Steinberg, M. et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. Int. J. Geriatr. Psychiatry 23, 170-177

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
International Journal of Geriatric Psychiatry (Impact Factor: 2.87). 02/2008; 23(2):170-7. DOI: 10.1002/gps.1858
Source: PubMed


Neuropsychiatric symptoms are nearly universal in dementia, yet little is known about their longitudinal course in the community.
To estimate point and 5-year period prevalence of neuropsychiatric symptoms in an incident sample of 408 dementia participants from the Cache County Study.
The Neuropsychiatric Inventory assessed symptoms at baseline and at 1.5 years, 3.0 years, 4.1 years, and 5.3 years. Point prevalence, period prevalence and mean symptom severity at each time point were estimated.
Point prevalence for delusions was 18% at baseline and 34-38% during the last three visits; hallucinations, 10% at baseline and 19-24% subsequently; agitation/aggression fluctuated between 13% and 24%; depression 29% at baseline and 41-47% subsequently; apathy increased from 20% at baseline to 51% at 5.3 years; elation never rose above 1%; anxiety 14% at baseline and 24-32% subsequently; disinhibition fluctuated between 2% and 15%; irritability between 17% and 27%; aberrant motor behavior gradually increased from 7% at baseline to 29% at 5.3 years. Point prevalence for any symptom was 56% at baseline and 76-87% subsequently. Five-year period prevalence was greatest for depression (77%), apathy (71%), and anxiety (62%); lowest for elation (6%), and disinhibition (31%). Ninety-seven percent experienced at least one symptom. Symptom severity was consistently highest for apathy.
Participants were most likely to develop depression, apathy, or anxiety, and least likely to develop elation or disinhibition. Give converging evidence that syndromal definitions may more accurately capture neuropsychiatric co-morbidity in dementia, future efforts to validate such syndromes are warranted.

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Available from: John C.S. Breitner, Oct 05, 2015
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    • "Although Alzheimer's Disease (AD) is the most common form of dementia, 25% of patients have vascular dementia (VaD) and a further 20–40% have mixed dementia with VaD and AD. More than 90% of patients with dementia will experience at least one behavioural and psychological symptoms of dementia (BPSD), such as delusions, hallucinations, agitation and aggression, during the course of their condition (Steinberg et al., 2008). These symptoms are frequently extremely distressing to patients, stressful to carers and present a significant clinical challenge for treatment. "
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    ABSTRACT: Objectives People with vascular dementia (VaD) are frequently prescribed atypical antipsychotics to treat behavioural and psychological symptoms, but there is an alarming lack of evidence regarding their safety or efficacy in VaD. This study sought to identify the mortality risk associated with the most commonly prescribed atypical antipsychotics in people with VaD compared with people not exposed to these drugs.MethodsA clinical cohort study of 1531 people with VaD performed using anonymised versions of full electronic health records from the Clinical Record Interactive Search application at the South London and Maudsley NHS Foundation Trust. Patients were identified from 2007 to 2010, of whom 337 were exposed to quetiapine, risperidone or olanzapine. The main outcome measure was mortality.ResultsPatients exposed to atypical antipsychotics were not at increased risk of mortality [hazard ratio (HR) 1.05, 95% confidence interval (CI): 0.87–1.26]. Exposure to risperidone did not result in an increased risk of mortality (HR = 0.85; 95% CI: 0.59–1.24), and patients exposed to quetiapine had a non-significant numerical increase in mortality risk (HR = 1.14; 95% CI: 0.93–1.39; p-value = 0.20) compared with untreated patients. Too few patients were exposed to olanzapine alone to provide reliable results.Conclusions The absence of a significant increase in mortality risk associated with atypical antipsychotics in people with VaD indicates that a clinical trial of antipsychotics focussing on the treatment of aggression and agitation in this patient group will be justified and feasible following further consideration of possible confounders, which will be critical to determine the role of antipsychotics in treatment of VaD. Copyright © 2014 John Wiley & Sons, Ltd.
    International Journal of Geriatric Psychiatry 12/2014; 29(12). DOI:10.1002/gps.4101 · 2.87 Impact Factor
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    • "Depressive symptoms in mild cognitive impairment subjects have also been linked to further progression to dementia (Gabryelewicz et al., 2007), and an increased brain atrophy over a period of 2 years (Lee et al., 2012), suggesting that depression in general may be a risk factor for developing AD (Ownby et al., 2006). Agitation and aggression have been reported to range from 48% to 80% in AD patients (Tractenberg et al., 2002) with symptoms remaining persistent over months and occurring across all AD stages (Steinberg et al., 2008). Neurochemical studies that assessed postmortem brain levels of different monoamines and metabolites associated with specific NPS features are very limited and date from over 2 decades ago (Palmer et al., 1988; Zubenko et al., 1990). "
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    ABSTRACT: Background: Depression and aggression in Alzheimer’s disease (AD) are two of the most severe and prominent neuropsychiatric symptoms (NPS). Altered monoaminergic neurotransmitter system functioning has been implicated in both NPS, although their neurochemical etiology remains to be elucidated. Methods: Left frozen hemispheres of 40 neuropathologically confirmed AD patients were regionally dissected. Dichotomization based on depression/aggression scores resulted in depressed/nondepressed (AD+D/-D) and aggressive/nonaggressive (AD+Agr/-Agr) groups. Concentrations of dopamine, serotonin (5-HT), (nor)epinephrine ((N)E) and respective metabolites were determined using RP-HPLC. Results: Significantly lower 3-methoxy-4-hydroxyphenylglycol (MHPG) and higher homovanillic acid levels were observed in Brodmann area (BA) 9 and 10 of AD+D compared to AD-D. In AD+Agr, 5-hydroxy-3-indoleacetic acid (5-HIAA) levels in BA9, 5-HIAA/5-HT ratios in BA11, and MHPG, NE, and 5-HIAA levels in hippocampus were significantly decreased compared to AD-Agr. Conclusions: These findings indicate that brain region-specific altered monoamines and metabolites may contribute to the occurrence of depression and aggression in AD.
    Neurobiology of Aging 05/2014; 35(12):2691-2700. DOI:10.1016/j.neurobiolaging.2014.05.031 · 5.01 Impact Factor
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    • "Behavioral and Psychological Symptoms of Dementia (BPSD) is present in up to 97% of persons with dementia over a five-year period [1], and often result in patient distress, caregiver stress, increased cost of care, nursing home admissions as well as a corresponding higher prevalence of antipsychotic use in the nursing homes compared to the social care setting [2]. Despite limited long-term benefits, numerous side effects, and associated higher risks of stroke and death [3], the use of antipsychotics for managing symptoms of severe agitation, aggression and psychosis in the nursing homes will likely continue, especially when these symptoms pose significant threats to the safety of the resident and those around him/her [4] [5]. "
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    ABSTRACT: In nursing homes, antipsychotic prescribing decisions (APDs) for managing behavioral and psychological symptoms of dementia (BPSD) depend on the nursing staff’s feedback. Inappropriate APDs can result in the lack of timeliness, objectivity and important clinical information when nursing staff’s feedback on residents’ behavior and pharmacotherapy outcomes. Currently, there are no reported interventions for improving psychiatrists’ APDs through nursing staff’s monitoring and feedback processes. This one-group pre-and-post pilot study aimed to evaluate the feasibility and impact of implementing a newly-developed Psychotropic Use Monitoring (PUM) program for improving the appropriateness of APDs in a 50-bed dementia ward of a nursing home. The PUM intervention involved 16 pharmacist-trained nursing staff, who monitored and reported residents’ BPSD changes and psychotropic side effects for 24 weeks, while carrying out their routine care duties. A face-to-face interview was then administered to determine the nursing staff’s perceptions of PUM. Data of 51 residents were collected from hardcopy individual patient records to evaluate the changes in APDs and the number of resident falls before and after implementing PUM. The nursing staff reported increases in their knowledge, awareness, confidence, and actual frequency of monitoring for side effects, as well as their ability in differentiating and managing BPSD (p < 0.05). After PUM, there was a significant increase in the number of APDs due to side effect-related reasons (4 versus 16) (p < 0.031). Although not significant, the number of APDs with no documented reasons (5 versus 9) and the number of resident falls (7 versus 15) appeared to be lesser after PUM. This study demonstrated the nursing staff’s positive participation in PUM intervention, specifically in monitoring and feedback of side effects. Furthermore, a potential exists for PUM to encourage more judicious APDs, which may be useful in settings with heavy patient load, limited human resources and dependence on foreign nursing staff from differing cultural backgrounds.
    Open Journal of Psychiatry 04/2014; 4(2):153-162. DOI:10.4236/ojpsych.2014.42020
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