Neuropsychiatric symptoms in South‐East Asian patients with mild cognitive impairment and dementia: prevalence,subtypes, and risk factors

Background

The subtypes and risk factors of neuropsychiatric symptoms remain largely unexplored in South‐East Asian populations.

Objective

We investigated the prevalence, subtypes, and risk factors, namely, demographic, medical morbidity, and cognitive impairment associated with neuropsychiatric symptoms in a South‐East Asian cohort of patients with mild cognitive impairment (MCI) and dementia.

Methods

A clinical cohort of 38 MCI and 198 mild–moderate dementia patients were assessed using the Neuropsychiatric Inventory‐Questionnaire.

Results

Neuropsychiatric symptoms were equally prevalent among patients with MCI (74%) and mild–moderate dementia (85%). Three subtypes of symptoms were identified for each diagnostic group; for MCI, they included mood disturbances, anxiety/sleep problems, and psychosis, while for dementia, the subtypes included behavioral disturbances, psychosis/mood, and hyperactive behaviors. The largest risk for neuropsychiatric symptoms for both MCI and dementia patients was male gender. Among patients with MCI, burden of cerebrovascular disease and global cognitive impairment were small risks for neuropsychiatric symptoms, while for patients with dementia, an older age (>65 years) was a small risk and lower educational attainment was a moderate risk.

Discussion

These findings contribute to the worldwide epidemiology of neuropsychiatric symptoms in MCI and dementia and highlight that the profile of symptoms, subtypes, and risks is fairly homogenous across Western and Asian cultures. Copyright © 2017 John Wiley & Sons, Ltd.     

Neuropsychiatric symptoms in mild cognitive impairment: a population‐based study

Introduction: Few studies have examined neuropsychiatric symptoms in community dwelling older adults with mild cognitive impairment (MCI). In the present study, we compared the prevalence of neuropsychiatric symptoms in older adults with normal cognition, MCI, and dementia in a population‐based sample. Methods: Subjects were selected from the Singapore Longitudinal Ageing study. Normal cognitive function was defined as Clinical Dementia Rating (CDR) global score=0 and Mini‐Mental State Examination (MMSE) total score ≥24. MCI was defined as CDR global score=0.5, and dementia was defined as CDR global score ≥1. Neuropsychiatric Inventory (NPI) was administered on reliable informants for 293 subjects (136 normal, 133 MCI, and 24 dementia). Results: The prevalence of neuropsychiatric symptoms (at lest one symptom) was 5.9% for normal cognition, 12.8% for MCI, and 50% for dementia. The most common neuropsychiatric symptoms in subjects with MCI were depression/dysphoria (6.8%), irritability/lability (3.8%), apathy/indifference (2.3%), and agitation/aggression (2.3%). NPI total score increased with increasing CDR global score (P<0.001). The adjusted mean NPI total score was 0.07 (SEM=0.49) for normal cognition, 0.86 (SEM=0.46) for MCI, and 4.50 (SEM=0.82) for dementia. Discussion: In community dwelling Asian older adults, we found an increasing prevalence of neuropsychiatric symptoms in subjects with normal cognition, MCI and dementia. Further studies with larger samples and strict criteria for MCI in an Asian population should be conducted.     

Non-cognitive symptoms in mild cognitive impairment subjects

The term mild cognitive impairment (MCI) is used to identify individuals with worse cognitive performance than those with normal aging, and who are at risk of dementia, especially Alzheimer's disease (AD). Although the MCI concept is based on the presence of specific cognitive deficits, several studies have shown that these subjects can develop depression, disruptive behaviors (e.g., agitation, aggression), and psychosis. In this study, we examined the baseline psychiatric characteristics of 228 MCI (Mean age: 71.2, Mini-mental State Examination [MMSE] score: 25.9) and 427 mildly demented Probable AD (Mean age: 73.2; Mean MMSE score: 23.5) subjects from a referral dementia clinic. The psychiatric assessment was conducted by geriatric psychiatrists using semi-structured interviews. The proportion of subjects with major depression (MCI: 7.5% vs. Probable AD: 8%) and aggression (MCI: 10% vs. Probable AD: 12.5%) was similar in the two groups. There were more Probable AD patients with psychomotor agitation (52% vs. 38%), delusions (29% vs. 14%), and hallucinations (9% vs. 4%) than MCI subjects. Within MCI groups, we did not observe any differences between MCI subjects with amnesic syndrome versus MCI subjects with a much broader cognitive deficit. These results showed that the MCI syndrome is not circumscribed to a neuropsychological definition, but occurs with a wide range of psychiatric syndromes. Furthermore, it is possible that the development of disruptive behaviors and psychosis, in MCI subjects with no previous history of psychiatric illness, constitutes a strong indication that there is an underlying neurodegenerative disorder.     

Prevalence of clinically significant depressive symptoms in an epidemiologic sample of community-dwelling elders with milder forms of cognitive impairment in Hong Kong SAR

BACKGROUND: Depression and cognitive impairment in later-life have great bearings on public health. The two conditions often co-occur and have mutual implications on short-term risk and long-term prognosis. METHOD: A two-phase epidemiologic survey on the prevalence of dementia in elders aged 60 and over was conducted in Hong Kong in 2005-2006. In the first phase, 6,100 randomly selected community dwelling elders were assessed with Cantonese version of Mini-Mental State Examination (C-MMSE) and Abbreviated Memory Inventory for Chinese (AMIC). Two thousand and seventy-three subjects were screened positive and invited for second phase cognitive and psychiatric assessment. 35.5% of screen-positive subjects participated in Phase 2 assessment conducted by psychiatrists for diagnosis of dementia. Severity of dementia was determined using Clinical Dementia Rating Scale (CDR). Cornell Scale for Depression in Dementia (CSDD) and a structured bedside cognitive battery were also administered to each subject. RESULTS: 1.7% of subjects with CDR 0.5 and 5.9% of subjects with CDR 1 had clinically significant depressive symptoms (>or= 8 on CSDD). Score on CSDD correlated positively with duration of cognitive symptoms, scores on CIRS and CMMSE in linear regression model. In a logistic regression model, male gender, duration of cognitive symptoms, CIRS and CMMSE was associated with increased risk for clinically significant depressive symptoms. CONCLUSIONS: In our sample, milder forms of cognitive impairment were associated with increased risk for depression in the presence of other risk factors such as male gender, higher physical illness burden and longer duration of cognitive symptoms.     

The rate of conversion of mild cognitive impairment to dementia: predictive role of depression

BACKGROUND: Mild cognitive impairment (MCI) is a condition referring to the persons with cognitive deficits measurable in some form or another, but not meeting criteria for dementia, and who have an increased risk of becoming demented. OBJECTIVE: To establish the rate of progression to dementia in MCI, to investigate the risk of conversion for amnestic vs multiple-domains subtypes, and to identify the predictors of progression. METHODS: MCI (n = 105) individuals enrolled in a longitudinal study received annual clinical and psychometric examinations for up to a mean of 3 years. The diagnosis of MCI according to Mayo Clinic Petersen's Criteria was conducted by a panel of specialists. RESULTS: After 3 years of follow-up, 23 of 105 subjects with MCI were diagnosed with dementia. 40 showed cognitive decline not dementia, 34 were stable and showed no cognitive decline or improvement, while eight showed cognitive improvement. CONCLUSIONS: We conclude that conversion rate from MCI to DSM-IIIR dementia was 21.9% over a period of 3 years. The occurrence of depressive symptoms may constitute a predictor for those who are more likely to progress to dementia. The risk of conversion to dementia was higher among the subjects with an evidence of impairment extending beyond memory than with those who suffered only from memory deficits, and the subjects who converted to dementia in this subtype had significantly higher baseline plasma total homocysteine levels than non-converters.     

Prevalence of mild cognitive impairment: a population-based study in elderly subjects

OBJECTIVES: Mild cognitive impairment (MCI) has been suggested as a term for a boundary area between normal aging and dementia, especially Alzheimer's disease (AD). In follow-up studies, more than 50% of MCI subjects have been converted to dementia in 3-4 years. However, the epidemiology of MCI is not well known. This study was designed to determine the prevalence of MCI in an elderly population. METHODS: A total of 806 subjects (60-76 years of age) from a population-based random sample of 1150 subjects living in the city of Kuopio in eastern Finland were evaluated. Neuropsychological tests and a structured interview including the modified Clinical Dementia Rating (CDR) were used to apply the diagnostic criteria of MCI as proposed by Mayo Clinic Alzheimer's Disease Research Centre. Thus, subjects having a test score more than 1.5 SDs below the age appropriate mean in memory tests and a CDR score of 0.5 but no dementia, were diagnosed as having MCI. RESULTS: A total of 43 subjects, 5.3%, met the MCI criteria. MCI was more prevalent in older and less-educated subjects, but no difference was found between men and women. The CDR appeared to be the most important part of the criteria. The memory tests had less impact on prevalence variables. CONCLUSIONS: The low prevalence of MCI indicate that in a population-based study design its criteria may identify a more homogeneous group of subjects at the lower end of the cognitive continuum as contrasted with various other criteria of cognitive impairment in the elderly population. This is compatible with follow-up studies showing a high probability of dementia in the MCI group. Thus, probable candidates for trials of preventive intervention for dementia can be screened from the elderly population using these diagnostic criteria.     

Neuropsychiatric Symptoms and Global Functional Impairment along the Alzheimer's Continuum

Background/Aims: Neuropsychiatric symptoms in Alzheimer's disease (AD) are highly prevalent. We sought to determine whether neuropsychiatric symptoms were related to global functional impairment at baseline and over a 3-year period in older normal control (NC), mild cognitive impairment (MCI) and mild AD dementia subjects. Methods: Eight hundred and twelve subjects (229 NC, 395 MCI, 188 AD) from the Alzheimer's Disease Neuroimaging Initiative study underwent cognitive and behavioral assessments over 3 years. Results: Greater hallucinations, anxiety and apathy were associated with greater global functional impairment at baseline, while the presence of hallucinations and apathy at baseline was associated with greater global functional impairment over time across all subjects. The following neuropsychiatric symptoms were not significantly associated with global functioning: delusions, agitation, depression, euphoria, disinhibition, irritability, aberrant motor behaviors, sleep and appetite. Conclusions: These results suggest that increased baseline hallucinations, apathy and anxiety are associated with current and future disease progression in AD.     

Psychosis associated behavioral and psychological signs and symptoms in mild cognitive impairment and Alzheimer's dementia

Objectives: The aim of this study is to determine the prevalence of psychosis in mild cognitive impairment (MCI, Petersen's criteria) and patients with Alzheimer's dementia, and to characterize the associated behavioral and psychological signs and symptoms of dementia (BPSD).

Method: A cross-sectional analysis of baseline data from an ongoing, prospective, longitudinal study on BPSD was performed, including 270 MCI and 402 AD patients. BPSD assessment was performed through Middelheim Frontality Score (MFS), Behave-AD, Cohen-Mansfield Agitation Inventory (CMAI) and Cornell Scale for Depression in Dementia (CSDD). Psychosis was considered to be clinically relevant when delusions and/or hallucinations occurred at least once in the last two weeks prior to the BPSD assessment.

Results: The prevalence of psychosis in AD (40%) was higher than in MCI (14%; p < 0.001). AD patients with psychosis showed more severe frontal lobe, BPSD, agitation and depressive symptoms (MFS, Behave-AD, CMAI and CSDD total scores), whereas MCI patients with psychosis only showed more severe frontal lobe and physically non-aggressive agitated behavior. In addition, only in psychotic AD patients, all BPSD and types of agitation were more severe compared to non-psychotic AD patients. Comparing MCI and AD patients, MCI patients with psychosis did not show more severe frontal lobe, behavioral and psychological (Behave-AD), depressive symptoms or agitation than AD patients without psychosis.

Conclusion: AD patients clearly display psychosis associated BPSD, whereas MCI patients only display more severe frontal lobe symptoms and physically non-aggressive agitated behavior, but also less pronounced than in AD.     

Longitudinal follow-up of depressive symptoms among normal versus cognitively impaired elderly

OBJECTIVES: This prospectively designed longitudinal study assesses prevalence, incidence and prognosis of depressive symptoms among cognitively normal elderly volunteers compared with patients with mild cognitive impairment (MCI), dementia of Alzheimer type (DAT), and vascular dementia (VAD). Possible relationships between depressive symptoms, cognitive performance, disease types, and effects of antidepressant treatment were analyzed. METHODS: Two hundred and ninety four subjects exhibiting different levels of cognitive performance were admitted to this study. Demographics, cardiovascular and neurodegenerative risk factors, together with measures of neuropsychological test performance, were obtained at sequential visits. Depressive symptoms were selectively treated with antidepressant medications. RESULTS: One hundred and forty six subjects with normal cognition, 19 subjects with MCI, 42 patients with DAT, and 32 patients with VAD were followed for a mean of 3.5 years. With the passage of time, there were trends showing prevalence of depressive symptoms to decrease among DAT and to increase among VAD patients. VAD patients exhibited the highest incidences of new-onset depressive symptoms, followed in incidence by DAT and MCI groups. Depressive symptoms among VAD and MCI patients were more persistent and refractory to antidepressant medications than for DAT patients. Trends suggested that antidepressant treatment might benefit MCI and VAD subjects more than DAT patients. Motivationally related depressive symptoms accounted for major components of elevated Hamilton depression rating scale scores. CONCLUSIONS: Depressive symptoms among DAT patients have higher rates of spontaneous resolution, without requiring intensive drug treatment, than among VAD patients in whom depressive symptoms are more persistent and refractory to drug treatment. Early depressive symptoms among subjects with MCI may represent a preclinical sign and should be considered as a risk factor for impending DAT or VAD among the elderly.     

Neuropsychiatric symptoms in older people with and without cognitive impairment

Neuropsychiatric symptoms (NPS) are non-cognitive disturbances such as depression. Rates of NPS have been shown to increase as cognitive ability declines and may be useful in predicting transition from mild cognitive impairment (MCI) to dementia. This community-based study reports the association between NPS and cognitive decline over two years. Participants included 873 community dwelling adults aged 70-90 years enrolled in the Sydney Memory and Ageing Study. NPS were assessed by the Neuropsychiatric Inventory (NPI). Cognitive impairment was defined by diagnosis (MCI or incident dementia) or neuropsychological test performance across five cognitive domains. Cognitive decline was defined by progression to dementia or worse neuropsychological performance. Total NPS at baseline did not differ between those without cognitive impairment (26.2%) and those with MCI (28.8%), but agitation and apathy were associated with MCI. Only baseline depression was associated with dementia at follow-up. Total NPS at baseline was cross-sectionally associated with cognitive impairment in executive function, attention, and global cognition, but did not predict cognitive decline. Depression, anxiety, agitation, anxiety, and apathy were all associated with impairment in at least one cognitive domain, but only anxiety and agitation were significantly associated with cognitive decline. Sensitivity analyses applied more stringent criteria for NPS and cognitive impairment in MCI but did not alter interpretation of results from the main analysis. Overall rates of NPS at baseline were not associated with MCI, dementia, or cognitive decline over two years. Additional follow-up is needed to further examine this association over a longer time course.     

Clinical correlates of functional performance in community-dwelling Chinese older persons with mild cognitive impairment

ABSTRACTBackground: Increasing evidence suggests that functional impairment can be detected in older persons with mild cognitive impairment (MCI). This study explores the functional profiles and the clinical correlates of a population-based sample of Chinese older persons with MCI in Hong Kong.Methods: A random sample of 765 Chinese elderly subjects without dementia was recruited, of which 389 were elderly normal controls (Clinical Dementia Rating = 0), and 376 had questionable dementia (CDR = 0.5). The latter were categorized into an MCI group (n = 291) and a very mild dementia (VMD) group (n = 85). Their functional performances were measured and compared with the normal controls (NC). Multiple regression analyses investigated the associations between functional scores (Disability Assessment in Dementia) and clinical correlates (cognitive test scores, neuropsychiatric symptoms and motor signs) in the NC subjects and cognitively impaired subjects.Results: Subjects with MCI had intermediate functional performance between the NC and those with VMD. Regression analyses revealed that lower scores of cognitive tests (delayed recall and categorical verbal fluency tests), apathy, aberrant motor symptoms and parkinsonism features were associated with lower functional scores in clinically non-demented subjects. Functional scores had no correlation with age, education and medical illness burden.Conclusion: Neuropsychiatric symptoms and parkinsonism features were associated with functional impairment in the clinically non-demented elderly in the community. Assessment of these should be incorporated in the evaluation of older persons for early cognitive impairment.     

Race and cognitive decline among community-dwelling elders with mild cognitive impairment: findings from the Memory and Medical Care Study

Objective: Previous studies have reported conflicting findings on the relationship between race and cognitive decline in elders with dementia. Few studies have examined the role of race in cognitive decline in mild cognitive impairment (MCI). We investigate the relationship between race and cognitive decline in participants with MCI in a community-based, longitudinal study of cognitively impaired elders.

Method: Based on a validated method utilizing a neuropsychiatric battery, 133 subjects [mean age: 78.7 years (SD?=?6.5); female: 112 (76.7%); black: 59 (44.4%)] out of 512 participants in the Memory and Medical Care Study were diagnosed with MCI. The main outcome measure was the Telephone Interview for Cognitive Status (TICS) score over three years. Other baseline subject characteristics (demographics, health-related variables, behavioral, and psychiatric symptoms) were included in the analysis.

Results: Overall, the three-year decline in mean TICS score was significantly higher among African Americans than non-African Americans [3.31 (SD: 7.5) versus 0.96 (SD: 3.0), t-value?=?1.96, p-value?=?0.05]. General estimating equation analyses revealed that African American race was associated with a faster rate of cognitive decline in all models.

Conclusion: The rate of cognitive decline in MCI appears to be faster in African Americans than non-African Americans in the community. Diagnosis of MCI among African American elders could lead to early interventions to prevent or delay cognitive decline in the future.     

From mild cognitive impairment to dementia: a prevalence study in a district of Tuscany, Italy

OBJECTIVE: A door-to-door two-phase study was designed in order to estimate the prevalence of cognitive deficit amongst the residents of a district in Tuscany (central Italy). Identification of cases with mild cognitive impairment (MCI) was given high priority, because this condition has been suggested as a term for the boundary area between normal aging and dementia. METHODS: Of the 1600 subjects who completed the screening phase, 354 scored under the cut-off point of the Mini Mental State Examination and Clinical Dementia Rating and were investigated by means of a standardized diagnostic protocol. RESULTS: The prevalence of MCI and age-related cognitive decline was 4.9 and 9.3%, respectively; low levels of education significantly increased the risk of these conditions. The prevalence of dementia over age 65 was 6.2%, with a significant risk association with age. In our population, Alzheimer's disease was the most frequent type of dementia (prevalence rate 4.2%) and increased risk depending on age, sex and education has been found. CONCLUSIONS: Our findings are somewhat similar to previous studies. Further epidemiological and longitudinal studies are warranted to identify which diagnostic category is more predictive for dementia.     

Clinical correlates of Parkinsonian signs in community- dwelling Chinese older persons: a population based study

BACKGROUND AND OBJECTIVE: This study examined the clinical correlates of parkinsonian signs including neuropsychiatric symptoms, cognitive impairment and medical illness burden in the community-dwelling non-demented Chinese elderly. METHODS: A random sample of 765 Chinese elderly subjects from a thematic household survey was recruited. There were 389 normal elderly controls (Clinical Dementia Rating [CDR] 0) (NC) and 376 subjects with questionable dementia (CDR 0.5). The subjects with questionable dementia (CDR 0.5) were categorized into two groups: a MCI group (n = 291) and a very mild dementia (VMD) group (n = 85). Parkinsonian signs were measured by Unified Parkinson Disease Rating Scale- motor scale (UPDRS). The clinical correlates were investigated in each group. RESULTS: UPDRS motor score was associated with age, cumulative medical illness burden and cerebrovascular accidents in the normal control and MCI groups. It correlated negatively with MMSE scores in the NC group. It was associated with presence of soft signs in the NC and MCI groups; and apathy in the VMD group. CONCLUSION: Neuropsychiatric symptoms, cognitive impairment and vascular risk factors had different patterns of associations with parkinsonian signs in the older persons with different degree of cognitive impairment.     

老年人轻度认知功能障碍不同诊断标准的比较

目的 使用广义轻度认知功能损害（MCI）诊断标准了解老年人MCI患病,与Petersen标准进行比较,观察3年后两种标准MCI痴呆发病情况.方法 以465名≥60岁老年人为研究对象,进行神经心理检查,观察MCI患病率,并与Petersen标准进行比较.3年后,对诊断为MCI的患者随访,比较两种标准MCI痴呆发病情况.结果 广义MCI患者76例（16.34％）,与Petersen标准诊断患病情况（50例,10.75％）比较,患病率较高,差异有统计学意义（x2=6.206,P＜0.05）.3年后,76例MCI患者中痴呆发病30例（年发病率为13.16％）,进展为AD者23例,其他类型痴呆7例;按Petersen标准诊断A-MCI组痴呆发病22例（年发病率为14.67％）,全部进展为AD.两种方法诊断的MCI痴呆发病率差异无统计学意义（x2=0.255,P＞0.05）.在广义MCI组内,A-MCI与非A-MCI痴呆发病差异无统计学意义（x2=1.253,P＞0.05）.同时,正常组痴呆发病19例（年发病率为4.54％）,MCI组痴呆发病率高,差异有统计学意义（x2=80.689,P＜0.05）.结论 采用广义MCI诊断标准较Petersen标准诊断MCI患病率高,其包含了更多类型的痴呆临床前体,有利于早期发现MCI及防治.     

Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy

Mitchell AJ, Meader N, Pentzek M. Clinical recognition of dementia and cognitive impairment in primary care: a meta‐analysis of physician accuracy. Objective: We aimed to examine the ability of the general practitioners (GPs) to recognize a spectrum of cognitive impairment from mild cognitive impairment (MCI) to severe dementia in routine practice using their own clinical judgment. Method: Using PRISMA criteria, a meta‐analysis of studies testing clinical judgment and clinical documentation was conducted against semi‐structured interviews (for dementia) and cognitive tests (for cognitive impairment). We located 15 studies reporting on dementia, seven studies that examined recognition of broadly defined cognitive impairment, and eight regarding MCI. Results: By clinical judgment, clinicians were able to identify 73.4% of people with dementia and 75.5% of those without dementia but they made correct annotations in medical records in only 37.9% of cases (and 90.5% of non‐cases). For cognitive impairment, detection sensitivity was 62.8% by clinician judgment but 33.1% according to medical records. Specificity was 92.6% for those without cognitive impairment by clinical judgment. Regarding MCI, GPs recognized 44.7% of people with MCI, although this was recorded in medical notes only 10.9% of the time. Their ability to identify healthy individuals without MCI was between 87.3% and 95.5% (detection specificity). Conclusion: GPs have considerable difficulty identifying those with MCI and those with mild dementia and are generally poor at recording such diagnoses in medical records.     

Validation of the modified telephone interview for cognitive status (TICS-m) in Hebrew

INTRODUCTION: The validity of the Hebrew version of the Telephone Interview for Cognitive Status-Modified (TICS-m) for Mild Cognitive Impairment (MCI), for dementia, and for cognitive impairment (either MCI or dementia) was investigated. METHODS: Of the 10 059 who took part of the Israel Ischemic Heart Disease Cohort, 1902 of the 2901 survivors in 1999 had TICS-m interviews. Those with a score of 27 or below and a random sample with a score of 28 or 29 were invited to have a physician's examination for the diagnosis of dementia. The analysis was performed on the 576 who agreed. RESULTS: Based on physician's diagnosis, 269 were diagnosed as suffering from dementia, 128 as suffering from MCI, and 179 were diagnosed with no cognitive impairment. The TICS-m Hebrew version's internal consistency was very high (Cronbach's alpha = 0.98) and showed a strong convergent validity with the MMSE (r = 0.82; p < 0.0005). The sensitivity was 100% for each of the conditions. Finally, after controlling for age, education and hearing impairment, TICS-m was a strong predictor of dementia, MCI and cognitive impairment. CONCLUSION: At a cut-off of 27/50 the Hebrew version of the TICS-m is a useful screening instrument to identify subjects suffering from mild cognitive impairment, dementia and cognitive impairment (MCI or dementia).     

Agitation-associated behavioral symptoms in mild cognitive impairment and Alzheimer's dementia

Objectives: The aim of this study is to determine the prevalence of agitation in mild cognitive impairment (MCI, Petersen's criteria) and patients with Alzheimer's dementia (AD), and to characterize the associated behavioral symptoms.

Method: A cross-sectional analysis of baseline data from a prospective, longitudinal study on behavioral symptoms was performed, including 268 MCI and 393 AD patients. Behavioral assessment was performed through Middelheim Frontality Score (MFS), Behavioral Pathology in Alzheimer's Disease Rating Scale (Behave-AD) and Cornell Scale for Depression in Dementia (CSDD). Agitated behavior was considered to be clinically relevant when one or more items of the Cohen-Mansfield Agitation Inventory (CMAI) occurred at least once a week.

Results: The prevalence of agitation in AD (76%) was higher than in MCI (60%; p < 0.001). Patients with agitation showed more severe frontal lobe, behavioral and depressive symptoms (MFS, Behave-AD and CSDD total scores). In agitated AD patients, all behavioral symptoms and types of agitation were more severe compared to non-agitated AD patients, but in agitated MCI patients only for diurnal rhythm disturbances. This resulted in more severe Behave-AD global scores in patients with agitation as compared to patients without agitation. Comparing MCI and AD patients, MCI patients with agitation showed more severe behavioral and depressive symptoms than AD patients without agitation. The structure of agitation in AD consisted of more aggressive and physically non-aggressive behavior than in MCI.

Conclusion: Frontal lobe, behavioral and depressive symptoms are more severe in MCI and AD patients with clinically relevant agitation as compared to patients without agitation. However, this association is less pronounced in MCI.     

Prevalence and correlates of disruptive behavior in patients in Norwegian nursing homes

BACKGROUND: Although Behavioral and Psychological Symptoms of Dementia (BPSD) increase with increasing dementia severity, and institutionalization of an individual with dementia is often caused by behavioral symptoms, relatively few studies have explored the prevalence of BPSD in nursing homes. OBJECTIVE: To study the prevalence and correlates of agitation in residents with dementia, in Norwegian nursing homes. METHODS: This study has taken place in dementia wards in four Norwegian nursing homes. To measure agitation in residents with dementia we used the Cohen-Mansfield Agitation Inventory (CMAI), consisting of 29 agitation items. Dementia stage was measured by Functional Assessment Staging (FAST). RESULTS: Two hundred and eleven patients (71% female) were included in the study: mean (SD) age 85.5 (8.4), FAST 4.7 (2.1), CMAI total sumscore 39.5 (12.6). Dementia was present in 167 (79%) subjects. Among those with dementia, weekly occurrence of at least one CMAI item (i.e. a score of 3 or higher) occurred in 75.4% (95% CI 68.4-81.4). Six of the items occurred at least weekly in 20% of the residents with dementia, and 11 of the items, including physical aggression, occurred in less than 5% of the residents. Agitation was associated with more severe dementia (p = 0.001), but not with age and gender. CONCLUSION: Symptoms of agitation were common, but may nevertheless be lower compared to findings in other geographical areas. Further studies are warranted to test this hypothesis, and if confirmed, to explore possible causes for such differences.     

The relationship of excess cognitive impairment in MCI and early Alzheimer's disease to the subsequent emergence of psychosis

BACKGROUND: Psychotic symptoms in Alzheimer disease (AD + P) identify a heritable phenotype associated with greater cognitive impairment. Knowing when the cognitive course of AD + P subjects diverges from that of subjects without psychosis would enhance understanding of how genetic variation results in AD + P and its associated cognitive burden. This study seeks to determine whether the degree of cognitive impairment and cognitive decline in early AD predicts subsequent AD + P onset. METHODS: 361 subjects with possible or probable AD or mild cognitive impairment (MCI) without psychosis were evaluated every 6 months until psychosis onset. RESULTS: Severity of cognitive dysfunction was a strong predictor of AD + P up to two years prior to psychosis onset. Cognition did not decline more rapidly prior to onset of AD + P. CONCLUSIONS: Individuals who will develop AD + P already demonstrate excess cognitive impairment during the mild stages of disease. Genetic variation and brain pathophysiology may lead to a cognitive risk phenotype which is present prior to dementia onset.