Neuropsychiatric Symptoms Of Dementia Research Articles

Ongoing Research Protocols for the Pharmacological Treatment of Neuropsychiatric Symptoms in Dementia.

The implementation of effective interventions for neuropsychiatric symptoms (NPS) is perceived as one of the most pressing research priorities in the field of dementia and one of the main unmet needs from the perspective of affected individuals and their caregivers and relatives. Nevertheless, to date, only a relatively marginal part of dementia research has focused on NPS. This study aimed to describe and discuss the state of the art concerning the identification and development of new pharmacological treatments for NPS in dementia. A review of 320 ongoing phase 1, 2, 3, and 4 protocols registered in the clinicaltrials.gov database was performed. All the trials enrolling patients with dementia were selected. Only studies adopting clinical measures of NPS frequency and/or severity as primary outcome were retained and analyzed. Overall, only a minority of ongoing phase 1, 2, 3 and 4 protocols on dementia (i.e., 9.0%) is primarily targeting NPS. Most of these studies are adopting a placebo-controlled parallel assignment design, testing oral compounds, and targeting specific NPS (mostly agitation and/or aggression). A total of 3,445 subjects with dementia will tentatively be recruited in these trials. The methodologies adopted in these studies, the characteristics of the tested interventions, the eligibility criteria, and the operational definitions of NPS are presented and discussed. The relevance of NPS is not yet matched by an adequate research effort. The current tendency at privileging disease-modifying approaches and other symptoms of dementia and the methodological complexity of studying NPS are still substantially contributing to the gap between research activities and clinical needs.

Run-in periods and clinical outcomes of antipsychotics in dementia: A meta-epidemiological study of placebo-controlled trials.

PurposeRun‐in periods are used to identify placebo‐responders and washout. Our aim was to assess the association of run‐in periods with clinical outcomes of antipsychotics in dementia.MethodsWe searched randomized placebo‐controlled trials of conventional and atypical antipsychotics for neuropsychiatric symptoms (NPS) in dementia in electronic sources and references of selected articles. We extracted (a) the presence of a run‐in period, use of placebo/investigated drug during run‐in (versus washout only), and run‐in duration (1 week or more) and (b) the reduction in NPS, number of participants with somnolence, extrapyramidal symptoms (EPS), and deaths per treatment group. We pooled clinical outcomes comparing antipsychotic and placebo groups in trials with and without run‐in.ResultsWe identified 35 trials. Twenty‐nine trials used run‐in. The pooled standardized mean difference in the reduction of NPS was −0.170 (95% CI, −0.227 to −0.112) in trials with run‐in and −0.142 (95% CI, −0.331 to 0.047) in trials without run‐in. The pooled odds ratio for somnolence was 2.8 (95% CI, 2.3‐3.5) in trials with run‐in and 3.5 (95% CI, 1.2‐10.7) in trials without run‐in; for EPS, these ORs were 1.8 (95% CI, 1.4‐2.2) and 2.0 (95% CI, 1.3‐3.1) respectively, and for mortality 1.4 (95% CI, 1.0‐2.0) and 1.6 (95% CI, 0.7‐3.4). The use of placebo/investigated drug during run‐in and run‐in duration did not affect the estimates in a consistent way.ConclusionsThe use of run‐in in trials might have led to overestimated efficacy and especially underestimated risks of side effects of antipsychotics compared with placebo for NPS in dementia.

Strengths and Weaknesses of the Gray Mouse Lemur (Microcebus murinus) as a Model for the Behavioral and Psychological Symptoms and Neuropsychiatric Symptoms of Dementia.

To face the load of the prevalence of Alzheimer’s disease in the aging population, there is an urgent need to develop more translatable animal models with similarities to humans in both the symptomatology and physiopathology of dementia. Due to their close evolutionary similarity to humans, non-human primates (NHPs) are of primary interest. Of the NHPs, to date, the gray mouse lemur (Microcebus murinus) has shown promising evidence of its translatability to humans. The present review reports the known advantages and limitations of using this species at all levels of investigation in the context of neuropsychiatric conditions. In this easily bred Malagasy primate with a relatively short life span (approximately 12 years), age-related cognitive decline, amyloid angiopathy, and risk factors (i.e., glucoregulatory imbalance) are congruent with those observed in humans. More specifically, analogous behavioral and psychological symptoms and neuropsychiatric symptoms of dementia (BPSD/NPS) to those in humans can be found in the aging mouse lemur. Aged mouse lemurs show typical age-related alterations of locomotor activity daily rhythms such as decreased rhythm amplitude, increased fragmentation, and increased activity during the resting-sleeping phase of the day and desynchronization with the light-dark cycle. In addition, sleep deprivation successfully induces cognitive deficits in adult mouse lemurs, and the effectiveness of approved cognitive enhancers such as acetylcholinesterase inhibitors or N-methyl-D-aspartate antagonists is demonstrated in sleep–deprived animals. This result supports the translational potential of this animal model, especially for unraveling the mechanisms underlying dementia and for developing novel therapeutics to prevent age-associated cognitive decline. In conclusion, actual knowledge of BPSD/NPS-like symptoms of age-related cognitive deficits in the gray mouse lemur and the recent demonstration of the similarity of these symptoms with those seen in humans offer promising new ways of investigating both the prevention and treatment of pathological aging.

Assessment of neuropsychiatric symptoms in dementia: validity and reliability of the Lebanese version of the neuropsychiatric inventory questionnaire

This study aims to examine the psychometric properties of an Arabic version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) that evaluates neuropsychiatric symptoms in patients with dementia. A cross-sectional study was carried out with a sample of 136 Lebanese demented patients aged 63–98 years. NPI-Q was completed by the patients’ primary caregiver and standard NPI was administered through personal interview by an experienced research assistant to the same caregiver. The internal consistencies of the Arabic NPI-Q total and distress scale were 0.680 and 0.684 respectively. One week test-retest reliability of the total NPI-Q and distress scores were 0.991 and 0.988 respectively (p-value <0.0001 for both). The NPI-Q correlated significantly with the standard NPI in individual and total symptom scores as well as caregiver distress scores. Exploratory factor analysis extracted five factors that explained 64.7% of variances. The prevalence of analogous symptoms reported on the NPI and NPI-Q differed on average by 3% while moderate or severe symptom ratings differed on average by 1%. The Arabic version of the NPI-Q showed evidence of good psychometric properties indicating that it is a suitable tool for the routine assessment of neuropsychiatric symptoms for Lebanese patients with dementia in clinical settings.

Subjective Versus Objective Outcomes of Antipsychotics for the Treatment of Neuropsychiatric Symptoms Associated with Dementia.

BackgroundKnowledge about treatment status can influence effects measured in trials when subjective scales are used.ObjectiveThe aim of this study was to compare subjective outcomes with objective outcomes of conventional and atypical antipsychotics for neuropsychiatric symptoms (NPS) in dementia.MethodsWe performed a meta-epidemiological study of 38 randomized, placebo-controlled trials. For effectiveness, we used change in NPS and response rate as subjective outcomes, while overall dropout and additional psychotropic use were used as objective outcomes. For side effects, extrapyramidal symptoms (EPS) and somnolence were used as subjective outcomes, while dropout due to adverse events, medication use for EPS, and participants falling were used as objective outcomes.ResultsConventional antipsychotics reduced NPS more than placebo (standardized mean difference [SMD] − 0.36, 95% confidence interval [CI] − 0.49 to − 0.23), as did atypical antipsychotics (SMD − 0.14, 95% CI − 0.19 to − 0.08). Response rates in the drug groups were also higher. Overall dropout did not differ between conventional antipsychotics and placebo (odds ratio [OR] 1.03, 95% CI 0.77–1.37) or atypical antipsychotics and placebo (OR 1.01, 95% CI 0.89–1.14). Furthermore, additional psychotropic use did not differ. The risk of EPS was higher for conventional (OR 2.93, 95% CI 2.04–4.22) and atypical antipsychotics (OR 1.52, 95% CI 1.23–1.88) versus placebo, as was the risk of somnolence and dropout due to adverse events, but medication use for EPS, as well as risk of falls, was not.ConclusionsThe effectiveness of antipsychotics for NPS in dementia based on subjective scales was not confirmed using objective outcomes, in contrast to the increased risk of side effects.

Improving environmental interventions for neuropsychiatric symptoms in dementia.

Improving environmental interventions for neuropsychiatric symptoms in dementia.

The Role of Sexual Disinhibition to Predict Caregiver Burden and Desire to Institutionalize Among Family Dementia Caregivers.

Neuropsychiatric symptoms in dementia are associated with greater caregiver burden and desire to institutionalize, though previous work largely examines the cumulative effects of many behavioral symptoms. Sexual disinhibition could be particularly stressful due to stigma attached to these behaviors. Links between care recipient sexual disinhibition, caregiver burden, and caregiver desire to institutionalize were examined by analyzing cross-sectional data from 730 family caregivers recruited online. Caregiver burden, caregiver desire to institutionalize, and neuropsychiatric symptoms, including sexual disinhibition, were assessed via caregiver report. Burden (P < .001) and desire to institutionalize (P = .008) were greater among caregivers who endorsed sexual disinhibition. Sexual disinhibition uniquely predicted desire to institutionalize after accounting for presence (P = .02) and severity (P = .03) of other neuropsychiatric symptoms. A similar pattern was seen for burden (presence P < .04; severity P = .06), and follow-up analyses revealed caregiver burden mediated the relationship between care recipient sexual disinhibition and caregiver desire to institutionalize (presence bias-corrected 95% confidence intervals [BCa 95% CI] [0.003, 0.08], severity BCa 95% CI [0.007, 0.06]). Sexual disinhibition appears to be a particularly difficult neuropsychiatric symptom for the family caregiver, contributing to desire to institutionalize via caregiver burden.

Adopting a Diary to Support an Ecological Assessment of Neuropsychiatric Symptoms of Dementia.

Neuropsychiatric symptoms (NPS) are one of the most challenging issues in the management and care of people with dementia. Their accurate assessment is thus crucial for properly approaching subjects with cognitive disorders in the clinical setting. In parallel, the correct evaluation of NPS is also particularly relevant in the research field where they serve as critical indicators for measuring the efficacy of interventions against cognitive disorders. However, the study of NPS is extremely challenging given their extreme inter- and intra-individual variability. Moreover, the available assessment tools are often inadequate to fully capture their complexity and phenotypic expression. Based on these considerations, novel modalities for the assessment and measurement of NPS may be important to identify and develop. In this regard, a promising alternative (or, at least, a complementary aid) to traditional scales and questionnaires might be constituted by diaries. In the present article, we discuss the potential advantages and implications that may result from the adoption of this kind of instruments for the ecological assessment of NPS in subjects with dementia.

Neuropsychiatric Symptoms in Dementia: Considerations for Pharmacotherapy in the USA.

Dementia affects all domains of cognition. The relentless progression of the disease after diagnosis is associated with a 98% incidence of neuropsychiatric symptoms (NPS) at some point in the disease, including depression, psychosis, agitation, aggression, apathy, sleep disturbances, and disinhibition. These symptoms can be severe and lead to excess morbidity and mortality. The purpose of this article was to describe current literature on the medication management of NPS of dementia and highlight approaches to and concerns about the pharmacological treatment of NPS in the USA. Guidelines and expert opinion favor nonpharmacologic management of NPS as first-line management. Unfortunately, lack of adequate caregiver training and a high failure rate eventually result in the use of psychotropic agents in patients with dementia. Various psychotropic medications have been studied, although how they should be used in the management of NPS remains unclear. A systematic approach to evaluation, treatment, and monitoring, along with careful documentation and evidenced-based agent and dose selection, is likely to reduce risk and improve patient outcomes. Considerations should be given to the NPS presentation, including type, frequency, and severity, when weighing the risks and benefits of initiating, continuing, or discontinuing psychotropic management. Use of antidepressants, sedative/hypnotics, antipsychotics, and antiepileptic agents should include a clear and documented analysis of risk and benefit in a given patient with dementia.

CEREBROSPINAL FLUID CORRELATES OF NEUROPSYCHIATRIC SYMPTOMS IN PATIENTS WITH ALZHEIMER'S DISEASE/MILD COGNITIVE IMPAIRMENT

Introduction Neuropsychiatric symptoms (NPS) are common in Alzheimer's Disease (AD) and Mild Cognitive Impairment (MCI) but their association with disease biomarkers remains unknown. The aim of this systematic review is to identify potential cerebrospinal fluid (CSF) biomarkers of neuropsychiatric symptoms in Alzheimer's disease (AD) and MCI based on a systematic review of the current literature. Methods We developed a pre-defined search strategy focused on the association between CSF biomarkers and NPS in patients with AD/MCI using an extensive list of relevant keywords and controlled vocabulary. The search was then performed on four databases: Pubmed, EMBASE, Cochrane, and PsycINFO. 8838 results were recorded and screened by 2 independent reviewers. Studies were selected for critical appraisal based on our inclusion/exclusion criteria. Inclusion criteria were defined as, (1) Study must be in English (2) at least one AD CSF biomarker has been measured (3) at least one NPS from the neuropsychiatric inventory (NPI) has been assessed (4) study population should at least include patients with AD or MCI (5) some type of statistical analysis has been done in an effort to elaborate the association between an AD CSF biomarker and the status of NPS. Furthermore, Non-English, animal and review studies or studies not including an NPS, AD CSF biomarker or AD/MCI patients were excluded. Eventually, a total of 23 studies qualified for the final systematic review and are presented in the study Results Among all neuropsychiatric symptoms, depression was the most evaluated NPS followed by sleep, psychosis, anxiety, agitation/aggression, eating/appetite, apathy, and irritability. Most studies have reported conflicting results regarding the presence/absence of any significant association between any NPS with any of the AD CSF biomarkers. However, the NPS of agitation/aggression was significantly related to at least one CSF biomarker across all the studies evaluating this NPS. Conclusions Our study has revealed agitation/aggression as the most consistent NPS related to AD CSF pathology based on a review of the current literature. However, multiple studies have also revealed a conflicting relationship between AD CSF biomarkers and other NPS. Future studies are required to clarify these associations. Future studies should also focus on other NPS such as elation/euphoria, motor disturbances, and disinhibition as it seems to be the neglected domains in previous studies. Our study has also revealed a great degree of heterogeneity among studies, hence calling for a more standardized “objective” approach for the evaluation of NPS in dementia. This research was funded by Not Applicable

Chapter 24 - Neuropsychiatric symptoms in dementia

The prevalence of dementia is expected to rise with the aging of our population for decades to come. Neuropsychiatric symptoms of dementia, also known as behavioral and psychologic symptoms of dementia, are extremely common. Symptoms are most prevalent in the moderate stages of the disease, often increase with advancing disease stage, and often more than one symptom is present. These symptoms can cause a great deal of distress for patients and families, and take a toll on society as well. Evaluation and management can be challenging, with nonpharmacologic strategies recommended as first-line approach. There is growing evidence for specific pharmacologic strategies, but these come with significant risk, such that informed consent with the patient and surrogate decision maker is critical. In this chapter, we focus on general principles of etiology, assessment, and management, and then turn to individual symptoms of agitation, psychosis, apathy, sleep disturbance, and feeding and eating problems more specifically. Depression and anxiety are covered elsewhere in this text.

Safety and effectiveness of cannabinoids for the treatment of neuropsychiatric symptoms in dementia: a systematic review.

Background:Neuropsychiatric symptoms (NPS) in dementia impact profoundly on the quality of life of people living with dementia and their care givers. Evidence for the effectiveness and safety of current therapeutic options is varied. Cannabinoids have been proposed as an alternative therapy, mainly due to their activity on CB1 receptors in the central nervous system. However, little is known regarding the safety and effectiveness of cannabinoid therapy in people with dementia. A literature review was undertaken to identify, describe and critically appraise studies investigating cannabinoid use in treating NPS in dementia.Methods:We undertook a systematic review adhering to PRISMA guidelines. Twenty-seven online resources were searched, including Medline, PsycINFO and Embase. Studies assessing the safety and or effectiveness of cannabinoids in treating NPS in dementia in people aged ⩾ 65 years were included. Study quality was assessed using the Johanna Briggs Institute and Cochrane Collaboration critical appraisal tools.Results:Twelve studies met the inclusion criteria. There was considerable variability across the studies with respect to study design (50% randomized controlled trials), intervention [dronabinol (33%), nabilone (25%) or delta-9 tetrahydrocannabinol (THC; 42%)] and outcome measures. Dronabinol (three studies) and THC (one study) were associated with significant improvements in a range of neuropsychiatric scores. The most common adverse drug event (ADE) reported was sedation. A high risk of bias was found in eight studies. The highest-quality trial found no significant improvement in symptoms or difference in ADE rate between treatment arms. Included studies used low doses of oral cannabinoids and this may have contributed to the lack of demonstrated efficacy.Conclusion:While the efficacy of cannabinoids was not proven in a robust randomized control trial, observational studies showed promising results, especially for patients whose symptoms were refractory. In addition, the safety profile is favourable as most of the ADEs reported were mild. Future trials may want to consider dose escalation and formulations with improved bioavailability.

Caregiver-Care Recipient Relationship Closeness is Associated With Neuropsychiatric Symptoms in Dementia

Closer caregiver-care recipient (CG-CR) relationships are associated with better cognitive and functional abilities, activities of daily living (in persons with dementia), and lower informal care costs. Due to the difficulty in treating neuropsychiatric symptoms (NPSs) and their detrimental effects on caregivers and care recipients, we examined whether closeness of CG-CR relationships was associated with overall NPS severity or with specific NPS symptom domains in care recipients. In a longitudinal population-based study in Cache County, Utah, the 12-item Neuropsychiatric Inventory (NPI-12) was assessed in 300 CG-CR dyads. Caregivers reported current relationship closeness using the Whitlatch Relationship Closeness Scale. Linear mixed models examined associations between CG-CR closeness and NPI-12 total score or selected symptom domains over time (observation period: 2002-2012). In unadjusted linear mixed models, higher closeness scores were associated with a five-point lower NPI-12 score and a one-point lesser increase in NPI-12 per year. NPI scores also showed lower affective cluster scores (two points) and lesser increase in psychosis cluster (approximately 0.5 points per year) and agitation/aggression (0.16 points per year) for each unit increase in closeness. When controlling for NPI caregiver distress, associations between closeness and NPSs diminished to a 0.5-point lesser increase in total NPI-12 score per year. Adjusted models for NPI domains/clusters showed -0.32 points per year for the psychosis cluster, -0.11 points per year for agitation/aggression, and -0.67 overall for the affective cluster. Higher CG-CR closeness, a potentially modifiable factor, is associated with lower NPS severity and may provide a target for intervention.

The Neuropsychiatric Inventory-Diary Rating Scale (NPI-Diary): A Method for Improving Stability in Assessing Neuropsychiatric Symptoms in Dementia

Background: In health-care settings, the use of the Neuropsychiatric Inventory-Nursing Home (NPI-NH) may not always be consistent with the authors’ guidelines, which affects its reliability. To avoid this bias, a diary version of the NPI (NPI-Diary) was developed. Aims: This study aimed to evaluate the psychometric properties (internal consistency and reliability) of the NPI-Diary, and examined its convergence with the NPI-NH. Methods: Two raters administered the NPI-NH and NPI-Diary to 40 participants with Alzheimer’s disease, selected randomly from a hospital’s weekly turnover. Results: The NPI-Diary exhibited adequate internal consistency (total: α = 0.581) and test-retest reliability (total: ρ = 0.711; p < 0.01). The interrater reliability values (ICC) for the NPI-NH and NPI-Diary differed significantly (Total: NPI-NH ICC = 0.506, NPI-Diary ICC = 0.879; Frequency: NPI-NH ICC = 0.51, NPI-Diary ICC = 0.798; Severity: NPI-NH ICC = 0.491, NPI-Diary ICC = 0.809). The convergent validity between the two inventories was also significant (total: ρ = 0.48; p < 0.01). Conclusions: The NPI-Diary showed more appropriate validity and reliability compared to the NPI-NH, when administered in a highly variable sample, as is generally the case in the current health-care setting.

Course of neuropsychiatric symptoms in dementia: 5-year longitudinal study.

Neuropsychiatric symptoms (NPS) in dementia are frequent and challenging for patients, carers, and the health care system, but few long-term studies exist. We analyse the longitudinal course of NPS in patients with mild dementia. A longitudinal cohort study of 223 patients with mild dementia and annual assessments using the Neuropsychiatric Inventory (NPI) for 5years. A total 1043 NPI assessments, representing 97% of all possible measurements of living cohort members, were analysed. Neuropsychiatric symptoms were common at baseline, and only a moderate increase in total NPS score from 15 to 17 with no increase in the proportion with high NPI total scores. Ninety seven percent scored ≥16, and 49% scored ≥36 on NPI total score at least once during follow-up. Individual NPS fluctuated and often reappeared. The most common symptoms ever reported was apathy (83%), depression (63%), appetite (63%), and aberrant motor behavior (60%). Cognitive decline was associated with higher NPI total score and several NPI items, but only the frequency of apathy increased significantly with time. Lewy body dementia was associated with higher NPI total score and psychotic symptoms. Alzheimer's disease was associated with increase in apathy. Severe NPS are already common at time of dementia diagnosis, and the increase in overall severity over 5years was moderate. Individual symptoms tend to fluctuate over time within patients and correspond to states rather than traits. These findings highlight the need to focus on, and plan for, NPS as part of dementia pathway, and are relevant for clinical trial design.

Approach to Neuropsychiatric Symptoms in Dementia

Approach to Neuropsychiatric Symptoms in Dementia

Farmakoterapie Alzheimerovy demence a přidružených neuropsychiatrických symptomů - 1. část

Alzheimerova choroba je nejcastějsi přicinou demence. Pro ucelnou lecbu je třeba vcasna a přesna diagnostika. K symptomaticke terapii jsou využivany inhibitory acetylcholinesterazy, v pozdějsich fazich take memantin. Soucasti demence bývaji neuropsychiatricke symptomy, jsou castou přicinou institucionalizace a stresu pacienta i pecovatelů. Snažime se zjistit a odstranit jejich přicinu, v lecbě preferujeme nefarmakologický přistup. Při neucinnosti režimových opatřeni lze volit vybrana antidepresiva, antipsychotika, anxiolytika, připadně dalsi latky. Nasledujici přehled pojednava o rozdilech v ucinnosti a bezpecnosti mezi jednotlivými latkami a upozorňuje na možna rizika, ktera jsou s terapii spojena.

Session 100 - A Path Forward: A Culturally Relevant Psychosocial Intervention for Depression in Cognitive Impaired Older Adults

Abstract: As the geriatric population increases, it has also become more diverse. According to the 2011 U.S. Census Bureau, 8 % of older adults are Non-Hispanic Black and 7% are Hispanic/Latino. Similarly in Bronx County New York, 53% of patients speak a language other than English in the home. The Bronx has a growing Hispanic and non-Hispanic Black population, which faces a high prevalence of poverty, medical morbidity and comorbid depression. In a pilot study conducted at the Bronx-based Montefiore Geriatric Neurology Center, rates of depression were over 40%. Ethnic minorities are less likely to be included in research trials and have less access to innovative treatment modalities. Hispanics and Non-Hispanic Blacks are also less likely to seek mental health treatment and to find antidepressants acceptable. According to the Alzheimer's Association, about 200,000 Latinos in the United States have Alzheimer's disease dementia (AD). Moreover the highest prevalence of dementia is found in Latin America at 8.5%. In 2004 Montefiore Home Care in collaboration with Cornell Westchester division established the Montefiore Home Care Geriatric Psychiatry Program (MHC-GPP) to provide depression screening for homebound, medically ill older adults. During the 13 years of this program, the MHC-GPP has not only identified and treated homebound adults with depression, but has reached a population comprised of mostly Hispanics and Non-Hispanic Blacks (49% and 30%, respectively). Additionally the program has identified cognitive disorders as 3/4 of the new diagnoses identified by the MHC-GPP were neurocognitive disorders. Previous literature has shown depression to be one of the most common neuropsychiatric symptoms of AD and dementia related disorders, with a prevalence from 25% to 75% of patients. Unfortunately, previous trials have also shown that depression in the setting of AD is minimally responsive to antidepressants. This population is also unlikely to benefit from short term evidenced based psychotherapeutic modalities such as Problem Solving Therapy (PST) due to cognitive limitations. Furthermore, depending on state mental health regulations, patients with neuropsychiatric symptoms of dementia cannot be served in a mental health clinic. Kiosses and colleagues developed a non-pharmacological intervention to treat older adults with depression in the setting of dementia known as Problem Adaptation Therapy (PATH). PATH is an evidenced based intervention using personalized strategies to decrease depression and disability in older adults with depression and cognitive impairment. To achieve this goal, PATH utilizes a simplified problem solving approach, employing compensatory strategies, environmental adaptations to bypass cognitive and functional limitations while incorporating the caregiver when necessary. In a randomized trial, PATH was yielded a significantly greater reduction in depression and disability when compared to home delivered supportive psychotherapy. In 2016, Montefiore and Cornell Westchester, collaborated again in a pilot study to adapt PATH to serve the diverse Bronx and Westchester county populations. In this program PATH is delivered in English and Spanish and in the home or office, in order to evaluate the efficacy of this model in all settings and establish the sustainability of this model within a larger and diverse health network. During this session, the presenters will describe the development and advances in the PATH model and various adaptations and how this model was adapted in Montefiore Medical Center health network. The director of MHC-GPP will discuss how the PATH is incorporated into a certified home health agency (CHHA) to reach homebound adults with complex medical and social backgrounds. Finally the presenters will discuss implications for future directions in aging research centered on emotional dysregulation and dementia while impacting a more diverse population of older adults.

Evidence for accuracy of pain assessment and painkillers utilization in neuropsychiatric symptoms of dementia in Calabria region, Italy.

During the clinical course of dementia, beside cognitive impairment and memory loss, a very complex challenge is posed by the neuropsychiatric symptoms (NPSs). Accurate evaluation and treatment of pain impacts positively the agitation of demented patients aged ≥ 65 years. To gather information on the utilization of pain killers in demented patients a preliminary survey has been conducted in collaboration with the Calabrian Pharmacovigilance Territorial Service of the health district of Catanzaro (Italy). The study has taken into consideration the prescriptions of acetylcholinesterase inhibitors and memantine during the period ranging from July 2015 to June 2016 and the percentage of patients treated against pain with non steroidal antinflammatory drugs, opioids, and anticonvulsants have been monitored. The latter have been evaluated statistically for difference between the treatment before (pre) and after (post) the settlement of acetylcholinesterase inhibitors (AChEI) or memantine therapy. The results do support accuracy in painkillers utilization in the course of dementia in the regional population of Calabria (Italy).

Decoding and Treating Neuropsychiatric Symptoms in Dementia

In assessing the neuropsychiatric symptoms of patients with dementia, Laura C. Hanson, MD, MPH, a professor in the division of geriatric medicine at the University of North Carolina at Chapel Hill, said one of her main teaching points is to avoid use of the nonspecific term “agitation.” “The term I use is physical restlessness or emotional restlessness, which I find to be at least slightly more descriptive than agitation ... We can better work [from there] on identifying underlying factors,” Dr. Hanson said during a dementia panel discussion at the annual meeting of the American Geriatrics Society. Some 85% of individuals with moderate to severe dementia experience neuropsychiatric symptoms, which can be caused by environmental triggers, distressing caregiver behaviors, lack of stimulation, physical pain, or other factors. “We know from a variety of descriptive studies that a very high percentage of people with even moderate and later-stage dementia are able to self-report pain,” she emphasized. Words are easier than numbers, however. “It is not worth asking them to rate their pain on a 1 to 10 scale. But they can answer the question, ‘Are you in pain now?’ or ‘Are you in discomfort now?’ They may respond better [to the word] discomfort,” she said. “Ask slowly — they may need time to answer. And we need to use our clinical observation skills.” At least one well-designed randomized controlled trial — a Norwegian trial of 352 nursing home residents — has shown that treating pain improves neuropsychiatric distress in patients with moderate to severe dementia, Dr. Hanson said. The residents randomized to an individualized stepwise pain treatment protocol beginning with an acetaminophen equivalent and “moving all the way [if necessary] to low-dose opioids” were more likely to have significant reductions in pain, agitation, and psychiatric symptoms than residents who received usual care (BMJ 2011;343:d4065). These findings “suggest there is a strong linkage between some neuropsychiatric distress and pain,” Dr. Hanson said. Depression should also be considered when neuropsychiatric symptoms are reported — they affect 25% of individuals with early-stage Alzheimer’s and significantly more who have vascular dementia — as should akathisia and psychosis in some cases. “I often ask myself, is it akathisia, a neurologic syndrome of physical restlessness that could be a side effect of an antipsychotic?” Dr. Hanson said. “And I also ask, are there psychotic symptoms involved, which could in some cases point to a medical delirium?” Unfortunately, “with depression, the treatment evidence is inconclusive for our ability to intervene with traditional SSRIs or other antidepressants,” she said. “Probably the most important evidence-based point is to avoid benzodiazepines when a person is expressing anxiety and sadness and has underlying dementia.” Otherwise, the treatment of neuropsychiatric symptoms is about symptom management with nonpharmacologic interventions. “Begin with decoding internal or environmental triggers for distress and reversing them,” she advised. Then use music, aroma, and other sensory modalities; most of these nonpharmacologic interventions are supported by moderate-quality evidence. Christine Kilgore is a freelance writer in Falls Church, VA.