW. Deficits in judgment and decision-making increased risk of no RTW 10-fold. One in ten patients was (temporarily) admitted to a nursing home or psychiatric institution. 13% Of caregivers received support for dealing with impairments of patients and 13% of the mTBI and 17% of the mod/sevTBI patients experienced relational problems.

Conclusions: The spectrum of behavioral disturbances differs between TBI severity categories and serious behavioral disturbances are present in a quarter of patients. Only half of the patients resumed work regardless of severity of injury suggesting that particularly the presence and not the severity of long-term behavioral disturbances interferes with RTW. Most patients returned home despite these behavioral disturbances. These findings underline the importance of early identification and appropriate treatment of behavioral disturbances in TBI patients.

Neuropsychiatric Symptoms as Predictors of Clinical Course in Neurodegeneration. A Longitudinal Study

Background: To study the extent to which neuropsychiatric symptoms (NPS) influence the cognitive and functional decline in frontotemporal degeneration (FTD) and Alzheimer’s disease (AD).

Methods: We assessed the progression of NPS and their influence on cognitive and functional progression in a group of FTD (n = 36) and AD patients (n = 47) at two different stages of the disease (2.5 years). A standardized scale was used to assess NPS—the Columbia University Scale for Psychopathology in Alzheimer’s Disease (CUSPAD)—which tracks different symptoms including depression, psychotic symptoms, as well as sleep and conduct problems. In addition, in a subsample of patients (AD n = 14 and FTD n = 14), we analyzed another group of NPS by using the Neuropsychiatric Inventory (NPI). Cognitive declines were tracked by using the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE), while functionality was tracked by using the Lawton scale and the Barthel Index.

Results: The presence of NPS impacts cognitive and functional decline in both groups of patients 2.5 years after disease onset. However, we observed a dissociable profile of the affectation of NPS in each group. In the AD group, results indicate that the progression of depressive symptoms and sleep problems predict cognitive and functional decline. In contrast, the progression of a mixed group of NPS, including conduct problems and delusions, predicts cognitive and functional decline in FTD.

Conclusion: The presence of NPS has a critical impact on the prediction of cognitive decline in FTD and AD patients after 2.5 years of disease progression. Our results demonstrate the importance of assessing different types of NPS in neurodegenerative disorders which, in turn, predict disease progression. Future studies should assess the role of NPS in predicting different neurocognitive pathways and in neurodegeneration.

Genotype and phenotype correlation in 103 individuals with 2q37 deletion syndrome reveals incomplete penetrance and supports HDAC4 as the primary genetic contributor

The 2q37 deletion syndrome, also described in the literature as brachydactyly-mental retardation syndrome (MIM 600430), is caused by deletion or haploinsufficiency of the HDAC4 gene, which encodes the histone deacetylase 4 protein. Although the most commonly described hallmark features of the 2q37 deletion syndrome include brachydactyly type E, developmental delay, obesity, autistic features, and craniofacial or skeletal dysmorphism, a literature review of 101 published cases plus two newly reported individuals indicates that there is a high degree of variability in the presence of some of the features that are considered the most characteristic of the syndrome: overweight and obesity (34%), cognitive-behavioral issues (79%), dysmorphic craniofacial features (86%), and type E brachydactyly (48%). These features overlap with other neurodevelopmental conditions, including Smith-Magenis syndrome (SMS), and may be incompletely penetrant or demonstrate variable expressivity, depending on the specific chromosomal anomaly. With the advent of fluorescence in situ hybridization (FISH), array-based comparative genomic hybridization, and next-generation DNA sequencing, more detailed molecular diagnoses are possible than in years past, enabling refined characterization of the genotype-phenotype correlation for subjects with 2q37 deletions. In addition, investigations into molecular and gene expression networks are expanding in neurodevelopmental conditions, and we surveyed HDAC4 downstream gene expression by quantitative real-time polymerase chain reaction, further implicating HDAC4 in its role in the regulation of RAI1. Correlation of clinical data defining the impact on downstream gene expression and the potential clinical associations across neurodevelopment will improve our understanding of these complex conditions and potentially lead to common therapeutic approaches.

Two Year Outcomes, Cognitive and Behavioral Markers of Decline in Healthy, Cognitively Normal Older Persons with Global Deterioration Scale Stage 2 (Subjective Cognitive Decline with Impairment)

BACKGROUND

Little is known with respect to behavioral markers of subjective cognitive decline (SCD), a condition initially described in association with Global Deterioration Scale (GDS) stage 2.

OBJECTIVE

Two-year interval behavioral markers were investigated herein.

METHODS

Subjects from a published 7-year outcome study of GDS stage 2 subjects were selected. This study had demonstrated a hazard ratio of 4.5 for progression of GDS stage 2, in comparison with GDS stage 1 (no subjective or objective cognitive decline) subjects, after controlling for demographic and temporal variables. Because GDS 2 subjects have previously demonstrated impairment in comparison with healthy persons free of complaints, we herein suggest the terminology "SCD(I)" for these persons. 98 SCD(I) persons, 63 women and 35 men, mean baseline age, 67.12±8.75 years, with a mean educational background of 15.55±2.60 years, and mean baseline MMSE scores of 28.9±1.24 were followed for 2.13±0.30 years.

RESULTS

Observed annual decline on the GDS was 6.701% per annum, very close to a 1986 published estimate. At follow up, the MMSE, and 7 of 8 psychometric tests did not decline significantly. Of 21 Hamilton Depression Scale items, 2 improved and the remainder were unchanged. Anxieties declined from multiple perspectives. The Brief Cognitive Rating Scale (BCRS) declined significantly (p < 0.001), with component declines in Remote memory (p < 0.01), and Functioning/self-care (p = 0.01).

CONCLUSION

SCD(I) persons decline at an annual rate of approximately 6.7% /year from several recent studies. The BCRS assessments and the Digit Symbol Substitution Test can be sensitive measures for future studies of progression mitigation.

Course of neuropsychiatric symptoms in dementia: 5-year longitudinal study

OBJECTIVE

Neuropsychiatric symptoms (NPS) in dementia are frequent and challenging for patients, carers, and the health care system, but few long-term studies exist. We analyse the longitudinal course of NPS in patients with mild dementia.

METHODS

A longitudinal cohort study of 223 patients with mild dementia and annual assessments using the Neuropsychiatric Inventory (NPI) for 5 years.

RESULTS

A total 1043 NPI assessments, representing 97% of all possible measurements of living cohort members, were analysed. Neuropsychiatric symptoms were common at baseline, and only a moderate increase in total NPS score from 15 to 17 with no increase in the proportion with high NPI total scores. Ninety seven percent scored ≥16, and 49% scored ≥36 on NPI total score at least once during follow-up. Individual NPS fluctuated and often reappeared. The most common symptoms ever reported was apathy (83%), depression (63%), appetite (63%), and aberrant motor behavior (60%). Cognitive decline was associated with higher NPI total score and several NPI items, but only the frequency of apathy increased significantly with time. Lewy body dementia was associated with higher NPI total score and psychotic symptoms. Alzheimer's disease was associated with increase in apathy.

CONCLUSIONS

Severe NPS are already common at time of dementia diagnosis, and the increase in overall severity over 5 years was moderate. Individual symptoms tend to fluctuate over time within patients and correspond to states rather than traits. These findings highlight the need to focus on, and plan for, NPS as part of dementia pathway, and are relevant for clinical trial design.

Psychiatric manifestations in Wilson's disease: possibilities and difficulties for treatment

Wilson's disease (WD) is an inherited metabolic disorder related to disturbances of copper metabolism, and predominantly presents with liver and neuropsychiatric symptoms. In most cases it can be successfully treated with anti-copper agents, and both liver function and neuropsychiatric symptoms typically improve. Treatment guidelines for WD include recommendations for anti-copper treatment as well as for the treatment of liver failure symptoms. Recently, recommendations for treatment of the neurological symptoms of WD have also been proposed. Although most WD patients present with psychiatric symptoms at some stage of the disease, currently there are no guidelines for the treatment of the psychiatric manifestations. Treatment of the psychiatric symptoms of WD is often guided by general psychiatric experience, which typically glosses over the specificity of WD, and can result in severe neurological and/or hepatic complications. Here we review and discuss the possible treatments available for the mood disturbances, psychosis, behavioral and cognitive disorders that can occur in WD, as well as their efficacy.

Memantine for Alzheimer's Disease: An Updated Systematic Review and Meta-analysis

BACKGROUND

The clinical benefit of memantine for Alzheimer's disease (AD) remains inconclusive.

OBJECTIVE

We performed an updated systematic review and meta-analysis of the efficacy/safety of memantine in AD.

METHODS

We included randomized trials of memantine for AD patients. Cognitive function scores (CF), behavioral disturbances scores (BD), and all-cause discontinuation were used as primary measures. Effect size based on a random-effects model was evaluated in the meta-analyses.

RESULTS

Thirty studies (n = 7,567; memantine versus placebo: N = 11, n = 3,298; memantine + cholinesterase inhibitors (M+ChEIs) versus ChEIs: N = 17, n = 4,175) were identified. Memantine showed a significant improvement in CF [standardized mean difference (SMD) = -0.24, 95% confidence intervals (95% CIs) = -0.34, -0.15, p < 0.00001, I2 = 35% ] and BD (SMD = -0.16, 95% CIs = -0.29, -0.04, p = 0.01, I2 = 52%) compared with placebo. In the sensitivity analysis including only patients with moderate-severe AD, memantine was superior to the placebo in reducing BD without considerable heterogeneity (SMD = -0.20, 95% CIs = -0.34, -0.07, p = 0.003, I2 = 36%). Compared with ChEIs, M+ChEIs showed a greater reduction in BD (SMD = -0.20, 95% CIs = -0.36, -0.03, p = 0.02, I2 = 77%) and a trend of CF improvement (SMD = -0.11, 95% CIs = -0.22, 0.01, p = 0.06, I2 = 56%). However, in the sensitivity analysis of double-blind, placebo-controlled studies only, M+ChEIs showed a significant reduction in BD compared with ChEIs without considerable heterogeneity (SMD = -0.11, 95% CIs = -0.21, -0.01, p = 0.04, I2 = 40%). When performing the sensitivity analysis of donepezil studies only, M+ChEIs was superior to ChEIs in improving CF without considerable heterogeneity (SMD = -0.18, 95% CIs = -0.31, -0.05, p = 0.006, I2 = 49%). No differences were detected in all-cause discontinuation between the groups.

CONCLUSIONS

The meta-analyses suggest the credible efficacy and safety of memantine in treating AD when used alone or in combination with ChEIs.

Memantine treatment for Japanese patients with moderate to severe Alzheimer's disease: a meta-analysis of double-blind, randomized, placebo-controlled trials

PURPOSE

Although previous meta-analyses of randomized trials in the world literature have provided strong evidence that supports the efficacy and safety of memantine for the treatment of patients with Alzheimer's disease (AD), it is unclear whether the drug is beneficial in the treatment of Japanese patients with moderate to severe AD because of differences in the formulation and regimen of memantine and the cholinesterase inhibitor (ChEI) used in combination with memantine between the drugs made in Japan and those made in other countries. To address this issue, we conducted a meta-analysis on the efficacy and safety of memantine using data from only double-blind, randomized, placebo-controlled trials (DBRPCTs) in Japan on Japanese patients with moderate to severe AD.

PATIENTS AND METHODS

Our primary analysis was conducted using data from both memantine monotherapy (memantine vs placebo) and memantine combination therapy (memantine+ChEI vs ChEI+placebo) studies. The primary outcomes measured were cognitive function and behavioral disturbances. The secondary outcomes measured were the subscale scores of Behavioral Pathology in Alzheimer's Disease (Behave-AD), discontinuation rate, and individual adverse events.

RESULTS

Four DBRPCTs (n=1,328) were detected. Memantine was superior to the control in cognitive functions (standardized mean difference [SMD]=-0.31, 95% CI=-0.53, -0.10) and behavioral disturbances (SMD=-0.16, 95% CI=-0.28, -0.05). Only memantine monotherapy was superior in both outcomes. It was also superior to the control in delusions, aggression, and diurnal rhythm disturbances based on the Behave-AD subscale scores. Although memantine was associated with a lower incidence of AD progression than that of the control, the incidence of somnolence was higher with memantine. There were no significant differences in other safety outcomes, including all-cause discontinuation, between the groups.

CONCLUSION

Our results suggest that memantine is useful for the treatment of patients in Japan with moderate to severe AD even though our meta-analysis comprised only four DBRPCTs.

A New Patient with Potocki-Lupski Syndrome: A Literature Review

Speech delay, intellectual disability, and behavioral disturbances are the main clinical manifestations of Potocki-Lupski syndrome. Other features include infantile hypotonia, the absence of major dysmorphism, sleep disorders, and congenital anomalies, particularly of the cardiovascular system. A male patient with Potocki-Lupski syndrome is reported herein. He showed speech and borderline cognitive delay, behavioral troubles with no signs suggestive of autism, in the absence of major dysmorphism. A de novo 17p12-p11.2 duplication spanning 3.6 Mb was detected, with boundaries from 15,284,052 to 18,647,233 (hg19 assembly). At the age of 5 years, the child showed a noticeable improvement of speech skills and a moderate scholastic performance was reached. Upon analysis of the clinical manifestations of the present patient and those reported in existing literature, we found that the syndrome may present in various degrees of clinical expressivity. Affected patients may manifest symptoms ranging from mild behavioral disturbances to severe degrees of autism.

Four novel ARSA gene mutations with pathogenic impacts on metachromatic leukodystrophy: a bioinformatics approach to predict pathogenic mutations

Metachromatic leukodystrophy (MLD) disorder is a rare lysosomal storage disorder that leads to severe neurological symptoms and an early death. MLD occurs due to the deficiency of enzyme arylsulfatase A (ARSA) in leukocytes, and patients with MLD excrete sulfatide in their urine. In this study, the ARSA gene in 12 non-consanguineous MLD patients and 40 healthy individuals was examined using polymerase chain reaction sequencing. Furthermore, the structural and functional effects of new mutations on ARSA were analyzed using SIFT (sorting intolerant from tolerant), I-Mutant 2, and PolyPhen bioinformatics software. Here, 4 new pathogenic homozygous mutations c.585G>T, c.661T>A, c.849C>G, and c.911A>G were detected. The consequence of this study has extended the genotypic spectrum of MLD patients, paving way to a more effective method for carrier detection and genetic counseling.

The treatment of behavioral disturbances and psychosis associated with dementia

Behavioral disturbances and psychosis associated with dementia are becoming an increasingly common cause of morbidity in patients with dementia. Approximately 70% of individuals with dementia will experience agitation, and 75% will experience symptoms of psychosis such as delusions or hallucinations. The goal of this article is to review the pharmacologic treatment options for behavioral disturbances and psychosis associated with dementia. A literature review was conducted on PubMed/Medline using key words of "dementia" and "interventions." The results were filtered for meta-analysis, clinical trials, and systematic reviews. The results were then reviewed. At this time, the most evidence exists for the use of a second generation antipsychotics (SGAs), but consideration should be given to their collective boxed warning of morbidity/mortality. The evidence for second line treatments are limited. There is limited evidence to support the use of first generation antipsychotics (FGAs), antidepressants, anticonvulsants, cognitive enhancers, and analgesics. Additional randomized control trials are needed to guide clinical decision making regarding the behavioral disturbances and psychosis associated with dementia.

The effects of memantine on behavioral disturbances in patients with Alzheimer's disease: a meta-analysis

BACKGROUND

Memantine is effective in the treatment of behavioral disturbances in patients with Alzheimer's disease. It has not yet been fully determined which behavioral disturbances respond best to memantine.

METHODS

We conducted a meta-analysis of memantine vs control (placebo or usual care) for the treatment of individual behavioral disturbances (delusion, hallucination, agitation/aggression, dysphoria, anxiety/phobia, euphoria, apathy, disinhibition, irritability/lability, aberrant motor activity/activity disturbances, nighttime disturbance/diurnal rhythm disturbances, and eating disturbances). Randomized controlled studies of memantine in patients with Alzheimer's disease were included in this study. To evaluate these outcomes, standardized mean difference (SMD), with 95% confidence intervals (95% CIs), based upon a random-effects model was evaluated in the meta-analysis.

RESULTS

A total of 11 studies (n=4,261; memantine vs placebo: N=4, n=1,500; memantine + cholinesterase inhibitors [M + ChEIs] vs ChEIs: N=7, n=2,761) were included in the meta-analysis. Compared to control, memantine showed significant improvement in agitation/aggression (SMD =-0.11; 95% CIs =-0.20, -0.03; P=0.01; I²=47%), delusion (SMD =-0.12; 95% CIs =-0.18, -0.06; P=0.0002; I²=0%), disinhibition (SMD =-0.08; 95% CIs =-0.15, -0.00; P=0.04; I²=0%), and nighttime disturbance/diurnal rhythm disturbances (SMD =-0.10; 95% CIs =-0.18, -0.02; P=0.02; I²=36%). Memantine was also marginally superior to control in hallucination (SMD =-0.06; 95% CIs =-0.12, 0.01; P=0.07; I²=0%) and irritability/lability (SMD =-0.09; 95% CIs =-0.19, 0.01; P=0.07; I²=42%). Memantine is similar to control in dysphoria, anxiety/phobia, euphoria, apathy, and eating disturbance.

CONCLUSION

The meta-analysis suggest that memantine has benefits for the treatment of most of the behavioral disturbances in patients with Alzheimer's disease. Memantine does not deteriorate negative symptoms as behavioral disturbances in patients with Alzheimer's disease.

Impact of dementia on behavioral independence and disturbance

AIM

Decreasing behavioral independence levels and increasing frequencies of behavioral disturbances are the most problematic aspects for people with dementia. However, the relative effects of dementia on these factors are unknown. We investigated variability in behavioral independence and disturbance profiles of patients with dementia.

METHODS

This was a cross-sectional correlation study in which 70 inpatients with dementia from convalescent wards in a hospital were enrolled. We assessed cognitive impairments with the Mini-Mental State Examination, evaluated behavioral independence levels with the Functional Independence Measure and assessed frequency of behavioral disturbances with the Dementia Behavior Disturbance Scale.

RESULTS

Coefficient determination was 0.395 (P < 0.0001) between the Mini-Mental State Examination and Functional Independence Measure scores, 0.261 (P < 0.0001) between the Mini-Mental State Examination and Dementia Behavior Disturbance Scale scores, and 0.355 (P < 0.0001) between the Functional Independence Measure and Dementia Behavior Disturbance Scale scores. The most easily accomplished behavioral independence was eating, and the hardest was transfer to tub/shower. The behavioral disturbance with the highest frequency was urinary incontinence, and the lowest was emptying drawers or closets.

CONCLUSIONS

Moderate correlations were found between severity of dementia and behavioral independence levels and frequencies of behavioral disturbances. There were both easier and harder to accomplish behaviors, and both higher and lower frequencies of behavioral disturbances. Geriatr Gerontol Int 2017; 17: 605-613.

Effect of Active Music Therapy and Individualized Listening to Music on Dementia: A Multicenter Randomized Controlled Trial

OBJECTIVES

To assess the effects of active music therapy (MT) and individualized listening to music (LtM) on behavioral and psychological symptoms of dementia (BPSDs) in persons with dementia (PWDs).

DESIGN

Randomized controlled trial.

SETTING

Nine Italian institutions.

PARTICIPANTS

Persons with moderate to severe dementia and BPSDs (N = 120) were randomized to one of three treatments.

INTERVENTIONS

All groups received standard care (SC), and two groups attended 20 individualized MT or LtM sessions, twice a week, in addition to SC.

MEASUREMENTS

The Neuropsychiatric Inventory (NPI), Cornell Scale for Depression in Dementia (CSDD), and Cornell-Brown Scale for Quality of Life in Dementia (CBS-QoL) were administered before treatment, after treatment, and at follow-up to evaluate behavioral and psychological outcomes. A specific coding scheme (Music Therapy Check List-Dementia) was used to evaluate the MT process.

RESULTS

Behavioral assessment did not show significant differences between groups. All groups showed a reduction over time in NPI global score (P ≤ .001), CSDD (P = .001), and CBS-QoL (P = .01). The NPI global score fell 28% in the MT group, 12% in the LtM group, and 21% in the SC group at the end of treatment. An exploratory post hoc analysis showed similar within-group improvements for the NPI Delusion, Anxiety, and Disinhibition subscales. In the MT group, communication and relationships between the music therapists and PWDs showed a positive albeit nonsignificant trend during treatment.

CONCLUSION

The addition of MT or LtM to standard care did not have a significant effect on BPSDs in PWDs. Further studies on the effects of the integration of standard care with different types of music interventions on BPSD in PWD are warranted.

The response of agitated behavior to pain management in persons with dementia

OBJECTIVES

Behavioral disturbances and pain are common in nursing home (NH) patients with dementia. An association between pain and increased agitation has been suggested, and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia. We now examined which specific agitated behaviors respond to individualized pain treatment.

DESIGN

Cluster randomized clinical trial.

SETTING

60 clusters (i.e., clusters defined as single independent NH units) in 18 NHs within five municipalities of Western Norway.

PARTICIPANTS

352 patients with moderate to severe dementia and clinically significant behavioral disturbances.

INTERVENTION

The control group received usual treatment and care. According to a predefined scheme for 8 weeks, all patients in the intervention group received individual daily pain treatment with acetaminophen, extended release morphine, buprenorphine transdermal patch, and/or pregabaline.

MEASUREMENTS

Cohen-Mansfield Agitation Inventory subscales and items.

RESULTS

Analyses demonstrated that Factor 3 (Verbally agitated behaviors) showed the largest significant difference (DF = 1204.0, t = -4.308, p <0.001), followed by Factor 2 (Physically non-aggressive behaviors) (DF = 1198.0, t = -2.672, p = 0.008), and Factor 1 (Aggressive behaviors) (DF = 1196.0, t = -2.093, p = 0.037) after 8 weeks, by a linear random intercept mixed model in two-way repeated-measures configuration with adjustment for heteroscedasticity.

CONCLUSION

We found that verbal agitation behaviors such as complaining, negativism, repetitious sentences and questions, constant request for attention, and cursing or verbal aggression responded to pain treatment. In addition, restlessness and pacing were sensible to analgesics. Such behaviors should therefore lead to an assessment of pain, and pain treatment. Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed.

Dronabinol for the treatment of agitation and aggressive behavior in acutely hospitalized severely demented patients with noncognitive behavioral symptoms

OBJECTIVE

Behavioral disturbances occur frequently in demented individuals and greatly increase the burden of their care. The efficacy of pharmacotherapeutic treatment options is modest. This study was conducted to explore the efficacy and safety of dronabinol as an adjunctive treatment for agitation and aggressive behavior in severely demented patients.

METHODS

Using a retrospective systematic chart review, we studied 40 inpatients from the McLean Hospital Geriatric Neuropsychiatry Inpatient Unit diagnosed with dementia and treated with dronabinol for behavioral or appetite disturbances. A group of geriatric psychiatrists consulted medical records to rate the patients' behaviors prior to initiation of dronabinol treatment and following up to seven days of treatment, using the Pittsburgh Agitation Scale, Clinical Global Impression, and Global Assessment of Functioning. Data on percentage of food consumed at each meal, sleep duration, and adverse events were also collected from medical records.

RESULTS

The addition of dronabinol to patients' treatment regimens was associated with significant decreases in all domains of the Pittsburgh Agitation Scale. There were also significant improvements in Clinical Global Impression scores, sleep duration and percentage of meals consumed during the treatment periods. Twenty-six adverse events were recorded during dronabinol treatment, none of which led to medication discontinuation.

CONCLUSION

This report represents the largest studied cohort of dementia patients treated with dronabinol to date and confirms earlier reports that dronabinol can serve as an adjunctive treatment for neuropsychiatric symptoms in dementia. Further research, including prospective controlled trials, is needed to clarify dronabinol's role in treating noncognitive behavioral symptoms of demented individuals.

Psychotropic medication use in canadian long-term care patients referred for psychogeriatric consultation

Background and Puspose

Prior studies have shown a high prevalence of psychotropic medication use among patients residing in long-term care homes (LTCHs). The purpose of this study was to examine psychotropic medication use by LTCH patients in a metropolitan Canadian city referred to outreach teams for psychiatric assessment.

Methods

A retrospective review of charts from specialized psychogeriatric outreach teams serving a large metropolitan city in Canada was undertaken. Data from 68 charts were reviewed. Data were analyzed using descriptive and correlational statistics.

Results

Antipsychotic medications were the most frequent drugs prescribed to patients referred for psychogeriatric assessment (55.9%), followed by antidepressants (50.0%), cognitive enhancers (44.1%) and benzodiazepines (29.4%). More than a quarter of patients (26.5%) were on three psychotropic medications. Medications were adjusted in 35.3% of cases mostly resulting in dose increases. Only 5.9% of patients had their medication dose reduced.

Conclusions

This preliminary exploratory study suggests that patients referred to specialized outreach teams may be a difficult-to-treat population. Further studies are required to establish effective prescribing practices and service delivery models.

Neuropsychological rehabilitation in a patient with ruptured anterior communicating artery aneurysm: 48 month outcomes

The neurobehavioral impairments associated with aneurysms of the anterior communicating artery (ACoA) are severe amnesia, executive problems and personality changes. Although most patients achieve a favorable neurological outcome, those cognitive deficits usually prevent return to previous activities and levels of social integration.