Diagnosis Of Major Neurocognitive Disorder Research Articles

Identifying pre-agitation biometric signature in patients with dementia: A feasibility study

Background:Agitation and aggression (AA) occur frequently in patients with dementia (PwD), and cause distress to PwD and caregivers. This study will investigate whether physiological parameters, such as actigraphy, heart rate variability, temperature, and electrodermal activity, measured via wearable sensors, correlate with AA in PwD. It will also explore whether these parameters could be compiled to create a pre-agitation biometric marker capable of predicting episodes of AA in PwD.Methods:This study will take place at Ontario Shores Centre for Mental Health Sciences. Thirty inpatient participants who are inpatients, males, and females, aged 60 or older, with clinically significant AA, and diagnosis of Major Neurocognitive Disorder will be recruited. Participants will wear the device for 48 to 72 hours on three occasions during an 8-week study period. Participant demographics and clinical measures used to assess behavior will be collected at specific time intervals during the study period.Ceiling mounted cameras and clinical data are collected to annotate episodes of AA, which will allow identification of peripheral physiological markers “signature” unique to the patientResults:the algorithm connecting wearable devices, cloud and cameras was tested on healthy volunteers and demonstrated feasibility and reliability. The feasibility of implementation in PwD has been demonstrated in our sample of PwD previously in a sample of 6 participants. Feasibility in this larger sample will be assessed. Correlation analysis between physiological measures, camera capture of agitation onset and clinical measures will be calculated to identify agitation events and pre-agitation triggers. Various machine learning and features extraction/exploration techniques will be used to test whether physiological measures can detect exact time of agitation and predict pre-agitation triggers. This study will provide a reasonable estimation of sample size needed to detect a meaningful effect size, which will be determined from the prediction model.Conclusion:Early detection of AA in PwD will allow caregivers to offer timely and personalized interventions which will help avoid crises and critical incidents and improve quality of life in PwD and their caregivers.

A - 94 A Case of New Onset Refractory Status Epilepticus (NORSE) Associated with COVID-19.

New Onset Refractory Status Epilepticus (NORSE) is a rare condition of prolonged medication-refractory seizures potentially due to elevated inflammatory molecules in the brain. NORSE can be triggered by a viral infection and is a documented neurologic consequence of COVID-19. A 74-year-old, left-handed, Hispanic male was in his usual state of health until experiencing 1-2weeks of speech decline, which culminated in an episode of altered mental status (disorientation and mumbling speech). He presented to the Emergency Department with drowsiness and complaints of a "funny feeling" on the left side of his head. Upon arrival, he was found to be COVID-19 positive and hyperglycemic with normal CT, MRI, lumbar puncture, and bloodwork. An EEG showed "focal temporal activity" and he was diagnosed with non-convulsant status epilepticus. Hospitalization and medical sedation lasted 2months followed by 8months of inpatient rehabilitation. The patient was discharged shortly before presenting for neuropsychological evaluation. Neuropsychological evaluation showed weaknesses in learning and free recall, visuospatial skills (due to disorganization and poor attention to details), processing speed, and executive functioning. The patient reported elevated anxiety symptoms. Collateral report indicated severe declines in executive organizational abilities, as well as mild memory and divided attention declines. Results suggest frontal cortical and subcortical impairments affecting multiple areas of cognition and functional decline consistent with a diagnosis of major neurocognitive disorder. Similar to the literature, status epilepticus was attributed to inflammatory meningoencephalitis triggered by the prior COVID-19 infection. Interdisciplinary care was an integral factor in this case.

Development and validation of the Ascertain Dementia 8 (AD8) Thai version.

The Ascertain Dementia 8 (AD8) is a brief informant-based questionnaire which reliably distinguishes patients with neurocognitive disorder (NCD) and normal cognition. Our objective was to translate the AD8 into Thai and test its validity as a potentially useful measure to detect patients with the mild stage of major NCD due to Alzheimer disease (major NCD-AD). Evaluations of 144 informant-patient dyads were made. Participants were patients who attended the memory clinic at Ramathibodi Hospital and non-patient volunteers. The AD8-Thai version was administered separately from doctor's interviews and neuropsychological assessments. Diagnostic workups included a complete medical history, physical and neurological examinations, neuropsychological testing, the Clinical Dementia Rating Scale-Sum of Boxes (CDR-SOB), Montreal Cognitive Assessment (MoCA), blood tests and brain imaging, preferably with magnetic resonance imaging. All researchers were blinded to the AD8 results. An AD8 score ≥3 had a sensitivity of 95.5%, a specificity of 89.5%, a positive predictive value of 84%, and a negative predictive value of 97.1% for screening major NCD-AD and those with normal cognition. A subgroup analysis with participants aged ≥65 years and with ≥12 years of education revealed comparable ability to the whole group. AD8 scores had a moderate negative relationship with MoCA scores (r= -0.470) and a strong positive relationship with CDR-SOB scores (r= 0.547). The performance of AD8 scores in differentiating mild NCD from normal cognition was not as good as for major NCD-AD. AD8-Thai version is an acceptable screening tool for major NCD-AD. For patients aged 65 years or older, with at least 12 years of education, and with cognitive complaints in memory clinic, an AD8-Thai score of 3 or more would be sufficient to work on major NCD diagnosis. The performance of the AD8-Thai in mild NCD needs further investigation.

Changes in Polypharmacy and Psychotropic Medication Use After Diagnosis of Major Neurocognitive Disorders: A Population-based Study in Québec, Canada.

Older adults with major neurocognitive disorder (MNCD) are often exposed to polypharmacy. We aimed to assess the prescribing and discontinuation patterns of medications following diagnosis of MNCD among community-dwelling older adults. Using the Quebec Integrated Chronic Disease Surveillance System, we conducted a population-based cohort study comparing 1-year prediagnosis and postdiagnosis use of medications between a group of individuals older than 65 years newly diagnosed with MNCD in 2016-2017 and a control group without MNCD. The difference-in-difference method was used to estimate the prediagnosis and postdiagnosis variation in the number of medications prescribed and in the proportion of psychotropic and anticholinergic medication users. In the MNCD group, the mean number of medications used (excluding Alzheimer disease treatments) increased by 1.25 in the year after the diagnosis. The respective increase was 0.45 in the control group, yielding an adjusted difference-in-differences of 0.81 (95% confidence interval: 0.74; 0.87) between groups. The adjusted difference-in-differences in the proportions of antipsychotic, antidepressant, and anticholinergic medication users was 13.2% (12.5; 13.9), 7.1% (6.5; 7.7), and 3.8% (3.1; 4.6), respectively. The medication burden among older adults tends to increase in the year following a diagnosis of MNCD. The use of antipsychotics and antidepressants may explain a part of the observed increase.

Optimizing Practices, Use, Care, and Services-Antipsychotics (OPUS-AP) in Long-Term Care Centers in Quebec, Canada: A Successful Scale-Up.

To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated. Prospective, closed cohort. Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada. The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9months. OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase2. The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing.

The Sound of Music: Short-term Effects of Live Music Performance on the Cognitive and Emotional Statuses of Residential Patients with Major Neurocognitive Disorder

<h3>Introduction</h3> Patientswith neurocognitive disorders (NCD) commonly experience a range of psychiatric symptoms such as depression, anxiety, psychosis, and agitation.¹ These comorbidities complicate the course of treatment for these patients as well as exacerbate caregiver burden. Since pharmacologic interventions are known to pose significant risks to these patients, there is great urgency to find additional non-pharmacologic options to improve quality of care.¹ Music therapy is becoming a more frequently used tool in different treatment settings and has been shown to improve anxiety and depression, however intensive and structured music therapy can also be a cost burden for residential facilities.^2,3 This study's aim was to assess the short-term benefits of a live music performance for residential patients with mild and moderate major NCD. <h3>Methods</h3> Thisis a prospective, non-blinded, longitudinal comparison study. Inclusion criteria were age 65-100, English speaking, and had either a diagnosis of major NCD, cognitive disorder, or dementia of the mild to moderate stage that required institutionalization at a residential facility. Exclusion criteria were severe presbycusis, and diagnosis of dementia or NCD of the severe stage. Participating residential facilities with connections to the Symphony of Soul Foundation and St. David's Foundation were asked to publicize this study to residents and their legally authorized representatives (LAR). The participants would then provide informed assent and consent, respectively, to enroll. The study intervention was a 30 minute live-performance of a set list of popular music from the 1930s-1950s (English language), given by a standard performer. The main statistical analysis will be a multivariate repeated measures comparison of scores that assess cognition, depression, and quality of life using the Montreal Cognitive Assessment (MoCA), Geriatric Depression Scale (GDS), and the Cornell-Brown Scale for Quality of Life (CBSQoL). The scales were administered 1 week before the study intervention to participating subjects for baseline scores, and then re-administered 1 week after the intervention. Different versions of the MoCA (v.1 and v.2) were used for the pre- and post-intervention assessments. <h3>Results</h3> Atotal of 8 subjects (n=8) and their respective LARs provided assent and consent to participate in the study. There was 1 complete dropout before the study began. The mean MoCA score pre-intervention, MoCA_pre = 7.3, with a 95% CI = [2.36, 12.25]; the mean MoCA score post-intervention, MoCA_post = 9.4, with a 95% CI = [3.41, 15.39]; the difference between the two mean MoCA scores was not statistically significant, since the 95% CI for this difference was [-5.65, 9.85]. Subjects did not have scores that indicated clinical depression throughout the study, with a mean GDS_pre = 1.5, and a mean GDS_post = 2.2. The mean CBSQoL_pre = -3.67, with a 95% CI = [-10.91, 3.57]; the mean CBSQoL_post = 17, with a 95% CI = [10.86, 23.14]; the CBSQoL scores between the two groups had statistically significant difference as evident in non-overlapping CIs; the 95% CI for the difference between the two mean CBSQoL scores was [11.19, 30.15]. <h3>Conclusions</h3> Thisstudy's initial results suggested that there was a statistically significant improvement in the subjects' quality of life after a brief, live-musical performance. However there were no significant differences in the subjects' cognition and mood. The labor intensity behind completing the pre- and post- intervention assessments was a notable barrier for subjects to participate effectively, and was also a deterrent for other eligible subjects to enroll in the study. Decreasing the difficulty for subjects to participate in the future (e.g., through optimizing the testing environment, shortening the music performance) might therefore increase the sample size and improve the study's power and validity.

Memantine resolves inappropriate sexual behavior in an elderly male with intellectual disability.

<h3>Introduction</h3> Memantine is a non-competitive N-methyl-d-aspartate receptor antagonist approved for the treatment of moderate to severe Alzheimer's disease. Given its connection with glutamate pathways, memantine is effective in many psychiatric conditions as monotherapy and as an adjunct. Inappropriate sexual behavior (ISB) incorporates sex talk, implied sexual behavior (openly reading pornography, requesting unnecessary genital care) and sexual acts (touching, grabbing, exposing, masturbating) privately or publicly. Hypersexuality has been regarded as a form of obsessive compulsive disorder. There is a dearth of literature about ISB in individuals with intellectual disability (ID), and diagnosing major neurocognitive disorder (NCD) is difficult, due to the lack of standardized diagnostic criteria. In this population, NCD is suspected in the context of new onset cognitive impairment, behavior disturbance and a functional decline. The prevalence of behavioral and psychiatric symptoms of minor and major neurocognitive disorders is 50–80 %, respectively. This patient was initially diagnosed with NCD and memantine was initiated. However, clinical follow ups and serial, stable Montreal Cognitive Assessments (MOCA) over three years, did not support this diagnosis. <h3>Methods</h3> Casereport of a male with ID who manifested novel, ISB at age 67. This includes history, clinical follow ups, physical and cognitive evaluation, neuroimaging, laboratory (lab) tests, literature review using PubMed. ISB uncontrolled with various pharmacologic agents eventually resolved with the addition of memantine which was gradually increased to 10 mg twice daily (BID). When a recurrence of ISB occurred after two years, it remitted with memantine 25 mg (administered in two divided doses). <h3>Results</h3> A67 year-old, single, white male with ID, hypertension, diabetes type 2 and hyperlipidemia who followed up in psychiatry for intermittent explosive disorder and anxiety, was stabilized on citalopram 40 mg daily (QD) and gabapentin 300 mg thrice daily (TID). He had special education through 12th grade and an intelligence quotient of 68. New onset ISB toward men was reported on January 2016. Episodes occurred in communal areas involving the touching of penises with pants down, propositioning someone at a public pool, and placing himself very close to a man during a class. Due to complaints, a team with a behaviorist was formulated to assist in preventing triggering of sexual impulse. Gabapentin was progressively increased to 600 mg TID; later risperidone was initiated, then increased to 0.5 mg BID in combination with citalopram 40 mg. Thereafter, the undesirable behavior gradually subsided. MOCA was 16/30. Labs included: creatinine; 1.28mg/dl (N<1.34mg/dl), GFR; >60ml/min(N), fasting glucose; 129mg/dl (N60-99mg/dl), vitamin B12; 291pg/ml(N>200pg/ml), vitamin B1; 75 nmol/L (N70-180 nmol/L), Methylmalonate, MRI and other dementia related labs were unremarkable. Vitamin B1 and B12 were started. Although ISB had ceased, the patient was seen again after two months due to progressive unsteadiness, falls, slurred speech and worsening cognition after gabapentin was increased. Mini mental status examination was 17/30. Memantine 5 mg daily was initiated and Gabapentin was gradually decreased to 300 mg QD. After two months, improved cognition with resolution of ISB was reported. After two years of stability, he began pursuing a man obsessively in a sexual manner over a two-month period. When examined on April 2019, his MOCA was 16/30 with stable labs. Memantine was increased to 10 mg in am and 15 mg at pm to target ISB. After 44 days, ISB was reported to have resolved soon after increasing memantine. At this visit, escitalopram 15 mg replaced citalopram 40 mg QD due to safety concerns. Sustained remission of ISB was reported in January, 2020. In March 2020, patient was seen again as he had touched a female inappropriately a few times during pool classes. MOCA was 18/30 (increased by two-points). He admitted to experiencing slight urges, but later quit the class and declined to attend the Pride parade to curb temptation. Although he had age related physical decline, there was no evidence of cognitive or functional impairment compared to baseline. Subsequently, the diagnosis of major neurocognitive disorder (NCD) was questioned. Additionally, he had demonstrated insight and successfully resolved ISB. To date, his ISB is in remission with stable labs. <h3>Conclusions</h3> Resolution of ISB in a patient with ID is a previously unreported therapeutic effect of memantine. ISB remitted with the addition of memantine 20 mg daily after multiple failed trials of various psychotropics. Two years later, the reemergence of ISB resolved with memantine 25 mg, and was well tolerated with stable medical tests. Memantine could be a promising medication for the control of ISB in these patients when used as an adjunct. <h3>This research was funded by</h3> NA

"Emergency Room Evaluation and Recommendations" (ER2) Tool for the Screening of Older Emergency Department Visitors With Major Neurocognitive Disorders: Results From the ER2 Database.

Purpose: The Emergency Room Evaluation and Recommendation (ER2) is an application in the electronic medical file of patients visiting the Emergency Department (ED) of the Jewish General Hospital (JGH; Montreal, Quebec, Canada). It screens for older ED visitors at high risk of undesirable events. The aim of this study is to examine the performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], positive likelihood ratio [LR+], negative likelihood ratio [LR-] and area under the receiver operating characteristic curve [AUROC]) of the ER2 high-risk level and its “temporal disorientation” item alone to screen for major neurocognitive disorders in older ED visitors at the JGH.Methods: Based on a cross-sectional design, 999 older adults (age 84.9 ± 5.6, 65.1% female) visiting the ED of the JGH were selected from the ER2 database. ER2 was completed upon the patients' arrival at the ED. The outcomes were ER2's high-risk level, the answer to ER2's temporal disorientation item (present vs. absent), and the diagnosis of major neurocognitive disorders (yes vs. no) which was confirmed when it was present in a letter or other files signed by a physician.Results: The sensitivities of both ER2's high-risk level and temporal disorientation item were high (≥0.91). Specificity, the PPV, LR+, and AROC were higher for the temporal disorientation item compared to ER2's high-risk level, whereas a highest sensitivity, LR-, and NPV were obtained with the ER2 high-risk level. Both area under the receiver operating characteristic curves were high (0.71 for ER2's high-risk level and 0.82 for ER2 temporal disorientation item). The odds ratios (OR) of ER2's high-risk level and of temporal disorientation item for the diagnosis of major neurocognitive disorders were positive and significant with all OR above 18, the highest OR being reported for the temporal disorientation item in the unadjusted model [OR = 26.4 with 95% confidence interval (CI) = 17.7–39.3].Conclusion: Our results suggest that ER2 and especially its temporal disorientation item may be used to screen for major neurocognitive disorders in older ED users.

Use of antipsychotic drugs and cholinesterase inhibitors and risk of falls and fractures: self-controlled case series

ObjectiveTo evaluate the association between the use of antipsychotic drugs and cholinesterase inhibitors and the risk of falls and fractures in elderly patients with major neurocognitive disorders.DesignSelf-controlled case series.SettingTaiwan’s National...

Monitoring Behaviors of Patients With Late-Stage Dementia Using Passive Environmental Sensing Approaches: A Case Series

To show the feasibility of using different unobtrusive activity-sensing technologies to provide objective behavioral markers of persons with dementia (PwD). Monitored the behaviors of two PwD living in memory care unit using the Oregon Center for Aging & Technology (ORCATECH) platform, and the behaviors of two PwD living in assisted living facility using the Emerald device. A memory care unit in Portland, Oregon and an assisted living facility in Framingham, Massachusetts. A 63-year-old male with Alzheimer's disease (AD), and an 80-year-old female with frontotemporal dementia, both lived in a memory care unit in Portland, Oregon. An 89-year-old woman with a diagnosis of AD, and an 85-year-old woman with a diagnosis of major neurocognitive disorder, Alzheimer's type with behavioral symptoms, both resided at an assisted living facility in Framingham, Massachusetts. These include: sleep quality measured by the bed pressure mat; number of transitions between spaces and dwell times in different spaces measured by the motion sensors; activity levels measured by the wearable actigraphy device; and couch usage and limb movements measured by the Emerald device. Number of transitions between spaces can identify the patient's episodes of agitation; activity levels correlate well with the patient's excessive level of agitation and lack of movement when the patient received potentially inappropriate medication and neared the end of life; couch usage can detect the patient's increased level of apathy; and periodic limb movements can help detect risperidone-induced side effects. This is the first demonstration that the ORCATECH platform and the Emerald device can measure such activities. The use of technologies for monitoring behaviors of PwD can provide more objective and intensive measurements of PwD behaviors.

Optimizing Practices, Use, Care and Services‐Antipsychotics (OPUS‐AP): A phase 2 scale‐up to 129 long‐term care (LTC) centers in Quebec, Canada

AbstractBackgroundAntipsychotics are often used for the first‐line management of behavioral and psychological symptoms of dementia (BPSD) despite risks and side effects, and with disregard for guidelines recommendations to prioritize non‐pharmacological interventions. OPUS‐AP builds on Canadian Foundation for Healthcare Improvement, Appropriate Use of Antipsychotic initiatives and previous work by the 4 university‐affiliated research centers on an aging population in Quebec. The OPUS‐AP strategy is supported by an evidence‐based approach, involving provincial clinical guidelines developed by Québec’s health‐technology assessment agency, the Institut national d’excellence en santé et en services sociaux (INESSS). In phase 1 of OPUS‐AP, conducted in 24 long‐term care (LTC) centers in Quebec, Canada, antipsychotic deprescribing (cessation or dose decrease) was achieved in 85,5% of residents in whom it was attempted (Cossette et al. JAMDA, 2019).MethodPhase 2 of OPUS‐AP was conducted in 129 LTC centres in Quebec, Canada, from April to December 2019. OPUS‐AP aims at improving resident care through increased staff’s knowledge and competency, resident‐centered approaches, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. OPUS‐AP is implemented through integrated knowledge translation and mobilization activities. Antipsychotic, benzodiazepine, antidepressant prescriptions and BPSD were evaluated every 3 months for 6 months.ResultAt baseline, 10,601 residents were admitted on OPUS‐AP participating wards from which 74% had a diagnosis of major neurocognitive disorder (MNCD) and 47% an antipsychotic prescription. The follow‐up cohort included 4,087 residents with both MNCD and antipsychotic prescription. Among the 1216 residents in whom antipsychotic deprescribing was attempted between baseline and 6 months and still included at 6 months, successful deprescribing was achieved in 85.6% (cessation 50.0% or dose decrease 35.6%). No increase in benzodiazepine or antidepressant prescriptions nor worsening of BPSD were observed.ConclusionPhase 2 of OPUS‐AP confirmed phase 1 results of successful antipsychotic deprescribing with scale‐up to 129 LTC centers. Phase 3 of OPUS‐AP is underway in 2020 in all of Quebec’s 341 public LTC centers.

201 - Behavioral and Psychological Symptoms of Dementia: a symposium of the IPA BPSD Shared Interest Forum

Section A. Psychotropic drug use (20 minutes)1) Sytse Zuidema: The RID (Reduction of inappropriate psychotropic drugs in dementia) study Nursing home residents with dementia and neuropsychiatric symptoms are prescribed psychotropic drugs too often and also sometimes inappropriate. Multidisciplinary interventions can help to facilitate better care by using psychosocial interventions and help to decrease inappropriate psychotropic drug use. We supported implementation of such interventions through participatory action research, to facilitate nursing homes to design, and implement their own local interventions. The results of the RCT (including a process evaluation) will be presented.2) Tzung-Jeng Hwang: dextromethorphan for treating agitationAgitation is highly prevalent in patients with dementia and associated with significant impairment of quality of life, early institutionalization, and higher mortality. Although no pharmacotherapy has been approved by the US FDA for dementia patients with agitation, off-label use of antipsychotic agents is common. But antipsychotic agents are clearly associated with increased adverse effects, including stroke and death. Dextromethorphan (DXM) is a low-affinity uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist, a high-affinity sigma-1 receptor agonist, a serotonin and norepinephrine reuptake inhibitor, and a nicotinicα3β4 receptor antagonist. The combination of DXM and low dose quinidine (Q) has been approved for the treatment of pseudobulbar affect in 2010. A recent study found that DXM/Q may be effective for the management of agitation in patients with Alzheimer disease (AD). In this talk, a pilot study on using DXM alone to treat agitation in dementia will be reported. Overall, the use of DXM 60-240 mg/day resulted in a high proportion of improvement (CGI-agitation: 69% much improved, 25% minimally improved). No severe adverse events were found. The results support DXM may be efficacious and safe.3) Marie Andree Bruneau: OPUS-APOPUS-AP aims at improving resident care through increased staff’s knowledge and competency, resident-centered approaches, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. OPUS-AP is implemented through integrated knowledge translation and mobilization activities. Antipsychotic, benzodiazepine, antidepressant prescriptions and BPSD were evaluated every 3 months for 9 months. Phase 2 of OPUS-AP was conducted in 129 LTC centres in Quebec, Canada, from April to December 2019. At baseline (April 2019), 10,601 residents were admitted on OPUS-AP participating wards from which 74% had a diagnosis of major neurocognitive disorder (MNCD) and 47% an antipsychotic prescription. The follow-up cohort included 4,087 residents with both MNCD and antipsychotic prescription. Among the 1381 residents in whom antipsychotic deprescribing was attempted between baseline and 9 months and still included at 9 months, successful deprescribing was achieved in 79,2% (cessation 44,8% or dose decrease 34,5%)). No increase in benzodiazepine or antidepressant prescriptions nor worsening of BPSD were observed.Section B. Updates on BPSD (20 minutes)1) Kathrin Schmuedderich: Severe agitation and quality of lifeA secondary data analysis was performed on the relationships between the severity of agitation (NPI-Q) and the single dimensions of quality of life (QUALIDEM) in people with dementia living in German nursing homes. In order to determine the differences between people with severe agitation and the group of people with mild or no agitation, a matching method and regression analyses were used. The findings show that severe agitation is related to lower quality of life in five out of six dimensions of quality of life.2) Wai-chi Chan: BPSD as a predictor of cognitive declineDescription will follow3) Huali Wang: Challenging behavior in ChinaDescription will followSection C. Measurement of BPSD (25 minutes)1) Wendy Moyle: Measurement of agitationThis presentation demonstrates how the use of video observation/coding, standardised measures of agitation (CMAI-SF), and physiological measures (actigraphy) produced different outcome results related to agitated behaviours following the introduction of a social robot. When measuring agitation, we need to consider using different types of measures to ensure data reliability and validity and longitudinal research methods to identify efficacy of psychosocial interventions and effective measurement of agitation when using social robots.2) Discussion on measurement of agitation, discussing and making plans for datasharing based on a template for datastructuresSection D. ECT (15 minutes)1) Rob Kok: short intro on ECT in BPSDThe majority of patients with dementia develop agitation or aggression in the course of their disease. In some severe cases, pharmacological and other interventions are not effective in improving these symptoms. A recent systematic review suggested that electroconvulsive therapy (ECT) could be an effective treatment for severe and treatment-refractory agitation and aggression in dementia, with few adverse consequences. We need to have controlled studies, address the stigma of ECT and develop professional guidelines for the application of ECT for agitation and aggression in dementia, particularly because most patients are not able to provide informed consent.2) Discussion and making plan for international survey on application of ECT in BPSD

Behavioural disturbances in patients with diagnosis of neurocognitive disorder in Bogotá (Colombia)

IntroductionThe main aim of this study is to determine the prevalence of behavioural disturbances (BD) in a group of patients with diagnosis of neurocognitive disorders assessed by a memory clinic in a referral assessment centre in Bogotá, Colombia, in 2015. Material and methodsThis is an observational, retrospective descriptive study of 507 patients with a diagnosis of neurocognitive disorder (according to DSM-5 criteria) evaluated in a referral centre in Bogotá, Colombia, in 2015. ResultsAmong the group of patients assessed, analyses reveal mean age for minor neurocognitive disorders of 71.04 years, and 75.32 years for major neurocognitive disorder (P < 0.001). A total of 62.72% of the sample were female. The most prevalent aetiology of the neurocognitive disorders was Alzheimer’s disease, followed by behavioural variant frontotemporal dementia and neurocognitive disorders due multiple aetiologies. BD occur more frequently in neurocognitive disorder due to behavioural variant frontotemporal dementia (100%), Alzheimer’s disease (77.29%) and vascular disease (76.19%). The most prevalent BD in the group assessed were apathy (50.75%), irritability (48.45%), aggression (16.6%), and emotional lability (14.76%). ConclusionsBD occur more frequently in patients with diagnosis of major neurocognitive disorder. BD are more prevalent in behavioural variant frontotemporal dementia than any other group. Apathy, irritability, emotional lability and aggression are the BD that occur with greater prevalence in our sample. We discuss the importance of BD in the clinical progression of neurocognitive disorders.

Assessment of Major Neurocognitive Disorders in Primary Health Care: Predictors of Individual Risk Factors.

Major Neurocognitive Disorders describe the symptoms of a large group of diseases causing a progressive decline in individual’s functioning. It is an umbrella term describing a decline in memory, intellectual ability, reasoning, and social skills, as well as changes in normal emotional reactions. The general practitioner is instrumental in the early diagnosis of Major Neurocognitive Disorder. Individual risk factors act as contributing variables affecting the probability of someone developing a Major Neurocognitive Disorder and may be considered predictive factors. This study aimed (i) to show the utility of using the Global Deterioration Scale in primary health care settings as a measure to assess the stage of cognitive function for individuals identified with Major Neurocognitive Disorders and (ii) to identify predictors of severe Major Neurocognitive Disorders. Potential predictors of Major Neurocognitive Disorders considered in this study were: sex, age, years of education, social isolation, hearing impairment, cardiovascular disease, hypertension, diabetes, smoking habits, alcohol consumption, physical activity, hand strength, and nutritional status. The sample comprised 250 adults, 30.4% were classified as having probable Major Neurocognitive Disorder. The variables significantly associated with probable Major Neurocognitive Disorder were age, years of education, hearing impairment, cardiovascular disease, hand strength, nutritional status, and physical activity. In the multivariable model, only age, education, physical activity and hand strength remained significant predictors of probable Major Neurocognitive Disorder. The Global Deterioration Scale seems to be a usefull instrument in primary healthcare settings, as it guides the general practitioner in observing the patients’ cognitive functioning. Advanced age, lower education, lower hand strength and absence of physical activities should be taken into account as they increase the chance of severe Major Neurocognitive Disorders. Primary health care providers, including general practitioners are very important in the diagnosis and follow up of Major Neurocognitive Disorder. The general practitioner is in most cases the patients’ first and for many patients the only contact, thus having a critical role in evaluating with caution what is part of normal or pathological aging, and the individual factors that can increase the likelihood of developing Major Neurocognitive Disorder to further support patients in the course of the disease.

THE SOUND OF MUSIC: SHORT-TERM EFFECTS OF LIVE MUSIC PERFORMANCE ON THE COGNITIVE AND EMOTIONAL STATUSES OF RESIDENTIAL PATIENTS WITH MAJOR NEUROCOGNITIVE DISORDER

Introduction Patients with neurocognitive disorders (NCD) commonly experience a range of psychiatric symptoms such as depression, anxiety, psychosis, and agitation. 1 These comorbidities complicate the course of treatment for these patients as well as exacerbate caregiver burden. Since pharmacologic interventions are known to pose significant risks to these patients, there is great urgency to find additional non-pharmacologic options to improve quality of care. 1 Music therapy is becoming a more frequently used tool in different treatment settings and has been shown to improve anxiety and depression, however intensive and structured music therapy can also be a cost burden for residential facilities. 2 , 3 This study's aim was to assess the short-term benefits of a live music performance for residential patients with mild and moderate major NCD. Methods This is a prospective, non-blinded, longitudinal comparison study. Inclusion criteria were age 65-100, English speaking, and had either a diagnosis of major NCD, cognitive disorder, or dementia of the mild to moderate stage that required institutionalization at a residential facility. Exclusion criteria were severe presbycusis, and diagnosis of dementia or NCD of the severe stage. Participating residential facilities with connections to the Symphony of Soul Foundation and St. David's Foundation were asked to publicize this study to residents and their legally authorized representatives (LAR). The participants would then provide informed assent and consent, respectively, to enroll. The study intervention was a 30 minute live-performance of a set list of popular music from the 1930s-1950s (English language), given by a standard performer. The main statistical analysis will be a multivariate repeated measures comparison of scores that assess cognition, depression, and quality of life using the Montreal Cognitive Assessment (MoCA), Geriatric Depression Scale (GDS), and the Cornell-Brown Scale for Quality of Life (CBSQoL). The scales were administered 1 week before the study intervention to participating subjects for baseline scores, and then re-administered 1 week after the intervention. Different versions of the MoCA (v.1 and v.2) were used for the pre- and post-intervention assessments. Results A total of 8 subjects (n=8) and their respective LARs provided assent and consent to participate in the study. There was 1 complete dropout before the study began. The mean MoCA score pre-intervention, MoCApre = 7.3, with a 95% CI = [2.36, 12.25]; the mean MoCA score post-intervention, MoCApost = 9.4, with a 95% CI = [3.41, 15.39]; the difference between the two mean MoCA scores was not statistically significant, since the 95% CI for this difference was [-5.65, 9.85]. Subjects did not have scores that indicated clinical depression throughout the study, with a mean GDSpre = 1.5, and a mean GDSpost = 2.2. The mean CBSQoLpre = -3.67, with a 95% CI = [-10.91, 3.57]; the mean CBSQoLpost = 17, with a 95% CI = [10.86, 23.14]; the CBSQoL scores between the two groups had statistically significant difference as evident in non-overlapping CIs; the 95% CI for the difference between the two mean CBSQoL scores was [11.19, 30.15]. Conclusions This study's initial results suggested that there was a statistically significant improvement in the subjects’ quality of life after a brief, live-musical performance. However there were no significant differences in the subjects’ cognition and mood. The labor intensity that was required for the subjects to complete the pre- and post- intervention assessments was a notable barrier for them to participate effectively as evident by the dropout rate, and was also a deterrent for additional eligible subjects to enroll in the study. Decreasing the difficulty for subjects to participate in the future (e.g., through optimizing the testing environment, shortening the music performance) might therefore increase the sample size and improve the study's power and validity This research was funded by: Symphony of Soul Foundation, St. David's Foundation

DIAGNOSING COGNITIVE DECLINE: COMPARING NIA-AA TO DSM-5 APPROACHES

Introduction Both the DSM-5 and NIA-AA (Albert et al., 2011) stipulate methods for assessing and diagnosing cognitive decline but differ in their approach for estimating cognitive ability. The DSM suggests that evidence of cognitive decline is demonstrated either through culturally normed neuropsychological evaluation or through the use of “bedside” assessments such as the Mini Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA). By contrast, the 2011 recommendations from the National Institute of Aging – Alzheimer Association (NIA–AA) emphasize the use of objective testing ideally via a neuropsychological evaluation of cognitive impairment in one or more cognitive domains. The current study compared differences in diagnostic rates between these two standards. Since the NIA-AA standards emphasize a more detailed cognitive assessment, we hypothesized that these criteria would identify a larger proportion of individuals with cognitive impairment than the DSM-5 criteria. We then examined possible clinical predictors of this discrepancy, including demographic, psychosocial, health-related, and genetic factors. Methods Data was drawn from 604 participants who were recruited into the Prevention of Alzheimer's Disease With Cognitive Remediation Plus tDCS in Mild Cognitive Impairment and Depression (PACt-MD; ClinicalTrials.gov Identifier: NCT02386670) trial. This is a randomized, controlled trial to evaluate brain stimulation and computerized brain training interventions for the prevention of cognitive decline in older adults. Participants either had a clinical history of mild cognitive impairment (MCI), major depressive disorder in remission, both, or were recruited as healthy controls without history of cognitive difficulty or mental disorder. All participants underwent a clinical and neuropsychological evaluation. Cognitive diagnoses were determined during biweekly consensus conferences. Both the DSM-5 and NIA-AA criteria were used during each consensus conference. The current analysis is based on the baseline data (i.e., prior to the intervention) of the 455 participants for whom a consensus conference was completed. We first compared diagnostic rates of MCI (NIA-AA) vs. mild neurocognitive disorder (DSM-5), as well as dementia (NIA-AA) vs. major neurocognitive disorder (DSM-5). We then used binary logistic regression models to examine demographic (age, education, race, sex, premorbid intellectual ability), psychosocial (English as a primary language, history of depression), health-related (severity of medical illness burden), and genetic (APOE e4 carrier status) predictors of diagnostic discrepancy between DSM-5 and NIA-AA criteria. Analyses were conducted separately for two groups of participants: (i) the group for which NIA-AA diagnoses reflected greater cognitive impairment than did the DSM-5 diagnoses (e.g., NIA-AA diagnosis of dementia but DSM-5 diagnosis of mild neurocognitive disorder); and (ii) the group for which DSM-5 diagnoses reflected greater cognitive impairment (e.g., DSM-5 diagnosis of major neurocognitive disorder but NIA-AA diagnosis of MCI. Results At baseline, there were 103 (22.6%) cases of discrepant diagnoses between the two classification systems: 50 cases had a NIA-AA diagnosis of MCI and no DSM-5 cognitive diagnosis (i.e., normal cognitive status); 41 cases had a NIA-AA diagnosis of dementia and a DSM-5 diagnosis of mild neurocognitive disorder; 12 cases had a DSM-5 diagnosis of mild neurocognitive disorder and no NIA-AA diagnosis. Compared to the 352 cases in agreement, the 91 cases with NIAA diagnoses reflecting greater cognitive impairment were more likely to have a history of major depressive disorder in remission (46% vs. 39%; B=-1.058, p=.003), be an APOE4 carrier (50% vs. 27%; B=-1.120, p=.001), and be older (72?vs. 71 years; B=.063, p=.02). APOE4 status, history of depression, and age were independent predictors. Compared to the 352 cases in agreement, the 12 cases with DSM-5 diagnosis reflecting greater cognitive impairment were less likely to have a history of depression (17% vs. 41%; B=2.414, p=.025). Conclusions While there was overall agreement with cognitive diagnoses when using NIA-AA or DSM-5 criteria, the two systems were discrepant in 22.6% of cases. Discrepancies were more likely to occur in participants with a history of depression, who were APOE4 carriers, or who were older. Overall, NIA-AA criteria yielded diagnoses reflecting greater cognitive impairment, especially in participants with a history of prior depression or those who were APOE4 carriers. These results suggest that more detailed neuropsychological evaluations may be indicated in older adults with a history of depression or who have a genetic vulnerability to dementia. This research was funded by: This project has been made possible by Brain Canada through the Canada Brain Research Fund, with the financial support of Health Canada and the Chagnon Family.

Spanish validation and cultural adaptation of the Five-Word Test for the detection of the neurocognitive disorder in older adults

Introduction. “Episodic” memory problems are common in people with cognitive impairment due to Alzheimer’s disease and related disorders. Dubois et al. developed the Five-Word Test (5WT) to evaluate episodic memory, which has proved to be an easy and valid test for identifying cognitive disorders. However, its validation and cultural adaptation from French to Spanish has not been undertaken and its usefulness in Mexican population is unknown. Objective. Validation and cultural adaptation of the 5WT for screening minor and major neurocognitive disorder (ND) in Mexican older adults with probable Alzheimer’s disease. Method. Two hundred and fifteen participants (70 cognitively healthy subjects, 73 with minor ND and 72 with major ND were included). The cognitive status (gold standard) was determined using current clinical criteria and neuropsychological evaluation. The Spearman coefficient, ROC curve, and multinomial logistic regression models were used to determine the concurrent validity of the 5WT. Results. The correlation between the 5WT and the Mini-Mental State Exam (MMSE) was .58, whereas for the clock face test it was -.37 (p &lt; .001). The area under the 5WT curve was .97 (95% CI [.94, .99]), with a cut-off point of ≤ 16/20 for the diagnosis of major ND (89% sensitivity, 98% specificity) and .77 (95% CI [.70, .85]) for minor ND with a cut-off point of ≤ 18/20 (66% sensitivity, 77% specificity). Discussion and conclusion. Since the 5WT is a simple, valid instrument for the identification of neurocognitive disorders like Alzheimer’s disease, it could be a practical screening test.

Use of medical care in the 7 years before dementia in the French health insurance database in 2016

Abstract Background The entry into dementia is a period of growing interest for clinical trials and public health policies. We described the frequency of medical care use in the 7 years prior to the first dementia identification (index date). Methods All French health insurance general scheme beneficiaries aged 65 or more with an incident dementia in 2016 (identified through long-term disease registry, hospitalization diagnoses, or specific drug delivery), were matched with beneficiaries without dementia of same age, gender, area of residence. The annual cumulative incidences (ACI) of visits (GP and specialists, including outpatient hospital visits) and hospitalizations were estimated over 7 years (Y-7 to Y-1 before index date), by age (65-74, 75-84, 85-89, 90+). Results Among 274166 subjects (median age 84, 65% women), the ACI of GP visit was stable and similar between cases and controls, around 95%. The ACI of neurologist, psychiatrist and internist visit and of hospitalization in a psychiatric unit increased in cases, especially in Y-1. They were higher than in controls in the youngest age classes. The ACI of visits to a dermatologist, a rheumatologist, an ophthalmologist, a dentist and for women a gynecologist, were lower in cases than in controls, with an increasing difference in the last years before dementia care. Similar patterns were observed in the oldest exclusively (generally ≥85 yo) for pneumologist, cardiologist, nephrologist, and in a lesser extent, endocrinologist visit. The ACI of hospitalizations increased with time in both groups, with a peak in Y-1 in cases. They were higher in cases than in controls in the youngest age classes. Conclusions The increase in hospitalization rate in Y-1 suggests a decline in clinical status leading to the diagnosis or a weakening at the time of entry into dementia. The lesser use of a specialist other than neurologist or psychiatrist suggests a focus of care around dementia, possibly to the detriment of the care of comorbidities. Key messages As most patients visit their GP at least yearly, specific GPs training could help to make a timely diagnosis of major neurocognitive disorders. The lesser use of a specialist other than neurologist or psychiatrist suggests a focus of care around dementia, possibly to the detriment of the care of comorbidities.

Optimizing Practices, Use, Care and Services–Antipsychotics (OPUS-AP) in Long-term Care Centers in Québec, Canada: A Strategy for Best Practices

ObjectivesAntipsychotic medications are often used for the first-line management of behavioral and psychological symptoms of dementia (BPSD) contrary to guideline recommendations. The Optimizing Practices, Use, Care and Services–Antipsychotics (OPUS-AP) strategy aims to improve the well-being of long-term care (LTC) residents with major neurocognitive disorder (MNCD) by implementing a resident-centered approach, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. DesignProspective, closed cohort supplemented by a developmental evaluation. Setting and ParticipantsResidents of designated wards in 24 LTC centers in Québec, Canada. MethodsProvincial guidelines were disseminated, followed by the implementation of an integrated knowledge translation and mobilization strategy, including training, coaching, clinical tools, evaluation of clinical practices, and a change management strategy. Antipsychotic, benzodiazepine, and antidepressant prescriptions; BPSD; and falls were evaluated every 3 months, for 9 months, from January to October 2018. Semistructured interviews (n = 20) were conducted with LTC teams to evaluate the implementation of OPUS-AP. ResultsOf 1054 residents, 78.3% had an MNCD diagnosis and 51.7% an antipsychotic prescription. The cohort included 464 residents with both MNCD and antipsychotic prescription. Antipsychotic deprescribing (cessation or dose decrease) was attempted in 220 of the 344 residents still admitted at 9 months. Complete cessation was observed in 116 of these residents (52.7%) and dose reduction in 72 (32.7%), for a total of 188 residents (85.5%; 95% confidence interval: 80.1%, 89.8%). A decrease in benzodiazepine prescriptions and improvements in Cohen-Mansfield Agitation Inventory scores were observed among residents who had their antipsychotics deprescribed. Caregivers and clinicians expressed satisfaction as a result of observing an improved quality of life among residents. Conclusions and ImplicationsAntipsychotic deprescribing was successful in a vast majority of LTC residents with MNCD without worsening of BPSD. Based on this success, phase 2 of OPUS-AP is now under way in 129 LTC centers in Québec.

Alteraciones del comportamiento de pacientes con diagnóstico de trastorno neurocognoscitivo en Bogotá (Colombia)

IntroductionThe main aim of this study is to determine the prevalence of behavioural disturbances (BD) in a group of patients with diagnosis of neurocognitive disorders assessed by a memory clinic in a referral assessment centre in Bogotá, Colombia, in 2015. Material and methodsThis is an observational, retrospective descriptive study of 507 patients with a diagnosis of neurocognitive disorder (according to DSM-5 criteria) evaluated in a referral centre in Bogotá, Colombia, in 2015. ResultsAmong the group of patients assessed, analyses reveal mean age for minor neurocognitive disorders of 71.04 years, and 75.32 years for major neurocognitive disorder (P <0.001). A total of 62.72% of the sample were female. The most prevalent aetiology of the neurocognitive disorders was Alzheimer's disease, followed by behavioural variant frontotemporal dementia and neurocognitive disorders due to multiple aetiologies. BD occur more frequently in neurocognitive disorder due to behavioural variant frontotemporal dementia (100%), Alzheimer's disease (77.29%) and vascular disease (76.19%). The most prevalent BD in the group assessed were apathy (50.75%), irritability (48.45%), aggression (16.6%), and emotional lability (14.76%). ConclusionsBD are highly prevalent in patients with diagnosis of major neurocognitive disorder. BD are more prevalent in behavioural variant frontotemporal dementia than any other group. Apathy, irritability, emotional lability and aggression are the BD that occur with greater prevalence in our sample. We discuss the importance of BD in the clinical progression of neurocognitive disorders.