Disturbances In Dementia Research Articles

P4-182: The behavioral disturbances in mild-moderate and severe stages of Alzheimer’s disease

To investigate the frequency and severity of the behavioral symptoms in Alzheimer's disease patients and the burden placed on their caregivers. The sample consists of 129 community–dwelling Alzheimer's disease patients at mild–moderate and severe stages of Alzheimer's Disease (Global Deterioration Scale, GDS, 3, 4, 5 and 6). Caregivers using Neuropsychiatric inventory were interviewed. The frequency and severity of the most common behavioral disturbances in dementia and their relationship with the GDS were investigated. In addition, those behavioral symptoms influence in caregivers well being was analyzed. The most frequent behavioral disturbances exhibited by mild moderate Alzheimer's disease patients were: Apathy, followed by Anxiety and Irritability. Concerning to behavioral symptoms severity, Anxiety, Apathy and finally, Irritability were the most severe. Depression, Apathy and Agitation were the most distressing behavioral symptoms for the caregivers. Results show that there is a significant relation (p<0.05) between GDS value and Hallucination behavior's severity and the score obtained in Frequency X Severity (FxS). Another significant association (p<0.05) observed was between Anxiety's Frequency X Severity (FxS) and GDS value. The most frequent behavioral disturbances exhibited by the patients at the severe stage were Apathy, Anxiety and Aberrant Motor Behavior. Anxiety, Apathy and Irritability were the most severe behavioural symptoms. Caregivers manifested that Depression, Deliriums and Night–time behavioral disturbances were the most distressing behavioral problems. The regression analysis revealed that there was a significant relation (p<0.05) between GDS value and Hallucination behavior's frequency, severity and the score obtained in Frequency × Severity (FxS). Another significant (p<0.05) association observed was among Anxiety behavior's frequency and Anxiety symptoms Frequency × Severity (FxS) with GDS value. Finally, there was a statistically significant relation (p<0.05) among all the Neuropsychiatric items and the distress or burden on the caregivers, in both the mild–moderate and severe stages of Alzheimer's disease. The management of behavioral symptoms in Alzheimer's disease patients is important for patients who suffer from dementia and their caregivers. Over 80% of Alzheimer's disease patients live at home and receive care from family and friends. Many family caregivers have difficulty managing behavioral symptoms of community–dwelling persons with dementia.

Delta-9-tetrahydrocannabinol for nighttime agitation in severe dementia

Nighttime agitation occurs frequently in patients with dementia and represents the number one burden on caregivers today. Current treatment options are few and limited due to substantial side effects. The aim of the study was to measure the effect of the cannabinoid dronabinol on nocturnal motor activity. In an open-label pilot study, six consecutive patients in the late stages of dementia and suffering from circadian and behavioral disturbances-five patients with Alzheimer's disease and one patient with vascular dementia-were treated with 2.5 mg dronabinol daily for 2 weeks. Motor activity was measured objectively using actigraphy. Compared to baseline, dronabinol led to a reduction in nocturnal motor activity (P=0.028). These findings were corroborated by improvements in Neuropsychiatric Inventory total score (P=0.027) as well as in subscores for agitation, aberrant motor, and nighttime behaviors (P<0.05). No side effects were observed. The study suggests that dronabinol was able to reduce nocturnal motor activity and agitation in severely demented patients. Thus, it appears that dronabinol may be a safe new treatment option for behavioral and circadian disturbances in dementia.

Sleep and its management in dementia

Sleep disturbance is a clinically significant problem in nearly one half of patients with dementia and is a predictor of cognitive and functional decline. There are multiple causes of sleep disturbance in dementia and all represent diagnostic and management challenges. Impaired circadian rhythm is a disorder characterized by an increase in daytime sleep with reduced night-time sleep, a reversal of the sleep/wake cycle. Such disrupted circadian rhythm may occur early in Alzheimer's disease, worsen over time, and is associated with behavioural disturbance, including aggression. In addition to the timing of sleep, the structure of sleep may deteriorate, giving rise to poor sleep quality.

Pharmacological management of behavioural and psychological disturbance in dementia

Behavioural and psychological symptoms in patients with dementia are common, distressing and often difficult to manage. This review evaluates a range of drugs commonly used to manage these symptoms including antipsychotics, anticonvulsants, antidementia drugs and antidepressants. The risks and benefits of individual treatments are discussed and the relatively poor evidence base and need for further research is highlighted.

Involvement of the Serotonergic System in Cognitive and Behavioral Symptoms of Alzheimers Disease

Alzheimers disease (AD) is a chronic progressive disorder characterized by dementia, but often featuring behavioral and psychological syndromes (BPSD), such as depression, overactivity, psychosis or aggressive behavior. Traditional treatments for BPSD are neuroleptics and sedatives, which are not devoid of serious adverse effects. Neurochemically, the classical hallmark of AD is the disruption of basal forebrain cholinergic pathways and consequent cortical cholinergic denervation of the neocortex and hippocampus. However, it is conceivable that, according to the complexity and diversity of BPSD, more than one transmitter system may contribute to a particular behavioral syndrome. The serotonergic system has been implicated not only in cognitive processes, but also in depression, psychosis or aggression. In AD, extensive serotonergic denervation has been reported. In particular, there is growing interest in the pathological functions and implication in BPSD of 5-HT6 receptors, due to its high affinity for antipsychotic drugs and its distribution in the brain. In this study we will review the present knowledge of the involvement of the serotonergic system and its receptors in cognitive deficits and BPSD. From the currently available data, it is possible to conclude that pharmacological manipulation of serotonergic system may improve not only cognitive function but behavioral disturbances in dementia. Keywords: learning, memory, depression, psychosis, 5-ht6 receptors, acetylcholine

Neuropsychiatric symptoms in dementia-frequency, relationship to dementia severity and comparison in Alzheimer's disease, vascular dementia and frontotemporal dementia

Noncognitive behavioral and psychiatric disturbances are common in dementia and help in the clinical differentiation of the various subtypes. We studied the frequency of neuropsychiatric disturbances, their relationship to dementia severity and compared these disturbances in Alzheimer's disease (AD), vascular dementia (VaD) and frontotemporal dementia (FTD) using the 12-item Neuropsychiatric Inventory (NPI). A total of 98 patients (AD—44, VaD—31, FTD—23) were evaluated. All subjects were community dwelling at the time of evaluation. The three groups were comparable on global dementia severity and functional ability. All patients had clinically significant scores on the NPI with apathy, irritability and agitation being very common (> 90% of patients). AD and VaD patients in Clinical Dementia Rating (CDR) stage 2 had significantly higher scores on the total NPI, agitation and disinhibition subscales compared to those in CDR stage 1. Mean scores in the domains of aberrant motor behavior, disinhibition and appetite/eating behavior differentiated FTD from AD and VaD. Neuropsychiatric disturbances in dementia appear to be universal with agitation, disinhibition and irritability being more frequent in the later stages. In this cohort disinhibition, aberrant motor behavior and appetite/eating disturbances could reliably differentiate AD and VaD from FTD. There were no significant differences between the neuropsychiatric profiles of AD and VaD.

Méthode de prise en charge globale non médicamenteuse des patients déments institutionnalisés

Over the last decades many approaches have been developed to manage cognitive and behavioral disturbances in dementia. The present work describes a global intervention program carried out with moderately to severely demented institutionalized patients. The aims of the intervention program are to stimulate and maintain the preserved abilities of demented patients in a supportive context, to decrease the behavioral disturbance and to avoid burnout of care-unit staff. This intervention combines different means: psychosocial care (validation therapy, social interaction), cognitive stimulation (memory and verbal training), and motor and sensitive stimulation. The global intervention program requires a special trained team composed of a supervisor, six aid-nurses, an occupational therapist, a speech therapist, a psychomotor therapist and a psychologist. The team cared for the patients five days per week over a three-month period. Assessments were conducted before and after the intervention program to measure the benefit. Positive effects were shown for cognitive abilities, nutritional problems and staff burnout. However, due to the small sample size for this study, more research is needed to verify the effectiveness of this global intervention program, particularly the implications for nutrition. This global intervention combined with pharmacological treatment seems to be useful for managing psychological and behavioral disorders of institutionalized demented patients.

P.5.017 Use of valproate in treatment of behavioural and psychological disturbances of dementia

P.5.017 Use of valproate in treatment of behavioural and psychological disturbances of dementia

A Randomized, Double-Blind, Crossover Comparison of Risperidone and Haloperidol in Korean Dementia Patients With Behavioral Disturbances

Objective Behavioral disturbances in dementia are extremely prominent and distressful, and often result in serious physical, social, and economic consequences. The authors compared the efficacy and tolerability of risperidone and haloperidol in the treatment of behavioral and psychological symptoms of dementia (BPSD) in institutionalized elderly Korean patients with Alzheimer disease, vascular dementia, or mixed dementia. Methods This was an 18-week double-blind, crossover study involving 120 patients who were randomly assigned to receive flexible doses (0.5–1.5 mg/day) of risperidone or haloperidol. BPSD were assessed using the Korean version of the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD-K), the Korean version of the Cohen-Mansfield Agitation Inventory (CMAI-K), and the Clinical Global Impression of Change scale (CGI-C). Safety and tolerability assessments included the Extrapyramidal Symptom Rating Scale and the incidence of adverse events. Results Both risperidone and haloperidol were efficacious in alleviating BPSD. However, when receiving risperidone, patients showed significantly greater improvement than when receiving haloperidol in the total and subscale scores of the BEHAVE-AD-K, the total and subscale scores of the CMAI-K, and the scores on the CGI-C scale. Also, risperidone had an additional benefit on aggressiveness and anxieties/phobias. The risk of antipsychotic-induced parkinsonism throughout this study was significantly lower with risperidone than with haloperidol. Conclusion Risperidone had a favorable efficacy and tolerability profile compared with haloperidol in the treatment of BPSD in this patient population.

Light therapy for managing sleep, behaviour, and mood disturbances in dementia.

Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light. The review assesses the efficacy of bright light therapy (BLT) in managing sleep, behaviour, mood, and cognitive disturbances associated with dementia. The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 27 January 2004 using the terms "bright light*", "light box*", "light visor*", "dawn-dusk*", phototherapy (MESH), phototherapy, "photo therapy", "light therapy" "light treatment", light*. All relevant, randomized controlled trials in which BLT, at any intensity and duration, was compared with a control group for the effect on managing sleep, behavioural, mood, and cognitive disturbances (as well as changes in institutionalization rates and cost of care) on people with dementia of any degree of severity. Three reviewers independently assessed the retrieved articles for relevance, methodological quality, and extracted data from the selected studies. The statistically significant differences in changes in outcomes from baseline to end of treatment and from baseline to follow-up between the light therapy and control groups were examined. Each study was summarized using a measure of effect (e.g. mean difference). Owing to lack of homogeneity between studies, their results were not combined. Five studies met the inclusion criteria. However, only three were included in the analyses because of inappropriate analyses reported or inability to retrieve the required data from the investigators. This review revealed no adequate evidence of the effectiveness of BLT in managing sleep, behaviour, and mood disturbances associated with dementia. There is insufficient evidence to assess the value of BLT for people with dementia. The available studies are of poor quality and further research is required.

Treatment of the Neuropsychiatric Symptoms in Alzheimer's Disease

Behavioral symptoms are common in Alzheimer’s disease (AD) and represent a major source of the disease morbidity. Neuropsychiatric disturbances have been associated with more rapid cognitive decline (1), increased caregiver burden (2,3), increases in patient care costs due to earlier institutionalization of the AD patient, greater medication use and more adverse side effects and more extensive institutional staffing needs (4,5). Kaufer and colleagues (6) reported a strong correlation between the amount of neuropsychiatric disturbance as measured by the Neuropsychiatric Inventory (NPI) and the degree of caregiver distress with little relationship between the degree of impairment on the Mini-Mental State Exam (MMSE) (7) and the degree of caregiver distress. In addition, a recent cost analysis showed that AD patients with higher NPI scores (worse psychopathology) had formal costs between $3,162 and $5,919 higher than those with low NPI scores and the total direct costs between $10, 670, and $16,141 higher, depending on the severity of cognitive impairments (8). Clinical research on the treatment of these non-cognitive symptoms has only recently become a subject of major investigation. Clinical drug trials of new therapeutic agents in AD are beginning to regularly include specific scales to measure potential changes in behavioral symptoms with respect to their therapeutic interventions. In addition, an increasing number of randomized, placebo-controlled clinical trials of a wide variety of psychotropic medications to treat significant behavioral disturbances in dementia are beginning to emerge. The successful management of troublesome behaviors associated with AD can significantly improve the overall quality of life for patients and their caregivers and could result in significant relevant benefit.

Treatment of the neuropsychiatric symptoms in Alzheimer's disease.

Behavioral symptoms are common in Alzheimer’s disease (AD) and represent a major source of the disease morbidity. Neuropsychiatric disturbances have been associated with more rapid cognitive decline (1), increased caregiver burden (2,3), increases in patient care costs due to earlier institutionalization of the AD patient, greater medication use and more adverse side effects and more extensive institutional staffing needs (4,5). Kaufer and colleagues (6) reported a strong correlation between the amount of neuropsychiatric disturbance as measured by the Neuropsychiatric Inventory (NPI) and the degree of caregiver distress with little relationship between the degree of impairment on the Mini-Mental State Exam (MMSE) (7) and the degree of caregiver distress. In addition, a recent cost analysis showed that AD patients with higher NPI scores (worse psychopathology) had formal costs between $3,162 and $5,919 higher than those with low NPI scores and the total direct costs between $10, 670, and $16,141 higher, depending on the severity of cognitive impairments (8). Clinical research on the treatment of these non-cognitive symptoms has only recently become a subject of major investigation. Clinical drug trials of new therapeutic agents in AD are beginning to regularly include specific scales to measure potential changes in behavioral symptoms with respect to their therapeutic interventions. In addition, an increasing number of randomized, placebo-controlled clinical trials of a wide variety of psychotropic medications to treat significant behavioral disturbances in dementia are beginning to emerge. The successful management of troublesome behaviors associated with AD can significantly improve the overall quality of life for patients and their caregivers and could result in significant relevant benefit.

The Incidence of Mental and Behavioral Disturbances in Dementia: The Cache County Study

A population-based prevalence sample of 355 residents of Cache County, Utah, who were diagnosed with dementia, was rated on the Neuropsychiatric Inventory (NPI). Of the 355 residents, 119 had no neuropsychiatric symptoms at baseline and were, consequently, at risk for incident mental and behavioral disturbances. The NPI was readministered approximately 18 months later to 61 surviving participants. Sixty-nine percent developed at least one mental or behavioral symptom. Delusions were most common (28%), followed by apathy (21%), and aberrant motor behavior (21%). When this incidence rate of 69% was combined with a previously estimated prevalence rate of 61%, the cumulative 18-month prevalence approached 90%. These results argue for a routine assessment of psychiatric disturbances in all patients with dementia, even among those who have never experienced symptoms of mental or behavioral disturbances.

A study of premorbid personality and behavioural and psychological symptoms of dementia in nursing home residents.

to investigate the relationship between pre-morbid personality and behavioural and psychological symptoms of dementia (BPSD). we studied 58 subjects with dementia and depression and/or psychosis residing in 11 Sydney nursing homes cross-sectionally. Informal caregivers completed ratings of residents' pre-morbid personality on the NEP Five-Factor Inventory (NEO-FFI). Information on BPSD was obtained using the BEHAVE-AD. higher neuroticism was predictive of delusions; higher agreeableness of hallucinations, aggressiveness, affective disturbance and overall behavioural disturbance; and higher openness of affective disorder. our findings are inconsistent with previous research and clinical experience. Prospective studies are needed to clarify the association between personality and behavioural disturbance in dementia.

Quality Care: A Practical Guide to Managing Behavioral Symptoms of Dementia

Although cognitive impairments usually precede the development of behavioral disturbances in dementia, it is the latter that most often precipitate caregiver burnout and requests for medical intervention and/or institutionalization.

Current management of sleep disturbances in dementia.

The management of sleep disturbances in patients with dementia is a complicated and enormously important clinical and societal problem. In this review, we present one approach to the diagnosis and management of such sleep disturbances. Most disturbances can be categorized into four primary symptoms: insomnia, hypersomnia, excessive nocturnal motor activity, and hallucinations or behavioral problems. We describe how each symptom may relate to the dementing illnesses themselves, which primary sleep disorders may be at play, which medications employed for dementia may impact on the symptom, the role of depression in that symptom, and how circadian dysrhythmias can underlie that symptom. Although few well-designed studies have been conducted, we present management strategies for several sleep disturbances based on the literature and our clinical experience. Considering the impact on patient and caregiver quality of life, and the potential for delaying institutionalization with appropriate therapy, further research is clearly warranted to optimize the diagnosis and management of sleep disturbances in the cognitively impaired elderly population.

Recognition and Management of Behavioral Disturbances in Dementia.

Behavioral disturbances are seen in most patients with dementia at some point in their course. They cause immense patient suffering and are responsible for caregiver stress, institutionalization, and hospitalization. Identification of predisposing and precipitating factors is very important. The approach to the management of behavioral disturbances in dementia patients should be structured and thorough. Ensuring the safety of the patient and others should be paramount. Addressing the causes of behavioral disturbances such as comorbid medical illnesses, polypharmacy, pain, personal need, environmental factors, etc. is critical to a successful outcome. Many behavioral disturbances such as wandering and hoarding are not amenable to pharmacotherapy. Nonpharmacologic interventions are the mainstay of managing behavioral disturbances. Success of pharmacologic interventions will depend on accurate identification of specific syndromes, e.g., depression-anxiety and psychosis and severity of symptoms. Response to pharmacologic interventions is usually modest and may be associated with significant symptom resolution. Many behavioral disturbances can be prevented by avoiding inappropriate medications and educating patient, family, caregivers, and health care providers. Hospitalization can be avoided and institutionalization delayed by early recognition and treatment of behavioral disturbances. Leadership from physicians to implement preventive measures is recommended. Research to clarify the biological underpinnings of behavioral disturbances and to address cost-effectiveness of currently identified interventions is needed.

Cholinesterase inhibitors for behavioral disturbance in dementia.

The authors review the literature from the last year examining the benefits of cholinesterase inhibitors in the treatment of behavioral disturbance in Alzheimer's disease (AD) and other dementias. Previous review has indicated that cholinesterase inhibitors have psychotropic properties. We found more evidence to support both the benefits of cholinesterase inhibitors in behavioral disturbance, and that specific behaviors may be selectively responsive to treatment.

Contribution of PTSD/POW history to behavioral disturbances in dementia.

As many World War II and Korean Conflict veterans suffering from posttraumatic stress disorder (PTSD) grow older, increasing numbers will be diagnosed with dementia. We retrospectively analyzed patients with dementia, comparing the behavioral disturbances of those with PTSD to those without PTSD. We hypothesized that due to the additive effect of the neurobiological and behavioral changes associated with PTSD and dementia, the dementia with PTSD group would show more agitation and disinhibition than the dementia without PTSD group. Sixteen patients with diagnoses of dementia and PTSD were matched on age and Mini-Mental States Examination (MMSE) scores to 16 patients with dementia without PTSD. Demographic characteristics, co-morbid diagnoses, global Assessment of Functioning (GAF), Cohen-Mansfield Agitation Inventory (CMAI), and paranoid items of Brief Psychiatric Rating Scale (BPRS) and Positive and Negative Syndrome Scale for Schizophrenia (PANSS) were assessed. The patients with diagnoses of dementia with PTSD did not differ significantly in their clinical presentation, hospital course, and condition at discharge from patients with dementia without PTSD. Chi-square analysis showed that significantly more subjects in the PTSD group were prescribed anti-depressants compared to the non-PTSD group. Interestingly, within the PTSD group, the subgroup of patients who were former prisoners of war had a significantly higher mean score for paranoia and significantly less verbal agitation. This pilot study reveals that a diagnosis of PTSD alone is not sufficient to influence behavior in veterans with dementia; however, we also present provocative results that patients with more severe trauma (POW) do have changes in their behavior.

Behavioral profile of Alzheimer's disease in Chinese elderly--a validation study of the Chinese version of the Alzheimer's disease behavioral pathology rating scale.

This study aims to examine the psychometric properties of the Chinese version of the Alzheimer's disease behavioral pathology rating scale (CBehave-AD) and the behavioral profile of Chinese patients with AD. Seventy-one subjects with NINCDS-ADRDA diagnosis of probable and possible AD were assessed for validation of the CBehave-AD. A behavioral symptom frequency checklist, the Chinese version of the Blessed Roth dementia scale (CDS) and the Cantonese version of the Mini-Mental State Examination (CMMSE) were used for comparison. An extended sample of 120 AD patients was then evaluated with the CBehave-AD. High correlations between the CBehave-AD and checklist scores were found (paranoid and delusional ideation, hallucinations, activity disturbances, aggressiveness and diurnal rhythm disturbances). The scale also demonstrated satisfactory inter-rater and test-retest reliabilities. The mean (SD) CMMSE score of the 120 patients was 9.4 (7.1). Among them, 32% have delusions, 15% had hallucinations, 54% had activity disturbances, 61% had aggressive behavior, 44% had sleep disturbance, 24% had affective disturbances, 19% had anxiety and phobias. Delusional ideation was significantly associated with hallucinations, aggressiveness, and affective disturbances. Diurnal rhythm disturbances were associated with activity disturbances and aggressiveness. CBehave-AD total scores were not significantly correlated with severity of AD, but individual symptom categories showed different pattern of correlation. Delusions, hallucinations, anxiety and phobias were significantly correlated with dementia staging. The findings suggest that the CBehave-AD is a valid assessment tool for behavioral disturbances in patients with AD. Variable associations between different symptom categories and dementia staging suggest a need for further exploration of the complex interactions between behavioral and cognitive disturbances in dementia.