The Neuropsychiatric Inventory Questionnaire and Mini-Mental State Examination in low- and middle-income countries: correlational insights from a Vietnamese memory clinic sample

A comparative study of behavioral and psychological symptoms of dementia in patients with Alzheimer's disease and vascular dementia referred to psychogeriatric services in Korea and the U.K.

Context: Non-cognitive symptoms of dementia, also known as behavioural and psychological symptoms of dementia (BPSD) are a less researched topic in developing countries like India. These symptoms not only affect the ability to sustain daily activities and reduce the quality of life but also increase morbidity and mortality in patients with dementia. Aims: The study aimed to assess the prevalence of BPSD and various correlates associated with the severity of BPSD and caregiver distress. Subjects and Methods: It was a cross-sectional, correlational study done on 80 consecutive patients and their caregivers attending the memory clinic of Indlas VIMHANS Hospital, Vijayawada. A semi-structured proforma to collect socio-demographic data, Mini-Mental Status Examination (MMSE), The Neuropsychiatric Inventory-Questionnaire (NPI-Q), and Everyday Abilities Scale for India (EASI) were used in the study. Descriptive and inferential statistical analyses were done to find the correlation between different study variables. Results: BPSD were reported in all the dementia patients. Night-time behaviour disturbances (100%), hallucinations (86.25%), irritability (76.25%), delusions (75%), and agitation (76.25%) were more commonly reported BPSD. There was a positive correlation between BPSD severity and caregiver distress on- hallucinations (r=0.661, P<0.001) delusions (r=0.840, P <0.001), agitation (r=0.823, P<0.001), depression (r=0.947, P<0.001), anxiety (r=0.971, P=0.038), disinhibition (r=0.917, P<0.001), irritability (r=0.875, P<0.001), night-time behaviour disturbances (r=0.451, P<0.001), and appetite abnormality (r=0.683, P<0.001) items. On Pearson correlation care giver distress was significantly associated with – age of the patient (r=0.325, P=0.003), MMSE score (r= -0.461, P<0.001), BPSD severity (r=0.780, P<0.001) and EASI score (r=0.475, P<0.001). Severity of BPSD showed significant correlation with- age of the patient (r=0.267, P=0.017), MMSE score (r= -0.269, P=0.016) and EASI score (r=0.356, P<0.001). Conclusion: BPSD are universal in dementia and they impact the quality of the life of the patients and the caregivers. Improvement in BPSD may reduce caregiver distress and improve the quality of care received by patients.

Alzheimer's disease (AD) is a common cognitive disease that can progress at an accelerating rate. Even with early diagnosis, the families might not recognize AD progressing unless behavioural and psychological symptoms of dementia (BPSD) develop. In many cases, discrepancies could exist between family-assessed AD stage and diagnosed AD stage. This study explored such discrepancies and potential clinical implications. Participants were 161 new outpatients with AD or mild cognitive impairment at four memory clinics whose AD stage was diagnosed using the Revised Hasegawa Dementia Scale (HDS-R) and Mini-Mental State Examination (MMSE). We classified patients into four groups according to AD severity. Family members completed the Functional Assessment Staging (FAST) scale during an interview. We then assigned patients to three groups according to discrepancies between family-assessed and diagnosed AD stage. Families also completed the Neuropsychiatric Inventory Questionnaire (NPI-Q), which assesses 12 neuropsychiatric domains, in order to examine the presence of BPSD in relation to AD stage. Most families (74%-80%) assessed patients as having milder AD than the diagnosed stage. NPI-Q scores and duration of education significantly affected discrepancies with HDS-R and MMSE scores. The NPI-Q domains of anxiety, apathy/indifference, aberrant motor behaviours, and appetite/eating disturbance significantly affected family-assessed FAST. Families of patients with more years of education assessed the AD stage as more advanced than the diagnosed stage. Surprisingly, living together did not significantly affect the discrepancy. Most families assessed AD as milder than the clinically diagnosed AD stage. In addition, high NPI-Q scores and more years of school education significantly affected the discrepancy. Family-assessed FAST was significantly affected by the NPI-Q domains of anxiety, apathy/indifference, aberrant motor behaviours, and appetite/eating disturbance. These results suggest that obvious BPSD are significant factors for Japanese families to recognize AD progress.

Introduction: Dementia is caused by various diseases, including Alzheimer’s disease dementia (ADD) and dementia with Lewy bodies (DLB). We often encounter patients with dementia who have limited shoulder joint range of motion (ROM), especially those with behavioral and psychological symptoms of dementia (BPSD). But the relationship between the diseases of dementia and restricted shoulder joint ROM is currently unclear. Methods: We examined cognitive function and shoulder joint ROM in 234 new outpatients at 7 memory clinics in Japan. We assessed cognitive function using the Mini-Mental State Examination (MMSE) and Revised Hasegawa Dementia Scale (HDS-R) and BPSD using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Patients were categorized by dementia diagnosis (ADD, DLB, other dementia, and control). Right, left, and total shoulder joint ROM was assessed using validated the Japanese Orthopaedic Association (JOA) score. Results: We found significant associations of lower right, left, and total shoulder joint ROM scores with male sex, advanced age, higher NPI-Q score, lower HDS-R, and MMSE scores. Little difference was found between right and left shoulder joint ROM scores. Restricted shoulder joint ROM was related to serial 7, verbal frequency domain scores on the HDS-R and repeat score on the MMSE. It was also related to the hallucinations, irritability/lability and nighttime disturbances scores on the NPI-Q. Furthermore, the dementia groups, especially the DLB group, showed worse shoulder joint ROM than the control group. Conclusions: Dementia was significantly related to restricted shoulder joint ROM. Maintaining communication and social interaction may help maintain shoulder joint ROM.

A comparative study of behavioral and psychological signs and symptoms of dementia in patients with dementia referred to psychogeriatric services in Korea and the United Kingdom.

Background: To investigate the efficacy and safety of donepezil hydrochloride (Aricept®; Eisai Co., Ltd, Tokyo, Japan), we conducted a post‐marketing survey in Japanese patients with Alzheimer's disease (AD) who also had behavioral and psychological symptoms of dementia (BPSD), such as hallucinations/delusions, wandering, and aggression, which cause the greatest burden on caregivers.Methods: A prospective, centrally registered investigation was conducted through regular clinical settings with patients diagnosed as mild to moderate AD presenting with hallucinations/delusions, wandering, and/or aggression. The treatment period was 12 weeks and no restrictions were placed on concomitant medications.Results: The BPSD improvement rates at last‐observation‐carried‐forward (LOCF) were 60.1% for hallucinations/delusions, 59.6% for wandering, and 65.6% for aggression. For all symptoms, improvement rates increased with the duration of the treatment period. The BPSD deterioration rates at LOCF were 1.3% for hallucinations/delusions, 3.4% for wandering, and 1.6% for aggression. Assessment of cognitive function with both the revised Hasegawa Dementia Scale (HDS‐R) and Mini‐Mental State Examination (MMSE) indicated significant improvements after treatment. There were significant differences in the changes in HDS‐R scores between patients whose hallucinations/delusions or wandering were improved and patients whose symptoms were not improved. Moreover, the data suggested a possible correlation between changes in hallucinations/delusions and HDS‐R scores, changes in hallucinations/delusions and MMSE scores, and changes in wandering and MMSE scores. Patients in whom BPSD improved also demonstrated a greater improvement in cognitive function compared with patients in whom no improvement in BPSD was noted. Nursing burden on caregivers at LOCF showed 3.6% for ‘No burden’, 54.1% for ‘Burden decreased’, and 4.5% for ‘Burden increased.’ There was an increase in the combined ratio of ‘No burden’ and ‘Burden decreased’ in proportion with prolonged treatment period. Patients with improved BPSD had a significantly greater ratio (88.5–94.4%) of ‘No burden’ plus ‘Burden decreased’ than those patients in whom no improvement in BPSD was noted.Conclusions: These results suggest that donepezil not only improves the cognitive dysfunction of AD patients, but may also relieve BPSD in these patients. Treatment with donepezil was also found to alleviate the burden of caregivers for approximately 60% of patients. Moreover, the results indicate that donepezil is unlikely to trigger potential risks of excessive deterioration of BPSD, which would result in a heavier burden of nursing care.

Aims: To elucidate the efficacy of galantamine on cognition and behavioral and psychological symptoms of dementia (BPSD) in outpatients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) who have switched from donepezil to galantamine. Materials and Methods: We performed an uninterrupted switch from donepezil to galantamine without a washout period or dose titration in 44 ambulatory outpatients with amnestic MCI (n = 12) or mild-to-moderate AD (n = 32). Three months after the switch, the efficacy of galantamine was evaluated with the Mini-Mental State Examination (MMSE), and the Neuropsychiatric Inventory (NPI) and NPI Brief Questionnaire Form (NPI-Q), respectively, using the Wilcoxon signed-rank test. Results: NPI scores improved significantly on BPSD, especially on delusions, agitation and aberrant motor activity in AD patients (p = 0.027); improvement was remarkable in patients with moderate AD (MMSE score 10-19; p = 0.007), while insignificant in those with MCI (MMSE score ≥24; p = 0.648). The NPI-Q score also improved significantly regarding both the severity of the disease (p = 0.009) and caregiver distress (p = 0.012) in AD patients. MMSE scores hardly improved in either MCI (p = 0.394) or AD patients (p = 0.265). Conclusions: An uninterrupted switch from donepezil to galantamine could be a useful alternative treatment option for AD patients whose BPSD are unresponsive to donepezil, or whose caregivers are not satisfied with donepezil treatment.

BackgroundBehavioural and psychological symptoms of dementia (BPSD) are non-cognitive symptoms commonly associated to Alzheimer's disease (AD). The characterization of the clinical profile of AD patients might help to better understand disease evolution and to improve diagnosis and treatment. Thus, the aim of the present study is to describe the clinical profile of AD patients, and to correlate the presence of BPSD with the severity of the disease.MethodsA cross-sectional, observational and multicenter study was conducted at 115 centres in Spain. Patients suffering from AD with higher and lower BPSD scores (ADAS-Noncog score 26-50 and ≤25, respectively) were included. Demographic and clinical data were collected, and dementia severity was assessed by the Mini Mental State Examination (MMSE) [mild 27-21, moderate 20-11, severe ≤10]. The use of ADAS-Noncog in clinical practice was also explored.ResultsA total of 1014 patients (463 with higher and 551 with lower BPSD scores) were included (mean age 77 ± 7 years, 65% women). Almost all patients (90%) had BPSD at inclusion, 17% of which reported psychotic outbreaks. The most prevalent symptoms were lack of concentration (56%), tremors (56%), depression (44%), lack of cooperation (36%), and delusions (32%). Patients with higher BPSD scores showed a significantly higher prevalence of psychotic symptoms (delusions, hallucinations, and delirium) and tremors, while emotional symptoms (tearfulness and apathy) predominated in patients with lower BPSD scores. MMSE and ADAS-Noncog scores were negatively associated (p = 0.0284), suggesting a correlation between cognitive impairment and BPSD. Lack of concentration and appetite change significantly correlated with MMSE (p = 0.0472 and p = 0.0346, respectively). Rivastigmine and donepezil were the first choice therapies in mild to moderate dementia. ADAS-Noncog was generally considered better or similar to other scales (82%), and 68% of the investigators were willing to use it in the future.ConclusionsOur study shows that patients with AD have a high prevalence of noncognitive symptoms, and that cognitive impairment and BPSD are correlated. Therefore, ADAS-Noncog is a useful evaluation tool.

Evidence-Based Pharmacological Management and Treatment of Behavioral and Psychological Symptoms of Dementia

Introduction Behavioral and psychological symptoms of dementia (BPSD) are observed in more than 90% of patients with Alzheimer’s disease (AD). BPSDs are remediable if detected early and managed appropriately. Behavioral Pathology in Alzheimer’s disease Rating Scale (BEHAVE-AD) and Empirical BEHAVE-AD (E-BEHAVE-AD) were designed to identify BPSD. The aim of this study is to validate and prepare BEHAVE-AD and E-BEHAVE-AD in Persian language for clinical and research applications. Method 120 patients were selected through a combination of intentional and convenience sampling. All participants should fulfill the NINCDS-ADRDA Work Group criteria for a clinical diagnosis of Alzheimer’s disease. Functional Assessment Staging Tool (FAST) was used to determine the rate of AD progression. All patients were evaluated using the BEHAVE-AD and E-BEHAVE-AD questionnaires, as well as the Persian version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Mini-Mental State Examination (MMSE). The Content Validity Index (CVI) is determined based on the compatibility of the Persian and the original version of the two scales according to the opinion of expert panels. Correlation of MMSE with BEHAVE-AD and E-BEHAVE-AD as well as the BPSD pattern on AD progression continuum by FAST were considered as indices of construct validity. Concurrent validity was estimated by correlating NPI-Q scores with BEHAVE-AD and E-BEHAVE-AD scores. For both scales, interrater reliability was extracted as a reliability index. Results Pearson correlation coefficients for the BEHAVE-AD scale were as follows: with NPI-Q (r = 0.77, p-value <0.01), with MMSE (r = −0.34, p-value <0.01), indicating concurrent and construct validity, respectively. The result for E-BEHAVE-AD was as follows: with NPI-Q-total (r = 0.59, p-value <0.01), and with MMSE (r = 0.31, p-value <0. 01). BEHAVE-AD and E-BEHAVE-AD scores increased in parallel with AD severity according to FAST, but not on the most severe AD stage. The area under the curve was estimated to be 0.84 (p-value <0.001) for BEHAVE-AD and 0.78 (p-value <0.001) for E-BEHAVE-AD. Correlation between BEHAVE-AD and E-BEHAVE-AD scores ranged from 0.45 to 0.63. The inter-rater reliability index ranged from 0.88 to 0.99 for BEHAVE-AD and from 0.74 to 0.95 for E-BEHAVE-AD. Conclusions The Persian version of BEHAVE-AD and E-BEHAVE-AD is valid and reliable for the assessment of BPSD in patients with AD.

The purpose of this study was to (1) validate the Thai version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) as a screening tool for behavioral and psychological symptoms of dementia (BPSD), and (2) examine the relationship between cognitive performance and BPSD in an elderly population with amnestic mild cognitive impairment (aMCI) and dementia of Alzheimer's type (DAT). One hundred and twenty participants, comprising 80 aMCI and 40 DAT patients, and their respective caregivers were included in the study. Participants completed the NPI-Q and the Neuropsychiatric Inventory (NPI) within 2 weeks of each other and cognitive performance was primarily assessed using the Montreal Cognitive Assessment (MoCA). The Thai NPI-Q had good validity and reliability. Pure exploratory bifactor analysis revealed that a general factor and a single-group factor (with high loadings on delusions, hallucinations, apathy, and appetite) underpinned the NPI-Q domains. Significant negative correlations between the MoCA total score and the general and single-group NPI-Q scores were found in all subjects (aMCI + DAT combined) and DAT alone, but not in aMCI. Cluster analysis allocated subjects with BPSD (10% of aMCI and 50% of DAT participants) into a distinct "DAT + BPSD" class. The NPI-Q is an appropriate instrument for assessing BPSD and the total score is largely predicted by cognitive deficits. It is plausible that aMCI subjects with severe NPI-Q symptoms (10% of our sample) may have a poorer prognosis and constitute a subgroup of aMCI patients who will likely convert into probable dementia.

Introduction: Alzheimer’s disease dementia (ADD) is a common cognitive disease in Japan. Mild cognitive impairment (MCI) is regarded as an early, but abnormal state of cognitive impairment, and amnestic MCI (aMCI) as a precursor of ADD. The Revised Hasegawa Dementia Scale (HDS-R) and the similar Mini-Mental State Examination (MMSE) are quick cognitive assessments widely used in Japan. Behavioral and psychological symptoms of dementia (BPSD) are commonly assessed using the Neuropsychiatric Inventory Questionnaire (NPI-Q). However, when the different types of BPSD appear and how they progress with the progression of ADD is not clear. Methods: A total of 553 outpatients with ADD or aMCI participated. We divided the patients into six cognitive function groups. We examined the relationship between the individual NPI-Q domain scores and cognitive function to reveal the appearance and progression of BPSD. We also examined the relationship of the NPI-Q domains with the HDS-R and MMSE domains to reveal the cognitive functions that affect the BPSD. Results: Our results suggested that hallucinations, agitation/aggression, anxiety, irritability/lability appeared in association with high MMSE scores and progressed slowly. Apathy/indifference and aberrant motor behaviors appeared in association with middle MMSE scores and progressed slowly. Delusions and nighttime behavior disturbances appeared in association with high MMSE score and progressed consistently with the ADD. Memory and orientation were the cognitive functions most related to NPI-Q domain scores and thus to progression of BPSD. Conclusions: Memory and orientation may be the most important cognitive functions related to the progression of BPSD in patients with ADD.

Background and objectives: Patients with Alzheimer's disease (AD) often experience abnormal mental and behavioral symptoms. Clinically, antipsychotic and antidepressant drugs are often used to control behavioral and psychological symptoms of dementia (BPSD), but these drugs have anticholinergic and vertebral effects and have the risk of affecting metabolic diseases and increasing stroke mortality. Infra-low-frequency transcranial magnetic stimulation (ILF-TMS) can regulate the electrical activity of each transmitter, modulating the physiological function of the transmitter to achieve therapeutic effects. Thus, this randomized parallel-design controlled trial examined the use of ILF-TMS as a treatment for BPSD in patients with AD. The study aims to evaluate the efficacy and safety of ILF-TMS in patients with AD who also show BPSD following conventional drug therapy. Design: This is a randomized parallel-design controlled trial. Methods: AD patients with BPSD in the Beijing Geriatric Hospital, China will be randomized into control (sham stimulation) and stimulation groups (n = 50/group). Eight patients from each group will participate in a preliminary experiment, and the remaining 42 will participate in the trial. For the stimulation group, along with conventional drug therapy, participants will be exposed to ILF-TMS (stimulation frequency Outcome measures: The primary outcome measure will be neuropsychiatric inventory score differences observed before treatment, at 4 and 8 weeks of treatment, and 4 weeks after treatment. The secondary outcome measures will be Mini-Mental State Examination and Barthel Index scores before treatment, at 4 and 8 weeks of treatment, and 4 weeks after treatment. Discussion: The trial is intended to explore a potential new approach for the treatment of behavioral and psychiatric symptoms in patients with AD. This will help to improve poor mental symptoms and the quality of life and reduce psychological and social burdens. Ethics and dissemination: The protocols have been approved by the ethics committee of Beijing Geriatric Hospital of China (approval No. 2016-021) on November 11th, 2016. Study design completed October 2016; ethical approval received November 2016; clinical registration conducted January 2017; patient recruitment began January 2017. Each patient will receive 8 weeks of treatment and 4 weeks of follow-up. Follow-up will be completed December 2017, and data analysis will be completed December 2018. Results will be disseminated through presentations at scientific meetings and publications in peer-reviewed journals. Trial registration: This trial has been registered in the Chinese Clinical Trial Registry (registration No. ChiCTR-INR-17010487) on January 20th, 2017.

Loneliness is considered to be a crucial factor in mental health of elderly people. However, the effects of loneliness on behavioral and psychological symptoms of dementia (BPSD) have not been fully examined. The aim of this study was to investigate whether loneliness in patients with dementia is related to BPSD. A total of 152 patients with dementia were assessed using the Neuropsychiatric Inventory (NPI-12) and the revised University of California at Los Angeles (UCLA) loneliness scale. Spearman correlation analysis and Mann-Whitney U-tests were used to examine factors associated with the revised UCLA loneliness scale. Logistic regression analysis with a forced entry method was performed to identify risk factors for BPSD. The revised UCLA loneliness scale score was not significantly associated with age, years of education, mini-mental state examination (MMSE) score, gender, living status, visual impairment, hearing impairment, and marital status. However, this score was a significant predictor of NPI delusion and hallucination subscale scores and Geriatric Depression Scale-15 score. The MMSE score was a significant predictor of NPI anxiety and apathy subscale scores. Loneliness is a risk factor for BPSD, especially for depressive symptoms and psychosis. Paying attention to loneliness in patients with dementia will help medical staff to intervene in psychiatric symptoms of these patients at an early stage.

Background: Multicomponent non-pharmacological therapies have been shown to be effective at reducing cognitive symptoms and slowing deterioration in abilities to perform activities of daily living (ADL) in individuals with cognitive impairment. However, little is known about response rates and predictors of response. Methods: We used data from the German day-care study (DeTaMAKS; De = dementia, Ta = Tagespflege/day-care, M = motor stimulation, A = activities of daily living stimulation, K = k/cognitive stimulation, S = social stimulation; n = 362), which was based on a cluster-randomized trial of the non-pharmacological, multicomponent, anti-dementia MAKS therapy for people with cognitive impairment in day-care centers. We investigated response (defined as improvement or no deterioration) for three different response criteria: cognition via Mini-Mental State Examination (MMSE) score, ADL via Erlangen Test of Activities of Daily Living in Persons with Mild Dementia or Mild Cognitive Impairment (ETAM) score, and behavioral and psychological symptoms of dementia (BPSD) via Neuropsychiatric Inventory Questionnaire (NPI-Q) score. In addition, we calculated the number needed to treat (NTT) and response rates according to net gain analyses. Results: For all three criteria, the response rates were higher in the intervention group than in the control group (chi2 test: p = 0.058 to p = 0.003). Compared with non-responders, responders according to cognition had higher ETAM scores (= better ADL abilities) at baseline; responders according to ADL had lower ETAM scores (= poorer ADL abilities) at baseline; and responders according to BPSD had higher NPI-Q scores (= more BPSD) at baseline. Classification rates based on these predictors ranged from 60.6 to 68.3%. Discussion: The response rates to the non-pharmacological MAKS therapy were greater than those reported for anti-dementia drugs. There were only a few differences between responders and non-responders. Because of the low classification rates, these variables had only a small impact on response predictions. Therefore, there are no empirically substantiated selection criteria for the application of MAKS therapy in facilities. Clinical Trial Registration: www.ClinicalTrials.gov, identifier ISRCTN16412551.