Among participants with Alzheimer's disease (AD) we estimated the minimal clinically important difference (MCID) in apathy symptom severity on three scales.

Retrospective anchor- and distribution-based analyses of change in apathy symptom scores.

Apathy in Dementia Methylphenidate Trial (ADMET) and ADMET 2 randomized controlled trials conducted at three and ten clinics specialized in dementia care in United States and Canada, respectively.

Two hundred and sixty participants (60 ADMET, 200 ADMET 2) with clinically significant apathy in Alzheimer’s disease.

The Clinical Global Impression of Change in Apathy scale was used as the anchor measure and the MCID on the Neuropsychiatric Inventory – Apathy (NPI-A), Dementia Apathy Interview and Rating (DAIR), and Apathy Evaluation Scale-Informant (AES-I) were estimated with linear mixed models across all study visits. The estimated thresholds were evaluated with performance metrics.

Among the MCID was a decrease of four points (95% CI: −4.0 to −4.8) on the NPI-A, 0.56 points (95% CI: −0.47 to −0.65) on the DAIR, and three points on the AES-I (95% CI: −0.9 to −5.4). Distribution-based analyses were largely consistent with the anchor-based analyses. The MCID across the three measures showed ∼60% accuracy. Sensitivity analyses found that MMSE scores and apathy severity at baseline influenced the estimated MCID.

MCIDs for apathy on three scales will help evaluate treatment efficacy at the individual level. However, the modest correspondence between MCID and clinical impression of change suggests the need to consider other scales.

Among people with dementia, poor nutritional status has been associated with worse cognitive and functional decline, but few studies have examined its association with neuropsychiatric symptoms (NPS). We examined this topic in a population-based sample of persons with dementia.

Longitudinal, observational cohort study.

Community.

Two hundred ninety-two persons with dementia (71.9% Alzheimer’s disease, 56.2% women) were followed up to 6 years.

We used a modified Mini-Nutritional Assessment (mMNA) and the Neuropsychiatric Inventory (NPI) to evaluate nutritional status and NPS, respectively. Individual linear mixed effects models examined the associations between time-varying mMNA total score or clinical categories (malnourishment, risk for malnourishment, or well-nourished) and NPI total score (excluding appetite domain) or NPI individual domain or cluster (e.g. psychosis) scores. Covariates tested were dementia onset age, type, and duration, medical comorbidities, sex, apolipoprotein E (APOE) genotype, and education.

Compared to the well-nourished, those at risk for malnourishment and those malnourished had higher total NPI scores [b (95% CI) = 1.76 (0.04, 3.48) or 3.20 (0.62, 5.78), respectively], controlling for significant covariates. Higher mMNA total score (better nutritional status) was associated with lower total NPI [b (95% CI) = −0.58 (−0.86, −0.29)] and lower domain scores for psychosis [b (95% CI) = −0.08 (−0.16, .004)], depression [b (95% CI = −0.11 (−0.16, −0.05], and apathy [b (95% CI = −0.19 (−0.28, −0.11)].

Worse nutritional status is associated with more severe NPS. Dietary or behavioral interventions to prevent malnutrition may be beneficial for persons with dementia.

Behavioral and psychological symptoms of dementia (BPSD) are a group of noncognitive symptoms that occur commonly among individuals with dementia. These symptoms worsen the morbidity and mortality among individuals with dementia and significantly increase the cost of caring for these individuals. Transcranial magnetic stimulation (TMS) has been shown to have some benefits in the treatment of BPSD. This review provides an updated summary of the effect of TMS on BPSD.

We conducted a systematic review of PubMed, Cochrane, and Ovid databases on the use of TMS to treat BPSD.

We found 11 randomized controlled studies that evaluated the use of TMS among individuals with BPSD. Three of these studies examined the effect of TMS on apathy, two of which showed significant benefit. Seven studies showed that TMS significantly improves BPSD: six using repetitive transcranial magnetic stimulation (rTMS) and one using transcranial direct current stimulation (tDCS). Four studies, two evaluating tDCS, one evaluating rTMS, and one evaluating intermittent theta-burst stimulation (iTBS) showed a nonsignificant impact of TMS on BPSD. Adverse events were predominantly mild and transitory in all studies.

Available data from this review indicate that rTMS is beneficial for individuals with BPSD, especially among individuals with apathy, and is well tolerated. However, more data are needed to prove the efficacy of tDCS and iTBS. Additionally, more randomized controlled trials with longer treatment follow-up and standardized use of BPSD assessments are needed to determine the best dose, duration, and modality for effective treatment of BPSD.

Dementia is a clinical syndrome characterized by a decline in cognitive abilities and memory deficits globally. About 90% of patients experience behavioral and psychological symptoms. The use of psychotropic drugs is influenced by the patient symptoms, burden of the caregiver, and the habit of health workers.

To determine the effect of psychoeducation modules to caregivers to increase knowledge, decrease of psychotropic drugs, reduce symptoms and burden of caregivers.

There are 2 steps of studies. The first was a qualitative study to create psychoeducation module and the second was to conduct a pre-experimental study (one group pretest-posttest study). Psychoeducation is given in 2 consecutive weeks.

Fourty caregivers of dementia patients aged 41.3 (± 9.72) years. The psychoeducation modules is associated with decreasing symptoms and the use of psychotropic drugs, increasing knowledge and decreasing the burden of caregivers. At the end, 23% of patients were able to stop using psychotropic drugs and 62% of patients reduced their dose and/or the amount of psychotropic drugs.

The psychoeducation modules to caregivers is associated with a decrease of patient symptoms and the use of psychotropic drugs. Psychoeducation also increases the knowledge of the caregiver and decreases the burden of the caregiver so that this psychoeducation module can be an additional therapy for patients with dementia.

Nursing home residents with dementia are sensitive to detrimental auditory environments. This paper presents the first literature review of empirical research investigating (1) the (perceived) intensity and sources of sounds in nursing homes, and (2) the influence of sounds on health of residents with dementia and staff.

A systematic review was conducted in PubMed, Web of Science and Scopus. Study quality was assessed with the Mixed Methods Appraisal Tool. We used a narrative approach to present the results.

We included 35 studies. Nine studies investigated sound intensity and reported high noise intensity with an average of 55–68 dB(A) (during daytime). In four studies about sound sources, human voices and electronic devices were the most dominant sources. Five cross-sectional studies focused on music interventions and reported positives effects on agitated behaviors. Four randomized controlled trials tested noise reduction as part of an intervention. In two studies, high-intensity sounds were associated with decreased nighttime sleep and increased agitation. The third study found an association between music and less agitation compared to other stimuli. The fourth study did not find an effect of noise on agitation. Two studies reported that a noisy environment had negative effects on staff.

The need for appropriate auditory environments that are responsive to residents’ cognitive abilities and functioning is not yet recognized widely. Future research needs to place greater emphasis on intervention-based and longitudinal study design.

Prior research and theories established the link between care environments and apathy. Yet, empirical evidence on how environmental stimulation impacts apathy is lacking. This study examined the association between environmental stimulation and apathy in nursing home residents with dementia.

This repeated-measure study analyzed 104 video observations of staff caregiver–resident interactions.

12 nursing homes.

63 unique staff caregiver–resident dyads that involved 42 caregivers and 44 residents with moderate to severe dementia.

Second-by-second behavioral coding using Noldus Observer software was conducted to assess apathy and environmental stimulation, using the Person-Environment Apathy Rating scale. The environment subscale includes six items: stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback. The apathy subscale includes six items: facial expression, eye contact, physical engagement, purposeful activity, verbal tone, and verbal expression. Multilevel linear models were used for analysis.

Results showed that apathy was not associated with the overall quality of environmental stimulation but was significantly associated with stimulation specificity (coefficient = −2.23, p = 0.049). However, the association was not significant after controlling for resident characteristics (p = 0.082). In addition, higher levels of environmental feedback were associated with lower apathy levels (coefficient = −2.14, p = 0.001). The association remained significant after controlling for resident characteristics (coefficient = −1.65, p = 0.014).

Findings reveal that when environmental stimulation is individually tailored and prompts engagement, residents are less apathetic. This study highlights the effect of environmental stimulation on apathy. Future research should explore interventions that modify environmental stimulation to reduce apathy and improve dementia care.

It is well established that there is a high prescribing rate of psychotropic agents in residential aged care (RAC). The appropriateness of these medications has become controversial, given the limited data on efficacy and growing evidence of associated adverse outcomes.

To assess psychotropic prescribing in RAC including identification of potentially inappropriate prescriptions (PIPs) and common psychological and behavioral symptoms indicated for prescribing. These were viewed in context of dementia and different RAC facilities.

Electronic care plans of 779 RAC residents across 12 facilities were examined to elucidate psychotropic prescribing rates, PIPs, and indications for use.

One in two residents (48.1%) were prescribed a psychotropic drug. The primary reasons for prescribing were depression (61.5%), anxiety (26.7%), sleep problems (25.4%), agitation (13.7%), psychosis (11.0%), and other behaviors (7.2%). Residents with dementia (56.6%) were more likely to be prescribed a drug for agitation and psychosis, and had a significantly increased prescription rate for antidepressants (OR = 1.50, 95% CI = 1.08–2.08, p = 0.01) and antipsychotics (OR = 1.88, 95% CI = 1.23–2.88, p < 0.01). Conversely, residents with dementia were less likely to receive medication to combat sleeping difficulties, with significantly lower benzodiazepine prescribing (OR = 0.63, 95% CI = 0.44–0.91, p = 0.01). Over half of all psychotropic prescriptions (54.0%) were potentially inappropriate based on the Beers Criteria. There was high variability of prescribing rates between homes.

There is a high prescribing rate of potentially inappropriate medications. Residents with dementia are more likely to receive medication for agitation and psychosis, and are less likely to receive medication to combat sleeping difficulties.

Behavioral and psychological symptoms of dementia (BPSD) are a primary manifestation of brain dysfunction in dementia and a great challenge in caregiving. While BPSD are historically associated with caregiver distress, it is unclear whether there is an identifiable point where BPSD number is associated with heightened caregiver distress. The purpose of this study was to determine if such a tipping point exists to assist clinicians in identifying caregiver compromise.

Analyses were performed with three datasets totaling 569 community-dwelling persons with dementia and their caregivers. Each included identical demographic, BPSD, cognitive, and caregiver well-being measures. Linear regression was performed with 16 BPSD symptoms on caregiver well-being measures and predictive values determined with receiver operating characteristic (ROC) curves and pre-defined scores for clinically significant distress.

Of the 569 persons with dementia, 549 (96%) displayed at least one BPSD, mean of 5.7 (SD = 3.06) symptoms in the past month. After controlling for covariates, BPSD symptom number was significantly associated with caregiver depression and burden (p < 0.01 for both models). Findings indicate ≥ 4 BPSD has strong predictive values for depression (sensitivity 85%, specificity 44%, area under ROC curve 0.62, p < 0.01), and burden (sensitivity 84%, specificity 43%, area under ROC curve 0.67, p < 0.01).

Caring for persons with four or more BPSD appears to reflect a tipping point for clinically meaningful distress. Findings have implications for clinicians working with persons with dementia and their caregivers and suggest need for continuous monitoring of BPSD and identification of at risk caregivers.

Caregivers of people with dementia are likely to have psychological distress that sometimes results in mental health problems, such as depression. The objective of this study was to examine some predictive factors that are thought to be associated with psychological distress of caregivers of people with dementia in Japan.

Design: A cross-sectional study. Sample: As part of a study to estimate the cost of dementia in Japan, 1,437 people with dementia-caregiver dyads were enrolled in the current informal care time study. The measurements in the study included were the basic characteristics of the caregivers and the people with dementia, and the informal care time during a week.

Factors that predict caregivers’ psychological distress, which was measured by Kessler's Psychological Distress scale (K6) score, were evaluated using univariate and multivariate regression analyses.

Approximately 69% of the caregivers recorded a K6 score higher than 4, while 18% scored higher than 12. According to the results of the logistic regression analysis (cut-off 4/5), the K6 score was associated with mental and comorbid diseases of people with dementia, informal care time, its lower number of caregivers, and the level of nursing care. According to the results of logistic regression analysis (cut-off 12/13), the K6 score was associated with mental symptoms and comorbid disease of people with dementia, sex of caregivers, informal care time, and its lower number of caregivers.

Our findings indicated that the psychological distress of the caregivers is quite high and that informal care time and behavioral and psychological symptoms of dementia are associated with it. These results corroborate with previous findings.

The ability of nursing staff to assess and evaluate behavioral and psychological symptoms of dementia (BPSD) to determine when intervention is needed is essential. In order to assist with the assessment process, the current use of the Neuropsychiatric Inventory Nursing Home version (NPI-NH) is internationally accepted. Even though the NPI-NH is thoroughly validated and has several advantages, there are also various challenges when implementing this system in practice. Thus, the aim of this study was to explore clinical reasoning employed by assistant nurses when utilizing the NPI-NH as a tool to assess frequency and severity of BPSD in individuals with advanced dementia.

Twenty structured assessment sessions in which assistant nurses used the NPI-NH were audio recorded and analyzed with a discourse analysis focusing on the activities in the communication.

Four categories were identified to convey assistant nurses' clinical reasoning when assessing and evaluating BPSD using the NPI-NH: considering deteriorations in ability and awareness, incorporating individual and contextual factors, overcoming variations in behaviors and ambiguous formulations in the instrument, and sense-making interactions with colleagues.

The NPI-NH served as a supportive frame and structure for the clinical reasoning performed during the assessment. The clinical reasoning employed by assistant nurses became a way to reach a consensual and broader understanding of the individual with dementia, with the support of NPI-NH as an important framework.

There are some existing barriers posed by neuropsychological tests that interfere with the assessment of cognitive functioning by staff who work in long-term care facilities. The purpose of this study was to investigate the feasibility of assessing cognitive function through conversation.

A total of 100 care staff was randomly selected as participants. Each staff member evaluated cognitive function in one to three residents using the Conversational Assessment of Neurocognitive Dysfunction (CANDy), which is a screening test for dementia using conversation. Other scales used were the Mini-Mental State Examination (MMSE), Behavioral Pathology in Alzheimer’ s Disease (BEHAVE-AD), and quality-of-life questionnaire for the elderly with dementia (QOL-D).

A total of 80 care staff members and 158 residents were analyzed. When the CANDy involved an evaluation based on face-to-face communication, it demonstrated significant correlations with the MMSE, BEHAVE-AD, and several indices of the QOL-D (e.g. negative affect and actions, communication ability, restless, and spontaneity and activity). In contrast, when the CANDy involved an evaluation based on an impression of a typical conversation, it only demonstrated significant relationships with the MMSE and the spontaneity and activity index of the QOL-D.

Conversational assessment is a useful means to assess cognitive functioning and to promote interactions between residents and care staff in long-term care facilities.

Impulsive–aggressive behavior is a significant challenge in geriatric psychiatry and requires professional evaluation and management.

SOAS-R scales (Staff Observation Aggression Scale-Revision) completed by medical staff on three secure psychiatric wards were analyzed during a period of 12 months. Patients were subdivided into the following two diagnostic subgroups: dementia and other diagnoses.

A total of 146 aggressive incidents involving 66 patients were reported (8.8% of patients treated during this period, n = 752). Fifty-seven percent of the incidents involved patients with dementia. In 20% of the incidents, no precipitating event could be identified; this was more common in patients without dementia (p = 0.005). The medical condition of the patient was considered the trigger in 55% of the cases. Aggression was directed at nurses in 82% of the cases. Visible injury was reported in 12 cases, 3 of which required medical treatment. Male gender, the presence of previous aggressive incidents, and the evening shift (in the case of dementia patients) were identified as risk factors.

Aggression in dementia is often reactive and seems to be more predictable than if occurring with other diagnoses. Prevention measures such as de-escalations techniques, warning notes in the patient's file with previous aggressive behavior and stepping up for evening shifts are of crucial importance. As nurses were primarily affected, employer support programs, and mental health interventions are proposed to avoid long-term consequences.

Agitation in patients with dementia increases caretaker burden, increases healthcare costs, and worsens the patient's quality of life. Antipsychotic medications, commonly used for the treatment of agitation in patients with dementia have a box warning from the FDA for elevated mortality risk. Electroconvulsive therapy (ECT) has made significant advances over the past several years, and is efficacious in treating a wide range of psychiatric conditions. We provide a systematic review of published literature regarding the efficacy of ECT for the treatment of agitation in patients with dementia (major neurocognitive disorder).

We searched PubMed, Medline, Google Scholar, UptoDate, Embase, and Cochrane for literature concerning ECT for treating agitation in dementia using the title search terms “ECT agitation dementia;” “ECT aggression dementia;” “ECT Behavior and Psychological Symptoms of Dementia;” and “ECT BPSD.” The term “dementia” was also interchanged with “Major Neurocognitive Disorder.” No time frame restriction was placed. We attempted to include all publications that were found to ensure a comprehensive review. We found 11 papers, with a total (N) of 216 patients.

Limited to case reports, case series, retrospective chart review, retrospective case-control, and an open label prospective study, ECT has demonstrated promising results in decreasing agitation in patients with dementia. Patients who relapsed were found to benefit from maintenance ECT.

Available studies are often limited by concomitant psychotropic medications, inconsistent use of objective rating scales, short follow-up, lack of a control group, small sample sizes, and publication bias. A future randomized controlled trial will pose ethical and methodological challenges. A randomized controlled trial must carefully consider the definition of usual care as a comparison group. Well-documented prospective studies and/or additional case series with explicit selection criteria, a wide range of outcome measures, and less selection bias of the study sample that may favor treatment response, is warranted. ECT may be a promising option for the treatment of aggression and agitation in patients with severe dementia who are refractory to other treatment options, but the limitations of available studies suggest that a cautious approach to future randomized controlled trials is warranted.

Several studies on the effect of physical exercise on activities of daily living (ADL) for people with dementia exist; yet, data concerning the specific context of acute psychiatric hospitals remain scant. This study measured the effect of a physical exercise program on ADL scores in patients with moderate to severe dementia hospitalized in an acute psychiatric ward.

A multicenter clinical trial was conducted in five Swiss and Belgian psychiatric hospitals. Participants were randomly allocated to either an experimental group (EG) or a control group (CG). Members of the EG received 20 physical exercise sessions (strengthening, balance, and walking) over a four-week period while members of the CG participated in social interaction sessions of equivalent duration and frequency, but without physical exercise. The effect of exercise on ADL was measured by comparing scores of the Barthel Index and the Functional Independence Measure in the EG and CG before and after the intervention, and two weeks later.

Hundred and sixty patients completed the program. Characteristics of participants of both groups were similar at the inception of the study. The mean ADL score of EG decreased slightly over time, whereas that of the CG significantly decreased compared to initial scores. Overall differences between groups were not significant; however, significant differences were found for mobility-related items.

ADL scores in elderly with moderate to severe dementia deteriorate during acute psychiatric hospitalization. An exercise program delays the loss of mobility but does not have a significant impact on overall ADL scores.

Neuropsychiatric Symptoms (NPS) are ubiquitous in dementia and are often treated pharmacologically. The objectives of this study were to describe the use of psychotropic, anti-cholinergic, and deliriogenic medications and to identify the prevalence of polypharmacy and psychotropic polypharmacy, among older hospitalized patients in Ireland, with and without dementia.

All older patients (≥ 70 years old) that had elective or emergency admissions to six Irish study hospitals were eligible for inclusion in a longitudinal observational study. Of 676 eligible patients, 598 patients were recruited and diagnosed as having dementia, or not, by medical experts. These 598 patients were assessed for delirium, medication use, co-morbidity, functional ability, and nutritional status. We conducted a retrospective cross-sectional analysis of medication data on admission for 583/598 patients with complete medication data, and controlled for age, sex, and co-morbidity.

Of 149 patients diagnosed with dementia, only 53 had a previous diagnosis. At hospital admission, 458/583 patients experienced polypharmacy (≥ 5 medications). People with dementia (PwD) were significantly more likely to be prescribed at least one psychotropic medication than patients without dementia (99/147 vs. 182/436; p < 0.001). PwD were also more likely to experience psychotropic polypharmacy (≥ two psychotropics) than those without dementia (54/147 vs. 61/436; p < 0.001). There were no significant differences in the prescribing patterns of anti-cholinergics (23/147 vs. 42/436; p = 0.18) or deliriogenics (79/147 vs. 235/436; p = 0.62).

Polypharmacy and psychotropic drug use is highly prevalent in older Irish hospitalized patients, especially in PwD. Hospital admission presents an ideal time for medication reviews in PwD.

This study explores the appropriateness of psychotropic drug (PD) use for neuropsychiatric symptoms (NPS) in nursing home patients with dementia.

A cross-sectional study on 559 patients with dementia residing on dementia special care units in Dutch nursing homes was conducted. Appropriateness of PD use was assessed using the Appropriate Psychotropic drug use In Dementia (APID) index. The APID index score is calculated using information about individual PDs from patients’ medical records. The index encompasses seven (different) domains of appropriateness, i.e. indication, evaluation, dosage, drug-drug interactions, drug-disease interactions, duplications, and therapy duration.

A total of 578 PDs were used for NPS by 60% of the nursing home patients. Indication, evaluation, and therapy duration contributed the most to inappropriate use. Ten per cent of the PDs scored fully appropriate according to the APID index sum score, 36% scored fully appropriate for indication, 46% scored fully appropriate for evaluation, and 58% scored fully appropriate for therapy duration. Antidepressants were used the most appropriately, and antiepileptics the most inappropriately.

The minority of the PD use was fully appropriate. The results imply that PD use for NPS in dementia can be improved; the appropriateness should be optimized with a clinical focus on the appropriate indications, evaluations, and therapy duration.

Behavioral and psychological symptoms of Dementia (BPSD) are a cause of significant stress in caregivers. The revised memory and behavior problems checklist (RMBPC) (Teri et al., 1992) is an instrument used for the assessment of BPSD. The psychometric properties of the RMBPC-Spanish version were analyzed.

361 family caregivers of people with dementia were interviewed individually. The RMBPC is a 24-item questionnaire that assesses both the frequency of the BPSD and the reaction they cause in the caregiver. It has three factors: memory problems, disruptive behaviors, and depressive behaviors. Caregivers’ depressive symptomatology, anxiety and burden, and the functional capacity of the person with dementia were also measured.

The results of a confirmatory factor analysis (CFA) show that the original three-factor model with 24 items, with error covariances, had a marginally acceptable adjustment for the frequency and reaction scales. The deletion of items with low factor loadings results in a better adjustment of the data to the model, for both the frequency and reaction scales. We found adequate internal consistency for all subscales, and significant associations between the subscales, burden, anxiety, and depression.

The results suggest that the Spanish version of the RMBPC shows adequate adjustment for the three-factor model with 24-items, but that removing some of the items improves the adjustment. The results support the use of this instrument for the assessment of BPSD in Spanish people with dementia.

We aimed to examine trends in the use of psychotropic medications among elderly outpatients with dementia in Japan between 2002 and 2010.

We used data from the 2002–2010 Survey of Medical Care Activities in Public Health Insurance (SMCA-PHI), a nationally representative cross-sectional survey of claims data for the month of June in every year. We included ambulatory care visits by patients aged 65 years or older who were prescribed cholinesterase inhibitors (n = 15,591), and identified use of any psychotropic medications during the survey month.

In 2008–2010, the most prevalently prescribed psychotropic medications to patients with dementia were sedatives-hypnotics (37.5%), antipsychotics (24.9%), antidepressants (13.0%), and mood-stabilizers (2.9%). Between 2002–2004 and 2008–2010, use of second-generation antipsychotics (SGAs) increased from 5.0% to 12.0%, while use of first-generation antipsychotics (FGAs) decreased from 20.6% to 12.9%. These numbers resulted in a 1.1-fold increase in the adjusted prevalence of the overall use of antipsychotics. Quetiapine and risperidone use showed a 4.8- and 1.8-fold increase, respectively, while haloperidol use showed a 2.3-fold decrease.

Despite safety warnings against the use of antipsychotics for patients with dementia in several countries, our study revealed a slight increase in the extensive use of off-label antipsychotics over time in Japan. This finding indicates an urgent need for evaluation of the efficacy of antipsychotics for the approved treatment of severe agitation, aggression, and psychosis associated with dementia. Moreover, psychosocial interventions and antipsychotic withdrawal strategies are needed in order to reduce the overall prevalence of antipsychotic use.