Behavior Rating Scale For Dementia Research Articles

In Thai Nationals, the ApoE4 Allele Affects Multiple Domains of Neuropsychological, Biobehavioral, and Social Functioning Thereby Contributing to Alzheimer's Disorder, while the ApoE3 Allele Protects Against Neuropsychiatric Symptoms and Psychosocial Deficits.

The apolipoprotein E epsilon 4 (ApoE4) allele is the strongest genetic risk factor for Alzheimer's disorder (AD) and is associated with semantic and episodic memory deficits. The aim of this study was to examine the associations between ApoE alleles (E2, E3, E4) and genotypes and neuropsychological tests, behavioral functions, and dementia symptoms as assessed using Consortium to Establish a Registry for Alzheimer's Disease (CERAD). This study included 60 patients with Alzheimer's disorder (AD), 60 with mild cognitive disorder (MCI), and 62 normal volunteers. ApoE4 carriers and individuals with E3/E4 and E4/E4 genotypes show an increased incidence of AD, but not MCI. ApoE4 carriers and especially E4/E4 homozygotes show a worse outcome on the CERAD total score, Blessed Dementia Scale, and Short Blessed Test and lower scores on the Verbal Fluency Test, Boston Naming Test, Constructional Praxis Recall, and Word List Memory, Recall, and Recognition. ApoE4 carriers and E4/E3 heterozygotes show higher scores on the Clock Drawing Test. ApoE4 carriers show a worse outcome on the CERAD clinical history scores of memory, language, personality, ADL, orientation, and social skills, while allele AopE3 carriers show better scores on activities of daily living (ADL) and social skills. ApoE3 carriers show lower total weighted, irritability/aggression, and behavioral dysregulation scores on the Behavior Rating Scale for Dementia. The results show that in Thai individuals, the presence of ApoE4 allele is accompanied by a multifarious decline in neurocognitive functions and behavioral features and that ApoE3 may convey protection against neuropsychiatric symptoms and a decline in social skills. ApoE4 and especially the E4/E4 genotype may affect multiple domains of cognitive, biobehavioral, and social functioning thereby contributing to AD phenomenology.

Patient Mood and Instrumental Activities of Daily Living in Alzheimer Disease: Relationship Between Patient and Caregiver Reports.

This retrospective study investigated the relationship between self-reports and caregiver perceptions of patients' depressive symptoms and the respective ability of these reports to predict instrumental activities of daily living (IADLs) beyond what is accounted for by cognitive abilities in 71 patients with mild Alzheimer disease. Patients completed the Geriatric Depression Scale-Short Form, and caregivers completed the Behavior Rating Scale for Dementia assessing their perception of patients' depressive symptoms. Caregivers also completed IADL items from the Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory. Cognitive measures included the Mini-Mental State Examination, Logical Memory from the Wechsler Memory Scale III, and Trail Making Test, Part B. The relationship between self-reported depressive symptoms and caregiver report of patients' depressive symptoms showed a trend toward significance (r = .22, P = .06). Measures of depressive symptoms significantly predicted 12.5% of the variance in IADLs performance, beyond that accounted for by patient demographics and cognitive functioning. Interestingly, patients' reports, rather than caregivers', were particularly useful in this prediction.

Genetic association between APOE*4 and neuropsychiatric symptoms in patients with probable Alzheimer's disease is dependent on the psychosis phenotype

BackgroundNeuropsychiatric symptoms such as psychosis are prevalent in patients with probable Alzheimer’s disease (AD) and are associated with increased morbidity and mortality. Because these disabling symptoms are generally not well tolerated by caregivers, patients with these symptoms tend to be institutionalized earlier than patients without them. The identification of protective and risk factors for neuropsychiatric symptoms in AD would facilitate the development of more specific treatments for these symptoms and thereby decrease morbidity and mortality in AD. The E4 allele of the apolipoprotein E (APOE) gene is a well-documented risk factor for the development of AD. However, genetic association studies of the APOE 4 allele and BPS in AD have produced conflicting findings.MethodsThis study investigates the association between APOE and neuropsychiatric symptoms in a large sample of clinically well-characterized subjects with probable AD (n=790) who were systematically evaluated using the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Behavioral Rating Scale for Dementia (BRSD).ResultsOur study found that hallucinations were significantly more likely to occur in subjects with no APOΕ4 alleles than in subjects with two Ε4 alleles (15% of subjects and 5% of subjects, respectively; p=.0066), whereas there was no association between the occurrence of delusions, aberrant motor behavior, or agitation and the number of Ε4 alleles. However, 94% of the subjects with hallucinations also had delusions (D+H).ConclusionThese findings suggest that in AD the Ε4 allele is differentially associated with D+H but not delusions alone. This is consistent with the hypothesis that distinct psychotic subphenotypes may be associated with the APOE allele.

The Measurement of Psychosis in Dementia

The precise operational definition of psychosis in dementia lacks consensus, partially owing to incongruence in the various assessment tools used. This study compares assessments of psychotic symptoms in persons with dementia, specifically of hallucinations and delusions, through the 4 most frequently used assessments. Participants were 74 nursing home residents from 9 nursing homes in Israel, diagnosed with dementia. Assessment tools used included the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), the Neuropsychiatric Inventory-Nursing Homes (NPI-NH), the Consortium to Establish a Registry for Alzheimer's Disease Behavior Rating Scale for Dementia (CERAD-BRSD), and the Columbia University Scale for Psychopathology in Alzheimer's Disease (CUSPAD). The highest prevalence rates of delusions were found through the CUSPAD, and the lowest through the CERAD-BRSD. Rates identified by the BEHAVE-AD were intermediate and similar to those of the NPI-NH. As for hallucinations, rates indicated by the BEHAVE-AD, the NPI-NH, and the CUSPAD were similar, with small sample-based differences, and higher than those found through the CERAD-BRSD. The CERAD-BRSD, soliciting reports of the fewest specific symptoms, detected the fewest psychotic symptoms. The CUSPAD, soliciting the most items, presented the highest prevalence rates. The BEHAVE-AD and the NPI-NH had similar rates and showed a high convergent validity.

Prevalence of neuropsychiatric syndromes in Alzheimer's disease (AD)

This study aimed to estimate the prevalence and explore the multidimensional complexity of the neuropsychiatric syndromes of AD. Neuropsychiatric symptoms and syndromes of 216 subjects with probable and possible AD diagnosed by NINCDS-ADRDA criteria were evaluated by the Korean version of behavior rating scale for dementia (BRSD-K). The prevalence rate of six neuropsychiatric syndromes (depressive symptoms, inertia, vegetative symptoms, irritability/aggression, behavioral dysregulation, psychotic symptoms) and comorbid neuropsychiatric syndromes were calculated according to the Clinical Dementia Rating scale. To investigate the relationship among neuropsychiatric syndromes, logistic regression analyses were performed. About 95% of patients with AD had one or more neuropsychiatric symptoms and syndromes during the past month. Among the neuropsychiatric syndromes, irritability/aggression (76.2%) was the most frequent, followed by apathy (72.3%) and depressive symptoms (68.0%). About 90% of the subjects had one or more comorbid neuropsychiatric syndromes. The mean numbers of comorbid neuropsychiatric syndromes were significantly varied according to the severity of disease ( p < 0.05). Depressive symptoms were significantly associated with vegetative symptoms and irritability/aggression ( p < 0.05). Inertia and psychotic symptoms were significantly associated with vegetative symptoms and behavioral dysregulation, respectively ( p < 0.05). This study demonstrated that neuropsychiatric syndromes of AD were highly prevalent and involved complex relationships among them.

Comparison of psychometric properties between the Behavior Rating Scale for Dementia (BRSD) and the Neuropsychiatric Inventory (NPI)

Comparison of psychometric properties between the Behavior Rating Scale for Dementia (BRSD) and the Neuropsychiatric Inventory (NPI)

Quality of life in older Belgian people: comparison between people with dementia, mild cognitive impairment, and controls

To assess the sensitivity of the 'Alzheimer's Disease Related Quality of Life' instrument (ADRQL) applied to Belgian people with dementia (n = 357), mild cognitive impairment (MCI) (n = 36), and controls (n = 72). We also determined the clinical parameters that influence the quality of life (QOL) of people with dementia. Each subject was evaluated with the ADRQL, the Mini Mental State Examination (MMSE), the cognitive scale of the Cambridge Examination for Mental Disorders of the Elderly (CAMCOG), the Katz's ADL classification (ADL), the Instrumental Activities of Daily Living (IADL), the Behavior Rating Scale for Dementia (CERAD/BRSD), and the Clinical Dementia Rating/Modified (CDR-M). The ADRQL showed that QOL of the dementia group (65.77 +/- 17.04) was significantly inferior to that of the MCI (82.11 +/- 13.31) and control groups (79.75 +/- 15.82). There were no significant differences between the MCI and control groups. Within the dementia group, the five ADRQL subscale results were similar to those reported in other studies. Gender, age and place of residence had no significant influence on ADRQL scores. In contrast, ADRQL scores correlated significantly with MMSE, CAMCOG, IADL, ADL, CERAD/BRSD, and CDR-M. The MMSE and CERAD/BRSD were significant predictors of ADRQL variability. QOL of people with dementia is inferior to that of people with MCI and controls. This demonstrates the ADRQL instrument is sufficiently sensitive for evaluating the QOL of people with dementia. Longitudinal studies are needed to specifically examine the rate of QOL evolution throughout the entire dementia process.

Development of a Korean version of the behavior rating scale for dementia (BRSD‐K)

The purpose of this study was to develop a Korean version of the behavior rating scale for dementia (BRSD-K) for evaluating behavioral and psychological symptoms of dementia. The BRSD-K was administered to the informants of 268 subjects with dementia. Internal, inter-rater and test-retest reliabilities were tested. To evaluate construct validity, exploratory factor analysis was performed. To evaluate concurrent validity, Pearson correlation coefficients between BRSD-K scores and the corresponding scores of the Korean version of the neuropsychiatric inventory (NPI-K) were calculated. BRSD-K demonstrated substantially high levels of reliabilities. Factor analysis identified seven factors, i.e. depressive symptoms, irritability/aggression, psychotic symptoms, behavioral dysregulations, sleep disturbance, inertia, and appetite. Correlations between BRSD-K and corresponding NPI-K scores were statistically significant (p < 0.05). BRSD-K was found to be a reliable and valid instrument for evaluating BPSD.

Assessment of Behavioural and Psychological Symptoms Associated with Dementia

Neuropsychiatric symptoms (mood, psychotic, and behavioural) are very common in dementia and do not necessarily correlate well with other measures of cognition. However, these symptoms are of great importance, as they are a major source of excess disability, patient distress and caregiver burden and have great impact on the level of care required, and the associated costs. This paper is a review of the most useful outcome measures for behaviour and mood symptoms. Investigators who require a comprehensive instrument to measure neuropsychiatric symptoms in studies of patients with dementia should consider using the Neuropsychiatric Inventory (NPI), the Behavior Rating Scale for Dementia of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD-BRSD) or, possibly, the Behavioral Pathology in Alzheimer's Disease Scale (BEHAVE-AD). The Cornell Scale for Depression in Dementia and the Dementia Mood Assessment Scale (DMAS) are recommended for evaluating depressive symptoms and the Cohen-Mansfield Agitation Inventory (CMAI) is very useful for evaluating the full range of agitation symptoms.

White Matter Changes Associated With Psychotic Symptoms in Alzheimer’s Disease Patients

This study explored the relationship between white matter changes seen on magnetic resonance imaging (MRI) and neuropsychiatric symptoms of Alzheimer's disease patients. Fifty-five probable Alzheimer's disease patients were assessed with Behavioral Rating Scale for Dementia (BRSD) and MRI. White matter changes in the bilateral frontal or parieto-occipital region and left basal ganglia significantly corresponded with the score of the Psychotic Symptoms subscale of BRSD. Secondary analyses revealed that white matter changes were not associated with paranoid delusion and hallucination, but only with delusional misidentification. Our results suggest that white matter changes in Alzheimer's disease patients probably contribute to the development of specific psychotic symptoms, namely delusional misidentification.

Impact of an activities-based adult dementia care program

The investigators studied over one year the impact of a newly established once-a-week activity-based day care program for dementia patients combined with 17 educational sessions for caregivers held at the same facility. Outcome measures were patient and caregiver quality of life (QOL), patient behavioral disturbance, and use of community-based resources. Of the 37 enrollees, 3 chose not to start the program and 13 dropped out before the end of one year, largely due to health-related issues. Of the initial group, 21 attended for the entire year. The average patient Mini-Mental State Exam (MMSE) score at entry was 16, indicating a moderate level of dementia. Average score on the CERAD Behavior Rating Scale for Dementia (BRSD) was 30.1, indicating a mild level of behavioral disturbance. Attendance at day care was 91%; at the caregiver educational sessions, 74%. Patient and caregiver enthusiasm for the program was high and all wanted to continue attendance beyond the study period despite the fact that patients reported no change in QOL. Caregivers rated patients as having significantly less QOL, and rated their own QOL as unchanged. Symptomatic patient behaviors, as measured by the BRSD, increased significantly over the period of study. Caregivers reported greater use of community resources.

The cognitive pattern of vascular dementia and its assessment

Prevailing definitions of dementia are based on the Alzheimer disease (AD) model, which places major emphasis on memory impairment. In other dementias, such as vascular dementia (VaD), several other cognitive dysfunctions predominate over the memory disorder. The cognitive pattern changes according to the type of VaD. In multi-infarct dementia (MID), cortical lesions may cause loss of instrumental functions manifested by aphasia, amnesia, apraxia, or agnosia. Language in MID patients has shorter phrase length, restricted lexical variability, simplified syntax, and low verbal fluency; dysarthria or mechanical impairment of speech with abnormal pitch, melody, or articulation rate also occur. The latter are rare in degenerative dementias. Compared with AD, patients with MID demonstrate superior performance on verbal learning and memory, better delayed recall, and lower rates of forgetting, intrusions, and false positives. Subcortical ischemic dementia, subcortical hemorrhages, or single subcortical strategic infarcts frequently impair executive functions, attention, and speed of information processing; anterograde memory is generally less impaired than in AD patients. The two main problems of batteries used for evaluation of dementia such as those recommended by CERAD (verbal fluency test, a brief naming test such as the Modified Boston Naming Test, free recall of a word list, with immediate and delayed recall, followed by a recognition task of the same words, and line drawings of figures), as well as the Mini-Mental State Examination (MMSE), are (1) their strong emphasis on memory, temporal and spatial orientation, calculation, language, and constructional praxis, and (2) their failure to assess executive functions. Simple tests of executive function include the Trail Making Test, the Wisconsin Card Sorting Test, and the EXIT-25. A simple and effective test is the CLOX, an executive variation of the clock-drawing task. Depressive symptoms and other psychiatric disturbances are particularly common in VaD and become sources of cognitive and functional disability. Several questionnaires assess the neuropsychiatric manifestations of dementia including the Neuro-Psychiatric Inventory (NPI), the BEHAVE-AD test, the Cohen-Mansfield Scale, and the CERAD Behavioral Rating Scale for Dementia. Finally, development of dementia after a stroke may represent true VaD in patients with intact cognition before the stroke, or AD + CVD when the dementia occurs in patients that already had memory problems before the ictus. The diagnosis of VaD is a challenging clinical problem that encompasses the fields of medicine, neurology, psychiatry, and psychology.

Comorbidity of psychopathological domains in community-dwelling persons with Alzheimer's disease.

In this post hoc analysis of baseline responses to the CERAD Behavior Rating Scale for Dementia in a clinical trial of interventions for agitation in Alzheimer's disease (AD), the authors investigated the distribution of, and relationships between, agitation, depression, and psychosis in 148 individuals with AD. Prevalence of depressive symptoms was highest (78.4%), followed by agitation (77.6%) and psychotic symptoms (69.3%); 51.1% of the sample had symptoms in all 3 domains. Cross-sectionally, psychotic symptoms were most closely associated with Mini-Mental State Examination (MMSE) scores, while agitation was less so. Depressive symptoms were relatively consistently prevalent across MMSE levels. After controlling for the presence of agitated symptoms, psychosis and depression were significantly associated, but neither symptoms of psychosis nor of depression were associated with agitation when depression or psychosis, respectively, was controlled for. Significant psychopathological comorbidity should be considered in the design of clinical trials targeting particular psychopathology in this disease population.

Emergent Psychopathology in Alzheimer's Disease Patients Over 12 Months Associated with Functional, Not Cognitive, Changes

In a large, well-characterized population of community-dwelling persons with Alzheimer's disease (AD), we investigated the emergence of behavioral symptomatology and its association with changes in cognitive, global-clinical, and functional status. Behavioral Rating Scale for Dementia (BRSD) item responses from 235 AD patients with varying levels of dementia severity and without significant behavioral disturbance were taken from the baseline and 12-month visits in a study of cognitive and behavioral instruments. Item-level analysis revealed new symptoms at every dementia severity level. The symptoms that emerged in the greatest proportion of patients were change in weight, change in appetite, diurnal confusion, uncooperativeness, restlessness, clingy behavior, loss of initiative, and change in sleeping pattern. Changes in cognitive status over the 12 months were associated with changes in functional status and not with the emergence of behavioral symptomatology; however, change in the latter two domains tended to be associated. The findings support the hypothesis that increasing behavioral disturbance is not strongly associated with decreasing cognitive status and that, except for psychotic symptoms, a previously observed association between dementia severity and behavioral status may have been mediated partly by changes in functional abilities.

Measuring Alzheimer's disease progression with transition probabilities: estimates from CERAD.

To estimate annual transition probabilities (i.e., the likelihood that a patient will move from one disease stage to another in a given time period) for AD progression. Transition probabilities are estimated by disease stages (mild, moderate, severe) and settings of care (community, nursing home), accounting for differences in age, gender, and behavioral symptoms as well as the length of time a patient has been in a disease stage. Using data from the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), the authors employed a modified survival analysis to estimate stage-to-stage and stage-to-nursing home transition probabilities. To account for individual variability, a Cox proportional hazards model was fit to the CERAD data to estimate hazard ratios for gender, age (50 to 64, 65 to 74, and more than 75 years), and level of behavioral symptoms (low/high, according to responses to the Behavioral Rating Scale for Dementia) for each of the key stage-to-stage and stage-to-nursing home transitions. The transition probabilities underscore the rapid progression of patients into more severe disease stages and into nursing homes and the differences among population subgroups. In general, male gender, age under 65, and high level of behavioral symptoms were associated with higher transition probabilities to more severe disease stages. Disease progression is roughly constant as a function of the time a patient has spent in a particular stage. Transition probabilities provide a useful means of characterizing AD progression. Economic models of interventions for AD should consider the varied course of progression for different population subgroups, particularly those defined by high levels of behavioral symptoms.

Prevalence of Symptoms on the CERAD Behavior Rating Scale for Dementia in Normal Elderly Subjects and Alzheimer's Disease Patients

The authors sought to define “abnormal” levels for total scores on the CERAD Behavioral Rating Scale for Dementia (BRSD) and for 37 BRSD items by comparing 242 patients with Alzheimer’s disease (AD) and 64 normal elderly control subjects (NEC). BRSD total scores for NEC ranged as high as 52 (out of a maximum 167), and although item prevalence rates were higher for AD patients, not all of these differences were significant. Many symptoms were observed in ≤10% of AD subjects. Lower Mini-Mental State Examination scores were not consistently associated with lower or higher levels of endorsement across all items. Over 6 and 12 months, endorsement rates were relatively stable for both groups. The authors conclude that assessment of behavior in long-term studies will be needed to quantify “abnormal” levels, and that item-level BRSD information could be important in clinical trials.

Prevalence of symptoms on the CERAD behavior rating scale for dementia in normal elderly subjects and Alzheimer's disease patients.

The authors sought to define "abnormal" levels for total scores on the CERAD Behavioral Rating Scale for Dementia (BRSD) and for 37 BRSD items by comparing 242 patients with Alzheimer's disease (AD) and 64 normal elderly control subjects (NEC). BRSD total scores for NEC ranged as high as 52 (out of a maximum 167), and although item prevalence rates were higher for AD patients, not all of these differences were significant. Many symptoms were observed in < or = 10% of AD subjects. Lower Mini-Mental State Examination scores were not consistently associated with lower or higher levels of endorsement across all items. Over 6 and 12 months, endorsement rates were relatively stable for both groups. The authors conclude that assessment of behavior in long-term studies will be needed to quantify "abnormal" levels, and that item-level BRSD information could be important in clinical trials.

Quantifying behavioral disturbance in Alzheimer's disease patients

In the course of a four-month study of interventions for behavioral disturbances in Alzheimer's disease (AD) patients, the following assessment instruments were examined for validity: the clinical global impression of change (CGIC), Cohen-Mansfield agitation inventory (CMAI); CERAD behavioral rating scale for dementia (BRSD), revised memory and behavioral problems checklist (RMBPC) and the agitated behavior in dementia scale (ABID). The four specific behavioral/agitation scales had excellent cross-sectional and longitudinal correlations with each other, suggesting high validity, but changes as indicated by CGIC scores did not correlate well with change scores on the other instruments. We conclude that specific behavioral instruments are preferable to the more general CGIC for detecting and quantifying behavioral disturbances in AD patients.

Behavior Rating Scale for Dementia: development of test scales and presentation of data for 555 individuals with Alzheimer's disease.

We studied 555 Alzheimer's disease patients on the Behavior Rating Scale for Dementia (BRSD), which uses informant interviews to measure behavioral pathology in demented patients. For the 45 items, ratings of present ranged from 5% to 66% of the subjects, with 39 rated present in at least 10%. Twenty-nine items were significantly correlated with dementia severity. The mean number of items present per subject was 13.5; only two subjects had none rated present. Factor analysis identified six factors common to mildly and moderately demented subjects. Six subscales were developed: Depressive Symptoms, Inertia, Vegetative Symptoms, Irritability/Aggression, Behavioral Dysregulation, and Psychotic Symptoms. Interitem consistency was high for three subscales (alpha's from .75 to .80) and moderate for three (alpha's from .48 to .56). Four subscale scores and total scores were significantly but weakly correlated with dementia severity. Detailed results and test instructions are presented in the BRSD manual, available from The Consortium to Establish a Registry for Alzheimer's Disease.

DOPAMINE RECEPTOR GENETIC VARIATION AND MOTIVATIONAL DISTURBANCE IN ALZHEIMER's DISEASE

Background: Behavioral syndromes are reported to occur in over 80% of patients with AD. Motivational disturbance (MD) varyingly characterized by loss of interest, fatigue, motor retardation, affective blunting, anhedonia, and social withdrawal occurs as frequently as aggression or psychosis and is as important a source of caregiver distress. Although the pathophysiology of MD in AD is not known, there are several reasons to suspect an underlying hypodopaminergic state. Among these are uncontrolled studies indicating benefit of the dopaminergic agent methylphenidate in the treatment of MD. Method: The authors examined whether MD was associated with genetic variation in the dopamine-1 (DRD1), DRD2, DRD3, and DRD4 receptors in patients diagnosed with probable AD. Severity of MD was rated using the CERAD Behavioral rating scale for dementia (items 10,11,12, and 33) at the time of initial presentation to the Alzheimer's Disease Research Center of the University of Pittsburgh. A total of 193 patients were available for analysis. Results: There was no association of MD with age, race, or gender. Severity of MD was correlated with increased measures of depression (Ham-D) and impaired cognition (MATTIS). MD was significantly more severe in subjects with a psychotic or depressed syndrome but not in subjects with aggression. After controlling for the effects of cognitive impairment, psychosis, and depression, MD was significantly more severe in individuals with long alleles of the DRD4 exon III repeat sequence. No association with DRD1, DRD2, or DRD3 were seen. Conclusion: The authors found increased severity of MD in AD subjects with DRD4 long alleles. These results must be considered preliminary pending independent replication. DRD4 may represent a site of action for dopaminergic treatment of MD in AD subjects. P43