Symptoms Of Agitation Research Articles

The experience of northern italy in elderly patients with COVID-19 infection and mental disorders

IntroductionIn December 2019, the first cases of Corona Virus Disease 2019 (COVID-19) outbreak related to acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were reported in the Chinese city of Wuhan. European countries experienced a tragic growth in the number of Covid-19 cases although several restrictions have been imposed.ObjectivesThe study is aimed to describe the first experience of the Hospital Papa Giovanni XXIII in the city of Bergamo, Northern Italy.MethodsThe most relevant clinical characteristics of aged patients with COVID-19 and mental disorders have been described.Results According to the experience of the Hospital Papa Giovanni XXIII, medical departments, after appropriate training of all healthcare workers, have been rapidly converted into specific units aimed at treating patients with COVID-19 infection. Specifically, we directly observed a rapidly growing request of psychiatric interventions in aged patients with COVID-19 infection due to the emergence of severe delirium (mainly hyperkinetic) which was reported in approximately 30−50% of cases increasing with age, psychomotor agitation, anxiety, and depressive symptoms. When compared with younger subjects, we found that subjects aged 65 or above with prolonged hospitalization in our hospital are more vulnerable to: 1) environmental factors (e.g., social isolation and distance from family members, stay in intensive/subintensive units, communication difficulties due to therapeutic devices); 2) individual factors (e.g., COVID-19 possible neurotropic properties, impairments in insight and cognitive dysfunctions, comorbid medical conditions, and use of multiple medications).ConclusionsThe main implications of the present findings have been discussed.

Psychiatric manifestations of anti-NMDAR encephalitis

IntroductionAnti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder characterized by neuropsychiatric symptoms before progressing to seizures, complex movement disorder, autonomic dysfunction and hypoventilation.ObjectivesPresenting a review of the psychiatric manifestations of anti-NMDAR encephalitis.MethodsSearch on Pubmed® and Medscape® databases with the following keywords: “psychiatric”, “anti-NMDA receptor encephalitis” and “anti-NMDAR encephalitis”. We focused on data from systematic reviews and meta-analyzes. The articles were selected by the authors according to their relevance.ResultsStudies show that 77% to 95% of patients with anti-NMDAR encephalitis initially present psychiatric manifestations. Age and sex distribution are young women, and the frequency of cases is lower after 40 years of age. The most common psychiatric symptoms are agitation (59%) and psychotic symptoms (54%). The psychotic symptoms more common are visual (64%), auditory (59%) hallucinations and persecutory delusions (73%). Catatonia is described in 42% of patients. Antipsychotic treatment induces an adverse drug reaction (33%), the neuroleptic malignant syndrome represents 22% of the cases. Delays in distinguishing this disease from a psychiatric disorder can have serious complications, with a mortality of up to 25% in patients receiving limited or delayed immunotherapy.ConclusionsIt’s important to consider anti-NMDAR encephalitis in the differential diagnosis of patients with an acute onset psychosis or unusual psychiatric symptoms. Antipsychotic treatment should be use with caution when suspected or confirmed anti-NMDAR encephalitis. Without appropriate treatment, patients may suffer a protracted course with significant long-term disability or death. A clinical index of suspicion is required to identify patients who would benefit from cerebrospinal fluid testing and immunotherapies.DisclosureNo significant relationships.

Impact of Social Isolation on People with Dementia and Their Family Caregivers.

People with dementia and their family caregivers may face a great burden through social isolation due to the COVID-19 pandemic, which can be manifested as various behavioral and clinical symptoms. To investigate the impacts of social isolation due to the COVID-19 pandemic on individuals with dementia and their family caregivers. Two semi-structured questionnaires were applied via telephone to family caregivers of people diagnosed with dementia in three cities in Argentina, Brazil, and Chile, in order to assess clinical and behavioral changes in people with dementia and in their caregivers. In general, 321 interviews were conducted. A significant decline in memory function has been reported among 53.0%of people with dementia. In addition, 31.2%of individuals with dementia felt sadder and 37.4%had increased anxiety symptoms. These symptoms of anxiety were greater in individuals with mild to moderate dementia, while symptoms of agitation were greater in individuals with severe dementia. Moreover, compulsive-obsessive behavior, hallucinations, increased forgetfulness, altered appetite, and increased difficulty in activities of daily living were reported more frequently among individuals with moderate to severe dementia. Caregivers reported feeling more tired and overwhelmed during this period and these symptoms were also influenced by the severity of dementia. Social isolation during the COVID-19 pandemic triggered a series of negative behavioral repercussions, both for people with dementia and for their family caregivers in these three South American countries.

Caring for Behavioral Symptoms of Dementia (CBD): A New Investigation into Cannabidiol for the Treatment of Anxiety and Agitation in Alzheimer's Dementia

<h3>Introduction</h3> Alzheimer's disease (AD) is a debilitating neurodegenerative disease accounting for 60-80% of dementia cases worldwide. In the United States alone, 13.8 million Americans are predicted to develop AD by 2050. The neuropsychiatric symptoms (NPS) of dementia affect up to 97% of AD patients over the course of their disease. A common NPS is agitation, characterized by problem behaviors that include combativeness and restlessness. Agitation is commonly associated with greater caregiver burden, shorter time to institutionalization, and anxiety. Anxiety symptoms affect 25-70% of the dementia population, and this wide range speaks to the inability to discern anxiety from agitation. Despite the pervasiveness of anxiety and agitation in the AD population, there are no FDA-approved medications that treat the behavioral symptoms of AD. Current treatments for these symptoms include time-intensive behavioral therapies and prescription of off-label antipsychotic medications that include an FDA warning of increased mortality in this population. Thus, the need for developing safe and efficacious treatments for anxiety and agitation in AD is dire. One potential treatment is cannabidiol (CBD), the major non-intoxicating constituent of cannabis sativa and industrial hemp, a variety of the cannabis plant that contains <0.3% delta9-tetrahydrocannabinol (THC), the main intoxicating constituent in cannabis, by weight. CBD modifies the endocannabinoid system and is thought to modulate effects via the 5-HT serotonergic system, μ-opioid receptors, and TRPV1/TRPV2 receptors. These interactions seem to result in an anxiolytic effect, as studies demonstrate CBD's ability to attenuate acute responses to stress in rats, act as a panicolytic in rats, and attenuate anxiety in humans. The utilization of CBD may extend beyond its role as an anxiolytic, as preclinical studies suggest widespread therapeutic impacts of CBD, including its ability to offer neuroprotective properties and inhibit tau hyperphosphorylation. Despite pre-clinical and animal evidence that CBD could modify neurodegeneration and behavioral symptoms in AD, no human clinical trials have investigated the impact of CBD on anxiety or agitation in AD. The present open-label clinical trial seeks to address this gap in knowledge by assessing the efficacy and tolerability of a high-CBD/low-THC sublingual solution as a treatment for anxiety and agitation in older adults with Alzheimer's disease. <h3>Methods</h3> An 8-week open-label clinical trial of an industrial hemp-derived custom-formulated high-CBD/low-THC sublingual solution developed by Dr. Staci Gruber, PhD, at McLean Hospital. We will recruit 12 research participants with mild to moderate Alzheimer's dementia and behavioral symptoms of anxiety with or without agitation. Our primary efficacy outcome measures are the anxiety domain of the Neuropsychiatric Inventory-Clinician Version (NPI-C) and the Generalized Anxiety Disorder-7 Item Scale (GAD-7). Our secondary safety outcome measures include continuous monitoring for serious adverse events and medication side effects, cognitive decline estimates from the Mini Mental Status Exam (MMSE), and the emergence of possible delirium from the 3D-Confusion Assessment Method (3D-CAM). Agitation and aggression domains on the NPI-C, scores on the Cohen-Mansfield Agitation Inventory (CMAI), and caregiver burden estimates from the Zarit Caregiver Burden Interview will be included as additional exploratory measures. <h3>Results</h3> Dr. Gruber's team is currently conducting a clinical trial for the treatment of anxiety in adults with moderate to severe anxiety using a similar custom-formulated high-CBD/low-THC sublingual solution. Preliminary analyses of Dr. Gruber's ongoing trial reveal that subjects experience significant reduction in anxiety symptoms along with improvements in mood, quality of life, and executive function over 4 weeks of treatment. Given these data and evidence of CBD's anxiolytic effects, we hypothesize that twice daily treatment with a high-CBD/low-THC solution in older adults with AD for 8 weeks will be associated with a statistically significant reduction in anxiety and agitation symptoms compared to baseline, as measured by our efficacy outcome measurements. We predict that the solution will be well-tolerated by the study population, as measured by our safety outcome measurements. <h3>Conclusions</h3> We seek a safe and effective treatment for the neuropsychiatric symptoms of anxiety and agitation in older adults with AD. With no current FDA-approved treatments for these behavioral symptoms, patients with AD risk ineffective therapies or mortality-associated antipsychotic treatments to address their NPS. Treating anxiety and agitation in these patients not only alleviates their symptoms but could also reduce caregiver burden and lengthen the time to institutionalization. CBD is a promising anxiolytic treatment that could advance our available treatment options for anxiety and agitation in AD. <h3>Funding</h3> The Spier Family Foundation

A systematic review of the novel applications of cannabinoids in dementia care: food refusal and neuropsychiatric symptoms

<h3>Introduction</h3> In recent years, there has been increased research interest investigating the novel use of cannabinoids in the treatment of patients living with dementia. Early clinical research suggests that cannabinoids may be beneficial in a variety of areas, including pain, sleep, weight loss, and behavioral aggression. In particular, cannabinoids may be especially valuable in dementia care in areas where there are currently limited therapies, including food refusal and neuropsychiatric symptoms (NPS) such as agitation and sleep disruption. Pharmacologic interventions for disordered eating in dementia are limited. And although atypical antipsychotics are commonly used to treat NPS, they are associated with an increased risk of serious adverse events and all-cause mortality in older patients. Thus, this study aims to review the current literature on the potential applications of cannabinoids in the treatment of food refusal and neuropsychiatric symptoms in dementia populations. <h3>Methods</h3> A systematic literature review was performed utilizing six major electronic databases (PubMed, MEDLINE, EMBASE, PsycINFO, Google Scholar, Cochrane CENTRAL) for articles published from database inception to November 2020. Search strings including keywords and Medical Subject Headings (MeSH terms) related to cannabinoids, dementia, food refusal, weight loss, agitation, and neuropsychiatric symptoms were used to identify relevant articles. <h3>Results</h3> A total of 23 relevant articles were identified that examined the use of cannabinoids including tetrahydrocannabinol, dronabinol, and nabilone in dementia patients. Regarding treatment of NPS in dementia, numerous studies found that use of cannabinoids was associated with potential benefits including reduced nighttime motor activity, improved sleep duration, reduced agitation, and lower Neuropsychiatric Inventory scores. With regards to food refusal, multiple articles documented use of cannabinoids being associated with increased percentage of meals consumed, with one crossover placebo-controlled trial finding increased overall body weight in dementia patients on dronabinol. Documented potential side effects include possible worsening of psychosis and anxiety, although overall, the literature appears to show cannabinoids to be generally well-tolerated. <h3>Conclusions</h3> Use of cannabinoids as potential treatments for food refusal and neuropsychiatric symptoms in dementia populations is an ongoing area of research. Completed clinical studies done on the subject to date have been small in scale, but have shown cannabinoids to be relatively well-tolerated and have yielded positive results. Thus, cannabinoids may have potential as a therapeutic intervention in dementia care, and these findings warrant further investigation. <h3>Funding</h3> Not applicable

Evaluation of the use of chlorpromazine for agitation in pediatric patients.

IntroductionChlorpromazine is a first-generation antipsychotic used for behavioral problems in pediatric patients. However, other therapies may demonstrate both improved outcomes and fewer side effects. Within our institution, chlorpromazine has been the standard medication used for treatment of pediatric agitation. The study objective was to evaluate the appropriateness of chlorpromazine use (including efficacy, appropriate dosing, drug interactions, and tolerability) to optimize the treatment of pediatric agitation.MethodsData regarding drug interactions, patient behavior, dosing, and side effects was collected for each patient administered chlorpromazine from January 2019 through June 2019. Data were analyzed using descriptive statistics assessing the incidence of drug-drug interactions (DDIs), incidences of inefficacy, inappropriate dosing, and side effects.ResultsA total of 70 patients and 130 administrations of oral or intramuscular chlorpromazine were evaluated. Of these administrations, 49 (38%) resulted in a DDI. Eighteen (14%) administrations were ineffective for managing symptoms of agitation. Eleven (8%) administrations were dosed inappropriately, and 46 (35%) administrations resulted in side effects possibly caused by chlorpromazine.DiscussionResults from this study demonstrate opportunities for improvement in patient care due to instances of drug interactions, inefficacy, inappropriate dosing, and side effects with the use of chlorpromazine.

Apathy and agitation in institutionalized older adults: an empirically derived classification.

Apathy and agitation are often recognized as the most problematic behavioural and psychological symptoms in care settings. In this study, we analyze the relationship between apathy and agitation symptoms other and their relationship with demographic, cognitive, and neuropsychiatric variables and psychotropic medication use. A retrospective study was conducted at a gerontological care centre in Láncara, Spain. Participants were 196 residents of the gerontological care centre, including 143 with a diagnosis of dementia. Apathy and agitation were assessed with the Apathy Scale for Institutionalized Patients with Dementia, Nursing Home version, and the Spanish version of the Cohen-Mansfield Agitation Inventory, respectively. Two-stage hierarchical cluster analysis (hierarchical cluster analysis in a first exploratory stage and K-means clustering to obtain the final solution in the second stage) was conducted to assign residents to different groups based on apathy and agitation scores. In cluster 1, a certain level of apathy, the highest levels of agitation, and the most frequent intake of atypical antipsychotics and clomethiazole were observed. The highest levels of apathy and the most frequent intake of memantine were seen in cluster 2. The lowest levels of agitation and apathy and the highest levels of cognitive performance were found in cluster 3. In this study, subjects with dementia were in a state of high agitation and eventual apathy, had low cognitive status, and were very old. Patients with this profile require well-designed non-pharmacological interventions.

Network analysis of impulse dyscontrol in mild cognitive impairment and subjective cognitive decline.

To investigate conditional dependence relationships of impulse dyscontrol symptoms in mild cognitive impairment (MCI) and subjective cognitive decline (SCD). A prospective, observational study. Two hundred and thirty-five patients with MCI (n = 159) or SCD (n = 76) from the Prospective Study for Persons with Memory Symptoms dataset. Items of the Mild Behavioral Impairment Checklist impulse dyscontrol subscale. Stubbornness/rigidity, agitation/aggressiveness, and argumentativeness were frequent and the most central symptoms in the network. Impulsivity, the fourth most central symptom in the network, served as the bridge between these common symptoms and less central and rare symptoms. Impulse dyscontrol in at-risk states for dementia is characterized by closely connected symptoms of irritability, agitation, and rigidity. Compulsions and difficulties in regulating rewarding behaviors are relatively isolated symptoms.

Neuropsychiatric symptoms and comorbidity: Associations with dementia progression rate in a memory clinic cohort.

Neuropsychiatric symptoms (NPS) are associated with dementia severity and progression rate. NPS clusters have different neurobiological underpinnings; therefore, their effect on dementia progression may differ. Furthermore, little is known about whether individual comorbidities affect progression rate. We investigated the effect of NPS clusters and individual comorbidities on dementia progression. A memory clinic cohort with all-cause dementia (N=442) was followed for up to 3 years from diagnosis. Previously, we found trajectory groups of dementia progression in this cohort: one with slow progression and two with rapid progression. In the present study, using principal component analysis, three symptom clusters of NPS were identified on the Neuropsychiatric Inventory Questionnaire (NPI-Q): agitation, affective and psychosis symptom clusters. Data regarding comorbidity were collected by linkage to the Norwegian Patient Registry. Multinomial logistic regression was applied to explore the association between NPS clusters and comorbidity with trajectory-group membership. Adjusted for demographics, dementia aetiology, comorbidity and cognition, we found that, at the time of dementia diagnosis, for every point within the psychosis symptom cluster of the NPI-Q, the risk of rapid progression increased by 53%; for every point within the affective symptom cluster, the risk of rapid progression increased by 29%. A previous diagnosis of mental and behavioural disorders (excluding dementia) decreased the risk of rapid dementia progression by 65%. Psychosis and affective symptom clusters at the time of diagnosis were associated with rapid progression of dementia. Previous diagnoses of mental and behavioural disorders (excluding dementia) were associated with slow progression.

Delirium in older adults

This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.

Promazyna — klasyk wart ponownego odkrycia?

Modern psychopharmacology offers an ever wide spectrum of psychotropic drugs that are in practice clinical adjustment to individual needs. Clinical practice shows that next to pharmaceuticals of the new generation, it is important to remember about older drugs, well known and embedded in the memory of subsequent generations psychiatrists. Promazine, among the phenothiazine-derived neuroleptics, is effective in managing the symptoms of agitation and anxiety of various etiologies, including in elderly patients. Thanks to this, promazine is still widely used, provided that the patient is properly selected and treated. The purpose of this article is to discuss the clinical profile of promazine and its principles in psychiatric practice. A case report of a 62-year-old woman with agitation and anxiety treated with promazine is also provided.

Effects of Ambient Bright Light on Neurobehavioral Symptoms in Dementia: A Systematic Review

Most persons living with dementia (PLwD) experience behavioral and psychological symptoms of distress in dementia (BPSDs). Despite increased utilization of bright light to improve BPSDs, the evidence of effectiveness and dosage using ambient light has not been comprehensively examined. This review synthesized research evidence on the effect of ambient light on BPSD in PLwD. A literature search conducted in Scopus, PubMed, CINAHL, and Web of Science included keywords: dementia, bright light, ambient light, indirect light, behavior symptoms, agitation, wandering, depression, aggression, and apathy. Original studies that examined the effect of ambient light on BPSDs were included. Six studies were identified. Sample size ranged from 6 to 189. Lighting delivery methods included a lighting table and ceiling-mounted fixtures in public areas and/or participant’s bedroom. Lighting intensity ranged from 1,000-3,000 lux, color temperature ranged from bluish white to warm white, and exposure duration ranged from 4 to 24 hours a day. PLwD with higher light exposure showed more pleasure and alertness. Ambient bright lighting showed mixed results in reducing agitation with one study reporting increased agitation. Three out of four studies showed positive effects upon depressive symptoms. Ambient bright light positively impacted pleasure and alertness. Mixed results on agitation and depressive symptoms may be explained by differences in illuminance, color, duration, and targeted lighting positions. Further studies are needed to confirm the positive effects of ambient light on BPSD. Accurate lighting exposure measurements related to spectral compositions and dosage for individual PLwD would help explain the underlying relationships between lighting and BPSD.

Toward Targeted ECT: The Interdependence of Predictors of Treatment Response in Depression Further Explained.

Several clinical variables assumed to be predictive of electroconvulsive therapy (ECT) outcome in major depressive disorder show substantial interrelations. The current study tries to disentangle this interdependence to distill the most important predictors of treatment success to help improve patient-treatment matching. We constructed a conceptual framework of interdependence capturing age, episode duration, and treatment resistance, all variables associated with ECT outcome, and the clinical symptoms of what we coin core depression, ie, depression with psychomotor agitation, retardation, psychotic features, or a combination of the three. The model was validated in a sample of 73 patients with a major depressive episode according to DSM-5 treated twice weekly with ECT (August 2015-January 2018) using path analyses, with the size and direction of all direct and indirect paths being estimated using structural equation modeling. Reduction in Montgomery-Asberg Depression Rating Scale (MADRS) scores during treatment was the ECT outcome measure. The baseline presence of psychomotor agitation, retardation, and/or psychotic symptoms strongly correlated with beneficial ECT outcome (z = 0.84 [SE = 0.17]; P < .001), and the association between age and the effect of ECT appears to be mediated by their presence (z = 0.53 [SE = 0.18]; P = .004). There was no direct correlation between age and ECT response (P = .479), but there was for episode duration and ECT outcome (z = -0.38 [SE = 0.08]; P < .001). ECT is a very effective treatment option for severe depressive disorder, especially for patients suffering from severe depression characterized by the presence of psychomotor agitation, psychomotor retardation, psychotic symptoms, or a combination of these 3 features, with the chance of a beneficial outcome being reduced in patients with a longer episode duration. Age may heretofore have been given too much weight in ECT decision making. ClinicalTrials.gov Identifier: NCT02562846.

“I just glove up and do what has to be done”: A mixed‐methods exploration of dementia care challenges and care management strategies

AbstractBackgroundMost family caregivers for persons living with dementia (PLwD) don’t receive training for their role and therefore adopt a variety of care management strategies, some of which may be harmful. The current study utilizes a mixed‐methods design to integrate family caregiver’s qualitative and quantitative descriptions of recent care challenges (e.g. cognitive, functional, and behavioral symptoms of dementia), and the strategies utilized to manage these symptoms.MethodParticipants included 100 primary family caregivers for PLwD who were 74% female, 18% non‐White, and on average 64 years old. Participants were interviewed qualitatively about their management of a recent care challenge and with the Caregiver Assessment of Function and Upset, Neuropsychiatric Symptom Inventory, Dementia Severity Rating Scale, and Dementia Management Strategies Scale (subscales: criticism, active management, encouragement). Care challenges and care management strategies are compared across qualitative analysis and T‐tests.ResultThe most common type of qualitatively reported care challenge was BPSD (45%) followed by symptoms of cognitive decline (18%). Quantitatively caregivers reported the most stressful ADL to be toileting and BPSD as aggression. Caregivers providing ADL/IADL care (r=.34, p&lt;.01) and with PLwDs with more severe cognitive symptoms (r=.30, p&lt;.01) had significantly higher use of active management care strategies, relative to caregivers not assisting with those tasks. In contrast, caregivers providing care for PLwDs with greater BPSD burden (r=.34, p&lt;.001) and particularly challenging symptoms of aggression (t=‐.4.0, p&lt;.001), agitation (t=‐3.4, p&lt;.001), irritability (t=‐.2.4, p&lt;.05) and hallucinations (t=‐2.3, p&lt;.05) reported more use of criticism as a management strategy.ConclusionMixed‐methods assessment of care challenges provides a more nuanced understanding of how caregivers manage care stressors. Active management or other straightforward assistive approaches may be required when the severity of dementia increases, yet critical strategies seem to emerge with greater severity of BPSD. Encouragement strategies, on the other hand, were independent of any care challenges and may be used to support the PLwD, not address an underlying symptom. As criticism tends to be associated with more negative care outcomes (burden, potentially harmful behavior), intervention approaches may help caregivers identify more adaptive responses to prepare for stressful challenges such as BPSD.

The impact of green care farms and other innovative nursing home models on BPSD symptoms in everyday life for people with dementia

AbstractBackgroundMany countries are introducing small‐scale, home‐like care facilities that represent a radically new approach to nursing home care for people with dementia. These facilities emphasize person‐centered care, focus on remaining strengths and value autonomy. Originated outside of the healthcare sector, green care farms (GCFs) are a new type of nursing home in the Netherlands. GCFs provide care in small‐scale, homelike environment, in which agricultural activities are combined with care and support services for a variety of client groups, including people with dementia. This study investigated effect of GCFs on residents, in particular on behavioral and psychological symptoms.MethodIn total, 115 residents with a formal diagnosis of dementia were included, living at GCFs (n=34), regular small‐scale living facilities (n=52) and traditional nursing homes (n=29). Residents were matched regarding cognitive status (S‐MMSE). Ecological momentary assessments (n=16,860) were conducted using the Maastricht Electronic Daily Life Observation Tool, assessing activity engagement, social interaction and emotional well‐being. Furthermore, neuropsychiatric symptoms (NPI‐NH), agitation (CMAI), depressive symptoms (CSDD), quality of life (Qol‐AD and QUALIDEM) and social engagement (RISE) were measured.ResultThe daily life of residents living at GCFs was significantly different compared with traditional nursing homes. Residents were significantly more active (p&lt;0.05, SE=0.9) and socially engaged (p&lt;0.05) at GCFs compared with traditional nursing home wards. Furthermore, residents living at GCFs scored significantly higher on the Qol‐AD (p&lt;0.05, ES=0.8) and on three domains of the Qualidem: positive affect, social relations and having something to do (p&lt;0.05, ES&gt;0.7) compared with traditional nursing homes. No significant differences were found regarding neuropsychiatric symptoms (mean NPI‐NH score 15.4), agitation (mean CMAI score 41.9) and depressive symptoms (mean CSDD score 5.4).ConclusionThis study showed that GCFs provide an attractive, homelike environment and activities that positively influence engagement and social interaction. GCFs appear to be a valuable alternative to existing nursing homes. This is important as people with dementia are a heterogeneous group with varying needs. In order to provide tailored care there also is a need for a variety of living environments.

Pharmacological treatment of neuropsychiatric symptoms of dementia: A systematic review and network meta‐analysis

AbstractBackgroundNeuropsychiatric symptoms (NPS) of dementia are a common issue in dementia patients. It generally presents as three disparate symptom clusters—agitation, psychosis, and mood disorders which have different biological and psychosocial triggers. Therefore, a “one size fits all” solution may not exist. Pharmacological treatments are its treatment of choice, but there is controversy about which agent should be used. We aimed to update and expand our previous work to compare and rank drugs for the treatment of neuropsychiatric symptoms of dementia.MethodsWe included all randomized controlled trials reported as double‐blind and comparing one active drug with another or with placebo. Studies searched Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, EMBASE, from database inception to Jun 28, 2019. Our primary outcome was change in overall neuropsychiatric symptoms measured with standardised rating scales. And the secondary outcomes were change in aggressive behavior, psychosis, apathy, and depressive symptoms. Effect size measures were standardised mean differences (SMD) with 95% credible intervals (CrIs). We ranked the comparative effects of all drugs against placebo with surface under the cumulative ranking probabilities. We conducted subgroup analyses to assess the robustness of our findings. Confidence in the evidence was assessed using CINeMA. The study protocol is registered with PROSPERO, number CRD42019132231.ResultsWe identified 8175 citations and of these included 114 trials comprising nearly thirty thousand participants. Effect size estimates suggested galantamine was more effective than placebo for reducing overall neuropsychiatric symptoms. SMD compared with placebo for reduction of aggressive behavior found that aripiprazole and risperidone appeared to be more efficacious, citalopram and methylphenidate for reduction of apathy symptoms, memantine and donepezil for reduction of psychosis. While the certainty of evidence was low to very low.ConclusionThis systematic review synthesized the available evidence on the comparative efficacy of different pharmacological approaches in the management of overall NPS, agitation, psychosis, apathy and depressive symptoms in dementia patients. These results may serve evidence‐based practice and inform patients, physicians, guideline developers. Especially, clinicians should differentiate these disparate symptom clusters since the appreciation of such complexity is vital to determine the appropriate treatment.

Defining agitation, apathy and other psychiatric symptoms in cognitive impairment and dementia: Why we need to intervene

AbstractBackgroundInternational Psychiatric Association (IPA) has a long history of defining and treating the behavioral and psychiatric symptoms that occur with cognitive impairment and dementia, including agitation and apathy. This presentation will describe the international and collaborative approach to creating definitions and diagnoses. Also a description of how these efforts have fostered trial design and can direct development of protocols with evidence‐ based selection of populations and meaningful outcomes.MethodThe methodology used by the IPA and other associations to characterize behavioral symptoms in aging and dementia begins with a review of the extant literature and the creation of a survey around the key elements of the diagnosis or definition of a given condition such as agitation or apathy. Elements of the definition are selected from the field and the surveys are disseminated via a link in an email. The email is distributed widely, to member of IPA and to its more than 20 different affiliates, which represent national organizations in geriatric psychiatry and allied fields. International working groups use the responses to formulate criteria that have meaning and importance to the largest number of stakeholders including, providers, regulators, researchers and patient advocates. The uptake of the criteria and their success in defining treatable conditions is monitored and in interactive process of updating the definitions to improve clinical utility is promoted.ResultThis approach has been used to create guidelines for defining agitation, apathy and psychosis. The presentation will include a review of the results of this process for agitation in which the publication of the provisional guidelines were followed by a notable increase in clinical trials and other research to address interventions and in work to improve outcome measures. Recent work in apathy has also provided support for selecting clinically relevant outcomes including measures of function, cognition and caregiver burden.ConclusionInternational collaboration to define psychiatric and behavioral symptoms associated with cognitive impairment can provide the stimulus to developing meaningful interventions.

Actigraphy as a proxy biomarker for motoric agitation in Alzheimer disease

AbstractBackgroundAgitation is an important symptom of dementia and is commonly assessed using clinician and/or caregiver rated scales. These scales are useful but they rely on a mixture of direct and indirect observations and therefore are subject to limited reliability and validity depending of factors such as staffing. Actigraphy is a tool to assess motoric activity, a core feature of agitation. There is a growing interest in using Actigraphy as a tool to diagnose and monitor agitation of dementia. We previously published a report demonstrating feasibility and a correlation between Actigraphy and informant‐based rating of physical agitation in a sample of hospital and nursing home patients with Alzheimer in moderate level of cognitive impairment from Kingston Ontario, Canada.MethodThis is an extension to our previous observational, cohort study now involving a sample of older adults with Alzheimer disease and agitation from London Ontario, Canada in hospital and nursing home with severe level of cognitive impairment. Measurements: Baseline characteristics included demographics, severity of cognitive impairment, medical comorbidity, and agitation symptoms assessed using CMAI and NPI. Actigraphy was measured over several continuous days.ResultsTwenty participants were enrolled (mean age=81.3/years, SD=7.97; Male=12; mean MMSE=6.3, SD=5.7; mean CMAI score=66.83, SD=10.79). Pearson correlation coefficient was explored between agitation and Actigraphy measures. We found that total CMAI scores correlated with 24‐hours Actigraphy data (r(18)= 51, p= .02), further analysis showed that only physical non‐aggressive agitation correlated with 24‐hours actigraphy measures (r(18)= 0.49, p=.03), this was mainly related to day‐time and evening‐time Actigraphy but not overnight.ConclusionsActigraphy was correlated significantly and moderately with informant‐based methods for measuring physical agitation in individuals with dementia and showed a temporal pattern of activity. Further studies are required to understand the application of Actigraphy as a biomarker for motoric agitation in this population.

Cannabis Use among Persons with Dementia and Their Caregivers: Lighting up an Emerging Issue for Clinical Gerontologists

ABSTRACT Objectives: Our goal is to illuminate cannabis use among persons with dementia (PwD) and their informal caregivers relative to the use of evidence-based as well as other complementary and alternative care practices. Methods: We analyzed focus group (FG) narratives provided by 26 caregivers of PwD and identified five themes concerning the provision of cannabis to PwD and caregivers’ self-use. Results: Three of the 26 caregivers provided PwD cannabis and also used themselves, another 3 of the 26 used themselves only, and all but two of the remaining FG participants indicated they would consider providing cannabis to PwD or using for themselves. These caregivers expressed a desire to obtain more empirically-based information about cannabis and to discuss options with their clinical care providers. Conclusions: A small but significant proportion of caregivers are providing cannabis to PwD as a possible treatment for agitation, sleep disturbances and other problematic secondary symptoms and using for themselves as way to relieve stress. Many other caregivers may start using cannabis upon receiving information and guidance from a credible source. Clinical Implications: Notwithstanding the need for more research, clinical gerontologists and other dementia care specialists are being looked upon to provide information and guidance about the benefits and harms of cannabis use among PwD and their caregivers.

Use of psychotropic agents to treat agitation and aggression in Brazilian patients with Alzheimer's disease: A naturalistic and multicenter study

We assessed psychotropic prescribing patterns in the clinical treatment of agitation and aggressive behavior in patients with Alzheimer's disease (AD) treated at specialist outpatient clinics in the Federal District of Brazil. This was a naturalistic, observational, multicenter study of a convenience sample of patients with AD (according to DSM-5) who had behavioral symptoms of aggression and/or agitation at outpatient visits, as assessed by the Neuropsychiatric Inventory (NPI), and required pharmacologic intervention. Participants were recruited in 2018-2019 from 11 AD treatment centers. Sociodemographic and clinical data were collected during routine visits. The sample consisted of 369 older adults with a mean age of 82.3 (SD, 7.7) years. The medications most commonly used in patients with behavioral disorders were antidepressants (79.1%), antipsychotics (70.2%), benzodiazepines (10.6%), and mood stabilizers (9.5%). Quetiapine was the most frequently prescribed antipsychotic medication (48.5%), at a mean dose of 57.4 (SD, 40.7) mg. Citalopram was the most widely used antidepressant medication (32.0%), at a mean daily dose of 24.1 (SD, 8.1) mg. In this sample, two or more pharmacologic agents were frequently used together to control aggression and agitation. Benzodiazepine was not frequently used.