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[Comparative study of two on aged care-based occupational (professional) training in medical home for aged and dependent patients with neuropsychiatric behaviors]
Abstract
Background:
Neuropsychiatric behaviours of the elderly is the main issue for caregivers' distress, burn out and high turn-over. This situation will steadily worsen with longer lifetime.
Aim of the study:
Specialised training of medical staff may decrease their distress: we compare both training programs Humanitude® et Formadep® outcomes.
Methods:
A comparative open multicentric non randomised study included 459 elderlies of 9 EHPAD of Korian Company into 3 training groups: Humanitude®, Formadep® and a group control, with 29 weeks follow-up. We studied the scoring NPI-ES (FG and R), BMS-10, ECPA and GIR, medications, caregivers' burn out/absences/turn-over levels. Statistical significance were done by Wilcoxon signed-rank test, Ancova and linear regression.
Results:
320 caregivers and 3 groups of nearly 150 elderlies each, with around 50% dementia. In Formadep® group : lower scoring for a short time of total NPI-R (p<0.05), sustained lower scoring of NPI-FG « agitation/agressivity» (p=0.035) but transitional for its NPI-R (p<0.05), sustained higher scoring of NPI-FG «apathy/indifference» (p=0.002) but transitional for its NPI-R (p=0 .003), sustained lower scoring of NPI-R (p=0.0039) for Motor Aberrant Behaviours (MAB). In Humanitude® group: transitional higher scoring of NPI-R (p=0.025) for MAB et transitional lower scoring NPI-R (p=0.0032) for depression (Alzheimer Disease sub-groupe). No change for other parameters.
Conclusion:
Despite high variability of the neuropsychiatric behaviours in elderly, Formadep® training has shown a positive impact on the global distress and on three main challenging behaviours, compared to Humanitude®: this may be depend on their own philosophy. But caregivers' burden in dementia is not a one-factor problem.
Résumé
Objectifs
Les symptômes psychocomportementaux liés aux démences (SPCD) sont fréquents et représentent un inconfort évident, à la fois pour les malades, mais aussi pour l’entourage et les soignants. Les difficultés des soignants, mal préparés et souvent en sous-effectifs, face à ces résidents ont motivé le développement d’une approche d’inspiration « Carpe Diem », par la formation de tous les effectifs. Cette démarche, développée au Québec depuis 20 ans, s’appuie sur certains concepts : les résidents sont considérés comme des personnes conservant des ressources et des capacités ; les accompagnements s’adaptent aux personnes ; chaque comportement a un sens et mérite un décryptage ; chaque action doit être menée avec cohérence et constance ; le contrôle est à l’opposé de l’accompagnement, comme la relation de pouvoir est à l’opposé de la relation de confiance. Les familles et les proches sont impliqués. Nous avons réalisé une étude mesurant l’impact de la formation des équipes soignantes sur les SPCD.
Méthode
Notre étude a porté sur la population des unités spécifiques de l’EHPAD de Marcheprime (33). La méthode retenue pour cette étude comportait trois étapes : l’évaluation initiale a permis de coter les SPCD et leur retentissement grâce au NPI-ES. Immédiatement après cette phase, tous les personnels ont bénéficié de 4 jours de formation à l’approche Carpe Diem. Le mois suivant la fin des formations, l’évaluation finale menée suivant les mêmes modalités a établi de nouveaux scores de NPI-ES. Ces scores ont été analysés statistiquement puis leur comparaison aux deux temps d’évaluation a été réalisée par un test de significativité, le seuil étant fixé à 5 %.
Résultats
Au départ, le score moyen du NPI était à 23,67 ± 10,79. Les comportements les plus intenses et sévères étaient l’apathie, l’irritabilité et les troubles de l’appétit. Il n’y avait toutefois pas de corrélation avec l’importance du retentissement. La comparaison entre les deux temps d’évaluation montrait une diminution significative du score global (p < 0,001) et du retentissement sur les soignants. Il en était de même de l’analyse item par item des SPCD et de leur retentissement.
Conclusion
Les résultats ont montré une diminution significative des SPCD et du retentissement après la formation « Carpe Diem ». On peut conclure à l’amélioration des symptômes mais aussi à l’évolution du regard des soignants, les deux paramètres entrant en corrélation. Par la suite, il est prévu de poursuivre avec la participation d’intervenants québécois au sein des équipes de l’EHPAD. L’encadrement s’est également engagé dans un réseau local d’inspiration « Carpe Diem » auquel l’Agence Régionale de Santé participe.
Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Their diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences on patient and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD. A comittee of geriatricians, neurologists and psychiatrists specialised in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent litterature reports, and was adapted to the French enthronement. This paper is a synthesis of this meeting, validated and corrected by the whole Thema 2 group.
Si les tendances démographiques récentes se maintiennent, la France métropolitaine comptera 73,6 millions d’habitants au 1er janvier 2060, soit 11,8 millions de plus qu’en 2007. Le nombre de personnes de plus de 60 ans augmentera, à lui seul, de plus de 10 millions. En 2060, une personne sur trois aura ainsi plus de 60 ans. Jusqu’en 2035, la proportion de personnes âgées de 60 ans ou plus progressera fortement, quelles que soient les hypothèses retenues sur l’évolution de la fécondité, des migrations ou de la mortalité. Cette forte augmentation est transitoire et correspond au passage à ces âges des générations du baby-boom. Après 2035, la part des 60 ans ou plus devrait continuer à croître, mais à un rythme plus sensible aux différentes hypothèses sur les évolutions démographiques.
Objectives:
The objective of the present study was to evaluate the frequency of neuropsychiatric symptoms in a sample of Alzheimer's disease patients and to analyze association between caregiver demographic characteristics and patient symptoms.
Methods:
Sixty Alzheimer's disease patients (NINCDS-ADRDA) and their caregivers were consecutively included in the investigation by the Dementia Outpatient clinic of Hospital de Clínicas de Porto Alegre. The Neuropsychiatric Inventory (NPI) was applied to evaluate behavioral symptoms and their impact upon caregivers. Age, sex, educational attainment, relationship to the patient, and time as caregiver were obtained from all caregivers.
Results:
Apathy was the symptom responsible for the highest distress level, followed by agitation and aggression. A significant correlation between total severity NPI and distress NPI was observed. None of the caregiver demographic data showed association to distress. The most frequent symptoms were apathy and aberrant motor behavior. Patients' relatives also considered apathy as the most severe symptom, followed by depression and agitation.
Conclusions:
Apathy was the most frequent and severe neuropsychiatric symptom. No relationship between caregiver demographic characteristics and distress was observed.
Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences for patients and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD.
A committee of geriatricians, neurologists and psychiatrists specialized in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent literature reports, and was adapted to the French environment. This paper is a synthesis of this meeting, validated and corrected by the entire Thema 2 group.
Behavioral disturbances in patients with Alzheimer's disease (AD) are ill-defined conditions. We hypothesize that the many behavioral disturbances hitherto described and studied might be grouped into few syndromes with separate determinants and correlates.
162 consecutive patients with probable AD admitted to a dementia unit were assessed by the UCLA Neuropsychiatric Inventory (NPI).
Factor analysis was carried out on NPI subscales, leading to three syndromes: 'mood', 'psychotic' and 'frontal'. Patients with the 'psychotic' syndrome were older, had older age at dementia onset, had poorer cognition, were more often males, and had faster rate of dementia progression. Patients with the 'frontal' syndrome had higher education, longer disease duration, and slower rate of progression.
Some combinations of behavioral disturbances occur more frequently together and might represent separate behavioral syndromes. Different clinical correlates of the syndromes suggest separate etiologies.
Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, represent a heterogeneous group of non-cognitive symptoms and behaviors occurring in subjects with dementia. BPSD constitute a major component of the dementia syndrome irrespective of its subtype. They are as clinically relevant as cognitive symptoms as they strongly correlate with the degree of functional and cognitive impairment. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. It is estimated that BPSD affect up to 90% of all dementia subjects over the course of their illness, and is independently associated with poor outcomes, including distress among patients and caregivers, long-term hospitalization, misuse of medication, and increased health care costs. Although these symptoms can be present individually it is more common that various psychopathological features co-occur simultaneously in the same patient. Thus, categorization of BPSD in clusters taking into account their natural course, prognosis, and treatment response may be useful in the clinical practice. The pathogenesis of BPSD has not been clearly delineated but it is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD. A high degree of clinical expertise is crucial to appropriately recognize and manage the neuropsychiatric symptoms in a patient with dementia. Combination of non-pharmacological and careful use of pharmacological interventions is the recommended therapeutic for managing BPSD. Given the modest efficacy of current strategies, there is an urgent need to identify novel pharmacological targets and develop new non-pharmacological approaches to improve the adverse outcomes associated with BPSD.
Behavioural and psychological symptoms have a high prevalence amongst patients with dementia and can be a significant source of distress to both patients and carers. The present study explored the relationships between quality of life and behavioural and psychological symptoms in dementia (BPSD) from both patient and carer perspectives. Contextual factors surrounding the occurrence of BPSD were explored.
Forty-six patients and 116 carers completed questionnaire measures of BPSD and quality of life.
BPSD were negatively associated with both patient and carer ratings of patient quality of life. The symptoms related to lower quality of life differed between patient and carer ratings: depression and irritability were found to predict lower carer ratings of quality of life, whilst delusions and apathy indicated lower patient ratings. Carers were found to be poor at identifying antecedents and consequences of BPSD.
The presence of BPSD is associated with lower quality of life in dementia. Interventions designed to improve the quality of life for patients should focus on the BPSD specifically associated with the patient's rating of quality of life. Information regarding the role of contextual factors in behaviour management should be made available to carers.
This study examines relationships between experienced aggressive behaviour and burnout of staff caring for residents living in homes for the elderly (n = 551). Burnout was conceptualized as a three-dimensional syndrome consisting of emotional exhaustion, depersonalization and reduced personal accomplishment. From the results of the hierarchical regression analyses it appeared that physical and psychological aggression and the number of weekly working hours had a significant relationship with emotional exhaustion of staff. Psychological aggression was found to have a significant relationship with depersonalization. Neither sex nor age had a relationship with any of the burnout dimensions. Implications for research and suggestions for work and training of staff caring for the elderly are discussed.
Behavioral and Psychological Symptoms are major and frequent manifestations of Alzheimer's Disease (AD). The aim of the present study was to evaluate neuropsychiatric symptoms in the PHRC REAL.FR cohort (for Réseau sur la maladie d'Alzheimer Français) after one year of evolution. Four hundred and eighty two patients with mild and moderate AD were assessed. A majority of them had significant symptoms at inclusion (85.3 % of subjects with mild AD, 89.7% of patients with a moderate AD). Patients with mild AD had a significant increase of the Neuropsychiatric Inventory (NPI) frequency x severity scores for apathy and aberrant motor behavior. Patients with moderate AD had a significant increase of NPI disinhibition, aberrant motor behavior and sleep disorders scores. The variation of NPI total score at one year correlated positively with change in Zarit's caregiver burden score, independently of global cognitive evolution. After one year, a group of 54 patients were institutionalized in nursing home or long term care unit. When compared to non institutionalized patients, the institutionalized group was characterized at base line by a lower MMSE score, a higher Zarit caregiver burden score, and a higher NPI agitation and disinhibition scores.
Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40-80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.
This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.
Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.
Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.
Management of behavioral symptoms of Alzheimer's disease and other progressive degenerative dementias poses continuous challenge to both family and professional caregivers. Behavioral symptoms are complex in nature and require that caregivers understand their presumed causes and intervene appropriately using validated caregiving techniques. Unfortunately, confusing terminology hampers improvement in management techniques. This review attempts to clarify terminology and specifically the behavioral symptoms "agitation" and "resistiveness to care" that require different management techniques. Several conceptual frameworks for behavioral symptoms of dementia are presented. These frameworks include behavioral models, a psychiatric model, and a comprehensive model that combines both behavioral and psychiatric strategies. Using precise terminology consistently and providing care based on a conceptual framework will facilitate the education of caregivers in appropriate techniques for management of behavioral symptoms of dementias.
Objective:
The authors report findings from a study of 5,092 community residents who constituted 90% of the elderly resident population of Cache County, Utah.
Method:
The 5,092 participants, who were 65 years old or older, were screened for dementia. Based on the results of this screen, 1,002 participants (329 with dementia and 673 without dementia) underwent comprehensive neuropsychiatric examinations and were rated on the Neuropsychiatric Inventory, a widely used method for ascertainment and classification of dementia-associated mental and behavioral disturbances.
Results:
Of the 329 participants with dementia, 214 (65%) had Alzheimer's disease, 62 (19%) had vascular dementia, and 53 (16%) had another DSM-IV dementia diagnosis; 201 (61%) had exhibited one or more mental or behavioral disturbances in the past month. Apathy (27%), depression (24%), and agitation/aggression (24%) were the most common in participants with dementia. These disturbances were almost four times more common in participants with dementia than in those without. Only modest differences were observed in the prevalence of mental or behavioral disturbances in different types of dementia or at different stages of illness: participants with Alzheimer's disease were more likely to have delusions and less likely to have depression. Agitation/aggression and aberrant motor behavior were more common in participants with advanced dementia.
Conclusions:
On the basis of their findings in this large community population of elderly people, the authors conclude that a wide range of dementia-associated mental and behavioral disturbances afflict the majority of individuals with dementia. Because of their frequency and their adverse effects on patients and their caregivers, these disturbances should be ascertained and treated in all cases of dementia.
Behavioral and psychological symptoms of dementia (BPSD) impact well-being for persons with dementia (PWD) and caregivers. Identifying the most problematic symptoms is vital in targeting interventions and allocating resources. The current study highlights inconsistencies in the "most problematic" symptoms when identified via prevalence, intensity, caregiver distress, or associations with caregiver depressive symptoms.
Caregivers (N = 177) were mostly female (77%) and spouses of PWD (73%), with average age of 66.7 years (SD = 16.1). They reported BPSD frequency and distress via the Revised Memory and Behavior Problem Checklist (RMBPC) and Neuropsychiatric Inventory (NPI), and their own depressive symptoms via the Geriatric Depression Scale (GDS). BPSD were ranked by prevalence, average frequency, and average distress ratings. RMBPC subscales were correlated with GDS, and discriminant function analyses used NPI symptoms to discriminate between caregivers' normal (range 0-9) or elevated (10+) GDS.
Most prevalent NPI symptoms were Apathy, Depression, and Agitation. Most intense (frequency × severity) were Appetite, Motor behaviors, and Apathy, and most distressing were Delusions, Agitation, and Irritability. For RMBPC, Memory was most frequent but least distressing, whereas Disruptive was least frequent but most distressing. RMBPC frequency and distress subscales were significantly associated with caregiver GDS. Discriminant function analyses were statistically significant (Lambda = 0.822; χ(2) (12) = 30.62; p = 0.002. Canonical correlation = 0.442); NPI symptoms correctly classified caregivers GDS status 72% of the time.
Symptoms revealed as "most problematic" varied by measurement criterion. Common or frequent symptoms are not necessarily the most distressing or most predictive of caregiver depression. Copyright © 2013 John Wiley & Sons, Ltd.
The aim of this research present the psychometrics properties of a global measure of burnout. This study concern a framework of Pines and Aronson (1988). The aim of the study consist in testing the structure validity, a confirmatory factorial structure and a reliability of the BMS (“Burnout Measure Short version”). The results show that a confirmatory factor analysis and the temporal stability led to a BMS in French version (participants: N1=111; for reliability: N2=32). The unidimensional dimension of BMS was correlated with other measures (positively with “emotional exhaustion” [r=0.53; p
Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) are important manifestations of Alzheimer's Disease (AD) and other forms of dementia, because they are associated with care-giver distress, increase the likelihood of institutionalization, and may be associated with more rapid cognitive declineIn this study (REAL.FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Neuropsychiatric Inventory NPI to examine BPSD. 255 AD patients with a Mini-Mental State Examination (MMSE) score between 11 and 20 and 244 AD patients with a MMSE between 21 and 30 were examined. Factor analysis was cerried out leading to three different syndromes according to the level of cognitive impairment.BPSD were detected in 92.5 % of the patients with a MMSE between 11 and 20, and in 84 % of the patients with a MMSE between 21 and 30. Apathy was the most common abnormality, followed by anxiety and dysphoria.These results in a French cohort of patients with AD underline the importance of the evaluation and finallv of the treatment of BPSD.
RÉSUMÉ
Les approches de soins centrées sur la personne sont de plus en plus recommandées en vue d’améliorer la qualité des soins de longue durée. Au Québec (Canada), l’approche relationnelle de soins a été implantée dans plusieurs établissements. Cette étude porte sur le point de vue des soignants formés sur l’utilité de cette approche ainsi que sur leur capacité à la transférer en pratique. Des questionnaires comportant des questions ouvertes ont été administrés un mois après la formation (n=392). Les réponses ont été catégorisées selon une approche qualitative. Les répondants perçoivent que certaines dimensions de l’approche sont hors de leur portée ou s’opposent à leurs croyances. Ils rapportent des pressions liées aux contraintes temporelles, à leurs collègues ainsi qu’aux familles des résidents. Ces résultats indiquent que la formation ne suffit pas à transformer les pratiques. Il faut également agir sur les croyances des individus ainsi que sur les situations de travail
Cluster analysis based on Alzheimer's disease (AD) neuropsychiatric profile demonstrated validity on caregiver burden, nursing-home placement and survival. The aims of our study were to explore the validity of this approach on caregiver burden, lack of insight and cognitive impairment and to examine the impact of neuropsychiatric profiles on these variables.
A data-driven approach (two-step cluster analysis) identified groups of patients based on similarities of their neuropsychiatric symptom profile, as assessed by the Neuropsychiatric Inventory (NPI). ANOVAs and chi(2) tests were used to compare groups with regard to continuous and categorical variables. Linear regressions tested the relationships between NPI and clinical variables.
Psychotic/behavioral, depressive and minimally symptomatic clusters differed for caregiver burden and lack of insight. Patients in the minimally symptomatic cluster showed better insight than those in the depressive cluster. Caregivers of the psychotic/behavioral cluster experienced the highest burden. We found positive relationships between NPI and lack of insight in the depressive and minimally symptomatic clusters and between NPI and caregiver burden in all three clusters. Caregiver burden was influenced by the type of symptoms.
The cluster analysis was valid for lack of insight and caregiver burden. Symptoms predominant on caregiver burden could become targets for therapy.
We investigated the range of behavioral abnormalities in patients with Alzheimer's disease (AD) compared with normal age-matched control subjects. The range of behavioral disturbances manifested and the relationship between specific abnormalities with the level of cognitive impairment have not been established. Fifty consecutive outpatients with mild (n = 17), moderate (n = 20), and severe (n = 13) AD and 40 age-matched normal controls were evaluated for behavioral abnormalities occurring in the month preceding the interview. The caregivers of the patients and the spouses of the control subjects were interviewed with the Neuropsychiatric Inventory (NPI). The frequency and severity of the following 10 behaviors were assessed: delusions, hallucinations, agitation, dysphoria, anxiety, euphoria, apathy, disinhibition, irritability, and aberrant motor behavior. Correlations among these 10 behaviors and their relationship with cognitive impairment were also investigated. Eighty-eight percent of AD patients had measurable behavioral changes. All 10 behaviors were significantly increased in the AD patients compared with normal subjects. The most common behavior was apathy, which was exhibited by 72% of patients, followed by agitation (60%), anxiety (48%), irritability (42%), dysphoria and aberrant motor behavior (both 38%), disinhibition (36%), delusions (22%), and hallucinations (10%). Agitation, dysphoria, apathy, and aberrant motor behavior were significantly correlated with cognitive impairment.
NEUROLOGY 1996;46: 130-135
The Neuropsychiatric Inventory (NPI) was developed to assess psychopathology in dementia patients. It evaluates 12 neuropsychiatric disturbances common in dementia: delusions, hallucinations, agitation, dysphoria, anxiety, apathy, irritability, euphoria, disinhibition, aberrant motor behavior, night-time behavior disturbances, and appetite and eating abnormalities. The severity and frequency of each neuropsychiatric symptom are rated on the basis of scripted questions administered to the patient's caregiver. The NPI also assesses the amount of caregiver distress engendered by each of the neuropsychiatric disorders. A total NPI score and a total caregiver distress score are calculated, in addition to the scores for the individual symptom domains. Content validity, concurrent validity, inter-rater reliability, and test-retest reliability of the NPI are established. Different neurologic disorders have characteristic neuropsychiatric manifestations and distinctive NPI profiles. The NPI is sensitive to treatment effects and has demonstrated the amelioration of behavioral symptoms in Alzheimer's disease by cholinergic agents. The NPI is a useful instrument for characterizing the psychopathology of dementia syndromes, investigating the neurobiology of brain disorders with neuropsychiatric manifestations, distinguishing among different dementia syndromes, and assessing the efficacy of treatment.
To compare 2 samples of patients with Alzheimer disease (AD), from Italy and the United States, in order to determine transcultural differences in the manifestation of noncognitive symptoms. To analyze the concurrent validity, internal consistency reliability, between-rater reliability, and test-retest reliability of the Neuropsychiatric Inventory Scale (NPI).
The NPI was given to 50 Italian and 50 US patients with AD. To demonstrate the validity and reliability of the Italian version of the instrument, several different methods of analysis were used. The total score on the NPI and the score of single items in the different stages of the disease were compared in the 2 samples of patients.
A high level of internal consistency reliability was confirmed, the between-rater reliability was very high, and the test-retest reliability was significantly correlated. Apathy was the most frequently recorded behavior in the Italian sample. Five of 10 NPI item scores showed a significant relation with the Mini-Mental State Examination scores in both samples. The Italian patients showed an increasing and significantly higher mean NPI total score at all levels of dementia severity when compared with the US patients. The scores on some NPI subscales, such as apathy, aberrant motor behavior, disinhibition, and agitation, were significant higher in Italian patients at different levels of severity covarying with educational level.
These results indicate that NPI is a reliable instrument with which to study transcultural differences in the presentation of neuropsychiatric disturbances in patients with AD. The described similar pattern of behaviors between Italians and US patients with AD suggests a biological origin of the disorders. However, cultural influences must be taken in account when the focus of the study is on psychopathological aspects of dementia.
The authors report findings from a study of 5,092 community residents who constituted 90% of the elderly resident population of Cache County, Utah.
The 5,092 participants, who were 65 years old or older, were screened for dementia. Based on the results of this screen, 1,002 participants (329 with dementia and 673 without dementia) underwent comprehensive neuropsychiatric examinations and were rated on the Neuropsychiatric Inventory, a widely used method for ascertainment and classification of dementia-associated mental and behavioral disturbances.
Of the 329 participants with dementia, 214 (65%) had Alzheimer's disease, 62 (19%) had vascular dementia, and 53 (16%) had another DSM-IV dementia diagnosis; 201 (61%) had exhibited one or more mental or behavioral disturbances in the past month. Apathy (27%), depression (24%), and agitation/aggression (24%) were the most common in participants with dementia. These disturbances were almost four times more common in participants with dementia than in those without. Only modest differences were observed in the prevalence of mental or behavioral disturbances in different types of dementia or at different stages of illness: participants with Alzheimer's disease were more likely to have delusions and less likely to have depression. Agitation/aggression and aberrant motor behavior were more common in participants with advanced dementia.
On the basis of their findings in this large community population of elderly people, the authors conclude that a wide range of dementia-associated mental and behavioral disturbances afflict the majority of individuals with dementia. Because of their frequency and their adverse effects on patients and their caregivers, these disturbances should be ascertained and treated in all cases of dementia.
Family physicians play a key role in assessing and managing patients with Alzheimer's disease and in linking the families of these patients to supportive services within the community. As part of comprehensive management, the family physician may be responsible for coordinating assessments of patient function, cognition, comorbid medical conditions, disorders of mood and emotion, and caregiver status. Suggestions for easily administered and scored assessment tools are provided, and practical tips are given for supporting primary caregivers, thereby increasing efficiency and quality of care for patients with Alzheimer's disease.
Mild cognitive impairment (MCI) may be a precursor to dementia, at least in some cases. Dementia and MCI are associated with neuropsychiatric symptoms in clinical samples. Only 2 population-based studies exist of the prevalence of these symptoms in dementia, and none exist for MCI.
To estimate the prevalence of neuropsychiatric symptoms in dementia and MCI in a population-based study.
Cross-sectional study derived from the Cardiovascular Health Study, a longitudinal cohort study.
A total of 3608 participants were cognitively evaluated using data collected longitudinally over 10 years and additional data collected in 1999-2000 in 4 US counties. Dementia and MCI were classified using clinical criteria and adjudicated by committee review by expert neurologists and psychiatrists. A total of 824 individuals completed the Neuropsychiatric Inventory (NPI); 362 were classified as having dementia, 320 as having MCI; and 142 did not meet criteria for MCI or dementia.
Prevalence of neuropsychiatric symptoms, based on ratings on the NPI in the previous month and from the onset of cognitive symptoms.
Of the 682 individuals with dementia or MCI, 43% of MCI participants (n = 138) exhibited neuropsychiatric symptoms in the previous month (29% rated as clinically significant) with depression (20%), apathy (15%), and irritability (15%) being most common. Among the dementia participants, 75% (n = 270) had exhibited a neuropsychiatric symptom in the past month (62% were clinically significant); 55% (n = 199) reported 2 or more and 44% (n = 159) 3 or more disturbances in the past month. In participants with dementia, the most frequent disturbances were apathy (36%), depression (32%), and agitation/aggression (30%). Eighty percent of dementia participants (n = 233) and 50% of MCI participants (n = 139) exhibited at least 1 NPI symptom from the onset of cognitive symptoms. There were no differences in prevalence of neuropsychiatric symptoms between participants with Alzheimer-type dementia and those with other dementias, with the exception of aberrant motor behavior, which was more frequent in Alzheimer-type dementia (5.4% vs 1%; P =.02).
Neuropsychiatric symptoms occur in the majority of persons with dementia over the course of the disease. These are the first population-based estimates for neuropsychiatric symptoms in MCI, indicating a high prevalence associated with this condition as well. These symptoms have serious adverse consequences and should be inquired about and treated as necessary. Study of neuropsychiatric symptoms in the context of dementia may improve our understanding of brain-behavior relationships.
This review of the literature examines the effectiveness of continuing education programs in long-term care facilities.
A comprehensive literature search was made for evaluation studies and included computerized bibliographic databases, manual searches of journals, the bibliographies of retrieved articles, and information from key informants.
Forty-eight studies met our selection criteria. Rigorous research in this area has been limited. Because of the lack of follow-up evaluation, there is minimal evidence that knowledge gained from training programs is sustained in the long term. Most studies do not consider organizational and system factors when planning and implementing training initiatives. This may account for difficulties encountered in the sustained transfer of knowledge to practice.
There is a need for further rigorous research on the effectiveness of continuing education in long-term care, with systematic attention to the role of organizational and system factors.
To review published reports of interventions for caregivers (CGs) of persons with dementia, excluding respite care, and provide recommendations to clinicians.
Meta-analytical review. Electronic databases and key articles were searched for controlled trials, preferably randomized, published in English from 1985 to 2001 inclusive. Thirty studies were located and scored according to set criteria, and the interventions' research quality and clinical significance were judged.
Home or noninstitutional environment.
Informal CGs-persons providing unpaid care at home or in a noninstitutional setting.
The primary measures were psychological morbidity and burden. Other varied outcome measures such as CG coping skills and social support were combined with measures of psychological distress and burden to form a main outcome measure.
The quality of research increased over the 17 years. Results from 30 studies (34 interventions) indicated, at most-current follow-up, significant benefits in caregiver psychological distress (random effect size (ES) = 0.31; 95% confidence interval (CI) = 0.13-0.50), caregiver knowledge (ES = 0.51; CI = 0.05-0.98), any main caregiver outcome measure (ES = 0.32; CI = 0.15-0.48), and patient mood (ES = 0.68; CI = 0.30-1.06), but not caregiver burden (ES = 0.09; CI = -0.09-0.26). There was considerable variability in outcome, partly because of differences in methodology and intervention technique. Elements of successful interventions could be identified. Success was more likely if, in addition to CGs, patients were involved. Four of seven studies indicated delayed nursing home admission.
Some CG interventions can reduce CG psychological morbidity and help people with dementia stay at home longer. Programs that involve the patients and their families and are more intensive and modified to CGs' needs may be more successful. Future research should try to improve clinicians' abilities to prescribe interventions.
Management of behavioral symptoms of Alzheimer's disease and other progressive degenerative dementias poses continuous challenge to both family and professional caregivers. Behavioral symptoms are complex in nature and require that caregivers understand their presumed causes and intervene appropriately using validated caregiving techniques. Unfortunately, confusing terminology hampers improvement in management techniques. This review attempts to clarify terminology and specifically the behavioral symptoms "agitation" and "resistiveness to care" that require different management techniques. Several conceptual frameworks for behavioral symptoms of dementia are presented. These frameworks include behavioral models, a psychiatric model, and a comprehensive model that combines both behavioral and psychiatric strategies. Using precise terminology consistently and providing care based on a conceptual framework will facilitate the education of caregivers in appropriate techniques for management of behavioral symptoms of dementias.
To evaluate the effectiveness of a training and support intervention for nursing home staff in reducing the proportion of residents with dementia who are prescribed neuroleptics.
Cluster randomised controlled trial with blinded assessment of outcome.
12 specialist nursing homes for people with dementia in London, Newcastle, and Oxford.
Residents of the 12 nursing homes; numbers varied during the study period.
Training and support intervention delivered to nursing home staff over 10 months, focusing on alternatives to drugs for the management of agitated behaviour in dementia.
Proportion of residents in each home who were prescribed neuroleptics and mean levels of agitated and disruptive behaviour (Cohen-Mansfield agitation inventory) in each home at 12 months.
At 12 months the proportion of residents taking neuroleptics in the intervention homes (23.0%) was significantly lower than that in the control homes (42.1%): average reduction in neuroleptic use 19.1% (95% confidence interval 0.5% to 37.7%). No significant differences were found in the levels of agitated or disruptive behaviour between intervention and control homes.
Promotion of person centred care and good practice in the management of patients with dementia with behavioural symptoms provides an effective alternative to neuroleptics.
We have constructed and validated the Elderly Pain Caring Assessment 2 (EPCA-2) an 8 items behavioural scale to rate the intensity of pain in non-verbally communicating older (age 65 years) patients (NVC-OP). It was postulated that the assessed pain had two dimensions (signs outside and during caregiving). The first version of the scale was constructed on the basis of the results of a survey among 48 experienced nurses and caregivers and of a review of the literature. After testing of three intermediate versions, the psychometrics properties of the final version were studied on 340 NVC-OP. The face and content validities were good. Convergent validity: the total score was well correlated both with a pain global clinical score given by two highly experienced observers (r(s)=0.846) and with the opioid dose prescribed in a sub-group of patients (r(s)=0.698). The discriminant and divergent validities were satisfactory. After factor analysis, the internal structure of the scale was consistent with the postulated two-dimensional structure of the construct. The inter-rater reliability was very good (ICC=0.877) and is always equally good irrespective of the status (doctor, nurse and caregiver) of the raters. The internal consistency was highly satisfactory (alpha=0.79). The responsiveness evaluated in 4 ways was always very good. EPCA-2 may provided nurses, caregivers and doctors with a validated instrument for pain assessment in NVC-OP.
Patient and caregiver perspectives of quality of life in dementia
- C Hurt
- S Bhattacharyya
- A Burns
- V Camus
- R Liperoti
- A Marriott
Hurt C, Bhattacharyya S, Burns A, Camus V, Liperoti R, Marriott A,
et al. Patient and caregiver perspectives of quality of life in dementia.
Méthodologie de soin Gineste-Marescotti®, dite « Humanitude » et pacification des comportements d'agitation pathologique (CAP). Actes colloque
- Y Gineste
- R Marescotti
- J Pellissier
Gineste Y, Marescotti R, Pellissier J. Méthodologie de soin Gineste-Marescotti®, dite « Humanitude » et pacification des comportements
d'agitation pathologique (CAP). Actes colloque. Paris, juin 2008.
Maladie d'Alzheimer et maladies apparentées : prise en charge des troubles du comportement perturbateurs
- Haute Autorité De Santé
Haute autorité de santé. Maladie d'Alzheimer et maladies apparentées : prise en charge des troubles du comportement perturbateurs.
Paris : HAS, mai 2009.
Apports théoriques référencés et issus de la littérature scientifique sur diaporamas. Échanges autour d'études de cas rapportés par les stagiaires Projection de films ou séquences filmées issues du programme MobiQual (Direction générale de la santé), de la Fondation nationale en gérontologie
- Les Moyens Pédagogiques Utilisés Sont
Les moyens pédagogiques utilisés sont :
Apports théoriques référencés et issus de la littérature scientifique sur diaporamas.
Échanges autour d'études de cas rapportés par les stagiaires.
Projection de films ou séquences filmées issues du programme MobiQual (Direction générale de la santé),
de la Fondation nationale en gérontologie, de la banque de données du Centre national audiovisuel en santé
mentale, de l'Espace éthique de l'AP-HP.
Apport de la méthodologie dans l'unité spécifique Alzheimer de la résidence de l'Abbaye à Saint-Maur-des-Fossés. journées annuelles de la société francise de gériatrie et de gérontologie
- N Sicard
- I Aubois
- F Lasnon-Dussaussay
Sicard N, Aubois I, Lasnon-Dussaussay F, Champvert. Apport
de la méthodologie dans l'unité spécifique Alzheimer de la résidence de l'Abbaye à Saint-Maur-des-Fossés. journées annuelles de la
société francise de gériatrie et de gérontologie. 2010. http://framework.
agevillage.com/documents/pdfs/etude_humanitude_saint_maur.pdf.
Projection des populations âgées dépendantes : deux méthodes d'estimation
- A Lecroart
- O Froment
- C Marbot
- D Roy
Lecroart A, Froment O, Marbot C, Roy D. Projection des populations
âgées dépendantes : deux méthodes d'estimation. Paris : Dress 2013 ;
Alzheimer et maladies apparentées : prise en charge des troubles du comportement perturbateurs
- Haute Autorité De Santé
Haute autorité de santé. Maladie d'Alzheimer et maladies apparentées : prise en charge des troubles du comportement perturbateurs.
Paris : HAS, mai 2009.
Association of caregiver demographic variables with neuropsychiatric symptoms in Alzheimer disease patients for distress on the neuropsychiatric inventory (NPI)
- C Godinho
- A Camazzato
- R Kochhann
- Mlf Chaves
Godinho C, Camazzato A, Kochhann R, Chaves MLF. Association
of caregiver demographic variables with neuropsychiatric symptoms in
Alzheimer disease patients for distress on the neuropsychiatric inventory (NPI). Dement Neuropsychol 2008 ; 2 : 211-6.
Person-centered care in long-term care settings : usefulness and facility of transfer into practice
- A Viau-Guay
- M Bellemare
- I Feillou
- L Trudel
- J Desrosiers
- M J Rabitaille
Viau-Guay A, Bellemare M, Feillou I, Trudel L, Desrosiers J, Rabitaille
MJ. Person-centered care in long-term care settings : usefulness and
facility of transfer into practice. La revue canadienne du viellissement
2013 ; 31 : 57-72.