Behavioral Disturbances In Patients Research Articles

Treatment of alzheimer's disease

A growing consensus indicates that Alzheimer's disease (AD) results from an increase in the production or accumulation of beta-amyloid protein (Aβ) leading to nerve cell death. Mechanisms by which Aβ accumulation leads to neuronal death include oxidative damage and inflammation. This article discusses the management of AD patients with antioxidants, cholinesterase inhibitors, and psychotropic agents. Studies show that these agents can slow the progression of the disease, improve cognition, and reduce behavioral disturbances. A therapeutic alliance between physician and caregiver is an essential element in successfully managing the AD patient. The 3Rs—repeat, reassure, and redirect—can help caregivers reduce behavioral disturbances in patients with AD and limit the need for pharmacologic management.

Acetylcholinesterase Inhibitors: Treatment of Dementia-Related Behavioral Disturbances.

Acetylcholinesterase Inhibitors: Treatment of Dementia-Related Behavioral Disturbances.

Cholinergic deficits contribute to behavioral disturbance in patients with dementia.

Noncognitive behavioral changes such as depression, aggressive behavior, psychosis, and overactivity occur frequently in patients with dementia, in addition to cognitive impairment, and often determine the need for institutionalization. The biochemical basis of such changes is poorly understood. Clinical trial data indicate that cholinomimetics improve noncognitive behaviors. This study investigated the relationship between markers of the cholinergic and dopaminergic neurotransmitter systems and noncognitive behavioral symptoms assessed during the course of dementing illness. Brains from 46 patients with dementia (36 with AD and 10 with mixed or other dementias using Consortium to Establish a Registry for AD criteria) were examined together with 32 normal controls. The patients with dementia had been evaluated every 4 months, often over several years, for cognitive performance (Mini-Mental State Examination) and behavior (Present Behavioral Examination). Concentrations of dopamine (DA) and major metabolites, choline acetyltransferase activity (ChAT), and density (Bmax) of DA D1 receptors in frontal and temporal cortex were studied by radioligand binding protocols. None of the patients was receiving cholinomimetic drugs. ChAT activity, but no other neurochemical markers, was reduced in AD compared with controls. Loss of ChAT activity correlated with cognitive impairment. Lowered ChAT activity also correlated with increasing overactivity in patients with dementia in both frontal and temporal cortex whereas ChAT:DA and ChAT:D1 ratios in temporal cortex correlated negatively with aggressive behavior. Disturbance of the cholinergic system may underlie both cognitive and some noncognitive behavioral changes in dementia, providing a basis for rational therapy.-1467

Combined Therapy: A Research Overview

Appropriate treatment of patients with dementia must incorporate pharmacologic and nonpharmacologic therapies. This is especially true in the treatment of behavioral disturbances in patients with Alzheimer's disease (AD). However, few studies have either compared or combined pharmacologic and nonpharmacologic methods to evaluate treatments that are often used and thought to be clinically effective.

The Relationship Between Donepezil and Behavioral Disturbances in Patients With Alzheimer's Disease

The authors tested the hypothesis that behavioral disturbances are reported at significantly lower rates by caregivers of Alzheimer's disease (AD) patients receiving the antidementia drug donepezil, compared with a group of patients receiving no antidementia drug treatment. Patients administered donepezil for 6 months (n = 84) were compared with patients not on donepezil (n = 248). Patients taking donepezil had significantly lower levels of behavioral disturbances than patients not receiving this agent (P≤0.01). Specifically, donepezil patients were described as significantly (P≤0.05) less likely to be threatening, destroy property, and talk loudly. Also, significantly fewer patients receiving donepezil were treated with sedatives (P≤0.05). These findings support the growing body of evidence that cholinesterase inhibitors have psychotropic properties and reduce behavioral disturbances in patients with AD. The authors tested the hypothesis that behavioral disturbances are reported at significantly lower rates by caregivers of Alzheimer's disease (AD) patients receiving the antidementia drug donepezil, compared with a group of patients receiving no antidementia drug treatment. Patients administered donepezil for 6 months (n = 84) were compared with patients not on donepezil (n = 248). Patients taking donepezil had significantly lower levels of behavioral disturbances than patients not receiving this agent (P≤0.01). Specifically, donepezil patients were described as significantly (P≤0.05) less likely to be threatening, destroy property, and talk loudly. Also, significantly fewer patients receiving donepezil were treated with sedatives (P≤0.05). These findings support the growing body of evidence that cholinesterase inhibitors have psychotropic properties and reduce behavioral disturbances in patients with AD.

Alzheimer disease and rivastigmine treatment

Alzheimer's disease (AD) is the most common form of dementia and is characterized clinically by a gradual decline in cognitive performance, an increasingly impaired ability to perform activities of daily living, and neuropsychiatric and behavioral disturbances.The goal of this study was to assess the effect of rivastigmine on the neuropsychiatric and behavioral disturbances of nursing home residents with moderate to severe probable AD and to evaluate the safety and tolerability of rivastigmine in this population.This prospective, 26-week, open-label study was conducted in 13 centers in the United States and involved a total of 29 nursing homes. The effects of rivastigmine 3 to 12 mg/d for 26 weeks were assessed in nursing home residents with moderate to severe probable AD. Efficacy was evaluated using the Neuropsychiatric Inventory-Nursing Home (NPI-NH) scale for neuropsychiatric and behavioral disturbances; the Mini-Mental State Examination and the naming subset of the Alzheimer's Disease Assessment Scale-Cognitive subscale for cognitive performance; and the simplified Clinician's Interview-Based Impression of Change Plus Caregiver Input for global functioning.A total of 173 patients (141 women, 32 men; mean [SD]age, 82.6 [5.9] years) were enrolled. After 26 weeks of rivastigmine treatment, the mean (SD) change from baseline for all treated patients in the observed cases population was −2.5 (16.4) (n = 100; P = 0.138); it was −0.8 (16.5) (n = 149; P = 0.576) for the last-observation-carried-forward population. Patients with at least 1 neuropsychiatric symptom present at baseline showed a 3.2-point mean improvement in NPI-NH total score (n = 92; P = 0.062), with 49% of these patients demonstrating a clinically meaningful (ie, ≥30%) reduction from baseline. At 26 weeks, scores for 8 of the 12 neuropsychiatric and behavioral disturbances in patients with the specific symptom present at baseline showed statistically significant improvements from baseline (delusions [n = 32; P = 0.007], hallucinations [n = 15; P < 0.001], agitation [n = 58; P = 0.044], apathy/indifference [n = 37; P < 0.001], irritability/lability [n = 50; P < 0.001], aberrant motor behavior [n = 32; P < 0.001], nighttime disturbances [n = 22; P < 0.001], and appetite/eating changes [n = 28; P = 0.002]) in the observed cases population. Limitations of this study include that it was open label and not restricted to patients with behavioral disturbances at baseline.In the current study, rivastigmine treatment for 26 weeks in nursing home residents with moderate to severe probable AD was associated with decreased NPI-NH item scores for a wide range of behavioral disturbances in the subgroup of patients with behavioral symptoms at baseline.

The Relationship Between Donepezil and Behavioral Disturbances in Patients With Alzheimer's Disease

The authors tested the hypothesis that behavioral disturbances are reported at significantly lower rates by caregivers of Alzheimer's disease (AD) patients receiving the antidementia drug donepezil, compared with a group of patients receiving no antidementia drug treatment. Patients administered donepezilfor 6 months (n=84) were compared with patients not on donepezil (n=248). Patients taking donepezil had significantly lower levels of behavioral disturbances than patients not receiving this agent (P< or =0.011). Specifically, donepezil patients were described as significantly (P< or =0.05) less likely to be threatening, destroy property, and talk loudly. Also, significantly fewer patients receiving donepezil were treated with sedatives (P< or =0.005). These findings support the growing body of evidence that cholinesterase inhibitors have psychotropic properties and reduce behavioral disturbances in patients with AD.

Cholinesterase inhibitors: A new class of psychotropic compounds.

This article reviews evidence indicating that acetylcholinesterase inhibitors have psychotropic properties. The author reviewed the English-language literature pertinent to the response of neuropsychiatric symptoms in Alzheimer's disease and related conditions to cholinergic agents. The cholinergic system originates in the basal forebrain and projects diffusely to the cerebral cortex; the limbic and paralimbic regions receive the most abundant cholinergic projections. The basal forebrain nuclei are positioned at the interface of the limbic system and cerebral cortex, where they play a role in mediating emotional responses. The basal forebrain nuclei are atrophic in Alzheimer's disease, leading to a widespread cholinergic deficit. The cholinergic disturbance may contribute to neuropsychiatric manifestations of the disease. The treatment of patients with Alzheimer's disease with acetylcholinesterase inhibitors reduces neuropsychiatric symptoms, particularly apathy and visual hallucinations. In some studies, a variety of other neuropsychiatric symptoms have been reported to respond to treatment with acetylcholinesterase inhibitors. Response profiles vary among acetylcholinesterase inhibitors. Acetylcholinesterase inhibitors have psychotropic effects and may play an important role in controlling neuropsychiatric and behavioral disturbances in patients with Alzheimer's disease. These agents also may contribute to the management of other disorders with cholinergic system abnormalities and neuropsychiatric symptoms. The beneficial response is most likely mediated through limbic cholinergic structures.

BEHAVIORAL SYMPTOMS IN ALZHEIMER's DISEASE AMONG ETHNIC MINORITIES

Background and Objective: Behavioral disturbances in patients with Alzheimer's disease are a major determinant of need for psychiatric services among elderly persons. Despite the disproportionate growth of the older minority population and the anticipated rapid rise in prevalence of dementia, participation of ethnic minorities in behavioral research on AD has been limited by language and cultural barriers. This descriptive study examined behavioral symptoms in an ethnolinguistically heterogeneous group of minority elderly with AD, as a starting point for the design of culturally congruent dementia services. Method: Potential subjects were identified in collaboration with community social services agencies serving ethnic minorities and enrolled in a multi-ethnic registry of the University of Washington ADRC. One hundred nineteen (91 women, 28 men) met NINCDS-ADRDA diagnostic criteria for probable or possible AD and DSM-IV criteria for AD. Ethnicities included African American (n=35), Asian-Pacific Islander (n= 62; Chinese, Korean, and Filipino), Hispanic (n=15), and Native American (n=7). Half spoke a language other than English. Behavioral symptoms were rated by caregiver interview using the BEHAVE-AD and dementia was staged using the CDR. Results: The mean BEHAVE-AD total score was 13.1 ± 8.3 and no significant differences between ethnic groups were observed. One or more symptoms occurred in 114 (96%) of this sample. Most occurred during CDR stage 1 to 3, with the peak at stage 3. Behavioral symptoms were less frequent in CDR stage 4 and 5. Conclusion: In this sample, ethnic minorities demonstrated levels of AD-associated psychopathology comparable to those previously reported in whites and at similar levels of disease severity. These data emphasize the need for development of geropsychiatric services accessible to older minorities, many of whom do not speak English, and the potential of University-community collaborations to bring older minorities into clinical dementia research.

Rehabilitation Approach to Patients with Unilateral Spatial Neglect

Unilateral spatial neglect (USN) is one of the most dramatic behavioral disturbances in patients with cerebral lesions. USN occurs more frequently following right parietal lesions. Patients with USN may neglect targets on the side opposite a brain lesion; and always look toward the contralateral side. This behavioral disorder impedes functional recovery. A number of approaches to patients with USN have been reported. This article discusses the manifestations, pathophysiology, and assessment of USN; and includes a review of the references to the rehabilitation approach to the USN patients.

Contribution of psychosis and depression to behavioral disturbances in geropsychiatric inpatients with dementia.

Specific behavioral disturbances in dementia may be associated with underlying disorders such as the presence of psychosis and depression. The objective of this study was to examine the association of depression and psychosis with behavioral disturbances in geropsychiatric inpatients with dementia. All admissions between October 1993 and May 1995 were reviewed to identify those patients admitted to the Houston Veterans Affairs Geropsychiatry Unit with a diagnosis of dementia; 208 patients were included in the study. Hierarchical regression models were constructed to explore the contribution of depressive and psychotic symptoms, and depression and psychosis diagnoses to Cohen-Mansfield Agitation Inventory (CMAI) scores. Both depression and psychotic symptoms were significantly and positively correlated with behavioral disturbances. Psychotic symptoms were associated with aggressive behavioral symptoms, and depressive symptoms were associated with constant requests for help, complaining, and negativism. Dementia severity accounted for significant variance in CMAI scores and was positively associated with behavioral disturbance; though disorder symptoms accounted for more behavioral disturbance variance than did depressive symptoms. Both depressive and psychotic symptoms were associated with overall behavioral disturbances in patients with dementia. Psychotic symptoms and depressive symptoms were associated with different types of behavioral disturbances. Our findings support the contention that underlying depression or psychosis may partially account for different behavioral disturbances and that not all behavioral disturbances should be globally labeled "agitation." Future studies should address symptom-specific treatment of behaviorally disturbed patients.

Behavioral Syndromes in Alzheimer’s Disease: Description and Correlates

Introduction: Behavioral disturbances in patients with Alzheimer’s disease (AD) are ill-defined conditions. We hypothesize that the many behavioral disturbances hitherto described and studied might be grouped into few syndromes with separate determinants and correlates. Patients and Methods: 162 consecutive patients with probable AD admitted to a dementia unit were assessed by the UCLA Neuropsychiatric Inventory (NPI). Results: Factor analysis was carried out on NPI subscales, leading to three syndromes: ‘mood’, ‘psychotic’ and ‘frontal’. Patients with the ‘psychotic’ syndrome were older, had older age at dementia onset, had poorer cognition, were more often males, and had faster rate of dementia progression. Patients with the ‘frontal’ syndrome had higher education, longer disease duration, and slower rate of progression. Discussion: Some combinations of behavioral disturbances occur more frequently together and might represent separate behavioral syndromes. Different clinical correlates of the syndromes suggest separate etiologies.

Determinants of carer stress in Alzheimer's disease.

To explore the impact of subgroups and individual symptoms of non-cognitive disturbance on the carers of Alzheimer's disease patients. Cross-sectional study using clinically valid scales to assess patient symptomatology and self-report questionnaires to measure carer variables. Old age psychiatry outreach services in South and Central Manchester. 100 patients with Alzheimer's disease living at home and their carers. Subjective burden and distress in carers. Separate statistical analyses were performed for subgroups and individual symptoms of non-cognitive disturbance. For subgroups, multivariate analyses identified depression and behavioural disturbances in patients as significant predictors of subjective burden in carers. Carer distress was predicted by depression, psychosis and cognitive impairments in patients and carer gender. For individual symptoms of non-cognitive disturbance, three features of depression in patients (mood-related signs, physical signs and behaviour changes), walking disruptions and the patient-carer relationship predicted of subjective burden in carers. Variance in the level of carer distress was accounted for by sleep disruptions, hallucinations and mood-related depressive features in patients and carer gender. The findings confirm that the non-cognitive features of Alzheimer's disease are stressful for carers and indicate specific relationships between mood-related and behavioural signs of depression, walking and sleep disruptions and hallucinations in patients and adverse carer outcomes. Patient depression and the mood-related signs of depression in particular were the most consistent and powerful predictors of psychological morbidity in carers. Intervention strategies need to identify and target troublesome behaviours in patients and aim to either change these behaviours or alter the way carers respond to them. Thus, interventions need to be symptoms-rather than service-led and are likely to require multidisciplinary and multi-agency approaches.

Risperidone therapy in the control of behavioural disturbances in patients with learning disability

AbstractObjective: The objective of this audit to examine the effect of risperidone therapy in controlling some behavioural disturbances in people with learning disability.Method: Retrospective analysis of various behavioural disturbances before and after beginning risperidone therapy (during the month before risperidone was started in each case, and during September 1994 in all cases).Results: Risperidone was found to be effective in controlling various behaviour problems in 12 of 17 patients.Conclusion: Risperidone may selectively influence behaviour problems secondary to possible underlying mental illness but not others. There was also some evidence that it was more effective in an average dose of 6-8mg/day, but was not beneficial in doses smaller or larger than this dose range.

Delusions

Patients with dementia may exhibit several types of delusions. Delusions have usually been described as simple and unsystematized paranoid beliefs, such as frequently accusing caregivers of stealing or being insincere or deceitful. Misidentifications—believing that another person is in the house or not recognizing one's own mirror image—also are common in patients with dementia. To further clarify the origin and clinical significance of delusions, the authors studied these behavioral disturbances in patients admitted to the 40-bed Alzheimer Unit at “Fatebenefratelli” Hospital in Brescia, Italy, and in community based patients with dementia.

Lessons from geriatric psychiatry in the long-term care setting.

Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.

Long-Term Studies of Metopic Synostosis: Frequency of Cognitive Impairment and Behavioral Disturbances

Although the occurrence of cognitive impairment and behavioral disturbances in patients with metopic synostosis has been described, the incidence of this dysfunction has not been established. The records of 36 consecutive children with metopic synostosis followed at one craniofacial center from 1978 to 1993 were reviewed and parental questionnaires were completed to establish the frequency of mental retardation, learning disabilities, and behavioral problems associated with this synostosis. Documentation of syndromes, abnormal karyotype, and central nervous system anomalies also was done. The study group consisted of 27 males and 9 females. The average age at most recent follow-up was 7 years and 1 month (range 6 months to 22 years). Two patients had chromosomal abnormalities (9p syndrome and trisomy 21). On the basis of CT and MRI scans, intracranial anomalies were identified for only one patient having an absent corpus callosum. Thirty-two of the study patients had adequate information for longitudinal assessment. Twenty patients have normal development without apparent disability. Of these, those of school age are at appropriate grade level. Eight patients have mild to moderate learning disabilities or behavioral problems, including attention deficit/hyperactivity disorder and impaired language development. Four patients have significant mental impairment. Impaired cognitive development was not limited to children with abnormal karyotype or central nervous system anomaly. Cognitive and behavioral abnormalities occur in at least a third of patients with metopic synostosis. The, at times, subtle nature of these abnormalities mandates longitudinal developmental and neurologic evaluation for infants with metopic synostosis.

Assessing behavioral symptoms of dementia of the Alzheimer type: categorical and quantitative approaches.

Behavioral disturbances are a prevalent and important aspect of dementia of the Alzheimer type, but they have been relatively neglected by researchers. To characterize patients as having dementia, at least two goals should be addressed: first, determining a reliable definition and categorical diagnosis of dementia using such criteria as the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the International Classification of Diseases (ICD)-10; second, establishing a reliable and valid measurement of the severity of cognitive and noncognitive impairment by means of rating scales. DSM-IV and ICD-10 do not provide definitions of behavioral disturbance, whereas more than 100 geriatric rating scales exist that include some measurement of behavioral disturbances of dementia. There is a need for consensus on the term for these noncognitive symptoms. Some authors prefer the subdivisions of (a) psychiatric and noncognitive symptomatology into psychiatric symptoms, or syndromes and behavioral disturbances; and (b) cognitive syndromes. Given the frequency and clinical significance of behavioral and psychiatric disturbances in dementia, a standardized assessment procedure is needed for reliably and comprehensively describing psychiatric phenomena and behavioral disturbances in patients with dementia.

Psychosis and physical aggression in probable Alzheimer's disease

The purpose of this study was to determine the frequency and type of psychotic symptoms in patients with probable Alzheimer's disease and to test whether there is a relationship between specific psychotic symptoms and episodes of physical aggression. From 209 patients with possible or probable Alzheimer's disease who had been assessed in a research clinic every 6 months for up to 4.5 years, 181 subjects with probable Alzheimer's disease were selected for study. On the basis of the summary note for each visit in the patients' charts, the presence of delusions, hallucinations, misidentifications, and episodes of physical aggression was determined. Data regarding psychotic symptoms and aggression were available for 170 and 169 subjects, respectively. Delusions had been reported for 74 (43.5%) of the patients and were the most frequent psychotic symptom; persecutory delusions were the most common type. Physical aggression had been noted for 50 (29.6%) of the patients. Delusions and misidentifications frequently preceded and were significantly associated with episodes of physical aggression. The presence of delusions was a significant predictor of physical aggression but accounted for only 3.5% of the variance. This study suggests that delusions are a risk factor for physical aggression in patients with probable Alzheimer's disease who have moderate to severe cognitive impairment. As delusions accounted for only a small percentage of the variance, further research is needed to identify other variables that may be significant predictors of physical aggression in this population.

Pharmacologic treatment of noncognitive behavioral disturbances in elderly demented patients

Fifty-nine elderly residents of long-term care facilities who had DSM-III diagnoses of dementia were studied in an 8-week randomized, double-blind comparison trial of haloperidol, oxazepam, and diphenhydramine to test the efficacy of these agents in the treatment of clinically significant behavioral disturbances in patients with dementia. All three agents demonstrated modest but significant efficacy as measured by clinician ratings of agitated behavior and activities of daily living. The absolute magnitude of improvement was greater for haloperidol and diphenhydramine than for oxazepam, but differences among groups did not approach statistical significance. Frequencies of acute adverse events during the trial were similar across the drug treatment groups. Although these drugs may differ in terms of long-term safety and efficacy, they appear to be equivalent for short-term management of agitated behavior in severely demented patients.