Non-cognitive Symptoms Of Dementia Research Articles

Younger people with dementia registered to public mental health services in Victoria, Australia.

ObjectivesIndividuals living with young-onset dementia fall through the gaps of adult and geriatric services. Given that non-cognitive symptoms of dementia in younger people are often psychiatric and behavioural in nature, these people may contact mental health services. There is sparse information investigating the frequency of people with young-onset dementia who contact mental health triage in Victoria.MethodsTriage data were obtained from the Victorian Agency for Health Information. The data contained demographics for people registered with Victorian mental health services. Consumers who had an International Classification for Diseases code for dementia and were aged less than 65 years were identified as people with young-onset dementia. Using information of the frequency of people with young-onset dementia who were registered with each area-based mental health service, population census statistics were used to make estimates of the frequency of young-onset dementia.ResultsOf the 6172 people who had a dementia diagnosis, 1020 of them were aged less than 65 years and had young-onset dementia. There were proportionally more men who had young-onset dementia compared to women. There were more people with young-onset dementia registered to rural mental health services compared to metropolitan services.ConclusionFindings provide important information for service planning in Victoria. Recommendations include upskilling and education for the assessment of dementia for those clinicians who work in mental health services, particularly in rural regions.

Psychotropic Medication Prescribing to Patients with Dementia Admitted to Acute Hospitals in Ireland.

Psychotropic medications are commonly prescribed to people with dementia (PwD) for non-cognitive symptoms of dementia (NCSD), but have significant risks. A national audit was performed in acute hospitals in the Republic of Ireland (ROI) to establish baseline practice prior to the launch and implementation of a National Clinical Guideline on the appropriate prescribing of psychotropic medications for NCSD. The objective of this study was to analyse psychotropic prescribing patterns and compare these with international data and with existing (limited) data from a previous audit round. The pooled anonymous dataset from the second round of the Irish National Audit of Dementia Care (INAD-2) was analysed. The audit had collected retrospective data from 30 random healthcare records from each of 30 acute hospitals in 2019. Inclusion criteria were a clinical diagnosis of dementia of any type, hospital stay of 72 hours or more, and discharge or death within the audit period. Most hospitals (87%) self-audited their healthcare records, but a random sample of six healthcare records (20%) from each hospital were re-audited by a highly trained healthcare auditor. The audit tool was based on a tool used in the England and Wales National Audit of Dementia audit rounds (Royal College of Psychiatrists), adapted to the Irish healthcare setting and national priorities. In total, 893 cases were included, as one hospital could not retrieve 30 cases even within a more prolonged audit period. The sample comprised 55% females and 45% males; the median age was 84 years (interquartile range 79-88 years) and the majority (89.6%) were >75 years of age. Only 52% of healthcare records specified the type of dementia; within these, the most common diagnosis was Alzheimer's disease (45%). Most PwD (83%) were receiving psychotropic medication on admission; 40% were prescribed new or increased psychotropic medication during admission, mainly for medical indications, including end-of-life care and delirium. Anticonvulsants or cognitive enhancers were rarely prescribed for NCSD in hospital. However, new/increased antipsychotic medication was prescribed for NCSD in 11.8-17.6% of the total cohort, while 4.5-7.7% were prescribed a benzodiazepine for anxiety or NCSD. Overall, there was poor documentation of risk/benefit, or of discussion with the patient/family, and apparently inadequate review for efficacy and tolerability. Concurrently, acetylcholinesterase inhibitors appeared to be underused for cognitive impairment in the community. This audit provides baseline data on psychotropic medication prescription for NCSD in Irish hospitals prior to a specific Irish guideline on this topic. Reflecting this, most PwD were receiving psychotropic medications on admission, and many were prescribed new/increased psychotropic medication in hospital, often without evidence of appropriate decision making and prescribing processes.

323 A MULTIDISCIPLINARY QUALITY IMPROVEMENT PROJECT FOR MANAGING NON-COGNITIVE SYMPTOMS OF DEMENTIA IN ACUTE CARE

Abstract Background Over 80% of patients with dementia in acute care hospitals are prescribed an antipsychotic drug (INAD2) for management of Non-Cognitive Symptoms of Dementia (NCSD). Antipsychotics have a high side effect burden including increased mortality. Non-pharmacological interventions are first line management but many acute care wards are poorly equipped to deliver such interventions. The project aims to improve management of patients’ NCSD and reduce pro re nata (PRN)/stat and intra-muscular (IM) antipsychotic prescribing in an acute care older adult ward. Methods Using Plan-Do-Study-Act cycles (PDSA) a multicomponent intervention was iteratively designed and the implementation strategy is being tested. The components includes: an antipsychotic decision algorithm, Clinical Nurse Specialist (CNS) led patient review, patient behaviour charts, staff education and one-to-one coaching by CNS, patient ‘Get-to-Know-Me’ document and distraction resources. The evaluation involves a monthly point-prevalence audit of patient drug charts. Results Over a seven-month period, baseline data indicated wide variability in patterns of antipsychotic prescribing. A median of 14 patients per month (min 7, max 18) were prescribed an antipsychotic drug, a median of five patients (min 3, max 12) were prescribed PRN antipsychotics and a median of two patients (min1,max3) received one or more IM injection for NCSD. There was often little information on the reason for administering PRN antipsychotic medication. There was some evidence of reduced PRN and IM medication for new patient admissions (0-4 doses), but individual patients with prolonged hospital stays had high levels of antipsychotic use. Conclusion Reducing reliance on antipsychotic drugs requires multicomponent intervention and MDT collaboration. This intervention focussed primarily on coaching of healthcare professionals and improving the quality and consistency of prescribing. However, much more is required on environment design and access to cognitively stimulating activities to achieve a sustained improvement in patient outcomes, especially patients who experience a prolonged hospital stay.

Service Evaluation Exploring the Use of Standardised Assessment Tools to Assess Non-Cognitive Symptoms of Dementia

AimsPain, depression, anxiety, and psychosis are common non-cognitive symptoms of dementia. They are often underdiagnosed and can cause significant distress and carer strain. Numerous standardised assessment tools (SATs) exist and are recommended for the assessment of non-cognitive symptoms of dementia. Anecdotal evidence suggests that SATs are used rarely and inconsistently. This study aims to explore which SATs to detect non-cognitive symptoms of dementia are recommended in local guidelines and used in practice across different organisations. Secondary aims were to identify barriers and facilitators to using these tools.MethodsThis service evaluation is cross-sectional in design. A questionnaire was developed and distributed to clinicians working with patients with advanced dementia in any setting, across four geographical locations (Leeds, Bradford, Hull, and Cambridge). Quantitative data were analysed descriptively, and qualitative data from free-text comments were interpreted using thematic analysis.Results135 professionals from a range of backgrounds and clinical settings completed the survey. Respondents indicated that SATs for non-cognitive symptoms in dementia were rarely used or recommended. Respondents were unaware of the existence of most SATs listed. 80% respondents felt that SATs were a useful adjunct to a structured clinical assessment. The most recommended tool was the Abbey Pain Scale, with 41 respondents indicating its recommendation by their Trust. Perceived facilitators to using SATs include education and training, reliable IT systems and accessibility. Barriers include lack of time and training.ConclusionNumerous SATs are available for use in dementia, but they are rarely recommended in local policy or used in practice. There appears to be a lack of consensus on which, if any, are superior diagnostic tools, and on how or when they should be applied.

Association of caregiver distress with behavioral and psychological symptoms of dementia-A cross-sectional correlational study from South India

Abstract Context: Non-cognitive symptoms of dementia, also known as behavioural and psychological symptoms of dementia (BPSD) are a less researched topic in developing countries like India. These symptoms not only affect the ability to sustain daily activities and reduce the quality of life but also increase morbidity and mortality in patients with dementia. Aims: The study aimed to assess the prevalence of BPSD and various correlates associated with the severity of BPSD and caregiver distress. Subjects and Methods: It was a cross-sectional, correlational study done on 80 consecutive patients and their caregivers attending the memory clinic of Indlas VIMHANS Hospital, Vijayawada. A semi-structured proforma to collect socio-demographic data, Mini-Mental Status Examination (MMSE), The Neuropsychiatric Inventory-Questionnaire (NPI-Q), and Everyday Abilities Scale for India (EASI) were used in the study. Descriptive and inferential statistical analyses were done to find the correlation between different study variables. Results: BPSD were reported in all the dementia patients. Night-time behaviour disturbances (100%), hallucinations (86.25%), irritability (76.25%), delusions (75%), and agitation (76.25%) were more commonly reported BPSD. There was a positive correlation between BPSD severity and caregiver distress on- hallucinations (r=0.661, P<0.001) delusions (r=0.840, P <0.001), agitation (r=0.823, P<0.001), depression (r=0.947, P<0.001), anxiety (r=0.971, P=0.038), disinhibition (r=0.917, P<0.001), irritability (r=0.875, P<0.001), night-time behaviour disturbances (r=0.451, P<0.001), and appetite abnormality (r=0.683, P<0.001) items. On Pearson correlation care giver distress was significantly associated with – age of the patient (r=0.325, P=0.003), MMSE score (r= -0.461, P<0.001), BPSD severity (r=0.780, P<0.001) and EASI score (r=0.475, P<0.001). Severity of BPSD showed significant correlation with- age of the patient (r=0.267, P=0.017), MMSE score (r= -0.269, P=0.016) and EASI score (r=0.356, P<0.001). Conclusion: BPSD are universal in dementia and they impact the quality of the life of the patients and the caregivers. Improvement in BPSD may reduce caregiver distress and improve the quality of care received by patients.

The therapeutic management of non-cognitive symptoms of dementia

It is estimated that, with the increase of the life expectancy of the population, one in two people at the age of 85 years old will have a form of dementia. This will represent a real burden for medical systems, and an increasing responsibility for their families and for society. The behavioral and psychological symptoms of dementia continue to receive insufficient attention. These symptoms can be observed some years before an adequate diagnosis of dementia, and they can be the first signs of alarm before the development of specific cognitive pathology. Patients suffering from dementia can benefit from integrated medical services, specialized care at home or at the hospital, day care services, specialized health services, memory assessment services, psychological and home care therapies, together with a specific drug therapy. Taking into account all of these aspects presented above, the aim of the paper is to analyze if an earlier diagnosis of dementia can be done in clinical practice, because the initiation of earlier treatment, in the mild-to-moderate phase, can lead to a considerable improvement of cognitive functions. In this context, as dementia is diagnosed earlier, an appropriate treatment can also improve the behavioral symptomatology. Also, a multidisciplinary approach can be of real help in assessing, anticipating and managing all these issues.

324 Effect of Regular Multidisciplinary Psychotropic Review Meetings on Anti-psychotic Prescribing Practices in a Community Nursing Unit

Abstract Background The management of non cognitive symptoms of dementia can be challenging for people living with dementia and their carers. The risks and limited benefit of antipsychotics in this setting is well documented however despite this they still are often prescribed. A previous study at our facility in 2016 highlighted a high prevalence of antipsychotic prescribing at 35% (Bambrick, et al. 2016). As a result of this, multidisciplinary psychotropic review meetings were established and are ongoing. Methods Two wards in our community nursing unit were selected. Inclusion criteria included residency &gt; 6 months. The case notes, medication lists (admission and current prescriptions), and psychotropic review meeting notes were reviewed. Results 43 residents were included in the study. 72% (n=31) were female. The average age was 85 years. 74% (n= 32) of residents had a documented dementia diagnosis. On admission, 7 residents were taking regular antipsychotics. 5 of these medications were subsequently either reduced or discontinued. At the time of the study, 16% (n=7) were prescribed regular antipsychotics. There was a definite indication for 3 of these (schizoaffective disorder, psychosis, paranoid depression). 1 resident had a traumatic brain injury with associated distressing symptoms with harm incidents. 3 had a dementia diagnosis with associated distressing symptoms. A further 14% (n= 6) were prescribed antipsychotics on a PRN basis. 5 had a documented diagnosis of dementia with associated distressing symptoms. None of these residents received these medications in the 4 weeks prior to the study. Conclusion Significant improvements are noted since 2016 with the overall prevalence of antipsychotic prescribing decreasing from 35% to 16%, with the majority of these prescriptions having a clear indication. It is reassuring that residents are not receiving prn medications frequently. We await the national clinical guidance on “Appropriate Prescribing of Psychotropic Medication in People with Dementia” to further guide our practice.

247 Antipsychotic Medication in the Management of Non-cognitive Symptoms of Dementia: An Updated Evidence Review

Abstract Background Antipsychotic medications are commonly used in the management of non-cognitive symptoms of dementia (also termed behavioural and psychological symptoms of dementia), such as agitation, calling out, hoarding, or aggression. This is despite increased recognition of adverse effects, including mortality, from these medications for people with dementia. The current aim was to review the most recent evidence for the efficacy and safety of antipsychotic medications in the management of non-cognitive symptoms in dementia. Methods Relevant studies published in English from March 2015 through to March 2018 were identified by searches of 5 databases: Medline, EBSCO, PsycINFO, Cochrane DARE, and Cochrane CENTRAL. Systematic reviews, meta-analyses, and controlled trials evaluating the safety of antipsychotic medication, or comparing the effectiveness of antipsychotic medication with placebo, another antipsychotic medication, or non-pharmacological intervention, were included. Independent article review and data extraction was performed by two reviewers. Study quality was appraised using the Joanna Briggs Institute critical appraisal tools. Results Thirteen studies were included. Benefits and harms vary among antipsychotic medications for people with dementia, however overall efficacy of antipsychotics remains modest at best. A significant number of side effects are associated with antipsychotics, not least cerebrovascular events, sedation, gait disturbances, falls, fractures, urinary tract infections, cognitive worsening, and mortality. Atypical antipsychotics have a more favourable safety profile in some respects. People with certain dementias, notably Lewy Body Dementia, may experience more severe side-effects. Conclusion The evidence reinforces caution when prescribing antipsychotic medications for people with dementia; these medications should only be considered when symptoms are severe or non-pharmacological interventions have failed. Clinicians should closely monitor people with dementia who are prescribed an antipsychotic for side effects, limiting use of these medications to short-term treatment if possible. The forthcoming national clinical guideline for appropriate prescribing of psychotropic medications for non-cognitive symptoms will support clinical decision-making in this regard.

Immediate Intervention Effects of Standardized Multicomponent Group Interventions on People with Cognitive Impairment: A Systematic Review.

Background:There is no curative medical treatment for dementia. Therefore, researchers turned their attention to non-pharmacological treatment approaches. Many reviews analyzed the efficacy of single-component interventions, but there has been no systematic review of multicomponent interventions so far.Objective:The aim was to systematically review studies using standardized multicomponent group interventions for persons with dementia or persons with mild cognitive impairment (MCI) and to analyze their immediate intervention effects.Methods:The databases PubMed, PsycINFO, PSYNDEX, and CINAHL were systematically searched. We included randomized controlled trials with people with MCI or dementia, which implemented interventions with at least two components that targeted different outcome domains. Additionally, the intervention had to be standardized and in a group setting.Results:Nine studies met the inclusion criteria with a total sample size of N = 513 participants. Six studies applied two, two studies applied three, and one study applied four components. Four studies, which combined at least a physical and a cognitive component, had a positive effect on non-cognitive symptoms of dementia. Two of these interventions additionally had a positive effect on cognitive abilities. One study reported a positive effect on activities of daily living and another study showed an effect on quality of life.Conclusion:In spite of the heterogeneity of the studies, multicomponent interventions suggest a positive effect on non-cognitive symptoms, especially the combination of cognitive and physical components. Single studies had also an effect on additional outcome domains. By trend the effects are dependent on application rate and used assessments.

Non-pharmacological approaches to non-cognitive symptoms in dementia.

Non-pharmacological approaches to non-cognitive symptoms in dementia.

Nonpharmacological Management of Behavioral and Psychological Symptoms of Dementia: What Works, in What Circumstances, and Why?

ObjectiveBehavioral and psychological symptoms of dementia (BPSD) refer to the often distressing, noncognitive symptoms of dementia. BPSD appear in up to 90% of persons with dementia and can cause serious complications. Reducing the use of antipsychotic medications to treat BPSD is an international priority. This review addresses the following questions: What nonpharmacological interventions work to manage BPSD? And, in what circumstances do they work and why?MethodA realist review was conducted to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases for empirical studies that reported a formal evaluation of nonpharmacological interventions to decrease BPSD.ResultsSeventy-four articles met the inclusion criteria. Three mechanisms emerged as necessary for sustained effective outcomes: the caring environment, care skill development and maintenance, and individualization of care. We offer hypotheses about how different contexts account for the success, failure, or partial success of these mechanisms within the interventions.DiscussionNonpharmacological interventions for BPSD should include consideration of both the physical and the social environment, ongoing education/training and support for care providers, and individualized approaches that promote self-determination and continued opportunities for meaning and purpose for persons with dementia.

Mild behavioral impairment (MBI): Background, description of the construct, and criteria development

Neuropsychiatric Symptoms (NPS) are common in dementia and pre-dementia syndromes such as Mild Cognitive Impairment (MCI). NPS in MCI confer a greater risk for conversion to dementia in comparison to MCI patients without NPS. Mild Behavioral Impairment (MBI) has been proposed as a diagnostic construct aimed to identify patients with an increased risk of developing dementia, but who may or may not have manifested cognitive symptoms. Initial discussion around the need for new MBI criteria stemmed from the annual meeting of the NPS Professional Interest Area (PIA) of the International Society to Advance Alzheimer's Research and Treatment (ISTAART) at the Alzheimer's Association International Conference (AAIC) 2012 in Vancouver, Canada. Conference proceedings and papers, Pubmed and Medline searches were performed with search criteria “mild behavioral impairment”, “MBI”, “prodromal dementia”, “neuropsychiatric symptoms of dementia”, “non-cognitive symptoms of dementia”, “NPS”, “behavioral and psychological symptoms of dementia” and “BPSD”. Both the American and United Kingdom spelling of “behavior/behaviour” were used in the search. Full text articles of relevant abstracts were reviewed, as were reference lists and citations. Authors ZI and CGL modified existing Taragano criteria, the Mendonca FTD-MCI criteria, and the NIA-AA Alzheimer's Disease criteria to incorporate current nomenclature and research. These criteria were then presented to the NPS-PIA at AAIC 2013 in Boston, Massachusetts. The criteria were then modified over the next year via in an iterative process by NPS PIA members. The final criteria then distributed to NPS PIA membership for approval and then subsequently to ISTAART for final approval prior to submission. We present the new proposed research diagnostic criteria for MBI. See Table. The MBI construct is a potential framework for detecting earlier, incipient neurodegenerative illness. The criteria extend previous research in this area and incorporate MCI into the framework. They will facilitate research into understanding NPS as a very early consequence of neurodegenerative disease in some cases, exploring targets for treatment and studying mechanisms of illness progression. The criteria will be subject to studies of reliability, concurrent validity, predictive validity and the development of biomarkers, ultimately leading to therapeutics.

Increased blood–brain barrier vulnerability to systemic inflammation in an Alzheimer disease mouse model

Behavioral and psychological problems are often observed in patients with dementia such as that associated with Alzheimer disease, and these noncognitive symptoms place an extremely heavy burden on the family and caregivers. Although it is well know that these symptoms often are triggered by infection of peripheral organs, the underlying mechanisms for these pathological conditions are still unclear. In this study, using an Alzheimer amyloid precursor protein (APP)-transgenic mouse, we analyzed behavioral changes and brain inflammatory response induced by peripheral administration of lipopolysaccharide. Application of a unique in vivo microdialysis system revealed that the increase in brain inflammatory cytokine (interleukin-6) level was significantly higher in APP-Tg than in wild-type mice after peripheral lipopolysaccharide injection, which was associated with more severe sickness behaviors. The blood–brain barrier became more permeable in APP-Tg mice during peripherally evoked inflammation, suggesting the increased vulnerability of the blood–brain barrier to inflammation in this animal model of Alzheimer's disease. These findings might provide insight into the pathogenesis of noncognitive symptoms in dementia and a basis to develop new therapeutic treatments for them.

The Impact of Perceived Knowledge of Dementia on Caregiver Burden

This study centered around 131 caregivers and their recipients to investigate whether the caregiver’s perceived knowledge of dementia may be a factor in reducing caregiver burden. We developed a questionnaire to measure this kind of knowledge. A significant relationship was shown between perceived knowledge and caregiver burden. Our multivariate analysis furthermore demonstrated that the caregivers’ self-assessed state of health also has a significant influence. A second regression model included the different aspects of perceived knowledge of our questionnaire and showed that certain aspects of perceived knowledge, especially concerning existing professional help services, noncognitive symptoms of dementia, and the importance of not neglecting one’s own personal needs, has an positive impact on caregiver burden.

Ginkgo biloba Special Extract in Dementia with Neuropsychiatric Features

In previous trials of the Ginkgo biloba special extract EGb 761 improvements in cognitive functioning and behavioural symptoms were found in patients with aging-associated cognitive impairment or dementia. This trial was undertaken to assess the efficacy of EGb 761 in mild to moderate dementia with neuropsychiatric features. Double-blind trial including 400 patients aged 50 years or above with Alzheimer's disease (AD) or vascular dementia (VaD), randomized to receive EGb 761 or placebo for 22 weeks. Patients scored below 36 on the Test for the Early Detection of Dementia with Discrimination from Depression (TE4D), between 9 and 23 on the SKT test battery and at least 5 on the Neuropsychiatric Inventory (NPI). There was a mean -3.2-point improvement in the SKT upon EGb 761 treatment and an average deterioration by +1.3 points on placebo (p < 0.001, two-sided, ANOVA). EGb 761 was significantly superior to placebo on all secondary outcome measures, including the NPI and an activities-of-daily-living scale. Treatment results were essentially similar for AD and VaD subgroups. The drug was well tolerated; adverse events were no more frequent under drug than under placebo treatment. The data add further evidence on the safety and efficacy of EGb 761 in the treatment of cognitive and non-cognitive symptoms of dementia.

Neuropsychiatric Profiles in Dementia

We compared patterns of neuropsychiatric symptoms across 4 dementia types [Alzheimer disease (AD), vascular dementia (VAD), dementia with Lewy bodies (DLB), and Parkinson disease dementia], and 2 mixed groups (AD/VAD and AD/DLB) in sample of 2,963 individuals from the National Alzheimer's Coordinating Center Uniform Data Set between September 2005 and June 2008. We used confirmatory factor analysis to compare neuropsychiatric symptom severity ratings made by collateral sources on the Neuropsychiatric Inventory Questionnaire for people with Clinical Dementia Rating scores of 1 or higher. A 3-factor model of psychiatric symptoms (mood, psychotic, and frontal) was shared across all dementia types. Between-group comparisons revealed unique neuropsychiatric profiles by dementia type. The AD group had moderate levels of mood, psychotic, and frontal symptoms whereas VAD exhibited the highest levels and Parkinson disease dementia had the lowest levels. DLB and the mixed dementias had more complex symptom profiles. Depressed mood was the dominant symptom in people with mild diagnoses. Differing psychiatric symptom profiles provide useful information regarding the noncognitive symptoms of dementia.

Effect of Bright Light and Melatonin on Cognitive and Noncognitive Function in Elderly Residents of Group Care Facilities

Cognitive decline, mood, behavioral and sleep disturbances, and limitations of activities of daily living commonly burden elderly patients with dementia and their caregivers. Circadian rhythm disturbances have been associated with these symptoms. To determine whether the progression of cognitive and noncognitive symptoms may be ameliorated by individual or combined long-term application of the 2 major synchronizers of the circadian timing system: bright light and melatonin. A long-term, double-blind, placebo-controlled, 2 x 2 factorial randomized trial performed from 1999 to 2004 with 189 residents of 12 group care facilities in the Netherlands; mean (SD) age, 85.8 (5.5) years; 90% were female and 87% had dementia. Random assignment by facility to long-term daily treatment with whole-day bright (+/- 1000 lux) or dim (+/- 300 lux) light and by participant to evening melatonin (2.5 mg) or placebo for a mean (SD) of 15 (12) months (maximum period of 3.5 years). Standardized scales for cognitive and noncognitive symptoms, limitations of activities of daily living, and adverse effects assessed every 6 months. Light attenuated cognitive deterioration by a mean of 0.9 points (95% confidence interval [CI], 0.04-1.71) on the Mini-Mental State Examination or a relative 5%. Light also ameliorated depressive symptoms by 1.5 points (95% CI, 0.24-2.70) on the Cornell Scale for Depression in Dementia or a relative 19%, and attenuated the increase in functional limitations over time by 1.8 points per year (95% CI, 0.61-2.92) on the nurse-informant activities of daily living scale or a relative 53% difference. Melatonin shortened sleep onset latency by 8.2 minutes (95% CI, 1.08-15.38) or 19% and increased sleep duration by 27 minutes (95% CI, 9-46) or 6%. However, melatonin adversely affected scores on the Philadelphia Geriatric Centre Affect Rating Scale, both for positive affect (-0.5 points; 95% CI, -0.10 to -1.00) and negative affect (0.8 points; 95% CI, 0.20-1.44). Melatonin also increased withdrawn behavior by 1.02 points (95% CI, 0.18-1.86) on the Multi Observational Scale for Elderly Subjects scale, although this effect was not seen if given in combination with light. Combined treatment also attenuated aggressive behavior by 3.9 points (95% CI, 0.88-6.92) on the Cohen-Mansfield Agitation Index or 9%, increased sleep efficiency by 3.5% (95% CI, 0.8%-6.1%), and improved nocturnal restlessness by 1.00 minute per hour each year (95% CI, 0.26-1.78) or 9% (treatment x time effect). Light has a modest benefit in improving some cognitive and noncognitive symptoms of dementia. To counteract the adverse effect of melatonin on mood, it is recommended only in combination with light. controlled-trials.com/isrctn Identifier: ISRCTN93133646.

Prescription patterns and efficacy of drugs for patients with dementia: physicians’ perspective in Italy

The aim of this study was to assess the prescription practices and judgment of efficacy of physicians of drugs used for the cognitive and non-cognitive symptoms of dementia. Physicians from 88 Italian Alzheimer Evaluation Units were surveyed by means of a structured questionnaire assessing the proportion of patients with four different types of dementia prescribed with drugs for cognitive and non-cognitive symptoms, and physicians' perceived efficacy of cholinesterase inhibitors. The Units prescribed cholinesterase inhibitors for 73 patients per year on average. Cholinesterase inhibitors are prescribed to 90% of patients with Alzheimer's disease (AD), 80% with with Lewy body dementia (LBD), and 35-45% with vascular dementia (VD) and frontotemporal lobar degeneration (FTLD). Selective serotonin uptake inhibitors (SSRIs) are prescribed for 28-45% of patients with all dementias except LBD (16%). Atypical neuroleptics were prescribed for 23-31% of patients, with no difference across types of dementia. Other drugs, such as ginkgo and nootropics, were prescribed less frequently, except in VD (20%). The perceived efficacy on cognitive and non-cognitive symptoms, assessed on a 0-to-10 ordinal scale, was highest in AD (4.3-6.1), intermediate in LBD (3.5-5.3) and VD (3.3- 4.7), and lowest in FTLD (2.0-2.7). The data indicate that, in specialized Italian centers, cholinesterase inhibitors and atypical neuroleptics are largely used in patients with AD and LBD, but the former are prescribed off-label to a remarkable proportion of patients with VD and FTLD. The efficacy of cholinesterase inhibitors is perceived to be highest in AD and poorest in FTLD. Perceived efficacy is affected more by whom is treated than by what is used.

P4-367: Prescription patterns and efficacy of drugs for patients with dementia: The physicians’ perspective

Available literature evidence on the efficacy of the drugs currently used to treat cognitive and non cognitive symptoms of patients with dementia is debated. Aim of this study was to assess the dementia specialist's prescription patterns and perception of efficacy of drugs for the cognitive and non cognitive symptoms of dementia. Physicians of 88 Italian Alzheimer Evaluation Units were surveyed with a structured questionnaire assessing: the proportion of patients with four different dementias prescribed with drugs for the cognitive and non cognitive symptoms, and the perceived efficacy of cholinesterase inhibitors. Cholinesterase inhibitors are prescribed to 90% of patients with AD, 80% with DLB, and 35 to 45% of patients with VD and FTLD. SSRIs are prescribed to 28 to 45% of patients with all dementias except DLB (16%). Atypical neuroleptics were also prescribed to 23 to 31% of patients, with no difference across dementias, and traditional neuroleptics were prescribed between 2 and 5 times less frequently. Ginkgo and nootropics were prescribed infrequently (1 to 6%) except in VD (20%). The perceived differences of efficacy of cholinesterase inhibitors on cognitive and non cognitive symptoms were relatively large across different dementias (highest ratio of 2.3) but only marginal among drugs (highest ratio 1.3). The perceived efficacy on cognitive symptoms was highest in AD (scores of 5.4 to 6.1) and lowest in FTLD (2.4 to 2.7; p<.0005), while on non cognitive symptoms was highest in AD and DLB (scores of 3.5 to 4.7) and lowest in FTLD (2.0 to 2.1; p<.0005). The perceived efficacy of donepezil, rivastigmine, and galantamine was different for the treatment of the cognitive symptoms of AD (6.1, 5.9, and 5.4; p=.01) and cognitive (4.3, 5.3, and 3.8; p=.003) and non cognitive symptoms (3.8, 4.7, and 3.5; p=.02) of DLB. These data indicate that in Italian expert centers cholinesterase inhibitors, and atypical neuroleptics are largely used in patients with AD and DLB, while therapy is more heterogeneous in VD and poorest in FTLD. Physician's perception of efficacy of cholinestrase inhibitors is affected more by whom is treated (dementia type) than what is used (drug type).

Cholinergic drugs for Alzheimer's disease enhance in vitro dopamine release.

Alzheimer's disease is a neurodegenerative disorder associated with a decline in cognitive abilities. Patients also frequently have noncognitive symptoms, such as anxiety, depression, apathy, and psychosis, that impair daily living. The most commonly prescribed treatments for Alzheimer's disease are acetylcholinesterase inhibitors, such as donepezil and galantamine. Enhanced cholinergic functions caused by these compounds are believed to underlie improvements in learning, memory, and attention. The noncognitive aspects of dementia, however, are usually linked to serotonin and dopamine rather than acetylcholine because those neurotransmitter systems most directly influence mood, emotional balance, and psychosis. Fast-scan cyclic voltammetry applied to mouse striatal brain slices was used to measure the real-time release of dopamine arising from spontaneous activity or from single electrical stimulations. At concentrations that include their prescribed dosage ranges, donepezil (1-1000 nM) and galantamine (50-1000 nM) increase action potential-dependent dopamine release. Consistent with previous literature, the data support slightly different modes of action for donepezil and galantamine. The ability of these commonly prescribed drugs to alter catecholamine release may underlie their influence over noncognitive symptoms of dementia. Furthermore, these results suggest that acting via nicotinic receptors, these drugs may serve presently untapped therapeutic roles by altering dopamine release in other disorders involving dopaminergic systems.