Disruptive Behavior as a Predictor in Alzheimer Disease

Gertrude H Sergievsky Center, Columbia University Medical Center, New York, NY 10032, USA.
JAMA Neurology (Impact Factor: 7.42). 01/2008; 64(12):1755-61. DOI: 10.1001/archneur.64.12.1755
Source: PubMed


Disruptive behavior is common in Alzheimer disease (AD). There are conflicting reports regarding its ability to predict cognitive decline, functional decline, institutionalization, and mortality.
To examine whether the presence of disruptive behavior has predictive value for important outcomes in AD.
Using the Columbia University Scale for Psychopathology in Alzheimer Disease (administered every 6 months, for a total of 3438 visit-assessments and an average of 6.9 per patient), the presence of disruptive behavior (wandering, verbal outbursts, physical threats/violence, agitation/restlessness, and sundowning) was extracted and examined as a time-dependent predictor in Cox models. The models controlled for the recruitment cohort, recruitment center, informant status, sex, age, education, a comorbidity index, baseline cognitive and functional performance, and neuroleptic use.
Five university-based AD centers in the United States and Europe (Predictors Study).
Four hundred ninety-seven patients with early-stage AD (mean Folstein Mini-Mental State Examination score, 20 of 30 at entry) who were recruited and who underwent semiannual follow-up for as long as 14 (mean, 4.4) years.
Cognitive (Columbia Mini-Mental State Examination score, < or = 20 of 57 [approximate Folstein Mini-Mental State Examination score, < or = 10 of 30]) and functional (Blessed Dementia Rating Scale score, parts I and II, > or = 10) ratings, institutionalization equivalent index, and death.
At least 1 disruptive behavioral symptom was noted in 48% of patients at baseline and in 83% at any evaluation. Their presence was associated with increased risks of cognitive decline (hazard ratio 1.45 [95% confidence interval (CI), 1.03-2.03]), functional decline (1.66 [95% CI, 1.17-2.36]), and institutionalization (1.47 [95% CI, 1.10-1.97]). Sundowning was associated with faster cognitive decline, wandering with faster functional decline and institutionalization, and agitation/restlessness with faster cognitive and functional decline. There was no association between disruptive behavior and mortality (hazard ratio, 0.94 [95% CI, 0.71-1.25]).
Disruptive behavior is very common in AD and predicts cognitive decline, functional decline, and institutionalization but not mortality.

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Available from: Jason Brandt, Oct 03, 2015
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    • "The environment at night can be perceived very differently and disorientation is more likely for a person with dementia due to a number of factors, e.g., low light conditions. A person with dementia is also more likely to be confused and disorientated on awakening [16]. Older people may also experience altered and irregular sleeping patterns. "
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    ABSTRACT: There is growing interest in the development of ambient assisted living services to increase the quality of life of the increasing proportion of the older population. We report on the Night Optimised Care Technology for UseRs Needing Assisted Lifestyles project, which provides specialised night time support to people at early stages of dementia. This article explains the technical infrastructure, the intelligent software behind the decision-making driving the system, the software development process followed, the interfaces used to interact with the user, and the findings and lessons of our user-centred approach.
    Behaviour and Information Technology 12/2014; 33(12). DOI:10.1080/0144929X.2013.816773 · 0.89 Impact Factor
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    • "About 40% of people with dementia get lost outside their home at least once [6], and just under 10% get lost on multiple occasions [7]. Wandering outside the home puts them at risk of exploitation and accidental injury [8], family members and other caregivers naturally become anxious spending long periods searching for them [6] and the police frequently need to be involved [7]. Often, however, the person does not walk far from home, may be in familiar territory, can find their way home and be at relatively low risk. "
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    ABSTRACT: Background Getting lost outside is stressful for people with dementia and their caregivers and a leading cause of long-term institutionalisation. Although Global Positional Satellite (GPS) location has been promoted to facilitate safe walking, reduce caregivers’ anxiety and enable people with dementia to remain at home, there is little high quality evidence about its acceptability, effectiveness or cost-effectiveness. This observational study explored the feasibility of recruiting and retaining participants, and the acceptability of outcome measures, to inform decisions about the feasibility of a randomised controlled trial (RCT). Methods People with dementia who had been provided with GPS devices by local social-care services and their caregivers were invited to participate in this study. We undertook interviews with people with dementia, caregivers and professionals to explore the perceived utility and challenges of GPS location, and assessed quality of life (QoL) and mental health. We piloted three methods of calculating resource use: caregiver diary; bi-monthly telephone questionnaires; and interrogation of health and social care records. We asked caregivers to estimate the time spent searching if participants became lost before and whilst using GPS. Results Twenty people were offered GPS locations services by social-care services during the 8-month recruitment period. Of these, 14 agreed to be referred to the research team, 12 of these participated and provided data. Eight people with dementia and 12 caregivers were interviewed. Most participants and professionals were very positive about using GPS. Only one person completed a diary. Resource use, anxiety and depression and QoL questionnaires were considered difficult and were therefore declined by some on follow-up. Social care records were time consuming to search and contained many omissions. Caregivers estimated that GPS reduced searching time although the accuracy of this was not objectively verified. Conclusions Our data suggest that a RCT will face challenges not least that widespread enthusiasm for GPS among social-care staff may challenge recruitment and its ready availability may risk contamination of controls. Potential primary outcomes of a RCT should not rely on caregivers’ recall or questionnaire completion. Time spent searching (if this could be accurately captured) and days until long-term admission are potentially suitable outcomes.
    BMC Psychiatry 05/2014; 14(1):160. DOI:10.1186/1471-244X-14-160 · 2.21 Impact Factor
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    • "There has been very little research data on prognosis of the sundown syndrome. Scarmeas et al.25 reported that the presence of sundown syndrome has been associated with more rapid cognitive function deterioration in patients with early stages of AD. "
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    ABSTRACT: "Sundowning" in demented individuals, as distinct clinical phenomena, is still open to debate in terms of clear definition, etiology, operationalized parameters, validity of clinical construct, and interventions. In general, sundown syndrome is characterized by the emergence or increment of neuropsychiatric symptoms such as agitation, confusion, anxiety, and aggressiveness in late afternoon, in the evening, or at night. Sundowning is highly prevalent among individuals with dementia. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition. Neurophysiologically, it appears to be mediated by degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin. A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications. To decrease the morbidity from this specific condition, improve patient's well being, lessen caregiver burden, and delay institutionalization, further attention needs to be given to development of clinically operational definition of sundown syndrome and investigations on etiology, risk factors, and effective treatment options.
    Psychiatry investigation 12/2011; 8(4):275-87. DOI:10.4306/pi.2011.8.4.275 · 1.28 Impact Factor
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