Agitation and other noncognitive abnormalities in Alzheimer's disease.

Agitation and other noncognitive abnormalities in patients with Alzheimer's disease are present in at least 50% of patients and are a serious problem for caregivers. Agitation can be divided into aggressive agitation, physically nonaggressive agitation, and verbal agitation. Persecutory delusions of suspiciousness and stealing are the most common psychotic symptoms. Auditory and visual hallucinations are also associated with delusions. Similar to delusions are misidentifications, which are false beliefs probably secondary to agnosia. They occur in one third of patients with dementia of the Alzheimer type in the form of the belief that strangers are living in the home and misidentification of the patient's home and reflection in the mirror. Passive personality changes are present early in the disease, whereas agitation and psychotic symptoms occur with disease progression and predict a more rapid rate of cognitive decline. Agitation and wandering are related to more severe cognitive impairment and psychosocial variables, and neurochemical variables that may be related to behavior disturbance require further study. There are few systematic studies of behavioral or environmental interventions for behavioral symptoms in patients with Alzheimer's disease. Current treatment emphasizes education of families, the formation of Alzheimer units in the nursing home, and adjunctive psychotropic agents to treat well-defined target symptoms.     

Paranoia, persecutory delusions and attributional biases

An influential model of persecutory delusions put forward by Bentall and colleagues hypothesizes that persecutory-deluded patients avoid the activation of negative self-beliefs by making externalising, personalising attributions for negative events. The first study reported here used a new instrument for the measurement of persecutory ideation, the Paranoid, Persecutory and Delusion-Proneness Questionnaire, to investigate whether attributional biases are associated with subclinical persecutory ideation. The second study extended this investigation by re-examining associations between attributional biases and persecutory delusions. Both studies used the Internal, Personal and Situational Attributions Questionnaire to measure attributional style. No evidence was found for a connection between attributional biases and subclinical persecutory ideation. Furthermore, there was no support for an association between persecutory delusions and an externalising bias, and only marginal support for the hypothesized relationship between persecutory delusions and a personalising bias. These results suggest that the putative link between persecutory ideation and attributional biases only manifests (if at all) when persecutory ideation is of delusional intensity, and that it is confined to a personalising bias.     

Persecutory delusions and the self: An investigation of implicit and explicit self-esteem

Persecutory delusions are proposed to be a defence against low self-esteem reaching conscious awareness (Bentall, Corcoran, Howard, Blackwood, & Kinderman, 2001). Key predictions of this proposal are that individuals with persecutory delusions will have lower implicit self-esteem and equivalent levels of explicit self-esteem compared to healthy controls. This study aims to test the predictions regarding implicit and explicit self-esteem in people with persecutory delusions. Of 22 people screened for persecutory delusions, 16 were recruited to the study. 20 healthy control participants were recruited. The Implicit Association Test was used to measure implicit self-esteem and the Rosenberg self-esteem scale was used to assess explicit self-esteem. Positive and negative self and other schemas were also assessed using the Brief Core Schema Scales. People with persecutory delusions had positive implicit self-esteem, comparable to that of the control group. Explicit self-esteem was lower for the persecutory delusion group, but was associated with increased depression and anxiety. Negative self and other schemas were higher in the clinical group. The results do not support the contention that persecutory delusions defend against negative self-representations and low self-esteem reaching conscious awareness. Non-defensive cognitive models are discussed as an alternative way of understanding persecutory delusions.     

Chinese demented inpatients admitted following a suicide attempt: a case series

OBJECTIVE: Suicide attempt is rarely reported in dementia. This study explores the clinical and phenomenological aspects as well as the treatment of Chinese demented patients who have attempted suicide. METHODS: During a 1-year period, demented patients admitted to a geropsychiatric unit as a result of suicide attempt were investigated for factors related to suicide attempt, such as motives and method. RESULTS: In this 1-year survey, seven demented patients (11.7% of all demented patients) were admitted immediately following a suicide attempt. All seven patients had mild or moderate dementia. Three had significant clinical depression symptoms on admission. In all patients, delusions were the primary cause of suicide attempt. Their suicidal ideations were improved with antipsychotic and antidepressant treatment. CONCLUSION: These cases, taken together, suggest that suicide attempt can occur in patients with dementia. It is important for clinicians to be aware of the risk of suicide in patients with dementia, especially those associated with delusions, even if they have no major depression or suicide attempt history. Antidepressants and antipsychotics may play a critical role in the treatment of suicide attempt in dementia.     

Psychiatric symptoms among patients with dementia seen in an ambulatory service

Subjects with dementia often display an array of neuropsychiatric symptoms that include disorders of mood, delusions, hallucinations, vegetative symptoms and psychomotor abnormalities. The present study was designed to investigate the prevalence of psychiatric morbidity amongst patients with the clinical diagnosis of dementia (ICD-10) assessed at a Memory Clinic in S?o Paulo-Brazil between February 1997 and May 1998. The mental and cognitive state of patients were assessed with an extended version of the SRQ-20 and the MMSE respectively. Thirty-four (45.3%) out of a total of 75 subjects scored 8 or more on the SRQ-20, indicating the presence of significant psychiatric morbidity. Depressive symptoms were reported by 69.3% of patients. Persecutory ideas and auditory hallucinations were observed in 20.0% and 16.0% of the sample respectively. Eight subjects (10.7%) described suicidal ideation--they all displayed depressive symptoms. Patients with scores on the SRQ-20 > or = 8 or who described suicidal ideation were significantly younger than their counterparts. Auditory hallucinations were more frequent amongst subjects with lower MMSE scores. There were no sex differences in the distribution of the psychiatric symptoms under investigation. The assessment of patients with dementia should always include a detailed psychiatric examination, as the detection and treatment of such symptoms may contribute to decrease the stress of patients and the burden on carers.     

Prevalence of dementia disorders in institutionalized Swedish old people THE WORK LOAD IMPOSED BY CARING FOR THESE PATIENTS

The prevalence of dementia disorders was determined among 3,523 institutionalized patients aged 65 years or more in the county of Vasterbotten. Approximately one-third of the clientele were considered demented. The prevalence was calculated to be 3.7 % of the population in the county. The frequency of dementia disorders among the patients in the somatic long-stay wards, the nursing homes, and the mental hospital was rather similar (55–65 %). A surprisingly high percentage of demented (17.1 %) was found in the homes for the aged. The work load was nighest in the somatic long-stay wards and in the nursing homes. Patients in the mental hospital, however, differed markedly from those in other institutions with higher scores for aggressive and disturbing behaviour, which accounted for the large number of patients in the mental hospital with maximal work load. The findings are discussed with regard to future institutional care of demented patients and point out the need for better education in psychiatric care for the staff.     

The consequences of non-cognitive symptoms of dementia in medical hospital departments

OBJECTIVE: To our knowledge, there are no studies investigating the non-cognitive symptoms of patients with dementia such as depression, agitation, or delusions among general hospital inpatients. The aim of this study was to investigate the frequency of such non-cognitive symptoms among medical inpatients and to analyze their impact on the length of hospital stay and on admission to nursing homes. METHOD: The sample consisted of 372 elderly inpatients admitted to four internal medical departments (i.e., not including psychiatric wards) in Austria. Patients were investigated by research psychiatrists using the Clinical Interview Schedule. For the analyses of the non-cognitive symptomatology, only marked and severe symptoms were included. To identify predictors for the length of hospital stay and for nursing home placement, multivariate regression procedures were used. RESULTS: Of all inpatients, 27.4% met criteria for dementia according to DSM-III-R. Of those with dementia, 27.8% had marked or severe non-cognitive symptoms. A diagnosis of dementia markedly increased the risk for nursing home referral and prolonged the duration of inpatient treatment. Among the demented, both, cognitive and non-cognitive symptoms turned out to be significant predictors for nursing home placement and for prolonged duration of acute hospital stay, even when controlling for other independent variables. CONCLUSIONS: Non-cognitive symptoms occur frequently among medical inpatients with dementia and considerably increase both the duration of inpatient treatment and the risk of nursing home placement. Since such non-cognitive symptoms are treatable, they should receive attention from the hospital staff.     

Agitation in demented patients in an acute care hospital: prevalence, disruptiveness, and staff burden

BACKGROUND/LITERATURE REVIEW: The prevalence of agitated behaviors in different populations with dementia is between 24% and 98%. Although agitated behaviors are potentially disruptive, little research attention has been focused on the effects of these behaviors upon nursing staff. The objectives of this study of demented patients in long-term-care beds at an acute care community hospital were to determine the frequency and disruptiveness of agitated behaviors; to investigate the associations of patient characteristics and interventions with the level of agitation; and to explore the burden of these agitated behaviors on nursing staff. METHOD: The study sample comprised 56 demented patients in the long-term-care unit during the study period. Twenty-seven staff who cared for these patients during three shifts over a 2-week period were interviewed to rate the frequency and disruptiveness of agitated behaviors using the Cohen-Mansfield Agitation Inventory, and the burden of care using a modified version of the Zarit Burden Interview. Data on patient characteristics and interventions extracted from the hospital chart included scores on the Barthel Index and Mini-Mental State Examination, the use of psychotropic medication, and the use of physical restraints. RESULTS: Ninety-five percent of the patients with dementia were reported to have at least one agitated behavior; 75% had at least one moderately disruptive behavior. A small group of six patients (11%) had 17 or more disruptive behaviors. The frequency of most behaviors did not vary significantly by shift. Length of stay on long-term care, Barthel Index score, and the use of psychotropic medications were significantly associated with the number of agitated behaviors. The number of behaviors, their mean frequency, and their mean disruptiveness were all significantly correlated with staff burden. DISCUSSION: The prevalence of agitated behaviors in patients with dementia in long-term-care beds at an acute care hospital is similar to that reported in long-term-care facilities. These behaviors are associated with staff burden.     

Psychotic symptoms in Alzheimer disease: evidence for subtypes.

OBJECTIVE: Psychotic symptoms in Alzheimer disease (AD) identify a phenotype with distinct neurobiology and genetic architecture. The authors investigated whether AD with psychosis is homogeneous or is a composite of subtypes. METHODS: Authors performed factor and cluster analyses of the psychotic-symptom items of the CERAD Behavioral Rating Scale in 188 probable and possible AD subjects who have displayed at least one psychotic symptom. RESULTS: Exploratory factor analysis resulted in a one-factor solution that comprised misidentification delusions, auditory and visual hallucinations, and the misidentification of people. Persecutory delusions were also frequently present and were independent of the misidentification/hallucination factor. Cluster analysis yielded similar results. CONCLUSION: Misidentification/hallucinations and persecutory delusions may identify two subtypes of psychosis in AD. Longitudinal study is needed to determine whether these proposed subtypes remain stable and independent over time or merge into a single group over the course of illness.     

The accusers in dementia

The purpose of this retrospective study of 116 dementia patients with and without accusatory behavior was to determine its frequency and evaluate its relationship to individual characteristics, behavioral and psychological symptoms, and certain dementia-related domains, namely, cognitive impairment, stage of disease, language difficulties, and functional disability. Little more than one third (38%) of the patients studied had accusatory behavior. The average age of the patients with accusatory behavior was 74 years, and the male to female ratio was 2.6:1. Accusatory behavior was more prevalent in the higher stages of dementia by 2- to 3-fold and was positively associated with hallucinations. Three patients with accusatory behavior had delusions of infidelity. There were no significant associations between accusatory behavior and other categories studied. This study raises a caveat of issues and, more important, whether the different themes relating to accusatory behaviors are true delusions, persecutory ideation, misidentification, nondelusional suspiciousness, or other. It is suggested that it would be more useful to relate them as symptoms.     

Preliminary pilot study of cyproterone acetate for the treatment of aggressive behavior associated with severe dementia

INTRODUCTION: Behavioral symptoms are common in dementia, and seem to be more frequent in men than in women. Agitation is frequently responsible for caregiver burn-out and leads to institutionalization. The dramatic increase in the prevalence of Alzheimer's disease and related disorders requires better management of behavior symptoms. Although environmental adaptation has been proposed recently, for many years, psychoactive medications and physical restraints were the primary approach. However, in severely demented patients, both pharmacologic and non-pharmacologic treatments are inoperative. In this situation, alternative pharmacologic approach should be tested. Cyproterone acetate, an antiandrogen and progestative steroid has never been proposed to prevent aggressive behavior in dementia, but its favorable effect is well described in rat and monkey aggressivity. PATIENTS AND METHODS: Cyproterone acetate was proposed for 19 demented patients who developed severe aggressive behaviors or an agitation unresponsive to psychoactive drugs (even in association) or to environmental adaptation. Clinical and behavioral analysis was carried out using the Cohen-Mansfield agitation inventory associated with an assessment of dependency in daily life activities, before and during treatment with cyproterone acetate. The behavioral status was stable, with permanent or repetitive agitation. Seven patients had vascular dementia, 7 had Alzheimer's disease, 2 had fronto-temporal degeneration, 2 had Huntington's disease and 1 a probable diffuse Lewy bodies disease. Fifteen patients had prominent aggressive behavior and 4 had predominant aberrant motor behavior with aggressive behavior. RESULTS: Cyproterone (50 to 100mg - mean: 92.5mg daily) improved significantly aggressive and impulsive behavior related to Alzheimer's disease or vascular dementia but had no effect on aberrant motor behavior. When cyproterone was stopped, aggressive behaviors reappeared more rapidly in vascular dementia. CONCLUSION: Cyproterone acetate is then an interesting choice when aggressive behavior is not improved with psychotropic drugs. A detailed clinical analysis is required to avoid the use of cyproterone in non-aggressive and non-impulsive patients. The results of this preliminary study suggest a randomized double-blind study should be carried out in the near future. The behavior improvement could be related to the blockage of androgen receptors, and simultaneously to the sedative effect of progestative drugs.     

A pilot study on a home-based caregiver training program for improving caregiver self-efficacy and decreasing the behavioral problems of elders with dementia in Taiwan

OBJECTIVE: To investigate the effectiveness of a home-based caregiver training program for caregivers of elders with dementia and behavioral problems. METHODS: A prospective study was conducted in the communities of Northern Taiwan. Forty-eight patients with dementia and their family caregivers were included. The experimental group (n = 24) received a two-session in-home caregiver training program, and the control group (n = 24) received only written educational materials. The Chinese version of Cohen-Mansfield Agitation Inventory (CMAI), community form, was used to measure the behavioral problems of patients with dementia. The caregiver's self-efficacy, for managing the demented person's agitation, was measured by the Agitation Management Self-efficacy Scale (AMSS). The CMAI and AMSS were administered before (baseline), three weeks (1st post-test), and three months (2nd post-test) after the two-session training program. RESULTS: Except for the physically aggressive behavior subscale, the scores of physically non-aggressive behavior, verbally aggressive and non-aggressive behavior subscales as well as the overall CMAI decreased significantly and continuously in the experimental group and differed significantly from the changed scores from those in the control group (p < 0.05). Physically aggressive behaviors showed a decreasing trend for both groups. Scores of the Agitation Management Self-Efficacy Scale and its subscales increased significantly and continuously in the experimental group in comparison to those in the control group (p < 0.05). CONCLUSIONS: This home-based caregiver training program is helpful for decreasing problematic behaviors of elder people with dementia and it improves the caregiver's self-efficacy for managing problematic behaviors.     

Prevalence of neuropsychiatric symptoms in a large sample of Dutch nursing home patients with dementia

OBJECTIVE: To estimate the prevalence of neuropsychiatric symptoms of dementia patients in Dutch nursing homes. METHODS: Cross-sectional study in a large sample of 1322 demented patients living in 59 dementia special care units (SCUs) in The Netherlands. Symptoms were observed by licensed vocational nurses during regular care-giving in a 2-week observational period prior to assessment. Neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory- Nursing home version (NPI-NH; frequency X severity score >/= 4) and the Cohen-Mansfield Agitation Inventory (CMAI; symptoms occurring at least once a week). RESULTS: More than 80% of these patients suffered from at least one clinically significant symptom, as defined with the NPI-NH frequency X severity score >/= 4. Measured with the NPH-NH agitation/aggression, apathy and irritability were the most frequently observed behaviors, with prevalences of 30-35%. Using the CMAI, 85% of the patients showed at least one symptom of agitation, of which general restlessness was observed most frequently (44%). Other frequently observed symptoms with prevalence rates of 30% were cursing or verbal aggression, constant request for attention, negativism, repetitious sentences, mannerisms, pacing, and complaining. Physically aggressive symptoms such as hitting, kicking, biting occurred less often (less than 13%). CONCLUSIONS: Prevalence rates of neuropsychiatric symptoms in Dutch nursing home patients with dementia residing in SCUs are high, especially agitation and apathy. Insight into the prevalence rates of individual symptoms in patients with dementia has important practical consequences for the accurate planning of staff allotment and stresses the need for patient oriented care.     

Repetitive phenomena in dementia

OBJECTIVE: Both repetitive talk and behaviors (repetitive phenomena) are common in demented patients and are bothersome to their caregivers and families. The purpose of this preliminary report was to explore these repetitive phenomena in demented patients admitted to a geropsychiatric ward. METHOD: The sample population consisted of 141 demented patients. Patients' caregivers were asked if patients had presented a repetitive fixed pattern of physical action or talk since the onset of dementia. RESULTS: Of the 141 demented patients included in the study, seventy-nine had repetitive phenomena. Patients with these phenomena had various presentations and developed them in the early stage of dementia. CONCLUSIONS: Repetitive phenomena are widespread in dementia, especially for older patients, and may be an early sign of dementia. The characteristics of repetitive phenomena and some likely underlying mechanisms are discussed.     

Delusional disorder in a chronic renal dialysis patient--deprivation and reclaiming of body and narrative]

We report a female case treated with hemodialysis over 20 years who demonstrated good social functioning, until she suffered from delusional disorder with persecutory delusions involving medical staff performing the dialysis and also auditory hallucinations involving them. We examined the bio-psycho-social invasiveness of the renal dialysis treatment, especially concerning the effects on the patient's self-image of her body resulting in the loss of a feeling of unity between her mind and body, or the sense of her body belonging to her, referring to J. Lacan's concept of "corps imaginaire= imaginary body". We supposed the situation of "body deprivation" on the ground of the patient's behavior when she developed persecutory delusions that the medical staff were trying to deprive her of her ideal body. In this case, her persecutory delusions should be regarded as a reclaim for her right not to be deprived of her self-body. We pointed out the general situation which the hegemony of modern medicine over patients brings about, where patients are deprived of chances to express their personal feelings about their illness and be listened to attentively by medical staffs. We recognized such a situation in the present patient and described the situation as "narrative deprivation". Her delusions seemed to have the aspect of the claim for her rebelling against the narrative deprivation. We emphasized the role of psychiatric staff to confirm the existence of the body-narrative deprivation situation on the side of the patient and listen attentively to the patient's personal narrative of illness in the practice of consultation-liaison psychiatry, especially when performing therapy in patients with persecutory delusions involving medical staff.     

Psychiatric diagnosis and uncooperative behavior in nursing homes.

The prevalence of psychiatric disorders and behavioral disturbances in nursing homes is high, but the relationship between the two is unknown. We studied 454 new admissions who were diagnosed by research psychiatrists using DSM-III-R criteria and compared patients who nursing staff designated as cooperative or uncooperative by psychiatric diagnosis and use of restraints and neuroleptics. Uncooperative patients (n = 79; 17.4%) had a variety of psychiatric disorders (total, 87.3%) but particularly had dementia syndromes complicated by delusions, depression, or delirium (44.3%). Uncooperative patients were more frequently restrained and prescribed neuroleptics. Determining the origins of behavior disorders in patients with psychiatric disorders in nursing homes may reduce behavior disturbances.     

Dementia and delirium in 4 patients with Machado-Joseph disease

BACKGROUND: Machado-Joseph disease (MJD; spinocerebellar ataxia type 3) is a hereditary neurodegenerative disease caused by mutation of the MJD1 gene. Patients with MJD usually present with cerebellar ataxia, external ophthalmoplegia, pyramidal and extrapyramidal signs, and muscle wasting. However, it has been reported that these patients do not demonstrate dementia. CASE DESCRIPTION: We noticed symptoms of dementia and delirium in 4 patients with MJD. The symptoms included abnormal behavior, excitation, an uncooperative attitude, crying, disorientation, slow thought processes, hallucinations, and delusions. These symptoms were observed in patients with a relatively young onset age, and after a long clinical course. In these patients, the CAG repeat length in the MJD1 gene was much longer compared with the mean repeat length found in patients with MJD. On electroencephalographical examination, they showed slow background activity, but computed tomography and magnetic resonance imaging scans showed no cerebrocortical atrophy. Neuropathological findings in 2 patients revealed a normal cortical structure on conventional morphological examination, but at immunohistochemical examination, we found abnormal staining by an antipolyglutamine antibody in the cerebrocortical neuronal nuclei. CONCLUSIONS: Symptoms of dementia and delirium in patients with MJD could occur in the late stages, and they might be caused not by loss of cerebrocortical neurons, but by their dysfunction.     

Agitation in Chinese elderly: validation of the Chinese version of the Cohen-Mansfield Agitation Inventory.

The reliability and validity of the Chinese version of the Cohen-Mansfield Agitation Inventory (CCMAI) were studied in 164 demented patients. The agitation pattern in Chinese elderly was also examined in this study. The CCMAI demonstrated high validity, test-retest reliability, and interrater reliability. Eighty-five percent of demented patients manifested one or more agitated behaviors at least once a week. Factor analysis yielded three subtypes of agitation: physically aggressive behaviors, physically nonaggressive behaviors, and verbally agitated behaviors. There was a linear upward trend in physical aggression as one progressed from one Global Deterioration Scale stage to the next. Community-living patients showed higher physically nonaggressive and verbally agitated behaviors, whereas institution residents exhibited a significantly higher level of physical aggression. The differences between residential and institutionalized patients need further research. Future study should focus not only on the behavioral disturbances; medical, psychological, and environmental factors should be taken into account to provide a more accurate profile.