Anosognosia and depression in patients with Alzheimer's dementia

Anosognosia refers to impaired awareness of patients to realize deficits related to a disorder and is a common symptom of dementia. Anosognosia has far-reaching consequences for diagnosis and treatment and is probably associated with unfavorable prognosis. This study examined the relationship between anosognosia and depression in patients with Alzheimer's dementia (AD). Assessment included interviews of patients and their caregivers. Depressive symptoms were evaluated with observer and self-rating instruments: the Geriatric Depression Scale (GDS), and the “mood” subscale of the Nurses Observation Scale for geriatric patients (NOSGER). Anosognosia was evaluated with the Anosognosia Questionnaire for Dementia (AQ-D). For the evaluation of behavioral and neuropsychological symptoms in dementia and the caregiver burden, the neuropsychiatric inventory (NPI) and the Cares of older People in Europe (COPE) Index were administered. A total of 47 patients were enrolled in the study at the department's geriatric psychiatry outpatient clinic. A considerable discrepancy was found between observer- and self-ratings of depressive symptoms. In 74.5% of the participants, caregiver ratings indicated secondary symptoms of depression as opposed to patient ratings. Thus, in AD, anosognosia may affect not only deficits in cognition and everyday functioning but also affective symptoms (“affective anosognosia”). Caregiver rating therefore is particularly important when assessing mood changes in AD patients.     

Correlates of depression and burden for informal caregivers of patients in a geriatrics referral clinic

Caregiver burden has been associated with patient dementia. In this study we tested the hypothesis that caregiver burden and depression are related to patient cognitive impairment. We analyzed records of 127 elderly male patients from a Veterans hospital geriatrics referral clinic. The patients and their informal caregivers had been referred to the clinic because the complexity and multiplicity of their problems were beyond the treatment capability of other clinics. There was a high prevalence of dementia (73%) and depression (69%) in these patients according to Diagnostic and Statistical Manual (DSM-III) criteria. Quantitative measures of patient dementia and dependency in activities of daily living were not statistically associated with measures of caregiver depression or burden. In contrast, measures of patient depression were significantly correlated with measures of caregiver depression and burden. We hypothesize that caregivers of chronically ill, elderly men cope better with physical and cognitive incapacity than with affective symptoms. Because caregiver support is the most important factor in maintaining a disabled elder in the community, we suggest evaluating patients and caregivers for depression as part of standard practice in geriatric clinical settings.     

The relationship between caregivers' global ratings of Alzheimer's disease patients' quality of life, disease severity, and the caregiving experience

OBJECTIVES: To compare caregivers' ratings of Alzheimer's disease (AD) patients' global quality of life (QOL) using direct assessments and substituted judgments, and to identify qualities of the patients and their caregivers that are associated with these QOL assessments. DESIGN: Cross-sectional interviews. SETTING: A university-based Memory Disorders Clinic. PARTICIPANTS: Forty primary caregivers of AD patients. MEASUREMENTS: Direct scaling of overall quality of life (poor, fair, good, very good, or excellent) and measures of dementia severity, the caregiving experience, and patient and caregiver demographics. RESULTS: The majority of patients had mild (n = 20) or moderate (n = 11) AD. Caregivers' direct assessments of patient QOL were poor (5%, n = 2), fair (28%, n = 11), good (40%, n = 16), very good (20%, n = 8), and excellent (8%, n = 3). Twenty-one (52.5%) of the caregivers rated the patient's QOL the same as they thought the patient would; 12 (30.0%) rated the patient's QOL worse; and seven (17.5%) rated the patient's QOL better. Agreement between the two ratings was fair to moderate. Bivariate analyses showed that lower ratings of caregivers' direct assessments of patient QOL were associated with decreasing ratings of patient mental health and increasing dementia severity, caregiver burden, and caregiver depression. Multivariate models showed burden to be the significant predictor of caregivers' rating of patient QOL and the subscale measuring the caregivers' distress at controlling patient behavior had the strongest association with QOL. Lower ratings of substituted judgment assessments of patient QOL were associated with lower caregiver ratings of the patient's mental health. CONCLUSIONS: Nearly one-half of the caregivers of patients with predominantly mild to moderate AD assess a patient's QOL differently than they believe the patient would. Dementia severity and the caregiver's experiences of depression and burden negatively affect caregivers' assessments of QOL. These results provide a compelling reason why clinicians should take the time to screen for and address caregiver depression and burden and problematic patient behaviors.     

Role of depressive and cognitive status in self-reported evaluation of quality of life in older people: comparing proxy and physician perspectives

OBJECTIVE: To assess the quality of life (QOL) of older adults aged over 65 years, who were healthy or suffering from depressive syndrome (DS) and/or Alzheimer's disease (AD); to analyse agreement between participants' and proxies' QOL ratings; to evaluate the association between participants' depressive and cognitive symptoms and QOL rating; to correlate participants' health ratings and the severity of physician assessment. METHODS: 138 non-institutionalised older people of both genders and their respective caregiver and treating doctor were consecutively recruited (response rate 74.6%). Forty suffered from AD, 36 from DS, 35 from both conditions and 27 had neither. All participants were evaluated by Mini Mental State Examination, Geriatric Depression Scale and World Health Organization Quality of Life (WHOQOL) questionnaire. The caregiver filled out QOL-Proxy and the physician filled out the 'Health and Severity of Illness' form. RESULTS: The four groups scored significantly differently in all areas of WHOQOL-100 (WHOQOL questionnaire with 100 items). Participants with DS perceived their QOL as poorer than did healthy and AD subjects. Participants with AD and DS obtained intermediate scores. Severity of depression correlated with worsening QOL. Subjects with DS--but not those with AD, AD and DS, and, in some areas, healthy participants--had similar perception of their QOL to their proxies. Poor physical health ratings by the physician corresponded to poorly perceived QOL by the patient. CONCLUSION: Older people with AD perceive their own QOL similarly to and, in some areas, even better than healthy people of the same age. The opposite was observed among the depressed. Informants do not always evaluate QOL in the same way as healthy elders and those with AD, while there is more agreement with depressed patients. Informant evaluation may be helpful but is not necessarily reliable.     

What causes grief in dementia caregivers?

Alzheimer's disease (AD) is the most prevalent neurodegenerative disease in the world. Most AD patients become dependent on their relatives, i.e. family caregivers. Providing care to a person with AD influences caregiver's life and leads to feelings of grief, which often precede caregiver depression. The purpose of the article was to evaluate the Meuser and Marwit Caregiver Grief Inventory (MM-CGI-50) for use in Polish family caregivers and to find out determinants of grief of family caregivers of AD individuals living in Poland. A sample of 151 spouse and adult child caregivers of community-dwelling AD patients (95 females and 56 males) was interviewed to determine the influence of such factors as caregiver's age, gender, family relation to the care recipient (CR) and caregiving-related changes in caregiver's working time, leisure time and material status to find out the impact of caregiving role on intensity of caregiver grief. Caregiver grief was measured by means of MM-CGI-50. Additionally, carers were administered a questionnaire including patient's and caregiver's demographics. Also, CR's dementia assessment was informant-based and determined with investigator-administered clinical dementia rating (CDR) scale. Of all analyzed factors, only caregiver's informant dementia rating significantly influenced caregiver grief. To conclude, the effect of caregiver's age, gender, family relation to the CR and caregiving-related changes in caregiver's working time; leisure time and material status could not be found. To add, MM-CGI-50 can be effectively used to assess grief in Polish family caregivers of AD patients.     

Depression and dementia

Data from the literature devoted to the relationships between dementia and depression are controversial on account of numerous methodological biases (community studies or from neurological or psychiatric departments), categorical versus dimensional approaches and variability of assessment tools for depression, aim of the study (depression versus dementia or versus Alzheimer's disease, AD). The difficulty to discriminate depression from AD is largely overestimated due to the confusion between depression, depressive symptomatology and apathy. The distinction is greatly facilitated by taking into account the qualitative differences of the memory deficits and cerebral imagery. Distinction of depression from frontotemporal or subcortical dementias could be much more difficult. Relationships between depression and AD are controversial. Most reports of depression as a risk factor for AD in the subsequent years, actually describe depressed symptomatology linked to apathy in preclinical AD. However, some studies found a relationship between AD and depression occurring more than 10 years before the onset of AD symptomatology, suggesting some common risk factors. The so-called symptoms of depression in AD are more related to apathy and affective disturbances than to dysphoria. The frequency of major depressive episode (MDE), greatly varies according to studies, but the frequency of suicide is low. Depression in dementia is related to neurobiological factors as well as to psychological mechanisms. Therefore, its treatment should associate antidepressant drugs and psychological support directed to the patient and family.     

Management of psychosis in patients with Alzheimer’s disease: focus on aripiprazole

Psychosis of Alzheimer’s disease (AD) is characterized by delusions or hallucinations and may be associated with agitation, negative symptoms or depression. There are no psychotropic medications that are approved by the US FDA for the treatment of psychosis of AD. However, atypical antipsychotics have been widely used and recommended by geriatric experts in the management of psychosis of AD in view of the modest efficacy and relative safety until FDA warnings were issued in 2005 and meta-analytic studies showed no significant difference to placebo. The FDA warnings on the cardiac, metabolic, cerebrovascular, and mortality risks have caused serious concerns for the use of atypical antipsychotic agents in elderly patients with dementia. Only a few studies have evaluated prospectively the effects of aripiprazole in psychosis associated with AD. These studies show improvement in the symptoms of psychosis associated with AD with aripiprazole. The safety and tolerability profile of aripiprazole suggests a low potential for negative impact on dementia and overall patient health. Further studies comparing the efficacy and tolerability of aripiprazole vs other atypical antipsychotics in dementia are needed.     

Psychopathology of stroke

The psychopathology of stroke encompasses several psychiatric and behavioral disorders that have high prevalence in the geriatric population, reduce the patient autonomy and increase the caregiver's burden. These disorders are usually associated with other cognitive and neurological deficits, and are labelled as neuropsychiatric when the whole clinical picture is consistent with the specific dysfunction of a neural system or brain region. Thus the neuropsychiatry of stroke comprises disorders of the perception/identification of the self and the environment (anosognosia of hemiplegia, misidentification syndromes, confabulations, visual hallucinations, delirium and acute confusional state), amotivational syndromes (apathy and athymhormia), disorders of emotional reactivity (blunted affect, emotional incontinence, irritability, catastrophic reactions), poor impulse or ideation control (mania) and personality changes. The clinical profile of the subcortical vascular dementia also points to specific brain dysfunction (frontal-subcortical pathways) that manifests with behavioral (depression, emotionalism, irritability) and cognitive symptoms (psychomotor retardation, attention, executive and memory deficits). However, post-stroke depression and anxiety, which have a more variable clinical presentation and might be assimilated, for several aspects, to post-traumatic or adaptive disorders, are disorders less characterized in their neural correlates.     

Behavioral and psychological symptoms, cognitive impairment and caregiver burden related to Alzheimer's disease patients treated in an outpatient memory clinic

AIM: The relationships among behavioral and psychological symptoms of dementia (BPSD), cognitive impairment of Alzheimer's disease (AD) patients and the caregiver burden of their caregivers were investigated in an outpatient memory clinic. METHODS: Forty-six pairs of AD patients and their family caregivers were involved in this study. Neuropsychiatry Inventory (NPI) was used to estimate BPSD, to which memory symptoms were added as a subcategory of BPSD. MMSE, word fluency, clock drawing test and category-cued memory test were used for cognitive measurement. Zarit burden interview (ZBI) and CES-D were used to assess caregiver burden. RESULTS: Among 11 BPSD subcategories, memory symptoms, apathy, depression, delusion, aggression and anxiety were prevalent BPSD was a strong determinant of caregiver burden. Among BPSD symptoms, anxiety, aggression and aberrant motor behavior were significantly related to ZBL In terms of the relationship between BPSD and cognitive impairment, the scores for delusion and apathy were significantly related to the cognitive decline. On the other hand, patients who showed symptoms related to memory and depression had higher cognitive function than those who did not. CONCLUSION: These analyses will contribute to better assessment of AD patients and their caregivers, hopefully resulting in better support for them.     

An integrated program for dementia evaluation and care management.

The growth of the geriatric population and the emergence of managed care dictate new approaches to dementia care. Management of Alzheimer's disease (AD) is a critical issue for health care policy as well as quality of life for patients and caregivers. The Alzheimer's Disease Education Program (ADEP) seeks to improve the quality of care for individuals with AD and to reduce the burden of caregiving experienced by families. Objectives of ADEP include early detection of AD through dementia screening followed by caregiver education and support. This article outlines an effective method of dementia evaluation and management.     

Effects of rivastigmine on actigraphically monitored motor activity in severe agitation related to Alzheimer's disease: a placebo-controlled pilot study

Acetylcholinesterase inhibitors (AChEIs) are effective in the treatment of cognitive symptoms in Alzheimer's disease (AD). Because the behavioral and psychological symptoms of dementia (BPSD) have also been attributed to central cholinergic deficits, we examined whether the AChEI rivastigmine can reduce motor activity as measured in a rater-independent manner by wrist actigraphy in agitated AD patients. A total of 20 consecutive AD inpatients (13 females, 7 males, 80.4+/-9.1 years, S.D.) were included from our geriatric psychiatry unit, all of whom were exhibiting agitated behavior not attributable to delirium. Patients were assigned randomly and in a single-blinded fashion to rivastigmine 3mg or placebo for 14 days. Motor activity levels were monitored using an actigraph worn continuously on the wrist of the non-dominant hand. At the beginning and end of the study, patients were assessed using the Neuropsychiatric Inventory (NPI) and Nurses' Observation Scale for Geriatric Patients (NOSGER). Patients in the rivastigmine group exhibited less agitation than placebo recipients on the NPI-agitation subscale, but not on NOSGER. Actigraphic measurements showed a tendency towards reduced motor activity in the rivastigmine group. Because rivastigmine usually exerts its main effects after a longer period of time, the short-term effects seen in our study justify further controlled clinical trials examining the use of rivastigmine in BPSD by means of actigraphy.     

Risk factors and type of dementia: vascular or Alzheimer?

The most efficient strategy for combating Alzheimer's disease (AD) is to prevent the onset of clinically significant symptoms. Determining the clinical characteristics, risk factors, and indices of cognitive reserve would help in achieving this goal. The aim of this study was to determine the risk factors for AD and vascular dementia (VD) in the elderly and to highlight the importance of risk factor modification in the early diagnosis. Consecutive 1436 patients (mean age=72.7+/-6.9 years, 34.2% male) were enrolled in the study. After a comprehensive geriatric and cognitive assessment, patients were grouped as AD group (n=203), VD group (n=73) and normal cognitive status (NCS) group (n=1160). Thirty-three possibly related factors including demographic characteristics, co-existing diseases and laboratory parameters were examined. The results revealed that female sex, advanced age, depression, and intake of vitamin supplements were independent related factors for AD; whereas depression and low-density lipoprotein-cholesterol (LDL-C) were independent related factors for VD. For every geriatric patient admitted for any reason, cognitive assessment should be performed, risk factors should be determined and the patients at high risk should be followed up carefully.     

The Caregiver Burden Inventory in evaluating the burden of caregivers of elderly demented patients: results from a multicenter study

BACKGROUND AND AIMS: The burden perceived by caregivers of patients with dementia is a fundamental prognostic aspect in the history of the disease. The aim of this study was to demonstrate the internal consistency of the Caregiver Burden Inventory (CBI), a scale used to quantify burdens in different aspects of a caregiver's life, and the influence of patients' and caregivers' characteristics on its different dimensions. METHODS: In this cross-sectional study, 419 demented patients and their caregivers were evaluated in 16 geriatric centers in Italy. Cognitive status and behavioral disturbances were assessed by the Mini Mental State Examination (MMSE) and Neuropsychiatric Inventory (NPI), respectively. Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) were also evaluated. Comorbidity was assessed by the Cumulative Illness Rating Scale (CIRS). The severity of dementia was evaluated by the Clinical Dementia Rating (CDR) score. Caregiver distress due to the behavioral problems of the patient was assessed by the Neuropsychiatric Inventory-Distress, a subscale of the NPI which evaluates stress caused by each behavioral disturbance of the patient, and by the Brief Symptom Inventory which evaluates anxiety and depression. Burden was evaluated by the CBI. RESULTS: The CBI showed very high internal consistency (Cronbach's alpha value > 0.80). Factor analysis showed that the items clustered into four dimensions, and not five as originally proposed. Multiple regression analysis revealed that patients' behavioral disturbances and disability were the major predictors of the time-dependent burden; the psychophysical burden was explained mainly by caregiver anxiety and depression. CONCLUSIONS: The CBI proved to be an effective multidimensional tool for evaluating the impact of burden on many aspects of caregivers' lives.     

Use of the Geriatric Depression Scale in dementia of the Alzheimer type

The Geriatric Depression Scale (GDS) has been shown to be an effective screening test for depression in selected geriatric populations. However, it has not been evaluated as a screening test for depression among elderly adults with dementia of the Alzheimer type. Over a two-year period 283 patients were seen in a geriatric assessment center and were screened for depression using the Geriatric Depression Scale. They also received a clinical psychiatric diagnosis by one of two geropsychiatrists. Patients with a Clinical Dementia Rating (CDR) of 0 (cognitively intact) (n = 70) and those with mild Alzheimer's disease (CDR of 1) (n = 72) were selected for comparison. The data were analyzed using Receiver Operating Characteristic Curves (ROCs) in order to compare the utility of the Geriatric Depression Scale in these two groups. ROC curves, which plot sensitivity against false positives, have come into increasing use as a method of examining the clinical performance of tests. The area lying beneath the curve (AUC) can be estimated and used as a quantitative measure of test performance (equivalent to the Wilcoxon rank sum). In the intact group, the Geriatric Depression Scale produced a ROC curve with an AUC of 0.85 (percent score = 1), which is significant (z = 7.28, P less than .0001). In the group composed of those with Alzheimer's disease, the Geriatric Depression Scale yielded a ROC curve with an AUC of 0.66, which was not significantly different from chance (z = 1.92, P = NS). This study provides empirical evidence that while the Geriatric Depression Scale is an accurate screening test for depression in cognitively intact geriatric populations, it does not maintain its validity in populations that contain large numbers of patients with dementia of the Alzheimer type.     

Patient and caregiver characteristics associated with depression in caregivers of patients with dementia

OBJECTIVE: Many patients with dementia who live at home would require nursing home care if they did not have the assistance of family caregivers. However, caregiving sometimes has adverse health consequences for caregivers, including very high rates of depression. The goal of this study was to determine the patient and caregiver characteristics associated with depression among caregivers of patients with dementia. DESIGN: Cross-sectional study. PARTICIPANTS AND SETTING: Five thousand six hundred and twenty-seven patients with moderate to advanced dementia and their primary caregivers upon enrollment in the Medicare Alzheimer's Disease Demonstration (MADDE) at 8 locations in the United States. MEASUREMENTS: Caregiver depression was defined as 6 or more symptoms on the 15-item Geriatric Depression Scale. Patient characteristics measured included ethnicity and other demographic characteristics, income, activities of daily living (ADL) function, Mini-Mental Status Exam (MMSE) score, and behavioral problems. Caregiver characteristics measured included demographic characteristics, relationship to the patient, hours spent caregiving, and ADL and Instrumental Activities of Daily Living (IADL) function. We used chi2 and t tests to measure the bivariate relationships between patient and caregiver predictors and caregiver depression. We used logistic regression to determine the independent predictors of caregiver depression. RESULTS: Thirty-two percent of caregivers reported 6 or more symptoms of depression and were classified as depressed. Independent patient predictors of caregiver depression included younger age (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.33 to 2.76 in patients less than 65 years compared to patients over 85 years), white (OR, 1.53; 95% CI, 1.18 to 1.99) and Hispanic ethnicity (OR, 2.50; 95% CI, 1.69 to 3.70) compared to black ethnicity, education (OR, 1.16; 95% CI, 1.01 to 1.33 for those with less than a high school education), ADL dependence (OR, 1.55; 95% CI, 1.26 to 1.90 for patients dependent in 2 or more ADL compared to patients dependent in no ADL), and behavioral disturbance, particularly angry or aggressive behavior (OR, 1.47; 95% CI, 1.27 to 1.69 for patients with angry or aggressive behavior). Independent caregiver predictors of depression included low income (OR, 1.45; 95% CI, 1.18 to 1.77 for less than 10,000 dollars/per year, compared to >20,000 dollars per year), the relationship to the patient (OR, 2.73; 95% CI, 1.31 to 5.72 for wife, compared to son of male patient), hours spent caregiving (OR, 1.89; 95% CI, 1.51 to 2.38 for 40 to 79 hours/week compared to less than 40 hours/week), and functional dependence (OR, 2.53; 95% CI, 2.13 to 3.01 for ADL dependent compared to IADL independent). CONCLUSION: Caregiver depression is a complex process, influenced by ethnicity as well as diverse patient and caregiver characteristics. Efforts to identify and treat caregiver depression will need to be multidisciplinary and focus on multiple risk factors simultaneously.     

Awareness of memory deficits in patients with dementias: a study with the Everyday Memory Checklist

AIM: We examined the level of awareness of memory deficits in 63 patients with Alzheimer's disease (AD), 17 patients with dementia with Lewy bodies (DLB), 14 patients with vascular dementia (VaD), and 56 patients with amnestic mild cognitive impairment (MCI). METHODS: The unawareness of memory impairment was evaluated with a standardized memory questionnaire system based on the Everyday Memory Checklist (EMC). The EMC scores for the patient's own rating, the caregivers' rating and the unawareness score, defined as the discrepancy between these (caregiver rating-patient rating), were analyzed. RESULTS: Although the EMC self-rating scores were comparable among the four groups, the EMC scores in caregivers were significantly higher in the AD group than in the DLB, VaD, and MCI groups. Therefore, the unawareness scores were significantly higher in the AD groups than in other groups. When an unawareness score of 9 or more was defined as significant, impaired awareness was found in 41 (65%) patients with AD, 1 (6%) patient with DLB, 5 (36%) patients with VaD, and in 19 (34%) patients with MCI. CONCLUSION: We found that impaired awareness was found in two-thirds of patients with mild AD and even in one-third of patients with MCI. However, other dementias, in particular DLB, had less severe and less frequent unawareness of memory deficits than AD, suggesting the difference in the pathophysiology between them.     

Estimation of Short Temporal Intervals in Alzheimer's Disease

This study investigated the estimation of short temporal intervals in Alzheimer's disease (AD). Eight patients with dementia of the Alzheimer type, and eight age-matched controls were evaluated in a time estimation task. The task consisted in the production of three short empty intervals (5, 10, and 25's). Results indicated that AD patients show deficits both in the accuracy and precision of time judgments: in the three intervals evaluated, the magnitude of absolute error and the variability in time judgments were significantly greater in AD patients than healthy respondents (p <.01). These findings are discussed taking into account the contribution of attentional processes during the performance of temporal tasks. It is concluded that the estimation of short temporal intervals could be useful as an objective indicator of cognitive decline in AD.     

Medical comorbidity in Alzheimer's disease: baseline characteristics of the REAL.FR Cohort

PURPOSE: Alzheimer's disease (AD) evolves over about ten years with cognitive decline that can be considered as linear. Comorbidities are frequent in geriatric population. The major objective of this study is to determine whether comorbidity influences natural history of AD. MATERIALS AND METHODS: This is a prospective, multicentric French study (REAL.FR) of a cohort of ambulatory patients suffering from AD from a mild to a moderately severe stage, with a Mini-Mental State between 10 and 26, and followed with a caregiver. We evaluated the comorbidities and they were quantified using the Charlson index. RESULTS: We analysed 579 AD patients enrolled between April 2000 and June 2002. Majority of patients were women (72%). Average age and MMS average score were respectively 77.4 +/- 7.1 and 20.1 +/- 4.5. Cardiovascular diseases were the most frequent comorbid conditions (34%), before sensorial handicap (23%), and neurological diseases (18%) apart from dementia. Four AD patients groups differed according to the comorbidities figures, from none to more than three (maximum 8). Average Charlson index was 1.5 +/- 0.9. CONCLUSION: The follow-up of the four AD patients groups, differentiated by the comorbidities figures, should allow to precise the influence of comorbidities on the AD evolution. Charlson index could be used to quantify the comorbidities in the cohort's follow-up. However, this index, validated in a cohort of cancer patients, show limits for its use in geriatric population.