The use of psychotropic drugs for behavioral and psychological symptoms of dementia among residents in long-term care facilities in Japan

Objective: To examine whether the use of psychotropic drugs (PDs) was related to behavioral and psychological symptoms of dementia (BPSD) focusing on the prevalence, numbers of symptoms, severity, and care burden among the elderly with BPSD living in long-term care facilities in Japan.

Method: We conducted a cross-sectional survey among older people with dementia or similar symptoms (n = 312) using a questionnaire for care staff in 10 selected long-term care facilities. A brief questionnaire form of the Neuropsychiatric Inventory was used to assess BPSD.

Results: PDs were used in 45% among all participants and 47.5% among those exhibiting at least one BPSD. We found that use of PDs was associated with greater numbers, severity, and care burden of BPSD. Also, there was significantly more use of PDs among people who had specific BPSD symptoms, such as delusions, anxiety, and disinhibition, compared with those who did not.

Conclusion: The use of PDs among residents in long-term care facilities with dementia or similar symptoms was relatively low compared with previous reports from other countries. Nonetheless, the greater numbers, severity, and care burden of BPSD were associated with the use of PDs.     

The relation between mood,activity, and interaction in long-term dementia care

Objective: The aim of the study is to identify the degree of association between mood, activity engagement, activity location, and social interaction during everyday life of people with dementia (PwD) living in long-term care facilities.

Method: An observational study using momentary assessments was conducted. For all 115 participants, 84 momentary assessments of mood, engagement in activity, location during activity, and social interaction were carried out by a researcher using the tablet-based Maastricht Electronic Daily Life Observation-tool.

Results: A total of 9660 momentary assessments were completed. The mean age of the 115 participants was 84 and most (75%) were women. A negative, neutral, or positive mood was recorded during 2%, 25%, and 73% of the observations, respectively. Positive mood was associated with engagement in activities, doing activities outside, and social interaction. The type of activity was less important for mood than the fact that PwD were engaged in an activity. Low mood was evident when PwD attempted to have social interaction but received no response.

Conclusion: Fulfilling PwD's need for occupation and social interaction is consistent with a person-centred dementia care focus and should have priority in dementia care.     

新入伍军人睡眠质量与潜在攻击性的关系

目的:探讨新入伍军人睡眠质量及攻击行为的现状及二者的关系,为新入伍军人攻击行为的预防提供参考。方法:应用修订版外显攻击行为量表(MOAS)和匹兹堡睡眠质量指数(PSQI)量表对某部816名新入伍军人进行测评。结果:新入伍军人MOAS总分为(1.15±3.49),PSQI总分为(3.21±3.07)分,攻击行为检出率为3.7%,睡眠异常检出率为13.8%,明显高于正常男性群体(9.76%,P0.001);新入伍军人睡眠异常者MOAS各项目分及总分均高于睡眠正常者(t=2.10~4.38,P0.05或P0.01);睡眠质量异常者攻击行为发生率(9.73%)高于睡眠质量正常者(2.70%),其差异有统计学意义(χ2=13.59,P0.001);新入伍军人MOAS总分及各项目分与PSQI总分及各因子分呈整体正相关(r=0.197~0.911,P0.05或P0.01)。结论:新入伍军人的攻击行为与其睡眠质量有关。     

Differentiation of the pattern of cognitive impairment between depressed and non-depressed patients with dementia living in long-term care facilities

Objective: The principal objective of this study is to examine the cognitive profile of patients with dementia plus (D+ group) and without (D? group) concomitant depression.

Method: The D+ (N = 61) and D? (N = 89) patients were recruited in long-term care facilities. The depression status of the participants was determined using the Cornell Scale for Depression in Dementia. Cognitive functioning was assessed using the Hierarchic Dementia Scale (HDS).

Results: The analyses first indicated that on the total HDS score, patients of the D+ group exhibited more severe cognitive impairment compared to those of the D? group. Further analyses revealed that the difference between groups pertained to perception, attention/memory, calculation, and language functions. Moreover, secondary analyses revealed that the cognitive deficits of the D+ group were associated with behavioral (agitation and retardation, in particular), but not with mood-related, symptoms of depression. Interestingly, ideational symptoms of depression (suicide and self-depreciation, in particular) were positively correlated with cognitive impairment.

Conclusion: These findings add to those of previous studies showing that D+ and D? patients differ not only regarding the presence or absence of depressive symptoms, but also regarding cognitive manifestations. This study thus reinforces the need to detect and treat accurately depression in dementia.     

Incidence, prevalence, and outcomes of depression in residents of a long-term care facility with dementia

BACKGROUND: The course of depression in residents of long-term care with dementia is not well studied. OBJECTIVES: To estimate the incidence, prevalence, and outcomes of depression in long-term care residents with dementia. METHOD: 201 residents of Copper Ridge, a long-term care facility for the memory impaired, were followed every six months during the first year after their admission. RESULTS: On admission 19.9% of the residents had depression, the majority (75%) occurring in persons with a prior history of depression. At six months, only 15% of the original 40 depressed patients were still depressed, while at twelve months only 7.5% were depressed. The incidence of depression at six and twelve months was 1.8% and 6.4% respectively. Most persons with new depression at six months were no longer depressed at one year. The annual attack rate (cumulative likelihood of depression over one year) for the total population was 26.4%. The rates for the subgroup of Alzheimer's were similar to the rates of the total population, except for an annual attack rate of 17.5%, reflecting a lower rate of depression on admission. The decline in depression over the year after admission is noteworthy and likely reflects appropriate diagnosis and treatment of depression. CONCLUSIONS: These results indicate that, over the course of one year, depression afflicts a considerable proportion of long-term care residents with dementia. Admission to a long-term care facility may actually result in a reduction of depression within the year after admission in part due to rapid recognition, appropriate diagnosis and treatment.     

The relationship between staff burnout/distress and interactions with residents in two residential homes for older people

Objective. The main hypothesis was that staff burnout/distress would be negatively associated with the quantity and quality of social interactions between staff and residents. The subsidiary hypothesis was that ‘perceived involvement in decision-making’ among staff would be positively associated with the quantity and quality of staff–resident interactions. Design. Cross-sectional and within-group. Standardized self-report questionnaires completed by staff; and non-participant, time-sampling observation and coding of staff–resident interactions. Setting. Two independent (not-for-profit) residential care homes for older people in the UK. Participants. 18 out of 24 residential workers completed questionnaires. Measures. The 12-item General Health Questionnaire (GHQ-12); the Maslach Burnout Inventory (MBI); the Perceived Involvement Personal Questionnaire (PIPQ); and the Quality of Interactions Schedule (QUIS). Results. Staff who reported higher levels of personal accomplishment (ie lower levels of burnout on the personal accomplishment subscale) exhibited significantly more staff–resident interactions; and staff who perceived more involvement in decisions relating to their work showed significantly fewer negative staff–resident interactions. Staff distress, emotional exhaustion and depersonalization were not found to be significantly related to the quantity or quality of staff–resident interactions. Conclusions. The results provide some support for the hypotheses. It appears that levels of personal accomplishment and perceived involvement in decision-making among staff may significantly influence the quantity and quality of staff-resident interactions in residential settings. However, the causal relationships are uncertain, and replication of these findings is required in other contexts. © 1998 John Wiley & Sons, Ltd.     

Predictors of need-driven behaviors in nursing home residents with dementia and associated certified nursing assistant burden

Objective: We examined predictors of staff-reported need-driven behaviors and resistiveness to care in nursing home residents with dementia and predictors of certified nursing assistant (CNA) burden related to both constructs. Background and proximal factors from the need-driven dementia-compromised behavior model [Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K., et al. (1996). Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer's Disease, 5, 10–19] were examined as potential predictors of need-driven behaviors (NDBs) and resistiveness to care and CNA burden.

Method: We used secondary data analysis of prospective data from 10 nursing homes in Birmingham, Alabama. One-hundred and sixty-one residents (83.43 ± 8.56 years) with mini mental state examination (MMSE) score = 6.41 (± 6.66) were assessed via chart review, resident surveys, and surveys of CNAs.

Results: Multiple regression models revealed that cognitive functioning, activities of daily living functioning, race, gender, and CNA-reported weekly resident pain intensity were associated with resident NDBs. Regression models also revealed that weekly pain intensity and medical comorbidity were associated with CNA burden associated with the resident NDBs. However, we were unable to explain a significant amount of variance in the resistiveness to care or CNA burden associated with resistiveness to care.

Discussion: Results underscore the role of pain in both resident NDBs and associated CNA burden. Future research should focus on predictors of resident resistiveness to care and the relation of pain assessment and management practices to CNA burden. Moreover, interventions to improve resident care should seek to include CNAs in institutional pain assessment and management processes.     

The relationship between non-cognitive symptoms and functional impairment in Alzheimer's disease

OBJECTIVE: Cognitive impairment is an important determinant for functional impairment in Alzheimer's disease. The role of non-cognitive symptom is uncertain. The objective of this study was to investigate the role of non-cognitive symptoms as predictive factors for functional outcome in A.D. METHODS: This was a retrospective study. Subjects were recruited from the Memory Clinic in Queen Mary Hospital over a two years period. Patients with diagnosis of probable A.D. by NINCDS-ADRDA were identified. Demographic data, Folstein Mini-Mental Status Examination (MMSE), Clinical Dementia Rating (CDR), Neuropsychiatric inventory (NPI), Barthel activities of daily living (ADL) as well as Lawton's Instrumental activities of daily living (IADL) were retrieved. RESULTS: 100 patients were identified. Univariate analysis identified statistically significant correlation between hallucination and disinhibition score with Barthel Index (r=-0.43, p <0.001; r=-0.30, p=0.002 respectively); hallucination and aberrant motor act score with Lawton's IADL (r=-0.21, p=0.038; r=-0.21, p=0.038). MMSE was statistical significantly correlated with the above two functional scores. NPI was not statistical significantly correlated with any one of the functional measures. Multivariate regression analyses showed that hallucination score was an independent predictive factors for the Barthel index but not for the Lawton's IADL. MMSE score was identified to be independent predictive factor for all functional measures. CONCLUSIONS: Global cognitive impairment and hallucination was an important independent predictive factor for functional outcomes. Screening hallucination during the course of A.D. would be helpful. Further studies are needed to show the benefit of treatment of hallucination on the improvement of functional outcomes.     

Cognitive impairment in older people: future demand for long-term care services and the associated costs

BACKGROUND: Projections are presented of future numbers of older people with cognitive impairment (CI) in England, their demand for long-term care (LTC) services and future costs of their care. The sensitivity of the projections to factors that are likely to affect future LTC expenditure is explored. These factors include future numbers of older people, prevalence rates of CI, trends in household composition, informal care provision, care service patterns and unit costs. METHODS: A macrosimulation (or cell-based) model was developed to produce the projections, building on an earlier PSSRU model. Base case assumptions are made about trends in key factors expected to impact on future LTC expenditure, and variant assumptions about the key factors are introduced to test for sensitivity. RESULTS: Expenditure on LTC services for older people with CI is projected to rise from 0.60% of Gross Domestic Product (GDP) ( pound5.4 billion) in 2002 to 0.96% of GDP ( pound16.7 billion) in 2031, under base case assumptions. Under variant assumptions, the projection for 2031 ranges from 0.83% to 1.11% of GDP. These figures do not include the opportunity costs of informal care. CONCLUSIONS: Sensitivity analysis shows that projected demand for LTC is sensitive to assumptions about the future numbers of older people and future prevalence rates of CI and functional disability. Projected expenditure is also sensitive to assumptions about future rises in the real unit costs of services.     

Psychiatric assessment in medical long-term care facilities: Reliability of commonly used rating scales

Clinical assessment of psychopathology includes quantifying symptoms on rating scales. Caution must be used in applying standardized instruments to new populations because their reliability may alter considerably. This study assesses the interrater reliability of six well-known rating scales when applied to patients residing in a medical long-term care facility. The scales include measures of depression, psychosis and cognitive impairment. The specific scales used were: Hamilton Depression Scale; Brief Psychiatric Rating Scale; Mini-Mental State Examination; Mental Status Questionnaire; Global Deterioration Scale; and Brief Cognitive Rating Scale.     

Relationship between behavioral disturbances and characteristics of patients in special units for dementia

Abstract The aim of the present study was to examine the relationships between behavioral disturbances and patient characteristics of inpatients with dementia nationwide. The five patient characteristics used were age, gender, years of education, cognitive status, and walking ability. The subjects consisted of 730 inpatients selected by systematic sampling from 180 units that have specialized psychiatric beds for acute/long‐term care of dementia. Clinical staff members assessed the 730 patients with the Mini‐Mental State Examination (MMSE), and filled out a questionnaire for long‐term care insurance, including 19 items relating to behavioral disturbances and walking scale. Five meaningful factors were identified out of the 19 behavioral disturbances by factor analysis. Linear regression analysis revealed that the factor ‘psychotic/neurotic’ was not related to any patient characteristics; ‘aggression/negativistic’ was related to male gender and a lower MMSE score; and ‘dirty/destructive’ and ‘disorientation/fire management’ were related to a lower MMSE score and higher walking score. The factor ‘sexual behavior’ included only one behavior at a very low frequency. These findings suggest that different behavioral disturbance factors have different correlations with patient characteristics, while cognitive dysfunction has a relatively important role in behavioral disturbances of inpatients with dementia.     

The relationship between treatment settings and diagnostic attributions of depression among African Americans

Objective

To explore the relationship between treatment setting characteristics and diagnostic attributions of depression among community-dwelling African Americans.

Methods

Data come from the National Survey of American Life, a nationally representative sample of African Americans and Caribbean Blacks. Major Depression (MD) was assessed using the Composite International Diagnostic Inventory. Participants were categorized into four diagnostic groups: never MD, MD never attributed to physical health problems (i.e., affective depression), MD sometimes attributed to physical health problems (i.e., complicated depression), and MD always attributed to physical health problems (i.e., physical depression). Multinomial regression was used for assessment.

Results

Among 441 participants, 66.4% were classified as affective depression, 17.8% as complicated depression and 15.8% as physical depression. Seeking treatment from a mental health professional was associated with increased likelihood of being in the complicated depression group [adjusted odds ratio (AOR): 5.52; 95% confidence interval (CI): 2.28-13.36]. Seeking treatment from a family doctor was associated with physical depression (AOR: 2.93; 95% CI: 1.18-7.26). Seeking care from three or more different health care providers was associated with complicated depression (AOR: 1.99; 95% CI: 1.17-3.40).

Conclusion

Results suggest that encounters with health care providers influence the diagnostic attribution of depression in a systematic manner.     

The relationship between religiosity and health behaviors in female caregivers of older adults with dementia

The current study explored the relationship between three dimensions of religiosity: (a) organizational religiosity (e.g. attendance at religious events), (b) non-organizational religiosity (e.g. prayer), and (c) subjective religiosity (e.g. importance of religion) and caregiver health behavior patterns in a sample of Latina and Caucasian female caregivers of older adult relatives with dementia. It was hypothesized that religiosity would have a significant association with reduced cumulative health risk as determined by an index of health behaviors. It was also hypothesized that, when examining the individual health behaviors subsumed in the overarching index, religiosity would be positively associated with adaptive health behaviors like exercise and negatively associated with health risk behaviors like smoking. Amongst Caucasians, increased subjective religiosity was related to increased cumulative health risk. Conversely, in Latinas, non-organizational religiosity was positively correlated with improved dietary practices (reduced dietary restriction). Increased levels of subjective religiosity were significantly associated with decreased maintenance of a routine exercise regimen across ethnic groups. Recommendations for clinicians and religious leaders, and avenues of future research are discussed.     

Post-stroke patients in rehabilitation. The relationship between biological impairment (CT scanning), physical disability and clinical depression

A study of 128 consecutive patients with thromboembolic stroke in a rehabilitation hospital from July 1988 to September 1990 found a prevalence of major depression of 17%. The patient population was described according to the principles of the World Health Organization's (WHO) International Classification of Impairments, Disabilities and Handicaps (ICIDH) according to biological impairment, measured by computerized tomography (CT) scanning of the brain and side of hemiparesis and physical disability, measured by functional movement and activities of daily living. Handicap, referring to the interaction between disability and the environmental situation, often defined as the subjective disadvantage of being ill, was not measured in this study. A stroke index with four items was generated from the parameters describing biological impairment and physical disability. The psychiatric rating scales (the 17-item Hamilton Scale for Depression (HAM-D), the Melancholia Scale [MES]and the Newcastle Diagnostic Depression Scale), and the new stroke-index showed adequate coefficients of Cronbach's alpha and Loevinger, suggesting that these scales have both adequate item correlation and homogeneity (adequate hierarchical structure). The impairment disability index of stroke thus seems to be a meaningful measurement of the specific factors of this disease. There was no correlation between the stroke-index and the psychiatric rating scales measuring the emotional dimension of disability caused by the disease expressed as depression. The results suggest that the depression found among stroke patients is not a simple reaction to the physical disability of the stroke.     

Fulfilled preferences,perceived control,life satisfaction,and loneliness in elderly long-term care residents

Objectives: Person-centered care constructs such as fulfilled preferences, sense of control, and life satisfaction might contribute to loneliness among nursing home residents, but these relationships have not been thoroughly explored. The aim of this study was to examine the relationship between fulfilled preferences and loneliness in nursing home residents with perceived control and life satisfaction as potential mediators.

Methods: The study utilized a cross-sectional design, examining the targeted variables with a questionnaire administered by trained research staff. A convenience sample of 65 residents (median age = 71) of eight nursing homes were interviewed. Linear regression analysis was utilized to examine the mediation hypotheses.

Results: The relationships between fulfilled preferences and loneliness (β = ?.377, p = .002), fulfilled preferences and perceived control (β = ?.577, p < .001), and perceived control and loneliness (β = .606, p < .001) were significant, and the relationship between fulfilled preferences and loneliness (β = ?.040, p = .744) became non-significant when perceived control was included in the model. The relationships between fulfilled preferences and life satisfaction (β = .420, p < .001) and life satisfaction and loneliness (β = ?.598, p < .001) were significant, and the relationship between fulfilled preferences and loneliness (β = ?.152, p = .174) became non-significant when life satisfaction was included in the model.

Conclusion: The findings suggest an important association between person-centered care, particularly fulfilling personal care and recreation preferences, and social-affective needs of long-term care residents. Fulfilling preferences may be an appropriate intervention target for loneliness.