Behavioral problems in dementia: a factor analysis of the neuropsychiatric inventory

The aim of this study was to detect behavioral subsyndromes of the 12-item Neuropsychiatric Inventory (NPI). Cross-sectional data of 199 patients with dementia living in the community were collected. Principal component analysis (with Varimax rotation) was used for factor analysis. Results showed the presence of three behavioral subsyndromes: mood/apathy, psychosis, and hyperactivity. Anxiety was regarded as a separate symptom. The subsyndrome mood/apathy was the most common, occurring in almost 80% of the patients, versus psychosis and hyperactivity, which occurred in 37 and 60% of the patients, respectively.     

Behavioral differences between white matter lacunar dementia and Alzheimer's disease: a comparison on the neuropsychiatric inventory

BACKGROUND AND PURPOSE: Behavioral abnormalities account for much of the morbidity of vascular dementia (VaD) and Alzheimer's disease (AD). The goals of the study were to compare the behavioral changes in patients with VaD associated with ischemic white matter subcortical changes and lacunar infarctions (VaD-WSI) to those in patients with AD. METHODS: Thirty outpatients with VaD and multiple lacunar infarctions in the periventricular white matter and 30 AD patients, matched for age and severity of dementia, were enrolled in this prospective study. The behavioral abnormalities of these patients were assessed by interviewing their caregivers with the Neuropsychiatric Inventory. RESULTS: A similar spectrum of noncognitive behavioral changes was found in AD and WSI patients. In VaD-WSI, the severity of delusions, hallucinations, aggression, irritability, aberrant motor behavior, nighttime behavior and appetite changes was correlated with cognitive decline, whereas depression, apathy, anxiety and euphoria were unrelated to the severity of dementia. In AD, none of the behavioral changes correlated with the severity of dementia. CONCLUSION: Behavioral changes are frequent in VaD-WSI and are present regardless of the severity of the cognitive decline. It is therefore important to assess behavioral as well as cognitive changes at early stages of the illness, to ensure appropriate treatment.     

Differences in neuropsychiatric symptoms between nursing home residents with young-onset dementia and late-onset dementia

Objective: The aims of the current study are (1) to explore the differences in neuropsychiatric symptoms (NPS) between young-onset dementia (YOD) and late-onset dementia (LOD), and (2) to investigate whether the possible differences can be attributed to differences in dementia subtype, gender, psychotropic drug use (PDU), or dementia severity.

Method: Three hundred and eighty-six nursing home (NH) residents with YOD and 350 with LOD were included. Multilevel modeling was used to compare NPS between the groups . Furthermore, dementia subtype, gender, PDU, and dementia severity were added to the crude multilevel models to investigate whether the possible differences in NPS could be attributed to these characteristics.

Results: Higher levels of apathy were found in NH residents with YOD. After the characteristics were added to the models, also lower levels of verbally agitated behaviors were found in YOD .

Conclusion: We recommend that special attention be paid to interventions targeting apathy in YOD. Although no differences in other NPS were found, the PDU rates were higher in YOD, suggesting that the threshold for the use of PDU in the management of NPS is lower. This underscores the need for appropriate attention to non-pharmacological interventions for the management of NPS in YOD.     

The use of the neuropsychiatric inventory in nursing home residents. Characterization and measurement.

The authors assessed the validity of the nursing home version of the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), comparing the responses of certified nurses' aides (CNAs) and licensed vocational nurses (LVNs) with research observations. Correlations were significant but moderate for all of the domains of the NPI-NH (delusions, hallucinations, agitation/aggression, depression, apathy, disinhibition, euphoria, irritability/lability, and aberrant motor disturbances) except anxiety and appetite disturbance. The LVNs' ratings showed consistently higher correlations with the researchers' behavioral observations than did the CNAs', but were moderate and generally better for residents with high levels of neuropsychiatric symptoms, thus, caution should be used with any untrained rater in the nursing home setting. The NPI-NH used by non-research staff can be useful in identifying residents with significant neuropsychiatric disturbances, but may be limited as an instrument for tracking behavioral changes.     

Undiagnosed illness and neuropsychiatric behaviors in community residing older adults with dementia

The aim of this retrospective analysis was to examine prevalence of undiagnosed acute illness and characteristics including neuropsychiatric symptoms associated with illness in community residing older adults with Alzheimer disease or related disorders. Subjects included 265 community residing older adults with dementia who participated in 1 of 2 interventions being tested in randomized clinical trials. Measures included a brief nursing assessment and laboratory evaluations including complete blood count, blood chemistry (Chem 7), and thyroid function tests of serum samples and culture and sensitivity tests of urine samples. Undiagnosed illness was identified according to currently published criteria. Neuropsychiatric behaviors were assessed using 21 behaviors derived from standard measures. Thirty-six percent (N=96) of patients had clinical findings indicative of undetected illness. Conditions most prevalent were bacteriuria (15%), followed by hyperglycemia (6%) and anemia (5%). The behavior most often demonstrated among those with detected illness was resisting or refusing care (66% vs. 47% for those without detected illness). Individuals with detected illness had significantly lower functional status scores [3.8 vs. 4.4, t(275)=7.01, P=0.01], lower cognitive status scores [10.5 vs. 14.4, t(275)=12.1, P<0.01], and were more likely to be prescribed psychotropic medications for behavior (41% vs. 26%, χ=3.67, P<0.05) than those without illness. Findings suggest that challenges of diagnosing acute illness with atypical presentation must be addressed to promote quality of care and the specialized needs for this vulnerable population.     

社区痴呆患者的家庭照料者心理状况研究

目的：为了社区痴呆患者的家庭照料者心理状况及相关因素，方法：采用MMSE，ADL，GDS，Be-AD和GHQ对103例社区痴呆患者的家庭照料者心理状况进行调查并分析。结果：家庭照料者的焦虑失眠症状明显，主要是痴呆患者的精神／行为问题相关，与照料者本身的年龄，文化和对痴呆知识的了解程度有关。结论：对老年痴呆的照料以及照料者的心理健康状况值得重视。     

Behavioural measures in frontotemporal lobar dementia and other dementias: the utility of the frontal behavioural inventory and the neuropsychiatric inventory in a national cohort study

BACKGROUND: Distinguishing between patients with frontotemporal lobar dementia (FTLD) and other dementing illnesses remains a difficult task for many clinicians. In this study, we aimed to provide further evidence for the construct validity of the frontal behavioural inventory (FBI) and assess its utility in differentiating FTLD patients from other groups using data from the Canadian Collaborative Cohort of Related Dementias (ACCORD) study. METHOD: Baseline scores on the FBI and neuropsychiatric inventory (NPI) were compared among several clinical groups (n = 177). RESULTS: The FBI discriminated a higher percentage of FTLD patients (>75% correct classification) from Alzheimer's disease and other groups compared to the NPI (54.2%). CONCLUSION: This study provides good evidence for convergent validity between the FBI and NPI (r = 0.72), indicating that both measures capture similar psychopathology in this nationwide cohort.     

The relationship between objectively measured sleep disturbance and dementia family caregiver distress and burden

The aim of this study was to determine whether distress and burden were associated with objective measures of sleep disturbance in dementia caregivers. Using wrist actigraphy, sleep was measured in 60 female, Caucasian dementia family caregivers (mean age, 64.8 years). Caregivers completed questionnaires about demographics, health, depression, duration of caregiving and care recipient nighttime behavior. Care recipients completed a mental status exam. We investigated whether these measures were associated with actigraphic sleep parameters. Greater depressive symptoms among caregivers were associated with poorer sleep efficiency. Older caregiver age and poorer self-rated health were associated with longer time in bed. Sleep disturbance, which is common among dementia caregivers, might be an important index of caregiver distress (ie, depression) but might not be associated with burden (based on the care recipient's general cognitive impairment or nighttime awakenings.).     

Occupation during life and risk of dementia in French elderly community residents

OBJECTIVE: To determine whether principal occupation during life is a risk factor for incident Alzheimer's disease, vascular dementia, or dementia with parkinsonism. METHODS: This study was carried out from the PAQUID (Personnes Agées QUID) cohort, an epidemiological study on normal and pathological aging after 65 years in the south west of France. At baseline, 2950 non-demented people living at home were identified and re-examined 1, 3, 5, 8, and 10 years later with identical standardised neurological and neuropsychological measures. Cox proportional hazards models with delayed entry were used, taking age as the time scale and adjusting for sex, education, tobacco, and wine consumption to estimate the risk ratio (RR) of incident dementia, Alzheimer's disease, vascular dementia, and dementia with parkinsonism associated with occupational category. RESULTS: Of the 2950 subjects, 393 became demented, of whom 251 had Alzheimer's disease, 112 had vascular dementia, and 27 had dementia with parkinsonism. The risk of Alzheimer's disease was not related to a given occupation. However the risk of dementia with parkinsonism seemed to be increased in farmers in comparison with professionals and managerials, particularly among women (RR 7.47; 95%CI, 1.80-31.07). CONCLUSION: The data suggest that occupation does not change the risk of Alzheimer's disease, which seems to be more influenced by cognitive abilities in childhood and adolescence than by occupation in adult life. However, being a farmer may increase the risk of dementia with parkinsonism among women; occupation could act by the way of differences in health behaviour or in exposure to environmental factors.     

Estimated prevalence of dementia among elderly black and white community residents

A stratified random sample of 83 black and 81 white community residents aged 65 years and older in a five-county area in the Piedmont region of North Carolina was evaluated for dementia, using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and the National Institute of Neurological Disorders and Stroke--Alzheimer's Disease and Related Disorders Association criteria. Of 164 subjects, 26 were found to be demented, resulting in an estimated prevalence rate of dementia in the five-county area of 16% (95% confidence interval, 7.92 to 24.08) for blacks and 3.05% (95% confidence interval, 0 to 6.91) for whites. The estimated prevalence of dementia for white women (2.9%) was similar to that for white men (3.3%), but the rate for black women was distinctly higher than for black men (19.9% and 8.9%, respectively). Blacks were more likely than whites to have a history of stroke, hypertension, and other chronic disorders that might have contributed to the development of dementia. Apart from differences in rates of institutionalization, no other relevant factors were identified that might explain the difference in the prevalence of dementia in these black and white community residents.     

Validity of the Mini-Mental State examination as a screening instrument for cognitive impairment and dementia in French elderly community residents

A survey was made of 2,792 subjects aged 65 and older living in the community of Gironde (South-Western France). The predictive value of the Mini-Mental state examination (MMS) as a screening instrument for the detection of cognitive impairment was tested against DSM-III criteria for dementing syndromes. Of the 2,792 subjects who consented to participate in the study, 101 met the DSM-III criteria for dementia, giving a 3.62% prevalence rate. With an MMS threshold of 24, the sensitivity was 100%, the specificity was 78%, and the positive predictive value was equal to 15%. Using the same MMS threshold, 572 subjects (85%) were false-positive for the diagnosis of dementia. A multiple logistic regression analysis revealed that age, sex, depressive symptomatology and educational level were independently correlated with false-positive cases of the MMS. Several issues are raised for using the MMS as the only screening instrument for cognitive impairment in elderly community residents.     

Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: a randomized pilot study.

OBJECTIVE: To test whether the Tailored Activity Program (TAP) reduces dementia-related neuropsychiatric behaviors, promotes activity engagement, and enhances caregiver well-being. DESIGN: Prospective, two-group (treatment, wait-list control), randomized, controlled pilot study with 4 months as main trial endpoint. At 4 months, controls received the TAP intervention and were reassessed 4 months later. SETTING: Patients' homes. PARTICIPANTS: Sixty dementia patients and family caregivers. INTERVENTION: The eight-session occupational therapy intervention involved neuropsychological and functional testing, selection, and customization of activities to match capabilities identified in testing, and instruction to caregivers in use of activities. MEASUREMENTS: Behavioral occurrences, activity engagement, and quality of life in dementia patients; objective and subjective burden and skill enhancement in caregivers. RESULTS: At 4 months, compared with controls, intervention caregivers reported reduced frequency of problem behaviors, and specifically for shadowing and repetitive questioning, and greater activity engagement including the ability to keep busy. Fewer intervention caregivers reported agitation or argumentation. Caregiver benefits included fewer hours doing things and being on duty, greater mastery, self-efficacy, and skill enhancement. Wait-list control participants following intervention showed similar benefits for reductions in behavioral frequency and caregiver hours doing things for the patient and mastery. Caregivers with depressed symptoms derived treatment benefits similar to nondepressed caregivers. CONCLUSIONS: Tailoring activities to the capabilities of dementia patients and training families in activity use resulted in clinically relevant benefits for patients and caregivers. Treatment minimized trigger behaviors for nursing home placement and reduced objective caregiver burden. Noteworthy is that depressed caregivers effectively engaged in and benefited from the intervention.     

Assessing the severity of dementia. Patient and caregiver

In dementia there is cognitive impairment, disability in daily life, and sometimes behavioral disturbance. These changes are a burden for the caregivers of patients with dementia. Few studies are available that examine all these aspects and their interrelationships in a single patient group. In our study we selected detailed methods for assessment of all these aspects. Interrelationships were studied in 30 mild to moderately impaired patients with dementia and their caregivers. Although the relations of cognitive deterioration to disability in daily life and of burden experienced by the caregiver to patient's condition were stronger than often reported, it was impossible to deduce the overall severity of dementia from one single aspect. Thus, for effective management of patients and caregivers, for evaluation of individual treatment or of clinical trials, attention should be paid to all the different aspects of patients' condition and caregivers' burden. Outcome measurements will then be more valid.     

The neurobiology of neuropsychiatric syndromes in dementia

PURPOSE OF REVIEW: Neuropsychiatric disturbances in dementia are prevalent, and research is uncovering their neurobiological correlates. RECENT FINDINGS: Late-onset depression appears to be associated with Alzheimer's disease pathology at autopsy, and lifetime depression episodes may worsen Alzheimer's disease pathology in the hippocampus. Vascular disease and elevated homocysteine increase risk for both late-onset depression and Alzheimer's disease and may partly mediate their relationship. Monoamine changes are robust finding in Alzheimer's disease and may account for many observed depression symptoms. Risk of psychosis of Alzheimer's disease appears to be increased by several genes also implicated in schizophrenia (e.g., catechol-O-methyltransferase, neuregulin-1). Psychosis in dementia with Lewy bodies appears to be related to cholinergic deficits. Alzheimer's disease is associated with changes in the circadian sleep-wake cycles, including decreased night-time melatonin. Sleep apnea may be related to apolipoprotein E genotype and impact cognition in Alzheimer's disease. Rapid eye movement sleep behavior disorder is intricately related to synucleinopathies, such as dementia with Lewy bodies, but synuclein changes may not totally explain this relationship. SUMMARY: Neuropsychiatric disturbances are a core feature of dementia and worsen many clinical outcomes. Among the most validated syndromes are depression, psychosis, and sleep disturbance of Alzheimer's disease. Neuropathology, neuroimaging, and genetic studies increasingly provide insight into the origins of these psychiatric symptoms in dementia.     

Health care in dementia: satisfaction and needs of the caregiver

Introduction

Primary care (PC) and general neurology clinics (NC) assume the leading role in the health care of patients with dementia. There are hardly any studies on the satisfaction of the caregiver at these settings of health care.

Methods

A questionnaire was designed and distributed to 75 caregivers of patients with dementia who were reviewed in an NC and who had been referred from PC. The questionnaire included questions associated with the care, the use of services, and satisfaction. Sociodemographic and clinical variables were also collected. The results of the questionnaire are described and a simple correlation analysis (Spearman r) was performed to determine the factors associated with satisfaction.

Results

The majority of carers were sons or daughters (60%) or spouses (31%), of which 73% were women. The service most used was home help (36%), but 41% of patients had no services available. Satisfaction was high (84% quite or very satisfied with PC, 97% quite or very satisfied with the NC, P < .01). A greater number of years giving care was associated with a lower satisfaction with PC ((r = −0.37, P < .005), while institutionalisation was associated with a lower satisfaction with the NC (r = −0.30, P < .01).

Conclusions

In a context of a scarcity of resources, the satisfaction of the caregivers of patients with dementia, as regards health care, was high, possibly due to the motivation of the health professionals and the positive attitude of the caregivers themselves.     

The prevalence of dementia as measured by the Cambridge Mental Disorders of the Elderly Examination

General practice patients aged 75 years and over were screened for cognitive impairment using the Mini-Mental State Examination. Those scoring 23 or below and a sample of those scoring 24 or 25 were assessed using the Cambridge Mental Disorders of the Elderly Examination (CAMDEX), a structured interview schedule specifically designed to detect mild dementia. The CAMDEX includes a mental state examination, a psychiatric history, detailed cognitive testing and an information interview. The prevalence of dementia in 2311 patients was found to be 10.5%, about half that found in most earlier studies. Possible reasons for this low rate are discussed.     

Prevalence and clinical correlates of neuropsychiatric symptoms in dementia

The purpose of this research was to assess the frequency and severity of neuropsychiatric and behavioral symptoms and to examine the association between preexisting medical conditions and specific neuropsychiatric symptoms in demented individuals. We studied 211 demented subjects (87.7 percent male) who were participants in epidemiological studies of dementia. Using the Neuropsychiatric Inventory (NPI), we assessed the frequency and severity of neuropsychiatric symptoms. We collected medical history information during a structured telephone interview. Our analyses focused on determining prevalence of neuropsychiatric symptoms by dementia diagnosis and severity. We also examined the association of history of head injury, alcohol abuse, and stroke with development of neuropsychiatric symptoms. We found that neuropsychiatric symptoms were common, with approximately three-fourths of the subjects exhibiting at least one symptom during the preceding month. Apathy (39.3 percent), agitation (31.8 percent), and aberrant motor behavior (31.1 percent) were the most frequent symptoms. Frequency and severity of symptoms were similar for the all-dementia and Alzheimer's disease-only groups, neuropsychiatric symptoms varied by severity of dementia, but generally not in a consistent ordinal pattern. History of alcohol abuse, head injury, or stroke was associated with presence of specific neuropsychiatric symptoms in dementia. While psychiatric symptoms are common in dementia, they also vary by type and severity of dementia. The finding that certain medical conditions may increase risk for specific types of neuropsychiatric symptoms expands our knowledge of the natural history of dementia and should improve management of dementia in medically ill patients. Our results may also shed light on mechanisms that underlie neuropsychiatric symptoms.