Observation Scale For Geriatric Patients Research Articles

Assessment of everyday behavior in Alzheimer's disease patients: its significance for diagnostics and prediction of disease progression.

In addition to cognitive decline, current diagnostic criteria for Alzheimer's disease (AD) require evidence of impaired social and/or occupational functioning. The Nurses' Observation Scale for Geriatric Patients (NOSGER) is used to rate the frequency of disturbances in everyday behaviors and, although not specifically developed for this purpose, is often applied for diagnostic purposes. The NOSGER assesses six dimensions: Memory, Instrumental Activities of Daily Living (IADLs), Self-Care (ADL), Mood, Social Behavior, and Disturbing Behavior. The goals of this study were 1) to establish normative data for the NOSGER as a function of demographic variables (i.e., age, years of education, and gender) in healthy elderly subjects; 2) to obtain cutoff values distinguishing healthy elderly subjects from probable AD patients with mild dementia; and 3) to describe the natural course of behavioral changes occurring in mild AD according to the NOSGER dimensions. NOSGER data of 445 normal controls [NCs, 376 men, 69 women; Mini-Mental Status Examination (MMSE) = 28.8 +/- 1.17] and 217 probable AD patients with mild dementia (97 men, 120 women; MMSE = 26.1 +/- 1.59) from the Memory Clinic of Basel, Switzerland, were analyzed. Cutoff scores for distinguishing between average NCs and mildly demented AD patients ranged between 7 and 9 for different NOSGER dimensions. Formulae to obtain demographically adjusted and z-transformed NOSGER dimension and MMSE scores for assessment of individual cases were determined. NCs were best distinguished from patients in the NOSGER dimension Mood, followed by Memory, ADLs, Social Behavior, and Disturbing Behavior. Linear courses of behavioral deterioration were found-in four NOSGER dimensions (Memory, IADLs, Mood, and Social Behavior) in these mildly demented patients. No quadratic course was found for any of the NOSGER dimensions. The NOSGER revealed good discriminatory power in those behavioral dimensions affected in early stages of AD and is suitable for monitoring behavioral changes as a function of disease progression. Its use in combination with the MMSE for dementia screening purposes is recommended.

Predicting the outcome of cholinesterase inhibitor treatment in Alzheimer’s disease

Objective: To investigate the possibility that response to cholinesterase inhibitor therapy could be predicted by easily measurable variables that are known to change as a result of treatment (such as...

Detecting depression in Alzheimer’s disease: evaluation of four different scales

Depression is a frequent condition in Alzheimer’s disease (AD). The prevalence of depressive symptoms depends on the severity of dementia and the instruments used. Our aim was to assess the prevalence of depression dependent on the severity of dementia by four different scales: The 15-point Geriatric Depression Scale (GDS), the Montgomery and Åsperg Depression Scale (MADRS), the Cornell Scale for Depression in Dementia (CSDD) and the Nurses Observation Scale for Geriatric Patients (NOSGER). The study population consisted of 316 patients with Alzheimer’s disease from a psychiatric out-patients memory-clinic, which was divided into two groups: mild AD (Mini-Mental Status Examination (MMSE) ≥ 18) and moderate to severe AD (MMSE < 18). Additionally, internal consistency and correlation of these scales were calculated. Prevalence of depression ranged between 27.5 and 53.4% in mild AD and between 36.3 and 68.4% in moderate to severe AD. Internal consistency was good in all scales (Cronbach’s alpha .63–.85). For MADRS and CSDD it was independent of the stage of AD, while in GDS and NOSGER internal consistency decreased with severity of dementia. Correlation between the scales was better in mild AD than moderate to severe AD; the best results were obtained for the correlation between CSDD and MADRS in both groups. We conclude that in our study population CSDD and MADRS were the most consistent tools for detecting depression in AD independently of the severity of dementia.

Effects of galantamine on behavioural and psychological disturbances and caregiver burden in patients with Alzheimer's disease

SUMMARYBackground: Behavioural and psychological disturbances occur in up to 90% of patients with Alzheimer's disease (AD), have a substantial impact on both patients and caregivers, and are often associated with the decision to institutionalise patients. Galantamine (Reminyl†) is a dual-acting cholinergic treatment that improves cognitive and functional performance, delays the onset of behavioural symptoms and decreases behaviour-associated caregiver distress.Objective: To assess the impact of galantamine on behavioural disturbances and associated caregiver burden in non-institutionalised patients with AD.Methods: This was a 3-month, open-label, multicentre study in Switzerland. Patients with mild-to-moderate AD received galantamine (escalated from 8 to 24 mg/day over 8 weeks). The primary outcome was the Neuropsychiatric Inventory (NPI) for patients who completed 3 months treatment (observed cases, OC). Secondary outcomes included the Nurses’ Observation Scale for Geriatric patients (NOSGER), and the Clinical Global Impression (CGI) of change.Results: 124 patients (mean age 75.2 years, 55.6% women) received galantamine and were included in the intention-to-treat (ITT) safety analysis. Significant improvements in NPI scores versus baseline were seen in the OC analysis ( p < 0.05, N = 91); mean total NPI scores (± SE) were reduced from 14.9 ± 1.2 at baseline to 11.3 ± 1.2 at month 3. Eleven out of 12 NPI domains were improved. Anxiety, aberrant motor behaviour, delusions, euphoria and night-time-behaviour all improved by > 30%. Symptoms with the highest baseline frequency and severity improved by 19–27%. A significant reduction in total NPI caregiver burden was observed at month 3 ( p < 0.05). Despite this short assessment period the NOSGER evaluation and physicians’ CGI also showed improvement. Adverse events (AEs) were mostly gastrointestinal.Conclusion: Galantamine significantly reduced behavioural disturbances after 3 months in this population and this had a positive impact on behaviour-related caregiver burden. Galantamine showed the expected safety profile and was well tolerated.

Further evidence of dementia in SPG4 -linked autosomal dominant hereditary spastic paraplegia

To investigate the progression of cognitive impairment and its behavioral aspects in patients with SPG4-linked autosomal dominant hereditary spastic paraplegia (SPG4-ADHSP). Sixteen patients, 45 years or older, from five families with SPG4-ADHSP were prospectively assessed. Eleven of these, from three families, were followed and 10 had two cognitive examinations using the Cambridge Cognitive Assessment (CAMCOG) 2.9 years apart. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Neuropsychiatric Inventory (NPI), and the Nurses' Observation Scale for Geriatric Patients (NOSGER) were completed by close relatives of the 11 patients at the second assessment. Eleven matched control subjects had CAMCOG examinations 3.1 years apart. The mean CAMCOG score at the initial assessment was lower for the 10 HSP patients (73.5/107) than for 10 control subjects (91.7/107, p = 0.005). After 2.9 years, the HSP patients experienced a fall in the mean CAMCOG by 9.1 points to 64.4/107 (p = 0.008). The mean CAMCOG score for the control subjects (90.8/107) fell by only 0.9 points after 3.1 years (p = 0.36). The CAMCOG scores of two HSP patients moved from the mild (60 to 80) into the moderate dementia category (35 to 59) and in three other patients into the mild dementia range from borderline normal scores (81 to 85). IQCODE scores were abnormal in 9/11 HSP patients and 1/11 controls (p = 0.001). Seven of the 11 HSP patients were considered as having dementia. This study indicates an active progression of cognitive deterioration and dementia in older patients with SPG4-ADHSP.

An Observational Clinical Study of the Efficacy and Tolerability of Donepezil in the Treatment of Alzheimer’s Disease

An open-label, observational Post-Marketing Surveillance (PMS) study was undertaken in Germany to examine the efficacy and tolerability of donepezil in routine clinical practice. Alzheimer’s disease (AD) patients were treated with donepezil (5 or 10 mg once daily) and observed for a period of approximately 3 months. Study assessments included the Mini-Mental State Examination (MMSE), the Nurses’ Observation Scale for Geriatric Patients (NOSGER), and adverse events (AEs). A total of 2,092 patients (mean age 73.0 years; mean ± SD MMSE score 17.8 ± 5.8) were included in the efficacy assessments. MMSE and NOSGER scores showed statistically significant improvements in the total patient population and in the subpopulations with severe AD or AD with concomitant Parkinsonian symptoms (ADPS cohort). AEs were reported in a total of 12% of patients and were mostly due to peripheral cholinergic effects. In this observational PMS study, donepezil was shown to be an effective and well-tolerated therapy in the overall patient population, in patients with severe AD, and in the ADPS cohort.

The sensitivity to change over time of the Bristol activities of daily living scale in Alzheimer's disease

Activities of daily living scales can be a useful tool in assessing change in people with dementia, either as the disease progresses or in response to treatment. However, little data exist as to the sensitivity to change of instruments used. The Bristol Activities of Daily Living Scale was developed with assistance from the carers of community dwelling people with dementia to be completed by such people and has been shown to have internal consistency as well as face and construct validity. This study aimed to analyse the sensitivity to change of the Bristol Activities of Daily Living Scale in people with Alzheimer's disease receiving anticholinesterase medication. Using the Clinician's Global Rating of Change as a gold standard for change, differences between Bristol Activities of Daily Living Scale scores before and after medication were compared with change in Mini-Mental State Examination, Alzheimer's Disease Assessment Scale — Cognitive and the Nurses Observation Scale for Geriatric Patients, in 61 older adults receiving anticholinesterase medication for Alzheimer's disease. Both the Bristol Activities of Daily Living Scale and the Nurses Observation Scale for Geriatric Patients are sensitive and specific in predicting improvement or stability as measured by the clinician's global rating of change. However, unlike the Nurses Observation Scale for Geriatric Patients, change over time in the Bristol Activities of Daily Living Scale significantly correlates with change in the Mini-Mental State Examination and the Alzheimer's Disease Assessment Scale — Cognitive. The Bristol Activities of Daily Living Scale is sensitive to change in activities of daily living and shows the expected and desirable relationship with measures of cognition. Copyright © 2000 John Wiley & Sons, Ltd.

Subnormal serum vitamin B12 and behavioural and psychological symptoms in Alzheimer's disease.

The objective of this study was to examine whether patients with Alzheimer's disease (AD) with subnormal vitamin B12 levels show more frequent behavioural and psychological symptoms of dementia (BPSD) than AD patients with normal vitamin B12 levels. The design was a prospective case-control study. The study took place at a memory-clinic of a department of geriatric medicine in a teaching hospital. There were seventy-three consecutive outpatients with probable AD, including 61 patients with normal and 12 patients with subnormal (<200 pg/ml) vitamin B12. BPSD were measured using the subscales disturbed behaviour and mood of the Nurses' Observation Scale for Geriatric Patients (NOSGER), the Cornell Scale for Depression and the four criteria for personality change in dementia from the International Classification of Diseases (ICD-10). Controlling for dementia duration and degree of severity of the cognitive deficits, there were significant inverse associations between vitamin B12 status and ICD-10 irritability (p=0.045) and NOSGER subscale disturbed behaviour (p=0.015). Low vitamin B12 serum levels are associated with BPSD in AD. Vitamin B12 could play a role in the pathogenesis of behavioural changes in AD.

Les deux infinis et l'esprit humain: Flammarion, coll. « Nouvelle bibliothèque scientifique , 1999, 222 p., 135 F.

Anosognosia refers to impaired awareness of patients to realize deficits related to a disorder and is a common symptom of dementia. Anosognosia has far-reaching consequences for diagnosis and treatment and is probably associated with unfavorable prognosis. This study examined the relationship between anosognosia and depression in patients with Alzheimer's dementia (AD). Assessment included interviews of patients and their caregivers. Depressive symptoms were evaluated with observer and self-rating instruments: the Geriatric Depression Scale (GDS), and the “mood” subscale of the Nurses Observation Scale for geriatric patients (NOSGER). Anosognosia was evaluated with the Anosognosia Questionnaire for Dementia (AQ-D). For the evaluation of behavioral and neuropsychological symptoms in dementia and the caregiver burden, the neuropsychiatric inventory (NPI) and the Cares of older People in Europe (COPE) Index were administered. A total of 47 patients were enrolled in the study at the department's geriatric psychiatry outpatient clinic. A considerable discrepancy was found between observer- and self-ratings of depressive symptoms. In 74.5% of the participants, caregiver ratings indicated secondary symptoms of depression as opposed to patient ratings. Thus, in AD, anosognosia may affect not only deficits in cognition and everyday functioning but also affective symptoms (“affective anosognosia”). Caregiver rating therefore is particularly important when assessing mood changes in AD patients.

Premorbid personality traits in Alzheimer's disease: do they predispose to noncognitive behavioral symptoms?

The purpose of this study was to examine whether premorbid personality traits predispose to noncognitive symptoms in Alzheimer's disease (AD). The Munich Personality Test was used to evaluate caregivers' perception of personality prior to symptom onset in 56 outpatients with probable AD. Caregivers also completed the "mood" and "disturbed behavior" scales of the Nurses' Observation Scale for Geriatric Patients. A neuropsychiatrist rated depressive symptoms on the Cornell Scale for Depression and the occurrence of personality change in four domains according to ICD-10. Under statistical control of confounding variables, results showed a moderate association between (high) premorbid neuroticism, subsequent troublesome behavior, and personality change, on the one hand, and (low) frustration tolerance and depression, on the other. Premorbid personality traits may indeed predispose to subsequent noncognitive symptoms in AD.

Early diagnosis of dementia via a two-step screening and diagnostic procedure.

We propose a two-step process for the assessment of dementia using standardized instruments. The family physician performs a screening consisting of taking a medical history, gathering information from relatives and friends of the patient, and administering the combined Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT). Specialists examine patients with suspected dementia to confirm the diagnosis of dementia and, after a thorough differential diagnostic process, provide the family physician with recommendations for treatment. Specialists should perform neurological and psychiatric examinations, imaging (computer-assisted tomography [CT], magnetic resonance imaging [MRI]), and laboratory work-up. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) core neuropsychological battery is proposed to serve as a minimal data set that is internationally compatible. In addition, we recommend the Nurses' Observation Scale for Geriatric Patients (NOSGER) as a standard tool for functional assessment.

Validation of the NOSGER (Nurses' Observation Scale for Geriatric Patients): reliability and validity of a caregiver rating instrument.

The Nurses' Observation Scale for Geriatric Patients (NOSGER) is a rating scale for use in geriatric patients that can be applied by nurses or other caregivers. It deals with the daily behavior of elderly patients and measures impairment in six areas (dimensions): memory; instrumental activities of daily living (IADL); (basic) activities of daily living (ADL); mood; social behavior; and disturbing behavior. Objectivity, stability, construct validity, and acceptance of the scale have been established in previous studies using an earlier version of the NOSGER. The present validation study considered 50 healthy old subjects, 25 patients with mild dementia, 25 patients with advanced (mostly moderate according to DSM-III-R criteria) dementia, and 25 elderly patients with depression. The NOSGER was completed by relatives in the case of subjects living in their own homes and by nurses or other caregivers for institutionalized subjects. In addition to the NOSGER, selected tests of concentration, memory, and performance were applied as outside criteria. Interrater reliability (objectivity) was estimated by variance component analysis. Values between rtt = .68 and rtt = .89 (all p < .001) were found for the six NOSGER dimensions, the values being higher for the cognitive dimensions (memory, IADL, ADL) than for the noncognitive ones (mood, social behavior, disturbing behavior). Retest reliability (stability), which was calculated via rank order correlations, was somewhat higher for the cognitive NOSGER dimensions (memory rs = .91, IADL rs = .92, ADL rs = .88; p < .001) than for the noncognitive ones (mood rs = .85, social behavior rs = .87, disturbing behavior rs = .84; p < .001). All these values satisfy the level of rtt > or = .80 required in accordance with psychometric standards. The concurrent validity of the NOSGER dimensions was assessed using correlations with external criteria with which similarity of content was expected. The NOSGER dimensions memory, IADL, ADL, and social behavior were found to correlate closely with external criteria of similar content, whereas no satisfactory concurrent validities were found for the dimensions mood or disturbing behavior. The NOSGER dimensions were also correlated with a number of unrelated external criteria so as to reveal any discordances. For the dimensions memory, IADL, ADL, and social behavior, no clear-cut discriminant validities were found. This suggests that these four dimensions may function as parameters not just of different areas of behavior, but also of a general factor that might be described as "cognitive intactness." As a further aspect of construct validity, significant differences (all p < .001) between the four groups of subjects were found in five of the six NOSGER dimensions (memory, IADL, ADL, mood, social behavior): The healthy subjects differed significantly from all three patient groups in five of the six dimensions; the moderately demented group differed from the depressed group in four of the six dimensions and from the mildly demented group in two of the six dimensions; and the mildly demented group differed significantly from the depressed group in terms of mood (significance levels are after application of the Bonferroni correction). Significant group differences (p generally < .001) were also found for most of the objective performance tests used (data not presented).

Efficacy and safety of idebenone in the long-term treatment of Alzheimer's Disease: a double-blind, placebo controlled multicentre study

The efficacy and safety of idebenone were studied in a prospective, randomized, double-blind, placebo controlled multicentre study in 3 parallel groups of patients with dementia of the Alzheimer type (DAT) of mild to moderate degree. Diagnosis was based on DSM-III-R (primary degenerative dementia) and NINCDS-ADRDA criteria (probable Alzheimer's disease). A total of 450 patients were randomized to either placebo (n = 153) or idebenone 90 mg tid (n = 148) or 120 mg tid (n = 149) and treated up to 12 months. The primary endpoint for the evaluation of efficacy was at month 6. Data of the month-12 assessments were considered for the evaluation of long-term treatment effects. The primary outcome measure was the total score of the Alzheimer's Disease Assessment Scale (ADAS-Total) at month 6. Secondary outcome measures were the ADAS cognitive (ADAS-Cog) and noncognitive score (ADAS-Noncog), the clinical global response (CGI-Improvement), the SKT neuropsychological test battery, and the Nurses' Observation Scale for Geriatric Patients (NOSGER-Total and IADL subscale). Safety parameters were adverse events, vital signs, ECG and clinical laboratory parameters. Clinical and psychometric evaluations were made at screening, at baseline, and after 1, 3, 6, 9 and 12 months of treatment. After months 6 and 12, idebenone showed statistically significant dose-dependent improvement in the primary efficacy variable ADAS-Total and in all the secondary efficacy variables. An analysis of therapy responders performed on 3 outcome measures (CGI, ADAS-Cog, NOSGER-IADL), selected to represent different levels of assessment, revealed significant dose-related superiority of idebenone with respect to placebo in each of the 3 variables and in the concordance of responses across the 3 measures. Safety results were inconspicuous on all assessments. The study results confirm the efficacy, clinical relevance and safety of idebenone in the long-term treatment of DAT.

Clinical experience with the nosger (nurses' observation scale for geriatric patients): Tentative normative data and sensitivity to change

AbstractThe NOSGER is an assessment instrument used in psychogeriatrics, consisting of 30 observable items of behaviour and measuring impairments in six areas: memory, IADL (instrumental activities of daily living), ADL (activities of daily living), mood, social behaviour and disturbing behaviour. Data collected in the course of validation studies were reanalysed to calculate tentative normative scores and to assess the scale's sensitivity to change. Cutoff scores for elderly normal subjects living in the community are estimated around 10 for ADL and around 15 for memory and IADL disturbances. Cutoff values for the three non‐cognitive NOSGER dimensions are not yet available. Sensitivity to change (over 3 months) was shown to be relatively highest for memory, IADL and disturbing behaviour and lowest for ADL in a group of patients with mild to moderate dementia. Correlations between NOSGER change scores and physicians‐ overall assessments of treatment efficacy in a drug study were highest for social behaviour, IADL and mood, suggesting that non‐cognitive factors were at least as important to determine doctors‐ assessments of change as changes in cognitive areas of behaviour. Further studies are on their way to supplement the present data set.

Depression in Alzheimer's Disease Significantly Improved under Treatment with Mianserine

To the Editor:—Depression is a frequent unspecific behavioral concomitant of Alzheimer's disease. Typically, the mood disorder is shortlived and fluctuating but may meet the diagnostic criteria for major depression in up to 30% of all cases.1 The efficacy of antidepressant treatment in demented patients has been observed using compounds such as monoamine-oxidase inhibitors2,3 or imipramine.4 There are no reports on the effects of the tetracyclic antidepressant mianserine on depression in Alzheimer's disease although this compound, a dipyrazinoazepine derivate, may be particularly useful in elder patients because it shows little vegetative and almost no anticholinergic side effects. In our outpatient clinic a 79-year-old woman, with clinically diagnosed moderate Alzheimer's disease (NINCDS-ADRDA), complaining of depressed mood, low self-esteem, and anxiety showed markedly reduced drive and mentioned occasional suicidal thoughts. She had lost interest in social activities during the past 4 weeks. The criteria for major depression (DSM-III-R) were fulfilled. Treatment was begun with mianserine 10 mg/day and after 1 week was raised to 20 mg/day. Two weeks after initial treatment, her symptoms of anxiousness, depression, drive, and self-esteem had improved clinically. According to her husband, suicidal thoughts were no longer present, and she had even started to participate in some activities (taking a walk, visiting friends). Six weeks after initial treatment, further substantial improvement of depression was clinically demonstrable. The patient could enjoy social activities in daily living. During the follow-up assessment over 6 weeks, no relevant side effects, such as tiredness, sedation or orthostatic hypotension, occurred. There was no change in cognitive impairment during these 6 weeks. The clinical observations were confirmed by baseline and follow-up assessments (Table 1) at 2 and 6 weeks with the Dementia Mood Assessment Scale,5 the Nurses' Observation Scale for Geriatric Patients,6 and the Cambridge Cognitive Examination.7 This case report suggests that treatment with mianserine can substantially improve major depression in Alzheimer patients. We did not find relevant side effects during treatment. In contrast to that, postural hypotension, drowsiness, and dizziness have been reported during treatment of depression in Alzheimer patients with tricyclic antidepressants4 and monoamino-oxidase inhibitors.3 Furthermore, treatment with monoamino-oxidase inhibitors requires dietary precautions to prevent potential hypertensive reactions.8 We therefore suggest that the tetracyclic antidepressant mianserine should be considered as a valuable alternative in the pharmacological treatment of depression in Alzheimer's patients.

A New Behavioral Assessment Scale for Geriatric Out‐ and In‐Patients: the NOSGER (Nurses' Observation Scale for Geriatric Patients)

Although a great number of psychometric tests and rating scales for the assessment of psychogeriatric patients is available, there is still an urgent need, in research and practice, for a clinical rating instrument that meets the following main requirements: (1) applicable to institutionalized and community patients and covering a wide range of behavioral pathology; (2) acceptable and easy to use for professionals and lay persons alike; (3) covering a wide range of behavior relevant to daily functioning but independent of sex or social status of the individual assessed. The NOSGER contains 30 items of behavior, each rated on a 5-point scale according to frequency of occurrence. Item scores are summarized into 6 Dimension scores (memory, instrumental activities of daily life, self-care, mood, social behavior, and disturbing behavior) which are clinically relevant in dementia, depression, and other psychiatric disorders of old age. Validation studies with a preliminary version of the NOSGER indicated good acceptance of the scale, high inter-rater and test-retest reliability, and high correlations of all NOSGER Dimension scores with results of a variety of established assessment instruments. The NOSGER is currently being used in a number of European and North American centers and should turn out to be a useful instrument for longitudinal studies in psychogeriatrics.