Antipsychotic Prescribing in Older Adults after In-Hospital Initiation

Background

In older adults, the use of antipsychotics to treat delirium or the behavioural and psychological symptoms of dementia is potentially inappropriate and may be associated with adverse effects. Antipsychotics newly initiated in hospital may be inadvertently continued after discharge. In the Saskatchewan Health Authority (SHA) - Regina area, the frequency and duration of antipsychotic continuation for older adults after initiation during a hospital stay is unknown.

Objectives

To describe potentially inappropriate antipsychotic use in older adults after discharge from hospital, specifically rates of postdischarge antipsychotic therapy after initiation in hospital and continuation up to 180 days after discharge; prescribing regimens used; risk factors associated with continuation; pharmacist involvement; and plans for antipsychotic discontinuation, tapering, and/or follow-up.

Methods

This retrospective chart review included inpatients 65 years of age or older who were discharged from medicine units at SHA - Regina area hospitals between September 30, 2021, and June 28, 2022. Outpatient dispensing histories were also gathered.

Results

Of the 189 patients included in the analysis, 60 (31.7%) had continuation of antipsychotic therapy at discharge. Of these, 48 (80.0%), 33 (55.0%), and 24 (40.0%) had continuation of antipsychotic therapy at 30, 90, and 180 days after discharge, respectively. Of the patients with continuing antipsychotic therapy, 53 (88.3%) were 75 years of age or older, and 9 (15.0%) had documentation of an outpatient antipsychotic follow-up plan.

Conclusions

Postdischarge continuation of antipsychotics was similar to that reported in the literature. Patients continued on antipsychotics after discharge were at a greater than 50% risk of continuation at 90 days and were unlikely to have a follow-up plan. Future quality improvement efforts should include standardized prioritization of medication reviews, documentation of indications, and regular reassessment of therapy.

The impact of a hospital-based special care unit on behavioural and psychological symptoms in older people living with dementia

BACKGROUND

Hospital patients with behavioural and psychological symptoms of dementia (BPSD) are vulnerable to a range of adverse outcomes. Hospital-based Special Care Units (SCUs) are secure dementia-enabling environments providing specialised gerontological care. Due to a scarcity of research, their value remains unconfirmed.

OBJECTIVE

To compare hospital based SCU management of BPSD with standard care.

DESIGN

Single-case multiple baseline design.

SETTING AND PARTICIPANTS

One-hundred admissions to an 8-bed SCU over 2 years in a large Australian public hospital.

METHODS

Repeated measures of BPSD severity were undertaken prospectively by specialist dementia nurses for patients admitted to a general ward (standard care) and transferred to the SCU. Demographic and other clinical data, including diagnoses, medication use, and care-related outcomes were obtained from medical records retrospectively. Analysis used multilevel models to regress BPSD scores onto care-setting outcomes, adjusting for time and other factors.

RESULTS

When receiving standard care, patients' BPSD severity was 6.8 (95% CI 6.04-7.64) points higher for aggression, 15.6 (95% CI 13.90-17.42) points higher for the neuropsychiatric inventory, and 5.8 (95% CI 5.14-6.50) points higher for non-aggressive agitation compared to SCU. Patients receiving standard care also experienced increased odds for patient-to-nurse violence (OR 2.61, 95% CI 1.67-4.09), security callouts (OR 5.39 95% CI 3.40-8.52), physical restraint (OR 17.20, 95% CI 7.94-37.25) and antipsychotic administration (OR 3.41, 95% CI 1.60-7.24).

CONCLUSION

Clinically significant reductions in BPSD and psychotropic administration were associated with SCU care relative to standard ward care. These results suggest more robust investigation of hospital SCUs, and dementia-enabling design are warranted.

A short staff training system for behavioural and psychological symptoms of dementia in care facilities, based on functional analysis and positive behaviour support: a single-arm pre- and post-comparative study

BACKGROUND

Work schedules can make it challenging for professional care workers to participate in long-term training programs on managing behavioural and psychological symptoms of dementia (BPSD). Simultaneously, it is necessary to prevent caregivers' negative responses to BPSD, provide a positive environment for people with dementia, and create a system for new management plans, since the initial one is often unsuccessful. Therefore, we developed a short manual-based training system for functional analysis including positive behaviour support and strategies when management plans do not function well. This study aimed to preliminarily examine the usefulness of this system.

METHODS

Thirty-five staff members from 12 care facilities participated in the training. For each facility, off-the-job training was performed in two 120-min sessions held over 2 days. Then, care plans were implemented by staff members for a month, during which on-the-job training was provided. The study included 14 people with dementia and BPSD. This was a single-arm study without a control group. Pre- and post-tests were conducted to examine the effects of the training system using the Neuropsychiatric Inventory-Nursing Home Version.

RESULTS

The results of the pre- and post-tests for the total scores on severity and occupational disruptiveness significantly improved, with large effect sizes. Regarding symptom domains, delusions, agitation/aggression, and aberrant motor behaviour significantly improved in both severity and occupational disruptiveness. Depression/dysphoria and anxiety significantly improved in severity; however, there were trends of improvement in occupational disruptiveness. In addition, the effect sizes for severity and occupational disruptiveness of delusions and agitation/aggression were large.

CONCLUSIONS

This preliminary study suggests that the training system is promising. A randomised controlled trial with a larger sample size is necessary to confirm the findings.

"It's Opened My Eyes to a Whole New World": Positive Behaviour Support Training for Staff and Family Members Supporting Residents With Dementia in Aged Care Settings

OBJECTIVES

This study examined the acceptability and usefulness of Positive Behaviour Support (PBS) training in enhancing the capabilities of support staff and family members providing behaviour support to residents with dementia in residential aged care (RAC).

METHODS

A mixed-methods pilot study was conducted across 3 RAC organisations, involving pre- and post-training questionnaire assessments for clinical leaders (n = 8), support staff (n = 37) and family members (n = 18).

RESULTS

Findings indicated increased confidence among support staff and family members in providing behaviour support, with 96% indicating it would support their practices across settings. Key training benefits included identifying and addressing underlying causes of challenging behaviours. A majority (89%) expressed the need for further behaviour support training.

CONCLUSION

Recommendations focus on developing systems to enable effective and collaborative behaviour support practices. Further research is needed to examine application of PBS principles and planning for residents living with dementia.

Multimodal nonlinear correlates of behavioural symptoms in frontotemporal dementia

Background

Studies exploring the brain correlates of behavioural symptoms in the frontotemporal dementia spectrum (FTD) have mainly searched for linear correlations with single modality neuroimaging data, either structural magnetic resonance imaging (MRI) or fluoro-deoxy-D-glucose positron emission tomography (FDG-PET). We aimed at studying the two imaging modalities in combination to identify nonlinear co-occurring patterns of atrophy and hypometabolism related to behavioural symptoms.

Methods

We analysed data from 93 FTD patients who underwent T1-weighted MRI, FDG-PET imaging, and neuropsychological assessment including the Neuropsychiatric Inventory, Frontal Systems Behaviour Scale, and Neurobehavioral Rating Scale. We used a data-driven approach to identify the principal components underlying behavioural variability, then related the identified components to brain variability using a newly developed method fusing maps of grey matter volume and FDG metabolism.

Results

A component representing apathy, executive dysfunction, and emotional withdrawal was associated with atrophy in bilateral anterior insula and putamen, and with hypometabolism in the right prefrontal cortex. Another component representing the disinhibition versus depression/mutism continuum was associated with atrophy in the right striatum and ventromedial prefrontal cortex for disinhibition, and hypometabolism in the left fronto-opercular region and sensorimotor cortices for depression/mutism. A component representing psychosis was associated with hypometabolism in the prefrontal cortex and hypermetabolism in auditory and visual cortices.

Discussion

Behavioural symptoms in FTD are associated with atrophy and altered metabolism of specific brain regions, especially located in the frontal lobes, in a hierarchical way: apathy and disinhibition are mostly associated with grey matter atrophy, whereas psychotic symptoms are mostly associated with hyper-/hypo-metabolism.

Trends in the use of psychotropics in older people with dementia: interrupted time series of Finnish clinical guidelines of behavioural and psychological symptoms of dementia

BACKGROUND

Up to 90% of people with dementia experience behavioural and psychological symptoms of dementia (BPSD) as part of their illness. Psychotropics are not recommended as the first-line treatment of BPSD because older people are more prone to adverse reactions. In this study, we evaluate the impact of the Finnish clinical guidelines of BPSD (published in 2017) on psychotropic use in people with dementia.

METHODS

This study is based on Finnish Prescription Register data from 2009 to 2020. The data included all community-dwelling Finnish people aged ≥65 and who had anti-dementia medication purchases (n = 217,778). We used three-phased interrupted time series design to evaluate the changes in levels and trends of monthly (n = 144) psychotropic user rates compared with the predicted trends. In addition, we evaluated the changes in levels and trends of monthly new psychotropic user rates.

RESULTS

The level of monthly psychotropic user rate decreased non-significantly during the intervention period (β -0.057, P = 0.853), and during the post-intervention period, there was an increase in the level (β 0.443, P = 0.091) and slope (β 0.199, P = 0.198), but not statistically significant. The level of monthly new psychotropic user rate (β -0.009, P = 0.949) during the intervention period and the level (β 0.044, P = 0.714) and slope (β 0.021, P = 0.705) during the post-intervention period were almost unchanged.

CONCLUSIONS

Results may indicate possible challenges in deprescribing and better adherence to the guidelines at the beginning of BPSD treatment. Further research into the barriers to implement BPSD guidelines and the availability of non-pharmacological treatments is needed.

Ten-Year Trends in Psychotropic Prescribing and Polypharmacy in Australian General Practice Patients with and without Dementia

OBJECTIVE

Little research has evaluated trends in psychotropic prescribing and polypharmacy in primary care patients, especially those with dementia. We sought to examine this in Australia from 2011 to 2020 using the primary care dataset, MedicineInsight.

METHODS

Ten consecutive serial cross-sectional analyses were performed to evaluate the proportion of patients aged 65 years or more, with a recorded diagnosis of dementia, who were prescribed psychotropic medications within the first six months of each year from 2011 to 2020. This proportion was compared with propensity score-matched control patients without dementia.

RESULTS

Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. In 2011, 42% (95% confidence interval [CI] 40.5-43.5%) of patients in the dementia group had at least one recorded prescription of a psychotropic medication, which declined to 34.2% (95% CI 33.3-35.1%; p for trend < 0.001) by 2020. However, it remained unchanged for matched controls (36% [95% CI 34.6-37.5%] in 2011 and 36.7% [95% CI 35.7-37.6%] in 2020). The greatest decline in the dementia groups by medication class was for antipsychotics (from 15.9% [95% CI 14.8-17.0%] to 8.8% [95% CI 8.2-9.4%]; p for trend < 0.001). During this period, the prevalence of psychotropic polypharmacy (use of two or more individual psychotropics) also decreased from 21.7% (95% CI 20.5-22.9%) to 18.1% (95% CI 17.4-18.9%) in the dementia groups, and slightly increased from 15.2% (95% CI 14.1-16.3%) to 16.6% (95% CI 15.9-17.3%) in the matched controls.

CONCLUSIONS

The decline in psychotropic prescribing, particularly antipsychotics, in Australian primary care patients with dementia is encouraging. However, psychotropic polypharmacy still occurred in almost one in five patients with dementia at the end of the study period. Programs focused on encouraging further reductions in the use of multiple psychotropic drugs in patients with dementia are recommended, particularly in rural and remote regions.

The Acceptability and Usefulness of Positive Behaviour Support Education for Family Carers of People With Frontotemporal Dementia: A Pilot Study

AIM

This pilot study investigated the acceptability and usefulness of 4 weekly Positive Behaviour Support (PBS) education sessions (delivered face-to-face and online) for family carers of individuals diagnosed with behavioural-variant frontotemporal dementia (bvFTD). These sessions were adapted from the Family-directed Approach to Brain injury (FAB)-PBS program to the FTD population.

METHODS

A pre-test post-test mixed-methods design was utilized. Primary outcome measures included a Carer Confidence questionnaire and post-intervention Feedback Questionnaire. Assessments were conducted prior to the 4-week education program, immediately following the final session and a 3 months follow-up.

RESULTS

Ten family carers completed the 4 PBS education sessions and indicated that the program was helpful in providing behaviour support. No significant changes in confidence ratings were found before and following the education sessions. A majority of participants, however, reported positive changes to their approach in providing behaviour support, with key themes including 'recognising the function of behaviour', 'changing their own behaviour' and 'promoting a calmer approach'.

CONCLUSIONS

The FAB-PBS education sessions demonstrate to be an acceptable approach to increasing the capability of family carers in providing behaviour support to individuals with FTD, which will need to be confirmed in a larger feasibility study.

Propranolol for the management of behavioural and psychological symptoms of dementia

Propranolol is a β-adrenergic antagonist used in the management of hypertension, cardiac arrhythmia, and angina pectoris. There is some evidence that propranolol may benefit individuals with behavioural and psychological symptoms of dementia (BPSD). A total of three case series, one randomized controlled trial and one case report were identified (from a literature search of three major databases: PubMed, Ovid, and Cochrane collaboration) that assessed the use of propranolol for the management of BPSD. From these studies, it appears that propranolol improves BPSD, including agitation and aggression. Propranolol is also well tolerated with no significant bradycardia or hypotension noted in these studies. Current data on the use of propranolol for the management of BPSD are limited in comparison to other pharmacological agents (atypical antipsychotics, antidepressants, acetylcholinesterase inhibitors, memantine, and cannabinoids) and treatment modalities (repetitive transcranial magnetic stimulation and electroconvulsive therapy). The efficacy and safety of these treatments among individuals with BPSD has been evaluated in multiple controlled studies. In clinical practice, the routine use of propranolol among people with BPSD cannot be recommended at this time given the limited data. However, propranolol can be trialled among individuals with BPSD when symptoms have not responded adequately to other medications. Propranolol may also be used prior to embarking on trials of repetitive transcranial magnetic stimulation and electroconvulsive therapy among people with BPSD given the greater acceptance of this medication in the general population.

Prevention and management of behavioural and psychological symptoms in patients with dementia in acute care: a best practice implementation project

INTRODUCTION

Behavioural and psychological symptoms of dementia are very common in acute care. Agitation and aggressive behaviours are the most common symptoms and are challenging to manage. Early detection and a nonpharmacological approach are recommended.

OBJECTIVES

To implement evidence-based recommendations for the prevention and management of aggression/agitation in patients with dementia in an acute geriatric care unit.

METHODS

The project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. A baseline audit was conducted with seven audit criteria based on evidence summaries. It was followed by the implementation of an action plan and a follow-up audit.

RESULTS

Results showed moderate improvements in compliance with best practice recommendations. The second audit indicated an improvement up to 46% with the identification of factors/triggers that precipitate aggression/agitation and completion of a risk assessment. The highest improvement was the training of the nursing team (79%). Compliance with the involvement of patients and their families in the care planning improved slightly (14%). The lowest improvement was for the development and implementation of individualized care plans (10%).

CONCLUSION

The project implementation achieved some positive changes. A formalized process for preventing aggression/agitation is in place. The interprofessional collaboration, the support given to the nursing team and the basket of nonpharmacological interventions were strengthened. The electronic documentation and a limited collaboration of the nursing team were challenging. As further strategies were implemented, further audit would be required to assess achievement in change and/or demonstration of improved care provided for this vulnerable population.

Distinguishing apathy and depression in dementia: A longitudinal study

OBJECTIVES

Apathy is a common symptom in dementia, though can be difficult to distinguish from depression due to shared features and frequent co-occurrence. As such, a significant limitation of much previous research on apathy is the failure to control for depression. The current study sought to address this by examining the trajectory and clinical correlates of apathy after controlling for depression.

METHODS

Seven hundred and seventy-nine patients with dementia were recruited from nine memory clinics around Australia. Measures of dementia severity, cognition, functional ability, neuropsychiatric symptoms, caregiver burden and medication use were completed at baseline and at regular intervals over a 3-year period. Driving and institutionalisation data were obtained throughout the study. Mortality data were obtained from state registries 8 years after baseline.

RESULTS

Of the 662 patients with completed measures of neuropsychiatric symptoms, 342 (51.7%) had apathy and 332 (50.2%) had depression at baseline, while 212 (32.0%) had both. Whereas apathy increased over time, depression remained relatively stable. Apathy, but not depression, was associated with greater dementia severity, poorer cognition and function, driving cessation and mortality. Both apathy and depression were associated with greater neuropsychiatric symptoms, psychosis, caregiver burden and institutionalisation.

CONCLUSIONS

Apathy increases over the course of dementia and is associated with worse clinical outcomes independent of depression. Distinguishing apathy and depression appears important given their different implications for prognosis and management.

Hippocampal calcification and its effects on cognitive function and symptoms in dementia

BACKGROUND

Hippocampal calcification (HC), highly prevalent in older people, has not attracted attention until recently. Despite its potential effects on cognition and behaviour, and its possible impact on the diagnosis and severity of dementia, it has not been investigated. This study aimed to evaluate the prevalence of HC and its influence on cognition and behavioural symptoms in patients with dementia.

METHODS

Data from consecutive patients who visited a medical centre for dementia, for the first time between April 2016 and September 2018, were extracted and analysed. These data included the patients' demographics, the presence of HC and hippocampal thickness as measured on computed tomography, the diagnosis of dementia and its type, cognitive function measured using the Mini-Mental State Examination and the Clock Drawing Test, and the chief complaints or symptoms prompting the visit.

RESULTS

A high incidence of HC (85/267 patients) was observed. There was no significant difference in the ages of patients with and without HC. Patients with HC had higher cognitive function than those without HC at their first visit. This result was contrary to our expectations as it was not explained by the chief complaints recorded at the first visit.

CONCLUSIONS

Our study showed a high prevalence of HC in older patients with dementia. Patients with HC had better cognitive function than did those without HC during their first hospital visit. This study suggests that HC may not affect the cognitive functions related to dementia. However, further research is needed to evaluate the long-term consequences of dementia with HC.

Behavioural and psychological symptoms of early-onset and late-onset Alzheimer's disease among Chinese adults: analysis of modifiable factors

BACKGROUND

To conduct a comprehensive comparison of behavioural and psychological symptoms of dementia (BPSD) in Chinese people with early-onset Alzheimer's disease (EOAD) and late-onset Alzheimer's disease (LOAD) and analyse the factors of differences.

METHODS

A cross-sectional survey of 93 EOAD and100 LOAD and their caregivers in China from November 2018 to May 2019.

RESULTS

The total Neuropsychiatric Inventory score was significantly higher in LOAD. A higher level of agitation in EOAD was related to a lower quality of life of caregivers and the emotional expression of ignoring people with dementia. Higher euphoria scores in LOAD were associated with reduced negative coping by caregivers and reduced stability and predictability at home.

CONCLUSION

The early identification and management of specific BPSD of EOAD and LOAD by family members and health professionals may improve the quality of care and life for people with dementia and that of caregivers.

Animal-assisted intervention and agitation in patients with dementia: evaluation in a special care unit by the Cohen-Mansfield Agitation Inventory

BACKGROUND

Animal-assisted interventions (AAI) show promising results, but they suffer from a lack of studies and contradictory results.

OBJECTIVE

Our study deals with dog intervention and agitation in older patients with dementia.

METHODS

An epidemiological quasi-experimental study was carried out in patients living in a special care unit (SCU) in an Ehpad in the French Haut-Rhin region. Agitation was assessed using the Cohen-Mansfield Agitation Inventory at three consecutive periods one month after the introduction, discontinuation and resumption of a dog mediation.

RESULTS

26 patients were included in the study (76.92% female); mean age was 85.35 years and the mean score on MMSE was 6.85. Stopping AAI leads to an 11.9% relative increase in agitation (P = 0.03) whereas reintroduction of AAI leads to a 29.9% relative decrease in agitation (P < 0.0001).

CONCLUSION

AAI presents an interesting and efficient therapy for agitation in older patients with dementia. However, further studies are needed to standardise their implementation (rhythm, duration and type of interaction) in order to ensure an optimal care.

A nursing mentoring programme on non-pharmacological interventions against BPSD: Effectiveness and use of antipsychotics-A retrospective, before-after study

Behavioural and psychological symptoms of dementia (BPSD) are common and have significant implications for patients and caregivers. Non‐pharmacological interventions (NPI) have shown to be effective in the management of BPSD. However, the use of antipsychotics to treat BPSD remains ubiquitous. This retrospective, before–after study aimed to examine whether a nurse mentoring programme promoting NPI for BPSD management had a significant association with the use of antipsychotics in older adults with major neurocognitive disorders residing in different settings. Results obtained from the medical files of 134 older adults having benefitted from the mentoring programme demonstrate that this intervention significantly reduced BPSD. The effect on antipsychotics use was modest: a 10% reduction in the use of antipsychotics has been observed among patients for which the NPI were effective. However, the use of antipsychotics remained widespread despite the nursing recommendations of the mentoring team of the Center of Excellence on Aging in Quebec (CEVQ).

Behaviour assessment tools in long-term care homes in Canada: a survey

OBJECTIVE

Many people living in long-term care homes (LTCH) experience changes in behaviour termed the behavioural and psychological symptoms of dementia (BPSD). The valid and reliable assessment of BPSD is essential to guide treatment and monitor the effect of interventions. The aim of this study was to identify behavioural assessment tools implemented in LTCH and factors that impact on their use in clinical care.

METHODS

We completed an online mixed-design survey of 300 randomly selected Canadian LTCH between September and November 2018. Respondents were asked to report tools used, reasons for use, methods of administration, training/supports available, confidence in use and challenges faced. Survey results were summarized descriptively and the correlation between implementation supports and confidence examined. Free-text responses were analysed qualitatively.

RESULTS

Of 300 LTCH invited to participate, 103 completed the survey. Homes reported using a mean 2.2 ± 1.1 (range 0-7) different tools. The two most commonly used tools were the Dementia Observation System (DOS) and Cohen-Mansfield Agitation Inventory (CMAI). Overall confidence in most aspects of tool use was reported to be high, with workload identified as the greatest challenge. Training and supports correlated with confidence in tool use. Qualitative findings indicate tools provide valuable data to understand behaviours, facilitate team communication, target interventions and track outcomes.

CONCLUSIONS

Behavioural assessment tools, in particular a direct observation tool, are widely used in clinical care in Canadian LTCH. Education, enhanced resources, leadership support and applications of technology represent opportunities to improve their use.

Longitudinal Changes in Cognition, Behaviours, and Functional Abilities in the Three Main Variants of Primary Progressive Aphasia: A Literature Review

Primary progressive aphasias (PPAs) are a group of neurodegenerative diseases presenting with insidious and relentless language impairment. Three main PPA variants have been described: the non-fluent/agrammatic variant (nfvPPA), the semantic variant (svPPA), and the logopenic variant (lvPPA). At the time of diagnosis, patients and their families' main question pertains to prognosis and evolution, but very few data exist to support clinicians' claims. The objective of this study was to review the current literature on the longitudinal changes in cognition, behaviours, and functional abilities in the three main PPA variants. A comprehensive review was undertaken via a search on PUBMED and EMBASE. Two authors independently reviewed a total of 65 full-text records for eligibility. A total of 14 group studies and one meta-analysis were included. Among these, eight studies included all three PPA variants. Eight studies were prospective, and the follow-up duration was between one and five years. Overall, svPPA patients showed more behavioural disturbances both at baseline and over the course of the disease. Patients with lvPPA showed a worse cognitive decline, especially in episodic memory, and faster progression to dementia. Finally, patients with nfvPPA showed the most significant losses in language production and functional abilities. Data regarding the prodromal and last stages of PPA are still missing and studies with a longer follow-up observation period are needed.

Neuropsychiatric symptoms in early stage of Alzheimer's and non-Alzheimer's dementia, and the risk of progression to severe dementia

BACKGROUND

Neuropsychiatric symptoms (NPSs) in early dementia have been suggested to predict a higher risk of dementia progression. However, the literature is not yet clear whether the risk is similar across Alzheimer's dementia (AD) and non-Alzheimer's dementia (non-AD), as well as across different NPSs. This study examined the association between NPSs in early dementia and the risk of progression to severe dementia, specifically in AD and non-AD, as well as across various NPSs.

METHOD

This cohort study included 7,594 participants who were ≥65 years and had early dementia (global Clinical Dementia Rating [CDR] = 1). Participants completed Neuropsychiatric-Inventory-Questionnaire at baseline and were followed-up almost annually for progression to severe dementia (global CDR = 3) (median follow-up = 3.5 years; interquartile range = 2.1-5.9 years). Cox regression was used to examine progression risk, stratified by AD and non-AD.

RESULTS

The presence of NPSs was associated with risk of progression to severe dementia, but primarily in AD (HR 1.4, 95% confidence interval [CI]: 1.1-1.6) and not in non-AD (HR 0.9, 95% CI: 0.5-1.5). When comparing across various NPSs, seven NPSs in AD were associated with disease progression, and they were depression, anxiety, apathy, delusions, hallucinations, irritability and motor disturbance (HR 1.2-1.6). In contrast, only hallucinations and delusions were associated with disease progression in non-AD (HR 1.7-1.9).

CONCLUSIONS

NPSs in early dementia-especially among individuals with AD-can be useful prognostic markers of disease progression. They may inform discussion on advanced care planning and prompt clinical review to incorporate evidence-based interventions that may address disease progression.

Effects of the Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant accident on behavioural and psychological symptoms of dementia among patients

BACKGROUND

The Great East Japan Earthquake triggered accidents at the Fukushima Daiichi Nuclear Power Plant, becoming the first complex disaster that included both a natural and a nuclear power disaster. This study examines how complex disasters affect patients with dementia.

METHODS

Participants included the 331 people diagnosed with dementia out of the 2482 new patients (between January 2008 and December 2015) at a psychiatric hospital located in the indoor sheltering zones nearby mandatory evacuation zones. Medical records were retrospectively examined to identify the number of new patients with dementia, the severity, their chief complaints, and the behavioural and psychological symptoms of dementia (BPSD) types. BPSD were classified into the hyperactive BPSD group and the hypoactive BPSD group. The hyperactive BPSD group was further subdivided into the hyperactivity-impulsivity-irritability-disinhibition-aggression-agitation group, which exhibited agitation, disinhibition, and irritability, and the psychosis group, which exhibited delusions and hallucinations. The hypoactive BPSD group included depression, inactivity, apathy, and anxiety. Results were divided into the period before the complex disaster (2008-2010) and after (2012-2015) and were compared. In addition, the post-complex-disaster period was subdivided into the early phase (2012-2013) and the late phase (2014-2015).

RESULTS

The proportion of new patients with dementia increased significantly after the disaster. Although there was no change in patients' age and the disease's severity, the proportion of patients whose chief complaint was BPSD increased significantly after the disaster. Furthermore, there was a significant increase in the hyperactivity-impulsivity-irritability-disinhibition-aggression-agitation group in the early post-complex-disaster phase and a significant increase in the psychosis group in the late post-complex-disaster phase.

CONCLUSION

This complex disaster caused increased consultations from patients with dementia and increased BPSD. Additionally, it increased participants' symptoms of agitation and irritability in the early post-complex-disaster phase and the proportion of hallucinations and delusions in the late post-complex-disaster phase.

Apathy and agitation in institutionalized older adults: an empirically derived classification

BACKGROUND

Apathy and agitation are often recognized as the most problematic behavioural and psychological symptoms in care settings. In this study, we analyze the relationship between apathy and agitation symptoms other and their relationship with demographic, cognitive, and neuropsychiatric variables and psychotropic medication use.

METHODS

A retrospective study was conducted at a gerontological care centre in Láncara, Spain. Participants were 196 residents of the gerontological care centre, including 143 with a diagnosis of dementia. Apathy and agitation were assessed with the Apathy Scale for Institutionalized Patients with Dementia, Nursing Home version, and the Spanish version of the Cohen-Mansfield Agitation Inventory, respectively. Two-stage hierarchical cluster analysis (hierarchical cluster analysis in a first exploratory stage and K-means clustering to obtain the final solution in the second stage) was conducted to assign residents to different groups based on apathy and agitation scores.

RESULTS

In cluster 1, a certain level of apathy, the highest levels of agitation, and the most frequent intake of atypical antipsychotics and clomethiazole were observed. The highest levels of apathy and the most frequent intake of memantine were seen in cluster 2. The lowest levels of agitation and apathy and the highest levels of cognitive performance were found in cluster 3.

CONCLUSIONS

In this study, subjects with dementia were in a state of high agitation and eventual apathy, had low cognitive status, and were very old. Patients with this profile require well-designed non-pharmacological interventions.

Personalised music for residents with dementia in an Australian rural aged-care setting

OBJECTIVE

Personalised music reportedly has a positive effect on behaviour and mood in people living with dementia. This intervention has not been conducted in low-resourced or rural aged-care settings. We evaluated the effect of a non-therapist-led personalised music listening intervention on residents with dementia and workplace culture in a rural aged-care facility in South Australia.

DESIGN

Qualitative pilot study.

SETTING

Rural aged-care home in South Australia.

PARTICIPANTS

Ten residents with dementia and 15 aged-care staff participated in this study.

INTERVENTIONS

Ten residents participated in an 8-week music program. Four focus groups were conducted with aged-care staff post-intervention. A thematic analysis was used to identify emerging themes.

MAIN OUTCOME MEASURE

Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care.

RESULTS

Three themes emerged: quality of life, personalised care and better aged-care environment. Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care.

CONCLUSION

Personalised music program is an effective, low-cost intervention to improve quality of life and personalised care of residents living with dementia, staff well-being, and a workplace and culture in low-resourced or rural aged-care settings.

Post-traumatic stress disorder mistaken for behavioural and psychological symptoms of dementia: case series and recommendations of care

In late life, traumas may act cumulatively to exacerbate vulnerability to post-traumatic stress disorder (PTSD). PTSD is also a risk factor for cognitive decline. Major neurocognitive disorder (MND) can be associated with worsening of already controlled PTSD symptoms, late-life resurgence or de novo emergence. Misidentifying PTSD symptoms in MND can have negative consequences for the patient and families. We review the literature pertaining to PTSD and dementia and describe five cases referred for consultation in geriatric psychiatry initially for behavioural and psychological symptoms of dementia (BPSD), which were eventually diagnosed and treated as PTSD in MND subjects. We propose that certain PTSD symptoms in patients with MND are misinterpreted as BPSD and therefore, not properly addressed. For example, flashbacks could be interpreted as hallucinations, hypervigilance as paranoia, nightmares as sleep disturbances, and hyperreactivity as agitation/aggression. We suggest that better identification of PTSD symptoms in MND is needed. We propose specific recommendations for care, namely: clarifying diagnosis by distinguishing PTSD symptoms coexisting with different types of dementia from a specific dementia symptom (BPSD), gathering a detailed history of the trauma in order to personalise non-pharmacological interventions, adapting psychotherapeutic strategies to patients with dementia, using selective serotonin reuptake inhibitors as first-line treatment and avoiding antipsychotics and benzodiazepines. Proper identification of PTSD symptoms in patients with MND is essential and allows a more tailored and efficient treatment, with decrease in inappropriate use of physical and chemical restraints.

Impact of sensory impairments on dementia incidence and symptoms among Japanese older adults

BACKGROUND

Dementia and behavioural and psychological symptoms of dementia affect older adults' care-need levels. With aging comes an increase in the incidence of sensory impairments, which promotes the development of dementia. We investigated the association between sensory impairments - visual impairment (VI), hearing impairment (HI), and dual sensory impairment (DSI), the behavioural and psychological symptoms of dementia, and dementia incidence.

METHODS

This was a retrospective study that used Japanese long-term care insurance certification data from 2010 to 2017 of City A. The 2190 older adults who did not have dementia in 2010 were classified into four impairment categories: VI, HI, DSI, and no sensory impairment. The incidence of dementia was examined using Kaplan-Meier survival analysis and log-rank testing. Cox proportional hazards analysis was used to investigate the risk of developing dementia associated with sensory impairments, compared to the risk for no sensory impairment. Pearson's χ² tests were used to compare the prevalence of behavioural and psychological symptoms of dementia among the four groups.

RESULTS

HI and DSI were associated with a higher cumulative dementia incidence compared to no sensory impairment (log-rank χ² = 10.42; P  < 0.001, and log-rank χ² = 39.92; P  < 0.001, respectively), and DSI showed higher cumulative dementia incidence than HI (log-rank χ² = 11.37; P  = 0.001). Cox proportional hazards analysis showed that DSI is the greatest risk factor for developing dementia among sensory impairments (hazard ratio, 1.45; 95% CI, 1.22-1.71; P < 0.001). Older adults with VI had a significantly higher prevalence of day-night reversal than the other groups.

CONCLUSIONS

Our results indicate that older adults with sensory impairments have a high incidence of dementia, with DSI presenting the greatest risk. Older adults with VI were found to be more likely to have day-night reversal symptoms when dementia occurs.

Prolonged use of antipsychotic medications in long-term aged care in Australia: a snapshot from the HALT project

OBJECTIVES

Use of antipsychotic drugs in long-term aged care (LTC) is prevalent and commonly exceeds the recommended duration, but contributors to this problem are not well understood. The objective of this study is to provide a snapshot of the features of and contributors to prolonged use of antipsychotic medications (>12 weeks) among a sample of LTC residents.

DESIGN

We present retrospective and baseline data collected for the Australian Halting Antipsychotic Use in Long-Term Care (HALT) single-arm longitudinal deprescribing trial.

SETTING

Twenty-four long-term care facilities in Sydney, Australia.

PARTICIPANTS

The HALT study included 146 older people living in 24 Sydney LTC homes who had been prescribed a regular antipsychotic medication for at least 3 months at baseline.

MEASUREMENTS

Detailed file audit was conducted to identify the date and indication recorded at initial prescription, consenting practices, longitudinal course of prescribing, and recommendations for review of antipsychotic medication. Behavioural and psychological symptoms of dementia (BPSD) and functional dependence at baseline were assessed via LTC staff interview. Cognition at baseline was assessed in a participant interview (where possible).

RESULTS

Antipsychotics were prescribed for 2.2 years on average despite recommendations by a doctor or pharmacist for review in 62% of cases. Consent for antipsychotic prescription was accessible for only one case and contraindications for use were common. Longer use of antipsychotics was independently associated with higher dose of the antipsychotic drug and greater apathy, but not with other BPSD.

CONCLUSION

Antipsychotic medications appeared to be prescribed in this sample as a maintenance treatment in the absence of active indicated symptoms and without informed consent. Standard interventions, including recommendations for review, had been insufficient to ensure evidence-based prescribing.

HOMESIDE: home-based family caregiver-delivered music and reading interventions for people living with dementia: protocol of a randomised controlled trial

INTRODUCTION

Pharmacological interventions to address behavioural and psychological symptoms of dementia (BPSD) can have undesirable side effects, therefore non-pharmacological approaches to managing symptoms may be preferable. Past studies show that music therapy can reduce BPSD, and other studies have explored how formal caregivers use music in their caring roles. However, no randomised study has examined the effects on BPSD of music interventions delivered by informal caregivers (CGs) in the home setting. Our project aims to address the need for improved informal care by training cohabiting family CGs to implement music interventions that target BPSD, and the quality of life (QoL) and well-being of people with dementia (PwD) and CGs.

METHODS AND ANALYSIS

A large international three-arm parallel-group randomised controlled trial will recruit a sample of 495 dyads from Australia, Germany, UK, Poland and Norway. Dyads will be randomised equally to standard care (SC), a home-based music programme plus SC, or a home-based reading programme plus SC for 12 weeks. The primary outcome is BPSD of PwD (measured using the Neuropsychiatric Inventory-Questionnaire). Secondary outcomes will examine relationship quality between CG and PwD, depression, resilience, competence, QoL for CG and QoL for PwD. Outcomes will be collected at baseline, at the end of the 12-week intervention and at 6 months post randomisation. Resource Utilisation in Dementia will be used to collect economic data across the life of the intervention and at 6-month follow-up. We hypothesise that the music programme plus SC will generate better results than SC alone (primary comparison) and the reading programme plus SC (secondary comparison).

ETHICS AND DISSEMINATION

Ethical approval has been obtained for all countries. Results will be presented at national and international conferences and published in scientific journals and disseminated to consumer and caregiver representatives and the community.

TRIAL REGISTRATION NUMBERS

ACTRN12618001799246p; NCT03907748.

Discrete effect of each mild behavioural impairment category on dementia conversion or cognitive decline in patients with mild cognitive impairment

BACKGROUND

Neuropsychiatric symptoms (NPS) have been recognized as risk factors for conversion to dementia in patients with mild cognitive impairment (MCI). Early detection of NPS may allow for possible interventions in such patients. The present study used mild behavioural impairment to explore the role of NPS in a wide range of patients, from those who are cognitively intact to those with dementia.

METHODS

A total of 234 patients with mild cognitive impairment were followed up for up to 3 years in a Japanese cohort study. Longitudinal data from patients who developed dementia during the study and those who did not were statistically analyzed.

RESULTS

Cox regression analysis revealed that only abnormal perception and thought was significant in terms of dementia conversion. Moreover, mixed-effects models indicated that baseline mild behavioural impairment symptoms did not affect cognitive trajectories such as changes in Mini-Mental State Examination or Alzheimer's Disease Assessment Scale-cognitive subscale scores.

CONCLUSION

We conclude that only abnormal perception and thought content were risk factors for dementia and that NPS may not lead to deterioration of cognitive function in patients with mild cognitive impairment.

Noninvasive brain stimulation for behavioural and psychological symptoms of dementia: A systematic review and meta-analysis

BACKGROUND

Pharmacological and conventional nonpharmacological treatments for behavioural and psychological symptoms of dementia (BPSD) have only modest efficacy. Furthermore, pharmacotherapy carries the risk of important side effects. Noninvasive brain stimulation (repetitive transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS)) are valuable and safe for cognitive function in Alzheimer disease (AD). However, there have been few studies, and there is no consensus, regarding the use of these techniques to treat BPSD.

METHODS

We performed a systematic review of the literature and meta-analysis of studies reporting the effect of rTMS or tDCS on BPSD.

RESULTS

Seven articles were included: five randomized, controlled clinical trials and two open-label clinical trials. Five studies investigated the effects of rTMS and two the effects of tDCS. Both studies using tDCS reported no evidence of efficacy on BPSD, while two of the three RCTs using rTMS found statistically significant benefits. In an exploratory meta-analysis with four of the RCT studies, we did not find evidence of efficacy of noninvasive brain stimulation techniques, with an overall effect of -0.02 (95% CI = -0.90, 0.94; I²  = 85%). However, when we used only the data from the studies that applied rTMS, we found a positive effect on BPSD, with an overall effect of -0.58 (95% CI = -1.02, -0.14; I²  = 0%). With regards to the adverse effects reported, these were mild and not clinically relevant.

CONCLUSIONS

Our results establish a tendency for efficacy of rTMS protocols on BPSD, while corroborating their safety and tolerability, suggesting the need for further research.

Phenomenological contribution to understanding of vocally disruptive behaviour: A clinical case study in a patient with dementia

BACKGROUND

Behavioural and psychological symptoms of dementia (BPSD) cause great suffering in patients and their families. Phenomenology can help clarify the diagnosis and propose some new therapeutic responses using Daseinsanalyse. Separation issues understood using the phenomenological description of the melancholic type (MT) by Tellenbach may further shed light on our understanding of depression in dementia.

SUBJECT AND METHODS

In a 90-year-old woman presenting with advanced (Clinical Dementia Rating 3) mixed dementia and BPSD in the form of vocally disruptive behaviour (VDB), we discuss separation anxiety as the aetiopathogenic hypothesis. Depression and BPSD were assessed using the Neuropsychiatric Inventory, Cornell scale, and Montgomery-Åsberg Depression Rating Scale to confirm our second phenomenological diagnostic hypothesis, ie, melancholy. The Big Five Inventory scale filled in by a proxy was also used to evaluate the patient's premorbid personality. We then propose an explanatory frame of VDB and depression through the standard phenomenological assessment of its relation to time, space, self, and other.

RESULTS

Confirming MT, we found an inhibited temperament and low openness to experience in the patient, as well as a symbiotic relationship with a close relative (the other).

CONCLUSION

Separation anxiety may well explain the patient's MT expressed by VDB. Melancholic type and her symbiotic relationship led to a situation unbearable to the patient and her close relative unable to delegate care to a specialized team.

RUNNING HEAD

Phenomenology in vocally disruptive behaviour in dementia. We have found new explanations in similar clinical cases in dementia as follows. A patient presenting with vocally disruptive behaviour has a melancholic type, a behavioural-inhibited temperament, and marital violence in the past. Phenomenology may help explain this profile with neurobiological disorders. The life trajectory, from childhood into older age, must be taken into account to understand behavioural and psychological symptoms of dementia.

Factors influencing hospital admission among patients with autopsy-confirmed dementia

BACKGROUND

The symptoms of geriatric syndromes and the behavioural and psychological symptoms of dementia (BPSD), in addition to clinical conditions, are associated with hospital admission among dementia patients. However, the principal factors that necessitate hospital admission among dementia patients have not been fully elucidated.

METHODS

We retrospectively reviewed the data in the medical and autopsy reports of patients who had been treated at a hospital in Toyohashi, Japan. Each patient had been hospitalized sometime between 2012 and 2016 and underwent a brain autopsy. Dementia and the subtypes of dementia were diagnosed neuropathologically. Information about patients' general backgrounds, clinical conditions at the time of admission, and the geriatric syndrome symptoms and BPSD before admission was collected; comparisons were then made between patients with and without dementia and among those with the different major subtypes of dementia. Then, the factors relating to hospital admission of dementia patients were comprehensively evaluated by using principle component analysis.

RESULTS

Of the 128 eligible patients, 100 (78.1%) had dementia. In the comparison of patients with and without dementia, patients without dementia were younger at both admission (P = 0.034) and death (P = 0.003). Among the patients with dementia with Lewy bodies, delusions had a significantly high prevalence (P = 0.014). Principal component analysis identified nine components (disinhibition, irritability/lability, agitation/aggression, anxiety, delusions, sleep/night-time behaviour disorders, hallucinations, aberrant motor behaviour, and speech impairment) as the principal factors related to hospital admission among dementia patients. Thus, BPSD were identified as principal factors.

CONCLUSIONS

Compared to other factors, BPSD are more likely to cause dementia patients to be admitted to hospital. The present results indicate that measures should be taken to ameliorate the difficulties associated with caring for patients with BPSD at home.

Medial temporal lobe atrophy is independently associated with behavioural and psychological symptoms in Alzheimer's disease

AIM

Evidence describing the contribution of cerebral white matter disease and medial temporal atrophy (MTA) to behavioural and psychological symptoms of dementia (BPSD) has been conflicting. The aim of this study was to assess the relationship of white matter hyperintensities (WMH) and MTA observed on magnetic resonance imaging with BPSD among patients with Alzheimer's disease.

METHODS

In a cross-sectional study of a prospective cohort of patients attending a memory clinic, 46 patients with probable Alzheimer's disease (mean age: 72.38 ± 7.05 years) were studied. Sociodemographic, cognitive, and BPSD data were collected. BPSD were assessed using the Neuropsychiatric Inventory. Magnetic resonance imaging, WMH, and MTA were rated using the Scheltens scales for the assessment of signal hyperintensities and atrophy of medial temporal lobes. For multivariate analysis, two binary logistic regression analyses were carried out, with presence or absence of each BPSD as the dependent variable and with WMH or MTA as the predictor variable. Results of the logistic regression were analyzed to see if the significance of the WMH or MTA score was maintained in a model that factored in other possible confounding variables identified in univariate analysis.

RESULTS

The results of binary logistic regression analysis showed that in models that accounted for confounding variables, increased total MTA was significantly associated with apathy (odds ratio = 1.605, adjusted P = 0.042) and disinhibition (odds ratio = 0.607, adjusted P = 0.042). WMH measures did not significantly predict any BPSD item.

CONCLUSIONS

These findings indicate that MTA potentially contributes to the aetiology of BPSD, and they provide evidence to support the hypothesis that Alzheimer's disease pathology itself can contribute to BPSD.

Multifunctional arylsulfonamide derivatives with 5-HT6/5-HT7 receptor antagonistic activity: a structural study

Nowadays, a search for antagonists co-acting on serotonin receptor subtypes 6 and 7 (5-HT₆R and 5-HT₇R, respectively) is of great interest due to the increasing number of patients suffering from dementia and related behavioural and psychological symptoms. The X-ray crystal structures of four promising multifunctional ligands in the hydrochloride forms were determined, namely 4-(6-fluoro-1,2-benzoxazol-3-yl)-1-[3-(3-methylbenzenesulfonamido)propyl]piperidin-1-ium chloride, C₂₂H₂₇FN₃O₃S⁺·Cl^-, (I), 4-(6-fluoro-1,2-benzoxazol-3-yl)-1-[4-(5-fluoro-3-methylbenzo[b]thiophene-2-sulfonamido)butyl]piperidin-1-ium chloride, C₂₅H₂₈F₂N₃O₃S₂⁺·Cl^-, (II), 4-(6-fluoro-1,2-benzoxazol-3-yl)-1-[4-(6-fluorobenzo[b]thiophene-2-sulfonamido)butyl]piperidin-1-ium chloride, C₂₄H₂₆ClFN₃O₃S₂⁺·Cl^-, (III), and 4-(6-fluoro-1,2-benzoxazol-3-yl)-1-[3-(3-chloro-4-fluorobenzenesulfonamido)propyl]piperidin-1-ium chloride, C₂₁H₂₂ClF₂N₃O₃S₂⁺·Cl^-, (IV). Two pharmacologically important functional groups, i.e. arylsulfonamide and piperidinyl-fluorobenzisoxazole, are linked by three- and four-membered aliphatic chains. These compounds crystallize as hydrochloride salts in monoclinic space groups, i.e. C2/c for (I), P2₁/c for (II) and (III), and P2₁/n for (IV). In the asymmetric unit, a charge-assisted hydrogen bond is observed between the cation located at the piperidine N atom and the chloride anion. The protonated piperidine N atom is critical to the pharmacological activity for the compounds, allowing for a strong interaction with monoaminergic receptors in the central nervous system. The sulfonyl group plays the role of a hydrogen-bond acceptor in the pharmacophore model and is involved in several C-H...O interactions. Two aromatic fragments of the presented structures are involved in C-H...π contacts, which were studied by Hirshfeld structure analysis. The distances between the mentioned functional groups are in agreement with pharmacophore models given in the literature. The studied interactions observed in the crystal structure indicate the main forces responsible for ligand-receptor recognition and binding.

Predictors of potentially harmful behaviour by family caregivers towards patients treated for behavioural and psychological symptoms of dementia in Japan

BACKGROUND

Potentially harmful behaviour (PHB) by caregivers is detrimental to the physical and psychological well-being of care recipients. In Japan, few studies have investigated caregivers' PHB towards dementia patients. This study examined PHB in family caregivers of dementia patients with behavioural and psychological symptoms of dementia (BPSD) and identified factors related to PHB.

METHODS

Following primary consultations at an elderly psychiatric patient department, we enrolled 133 pairs of dementia patients and their family caregivers. We assessed PHB using the Japanese version of the modified Conflict Tactics Scale. We defined the presence of PHB as two or more points (PHB frequency of 'sometimes' or more) on at least one indicator of the modified Conflict Tactics Scale. We investigated the prevalence of PHB in relation to the clinical characteristics of the patients and their family caregivers. We evaluated BPSD using the Neuropsychiatric Inventory and caregiver burden using the eight-item Japanese version of the Zarit Caregiver Burden Interview.

RESULTS

Of the family caregivers, 48.9% showed PHB. Multivariate analysis identified the following association with PHB: caregiver's Zarit Caregiver Burden Interview total score (odds ratio [OR], 1.09 per unit increase; 95% confidence interval [95%CI], 1.02-1.16), and Neuropsychiatric Inventory scores for patient irritability (OR, 1.22 per unit increase; 95%CI, 1.06-1.40), appetite/eating disorders (OR, 1.41 per unit increase; 95%CI = 1.08-1.84) and daughters-in-law caregivers (OR, 0.17, 95%CI, 0.05-0.57).

CONCLUSIONS

Specific BPSD symptoms could contribute to the expression of PHB. In addition to decreasing caregiver burden, more intensive treatment and care strategies are required to manage individual symptoms.

Alzheimer disease: Non-pharmacological and pharmacological management of cognition and neuropsychiatric symptoms

OBJECTIVES

This clinical update review focuses on the management of cognition and the neuropsychiatric features of Alzheimer's disease (AD) and highlights current issues regarding pharmacological and non-pharmacological treatment, putative therapeutics and recent relevant research findings in this area.

CONCLUSIONS

AD is a neurodegenerative progressive condition characterised by cognitive impairment and functional decline. Most people with AD will demonstrate neuropsychiatric features, better known as behavioural and psychological symptoms of dementia (BPSD). Early recognition and treatment of BPSD are essential, as these cause considerable distress and carer burden. While there are many disease-modifying therapies for the cognitive symptoms still in the research stage, only symptomatic treatments are currently available for these and the BPSD.

Alzheimer's disease: clinical update on epidemiology, pathophysiology and diagnosis

OBJECTIVES

To provide a clinical update for general psychiatrists on the assessment and diagnosis of Alzheimer's disease (AD), highlighting current issues regarding epidemiology, risk factors and pathophysiology from recent relevant research findings.

CONCLUSIONS

Psychiatrists can apply their skills and training in the diagnosis of AD, which is based upon a comprehensive assessment comprising history, investigations, and cognitive and functional assessment, guided by accepted diagnostic criteria.

Behavioural and psychological symptoms in general hospital patients with dementia, distress for nursing staff and complications in care: results of the General Hospital Study

AIMS

Little is known about how behavioural and psychological symptoms of dementia (BPSD) manifest in the general hospital. The aim was to examine the frequency of BPSD in general hospitals and their associations with nursing staff distress and complications in care.

METHODS

Cross-sectional representative study with 1469 patients aged ≥65, including 270 patients with dementia, of 33 randomly selected general hospitals in Germany. BPSD and complications were reported by nurses.

RESULTS

Overall frequency of BPSD was higher in patients with dementia (76%) than without (38%). The most frequent symptoms in patients with dementia were nighttime disturbances (38%), depression (29%) and aberrant motor behaviour (28%) and the most distressing symptoms for nursing staff were delusions, aggression and nighttime disturbances. The overall frequency of BPSD increased from 67% in mild dementia, to 76% in moderate dementia and to 88% in severe dementia. The most frequent symptoms in patients without dementia were depression (19%), nighttime disturbances (13%) and irritability (13%). The most distressing symptoms were aggression and delusions, while the same symptoms were consistently rated as less distressing than in patients with dementia. Factor analysis revealed three independent groups of BPSD that explained 45% of the total variance. First, expansive symptoms (aggression, irritability, nighttime disturbances, aberrant motor behaviour and disinhibition) were frequent, distressing for nursing staff and associated with many complications. Second, psychotic symptoms (delusions and hallucinations) were infrequent, distressing and associated with some complications. Third, affective symptoms (apathy, anxiety and depression) were frequent, non-distressing and associated with few complications. The results did not change when cases with delirium were excluded from both groups.

CONCLUSIONS

BPSD are common in older hospital patients with dementia and associated with considerable distress in nursing staff, as well as a wide range of special treatments needs and additional behavioural and medical complications. Management strategies are needed to improve the situation for both patients and hospital staff.

Factors associated with quality of life of dementia caregivers: Direct and indirect effects

AIMS

To examine the direct and indirect relationships between the characteristics of people with dementia and caregivers associated with caregivers' quality of life.

BACKGROUND

Complex relationships exist among the factors associated with caregivers' quality of life.

DESIGN

This study was a retrospective cross-sectional design.

METHODS

The data were retrospectively extracted from participants who had visited the Center for Diagnosis of Dementia at Kyoto Prefectural University of Medicine from April 2013-March 2016. The data search was conducted on 21 April 2017. In total, 110 people with dementia and their caregivers participated. The characteristics of people with dementia were evaluated in terms of cognitive function, basic and instrumental activities of daily living and neuropsychiatric symptoms. We also evaluated caregivers' quality of life, depressive symptoms and care burden. Path analysis was used to investigate direct and indirect relationships.

RESULTS

The path analysis revealed that care burden and depressive symptoms directly affected caregivers' quality of life. Furthermore, declines in instrumental activities of daily living among people with dementia indirectly affected caregivers' quality of life, while declines in cognitive function of people with dementia also indirectly affected caregivers' care burden and depressive symptoms.

CONCLUSION

Caregiver quality of life was directly and indirectly affected by the characteristics of caregivers and people with dementia. The present findings provided evidence that factors related to both people with dementia and caregivers should be considered when nursing interventions are conducted.

The effect and importance of physical activity on behavioural and psychological symptoms in people with dementia: A systematic mixed studies review

Background

People with dementia may benefit from the effect of physical activity on behavioural and psychological symptoms of dementia. Qualitative synthesis of the importance of physical activity might complement and help clarify quantitative findings on this topic. The purpose of this systematic mixed studies review was to evaluate findings from both quantitative and qualitative methods about the effect and importance of physical activity on behavioural and psychological symptoms of dementia in people with dementia.

Methods

The systematic literature search was conducted in EMBASE, CINAHL, PubMed, PEDro and PsycINFO. Inclusion criteria were: people with a light to moderate degree of dementia, interventions including physical activity and outcomes focusing on behavioural and psychological symptoms of dementia or quality of life. To assess the methodological quality of the studies, the AMSTAR and GRADE checklists were applied for the quantitative studies and the CASP qualitative checklist for the qualitative studies.

Results

A small reduction in depression level and improved mood were seen in some quantitative studies of multi-component physical activity interventions, including walking. Due to high heterogeneity in the quantitative studies, a single summary of the effect of physical activity on behavioural and psychological symptoms of dementia should be interpreted with some caution. Across the qualitative studies, the common themes about the importance of physical activity were its ‘socially rewarding’ nature, the ‘benefits of walking outdoors’ and its contribution to ‘maintaining self-hood’.

Conclusion

For people with dementia, there was a small, quantitative effect of multi-component physical activity including walking, on depression level and mood. People with dementia reported the importance of walking outdoors, experiencing the social rewards of physical activity in groups, as well as physical activity were a means toward maintaining self-hood.

Use of parametric speaker for older people with dementia in a residential care setting: A preliminary study of two cases

Objective/Background

Older people with dementia often show behavioural and psychological symptoms of dementia such as agitation, aggression, and depression that affect their activities of daily living, and hence reduce the quality of life of their caregivers. The aim of this study was to investigate the effects of a new technological intervention-a parametric speaker, creating a narrow personal acoustic environment, which may reduce the manifestation of behavioural and psychological symptoms of dementia symptoms.

Methods

A parametric speaker was placed on the ceiling of a large day room, and personally selected pieces of music were provided in a narrow space just under the speaker during the intervention. Two older residents with behavioural and psychological symptoms of dementia participated in the experiment.

Results

Playing pieces of favorite music via the parametric speaker decreased their behavioural and psychological symptoms of dementia during the intervention. In addition, this intervention reduced the burden on caregivers. One of the advantages of using parametric speaker was being able to create a personal space in a common room.

Conclusion

We considered that the parametric speaker might be useful to reduce behavioural and psychological symptoms of dementia and the burden on caregivers, providing individualized rehabilitation for the improved quality of life of residents.

Vocally disruptive behaviors management in older people with dementia

Although shouting is a common psycho-behavioral symptom in geriatric institutions, the question of its assessment and treatment remains seldom studied and has rarely been the subject of specific recommendations. The combination of the focus group method and brainstorming has emerged as a methodology both relevant and feasible in geriatric facility to identify the coping strategies used by professionals and generalize guidelines for clinical observation and vocally disruptive behaviors management (shouting). The standardized gathering of professional experiences in nursing homes and their analysis with reference to results of the literature enabled the development of an analytical and clinical decision making diagram that can be an operational tool to cope with the occurrence of shouting in older people with dementia. Five types of triggers/aggravating shoutings emerged: 1) physical or moral pain and emotional reactions, 2) presence of sensory loss, 3) social isolation, under-stimulation or hyper sensitivity to stimulation and care, 4) reminiscences and 5) re-emergence of painful memories and loss of language skills. These factors have been associated with five methods of intervention : 1) pharmacological treatments, 2) animations, such as listening to music, physical activity and workshops using therapeutic mediation, 3) family or animal support and use of interventions to provide relaxation or stimulation, 4) interventions to deal with sensory deficits and 5) interventions modifying the environment.

Neuropsychiatric Symptoms in Mild Cognitive Impairment

OBJECTIVE

Neuropsychiatric symptoms (NPS) may be the first manifestation of an underlying neurocognitive disorder. We undertook a review to provide an update on the epidemiology and etiological mechanisms of NPS that occur in mild cognitive impairment (MCI) and just before the onset of MCI. We discuss common clinical presentations and the implications for diagnosis and care.

METHOD

The authors conducted a selective review of the literature regarding the emergence of NPS in late life, before and after the onset of MCI. We discuss recent publications that explore the epidemiology and etiological mechanisms of NPS in the earliest clinical stages of these disorders.

RESULTS

NPS have been reported in 35% to 85% of adults with MCI and also occur in advance of cognitive decline. The occurrence of NPS for the first time in later life should increase suspicion for an underlying neurocognitive disorder. The presenting symptom may provide a clue regarding the etiology of the underlying disorder, and the co-occurrence of NPS may herald a more accelerated cognitive decline.

CONCLUSIONS

NPS are prevalent in the early clinical stages of neurocognitive disorders and can serve as both useful diagnostic and prognostic indicators. Recognition of NPS as early manifestations of neurocognitive disorders will become increasingly important as we move towards preventative strategies and disease-modifying treatments that may be most effective when deployed in the earliest stages of disease.

What is the therapeutic value of antidepressants in dementia? A narrative review

OBJECTIVES

Antidepressants are commonly used in dementia. Depression is a frequent and important co-morbidity in dementia, and antidepressants are often used to treat depression and more widely. However, there are questions about their utility in depression in dementia and other behavioural and psychological symptoms of dementia. The aim of this narrative review is to summarize the evidence on whether there is therapeutic value in prescribing antidepressants to people with dementia.

METHODS

A PubMed search was performed to identify randomized controlled trials that prescribed antidepressants to people with dementia, either in the treatment of behavioural and psychological symptoms of dementia (depression, anxiety, agitation/aggression, psychosis and apathy) or for secondary outcomes (quality of life, carer burden, activities of daily living, cognition, clinical severity and adverse events).

RESULTS

Thirty-six randomized controlled trials were identified (participant n = 3386). A consistent finding in well-designed blinded placebo controlled trials in dementia is the lack of positive effect of antidepressants on outcomes of interest, including depression. One large well-designed study has reported a significant reduction in agitation in people with dementia, but at the expense of clinically significant adverse events. Otherwise, change observed in open trials is also seen in the placebo group, suggesting that any effect is not attributable to the prescription of antidepressants.

CONCLUSIONS

It is striking how few data there are on indications other than depression. We should question the use of antidepressants in dementia. Definitive trials of clinical effectiveness of specific indications such as anxiety and agitation in dementia and discontinuation of antidepressants in dementia are needed. Copyright © 2016 John Wiley & Sons, Ltd.

Development and effectiveness of an integrated inpatient and community service for challenging behaviour in late life: From Confused and Disturbed Elderly to Transitional Behavioural Assessment and Intervention Service

A common method of managing challenging behaviour associated with dementia is long-stay special care units, though models are very diverse. In New South Wales, Australia, the five remaining state-run long-stay special care units for this population were funded to adopt a shorter-term model which had been trialled by one of the units. Transitional Behavioural Assessment and Intervention Service Units, incorporating an integrated outreach team, were to provide multi-disciplinary assessments, develop individualised bio-psychosocial management plans for, and appropriately discharge people with significant levels of Behavioural and Psychological Symptoms in Dementia. The current study assessed both the effects of the change and the clinical effectiveness of the model.

METHOD

A repeated measures design, supplemented by multiple one-time measures. A range of standard instruments were administered, patient data from other types of inpatient units were obtained, interviews conducted, and medical records examined.

RESULTS

Transitional Behaviour Assessment and Intervention Service units were admitting patients with dementia and a variety of significant challenging behaviours. Length of stay was shortened in all units, patients turnover greatly increased, and there was a low re-admission rate. The model was substantially cheaper than psychiatric care in two units where it was fully implemented; one unit cost the same as psychiatric care, and two units were not cost-effective because of low occupancy - related to not fully implementing the model. Referring facilities reported that in the absence of the units, their main strategy would have been to increase sedation. In the Transitional Behavioural Assessment and Intervention Service units, behavioural incidents were primarily managed through psychosocial means. It is not known whether behaviour is reduced over time, staff become better at managing the behaviour when it occurs, or both.

CONCLUSION

The evaluation showed that the model can be transferred to other units and is a cost-effective way of assessing, managing, and successfully discharging people with complex challenging behaviours, though only when fully implemented.

Concept mapping to improve team work, team learning and care of the person with dementia and behavioural and psychological symptoms

The incidence of behavioural and psychological symptoms of dementia in residential aged care facilities is high. Effective team work and knowledgeable staff are cited as important facilitators of appropriate care responses to clients with these symptoms, but to achieve this within a resource-poor workplace can be challenging. In the study reported in this paper, concept mapping was trialled to enhance multifocal person-centred assessment and care planning as well as team learning. The outcomes of team concept mapping were evaluated using a quasi-experimental design with pre- and post-testing in 11 selected Australian residential aged care facilities , including two control residential aged care facilities , over a nine-month period. It was demonstrated that use of concept mapping improved team function, measured as effectiveness of care planning, as well as enhancing learning, with increased knowledge of dementia care even amongst staff who were not directly involved with the process. It is suggested that these results may be generalizable to other countries and care settings.

Alzheimer's disease patients institutionalized in group homes run by long-term care insurance exhibit fewer symptoms of behavioural problems as evaluated by the Behavioural Pathology in Alzheimer's Disease Rating Scale

BACKGROUND

The behavioural and psychological symptoms of dementia (BPSD) caused by Alzheimer's disease (AD) can burden caregivers. Group homes (GH), small nursing homes, for the elderly with dementia are institutions commonly run by the public long-term care insurance system in Japan. The purpose of this study was to compare the prevalence of BPSD of AD, as evaluated by the Behavioural Pathology in Alzheimer's Disease Rating Scale, between GH patients and community residents.

METHODS

A total of 74 patients with AD were enrolled: 37 were patients institutionalized in GH (Hachinski score < 5) and 37 were demographic-matched community residents undergoing treatment at the Osaki-Tajiri SKIP Center. There were no significant differences in mean age (81.4 vs 81.1 years, P = 0.816), mean educational level (7.7 vs 8.0 years, P = 0.497), sex (women/men: 30/7 vs 30/7, P = 1.000) and mean Mini-Mental State Examination scores (14.1 vs 14.1, P = 0.950) between the two groups. Care level (range: 0.5-5.0, slight to bedridden), activities of daily living care level (range: 1-7, almost normal to severe), and the presence or absence BPSD based on the domains of the Behavioural Pathology in Alzheimer's Disease Rating Scale were compared.

RESULTS

GH patients had a significantly higher care level (P < 0.05) and activities of daily living care level (P < 0.05) but had fewer symptoms of BPSD (P < 0.05) than community residents. When the activities of daily living care level was controlled, GH patients had significantly fewer symptoms than community residents in Aggressiveness (21% vs 50%; χ² = 4.5, P = 0.035), Affective disturbances (13% vs 42%; χ² = 5.1, P = 0.023), and Anxieties and phobias (4% vs 46%; χ² = 11.1, P = 0.001).

CONCLUSIONS

GH run by the long-term care insurance system appear to be effective in improving environmental factors for moderate AD patients and reducing Aggressiveness, Affective disturbances, and Anxieties and phobias.

Clinical efficacy of lamotrigine and changes in the dosages of concomitantly used psychotropic drugs in Alzheimer's disease with behavioural and psychological symptoms of dementia: a preliminary open-label trial

AIM

We investigated the clinical efficacy and changes in the dosages of concomitantly used psychotropic drugs in lamotrigine therapy in Alzheimer's disease with behavioural and psychological symptoms of dementia (BPSD).

METHODS

This study was a 16-week, preliminary open-label trial. The subjects were 40 inpatients. The outcome measures assessed were BPSD and cognitive function. BPSD was assessed with the Neuropsychiatric Inventory (NPI) and cognitive function was assessed with the Mini-Mental State Examination. The changes in the dosages of concomitant psychotropic drugs were also assessed.

RESULTS

Although the mean changes from baseline NPI scores and the two NPI subscales (anxiety and irritability) were significantly lower within the lamotrigine therapy group, no significant differences were found when we compared the lamotrigine therapy group to the control group. The mean decrease from baseline on the NPI agitation subscale, however, was significantly greater in the lamotrigine therapy group than in the control group (P < 0.05). Furthermore, the mean decrease from baseline in the diazepam-equivalent dose was significantly greater in the lamotrigine therapy group than in the control group (P < 0.05).

CONCLUSIONS

The results of this study suggest that the administration of lamotrigine to patients with severe Alzheimer's disease with BPSD may be effective and may make it possible to avoid increasing the dosage of antipsychotic medications prescribed to elderly patients.

Initial and long-term evaluation of patients with Alzheimer's after hospitalization in cognitive and behavioural units: the EVITAL study design

BACKGROUND

Alzheimer's disease and related disorders are characterized by cognitive impairment associated with behavioral and psychological symptoms of dementia. These symptoms have significant consequences for both the patient and his family environment. While risk factors for behavioral disorders have been identified in several studies, few studies have focused on the evolution of these disorders. Moreover, it is important to identify factors linked to the long-term evolution of behavioral disorders, as well as patients' and caregivers' quality of life. Our purpose is to present the methodology of the EVITAL study, which primary objective is to determine the factors associated with the evolution of behavioral disorders among patients with Alzheimer's disease and related disorders during the year following their hospitalization in cognitive and behavioral units. Secondary objectives were 1) to assess the factors related to the evolution of behavioral disorders during hospitalization in cognitive and behavioral units; 2) to identify the factors linked to patients' and caregivers' quality of life, as well as caregivers' burden; 3) to assess the factors associated with rehospitalization of the patients for behavioral disorders in the year following their hospitalization in cognitive and behavioral units.

METHOD/DESIGN

A multicenter, prospective cohort of patients with Alzheimer's disease and related disorders as well as behavioral disorders who are hospitalized in cognitive and behavioral units. The patients will be included in the study for a period of 24 months and followed-up for 12 months. Socio-demographic and environmental data, behavioral disorders, medications, patients and caregivers quality of life as well as caregivers burden will be assessed throughout hospitalization in cognitive and behavioral units. Follow-up will be performed at months 3, 6 and 12 after hospitalization. Socio-demographic and environmental data, behavioral disorders, medications, patients and caregivers quality of life, unplanned rehospitalization as well as caregivers burden will also be assessed at each follow-up interview.

DISCUSSION

The present study should help better identify the factors associated with reduction or stabilization of the behavioral and psychological symptoms of dementia in patients with Alzheimer's disease. It could therefore help clinicians to better manage these symptoms.

TRIAL REGISTRATION

Clinical Trials NCT01901263. Registered July 9, 2013.

Staff's views on managing symptoms of dementia in nursing home residents

Aim To identify the most common and distressing behavioural and psychological symptoms of dementia (BPSD) in nursing homes and to identify staff preferences regarding its behavioural management. Method A descriptive cross-sectional survey was completed by a self-selected sample of 247 staff working in 21 nursing homes in a defined catchment area. The survey contained items relating to experience in aged care work, attitudes towards BPSD, ratings of the importance of certain behavioural strategies for managing BPSD, and the Challenging Behaviour Scale. Results Shouting, wandering and restlessness had the highest incidence, frequency and difficulty ratings. Frequency of BPSD and level of satisfaction with how they were managed had the greatest effect on overall level of difficulty in managing behaviours. Staff rated discussing behavioural concerns at a group level and with senior nursing staff as the most important behavioural strategies. Conclusion A strong relationship was found between frequency and difficulty of BPSD. Therefore, interventions targeted at lowering frequency of BPSD are recommended. Communication across a number of levels may enhance the implementation of behavioural interventions.

Grouping of behavioural and psychological symptoms of dementia

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Instruments to measure behavioural and psychological symptoms of dementia

Reliable and valid measurement of behavioural and psychological symptoms of dementia (BPSD) is important for research and clinical practice. Here we provide an overview of the different instruments and discuss issues involved in the choice of the most appropriate instrument to measure BPSD in research. A list of BPSD instruments was generated. For each instrument Pubmed and SCOPUS were searched for articles that reported on their use or quality. Eighty-three instruments that are used to measure BPSD were identified. Instruments differ in length and detail, whether the interview is with participants, informants or by observation, the target sample and the time frames for use. Reliability and validity is generally good, but reported in few independent samples. When choosing a BPSD instrument for research the research question should be carefully scrutinised and the symptoms of interest, population, quality, detail, time frame and practical issues should be considered.