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Objectives: This study aimed to determine the prevalence and types of young onset dementia (YOD) in New South Wales (NSW), Australia, in 1891 with comparisons to 21st century estimates. Changes might inform future service planning for persons with YOD. Methods: Medical case books of two Hospitals for the Insane were examined at the State Archives and clinical and sociodemographic information extracted of persons who were under the age of 65 in April 1891, when a NSW Census occurred, and were given a dementia diagnosis or had symptoms consistent with dementia. Consensus 21st century 'probable' and 'possible' all cause dementia and major neurocognitive disorder diagnoses were determined by two psychiatrists. Prevalence estimates of moderate‐severe dementia were determined and compared with 21st century estimates and dementia types. Results: Of 161 potential dementia cases, 123 were given a consensus 'probable' dementia diagnosis, 28 a 'possible' dementia diagnosis, and ten were given a non‐dementia diagnosis, with 'all cause dementia' and 'major neurocognitive disorder' diagnoses identical. Most dementia cases were male (n = 119, 78.8%). 'Unspecified dementia' was the most frequent diagnosis (n = 47, 31.1%), followed by dementia secondary to syphilis (n = 35, 23.2%), epileptic dementia (n = 30, 19.9%), alcohol‐related dementia (n = 17, 11.3%), and mixed dementia (n = 16, 10.6%). Epileptic dementia had the youngest average age of admission (34.9 years). Other than epileptic dementia, all other dementia types were more frequent in males. Prominent clinical symptoms included neurological signs (n = 79, 52.3%), psychosis (n = 77, 51.0%), agitation (n = 75, 49.7%), and aggression (n = 45, 29.8%). Most dementia cases either died in hospital (n = 79, 52.3%) or were transferred to a long stay hospital (n = 57, 37.7%). The estimated point prevalence of YOD in persons aged 30–59 in 1891 (86 per 100,000) was higher than current Australian and global estimates in this age group due to the high rates in males (126 per 100,000), but in those aged 60–64, the prevalence in 1891 (159 per 100,000) was much lower than current estimates. Conclusions: This first examination of YOD in the nineteenth century found high rates of dementia in those under the age of 60 compared with current estimates, particularly in men aged between 30 and 59 years old, and largely due to syphilis, alcohol and epilepsy, conditions that are now treatable and thus demonstrating the potential of effective treatments for YOD. [ABSTRACT FROM AUTHOR]

Objectives: Neuropsychiatric symptoms (NPS) increase risk of developing dementia and are linked to various neurodegenerative conditions, including mild cognitive impairment (MCI due to Alzheimer's disease [AD]), cerebrovascular disease (CVD), and Parkinson's disease (PD). We explored the structural neural correlates of NPS cross‐sectionally and longitudinally across various neurodegenerative diagnoses. Methods: The study included individuals with MCI due to AD, (n = 74), CVD (n = 143), and PD (n = 137) at baseline, and at 2‐years follow‐up (MCI due to AD, n = 37, CVD n = 103, and PD n = 84). We assessed the severity of NPS using the Neuropsychiatric Inventory Questionnaire. For brain structure we included cortical thickness and subcortical volume of predefined regions of interest associated with corticolimbic and frontal‐executive circuits. Results: Cross‐sectional analysis revealed significant negative correlations between appetite with both circuits in the MCI and CVD groups, while apathy was associated with these circuits in both the MCI and PD groups. Longitudinally, changes in apathy scores in the MCI group were negatively linked to the changes of the frontal‐executive circuit. In the CVD group, changes in agitation and nighttime behavior were negatively associated with the corticolimbic and frontal‐executive circuits, respectively. In the PD group, changes in disinhibition and apathy were positively associated with the corticolimbic and frontal‐executive circuits, respectively. Conclusions: The observed correlations suggest that underlying pathological changes in the brain may contribute to alterations in neural activity associated with MBI. Notably, the difference between cross‐sectional and longitudinal results indicates the necessity of conducting longitudinal studies for reproducible findings and drawing robust inferences. Key points: What is the primary question addressed by this study? The structural neural correlates of neuropsychiatric symptoms (NPS) in multiple neurodegenerative diagnoses. What is the main finding of this study? Our study reveals the involvement of both corticolimbic and frontal‐executive circuits in three populations at risk for developing dementia, with these circuits showing significant associations with NPS. The distinct neural correlates were observed within each population, shedding light on the neurobiological mechanisms underlying NPS in these disorders and providing a better understanding of their progression toward dementia. What is the meaning of the finding? These results have significant implications for the early detection and management of NPS in patients with neurodegenerative disorders and may inform the development of more effective treatment strategies in the future. Furthermore, the difference between cross‐sectional and longitudinal results indicates the necessity of conducting longitudinal studies for reproducible findings and drawing robust inferences. [ABSTRACT FROM AUTHOR]

Objective: To compare the number and severity of neuropsychiatric symptoms (NPS) and associated caregiver distress between those with and without a noted history of psychological trauma among those referred to a specialised national dementia NPS support service. Methods: This was a 5‐year retrospective observational study of records from the Dementia Support Australia NPS support service. NPS were reported by formal or informal caregivers at service entry using the Neuropsychiatric Inventory Nursing Home version or Questionnaire version. A history of psychological trauma was recorded in the person's social or medical history and/or endorsed as a contributor to NPS by a trained dementia consultant after a comprehensive clinical review. Regression was used to examine the impact of a recorded history of psychological trauma on NPS severity and associated caregiver distress, controlling for age and sex. Results: Among 41,876 eligible referrals with dementia, 6% (n = 2529) had some reference in their records to a history of psychological trauma. Referrals with a recorded history of psychological trauma were rated with a higher rate of both NPS severity (mean = 12.0) and associated caregiver distress (mean = 16.5) at service entry than those without a recorded history of psychological trauma (means = 10.7 and 14.5, respectively). A recorded history of psychological trauma was associated with higher odds of psychotic symptoms, agitation/aggression, irritability, disinhibition, affective symptoms and night‐time behaviours. Conclusions: Traumatic stress symptoms may represent a neglected target for intervention to reduce the impact of NPS in people with dementia. Key points: Psychological trauma is a putative risk factor for dementia, and dementia onset can also trigger the re‐emergence or exacerbation of traumatic stress. However, little is known about how trauma contributes to neuropsychiatric symptoms (NPS) in dementia.People with dementia and a recorded history of psychological trauma were rated as having more frequent, more severe, and more distressing NPS than people without a recorded history of psychological trauma.Traumatic stress symptoms are modifiable and therefore may represent a neglected target for intervention to reduce the impact of NPS in people with dementia. [ABSTRACT FROM AUTHOR]

Introduction: Predicting caregiver burden in individuals with suspected dementia – is critical due to the debilitating nature of these disorders and need for caregiver support. While some examination of the factors affecting burden has been undertaken in Sub‐Saharan Africa, each country presents with its own unique challenges and obstacles. This pilot study investigates predictors of caregiver burden in family caregivers of individuals with suspected dementia living in the Democratic Republic of the Congo (DRC). Methods: Linear and multiple regression analyses were conducted to explore factors associated with caregiver burden in 30 patient‐caregiver dyads with the Zarit Burden Interview (ZBI) for caregiver burden evaluation. Cognitive impairments of patients were assessed using the Community Screening Instrument for Dementia, Alzheimer's Questionnaire (AQ), the African Neuropsychology Battery, and the Neuropsychiatric Symptoms Inventory (NPI). Results: Average caregiver burden on the ZBI was 36.1 (SD = 14.6; range = 12–58). Greater impairments in patient cognition (orientation, visuospatial, memory, executive functioning), fragility, and neuropsychiatric symptoms (delirium, agitation, depression) were predictive of caregiver burden. After controlling for AQ scores and caregiver gender, greater symptoms of depression, and worse performances on verbal memory and problem solving were associated with greater caregiver burden. Conclusion: Worsening patient fragility, cognition, functioning, and neuropsychiatric symptoms influenced caregiver burden in caregivers of individuals with suspected cognitive impairment in the DRC. These findings are consistent with the prior literature. Future studies may wish to explore supportive factors and caregiver specific characteristics that buffer against perceived burden. Key points: It is critical to predict caregiver burden in individuals with suspected dementia due to the debilitating nature of these disorders and need for caregiver support.While some examination of the factors affecting caregiver burden has been undertaken in Sub‐Saharan Africa, these findings have had little impact on clinical care or research in Democratic Republic of Congo (DRC) where dementia is considered as "witchcraft."This study has shown that the worsening of patient fragility, cognition, functioning, and neuropsychiatric symptoms influenced caregiver burden in caregivers of individuals with suspected cognitive impairment in the DRC. [ABSTRACT FROM AUTHOR]

Background: There is ample evidence in animal models that lithium increases Brain‐Derived Neurotrophic Factor (BDNF) with supporting evidence in human studies. Little is known, however, about the effects of lithium on BDNF in Alzheimer's Dementia (AD). In one study of patients with Mild Cognitive Impairment, serum BDNF increased after treatment with lithium. These patients also showed mild improvement in cognitive function. Objectives: To evaluate low‐dose lithium treatment of agitation in Alzheimer's disease (AD). Method: We measured levels of BDNF in patients treated with lithium prior to and after a 12‐week randomized placebo‐controlled trial. Results: BDNF levels did not change significantly and were not associated with improvement in overall neuropsychiatric symptoms or in cognitive function. Conclusions: More research is needed to understand the potential effects of lithium on BDNF in AD including whether its use might be dependent on the stage of cognitive decline and dementia. Key points: Lithium is known to increase Brain‐Derived Neurotrophic Factor (BDNF) levels.BDNF has neuroprotective properties.Decreased levels of BDNF have been found in the brains of people with AD.Little is known about the association between the effects of Lithium on BDNF in patients with AD. [ABSTRACT FROM AUTHOR]

Background: Alzheimer disease (AD) is more prevalent in African American (AA) and Hispanic White (HIW) compared to Non‐Hispanic White (NHW) individuals. Similarly, neuropsychiatric symptoms (NPS) vary by population in AD. This is likely the result of both sociocultural and genetic ancestral differences. However, the impact of these NPS on AD in different groups is not well understood. Methods: Self‐declared AA, HIW, and NHW individuals were ascertained as part of ongoing AD genetics studies. Participants who scored higher than 0.5 on the Clinical Dementia Rating (CDR) Scale (CDR) were included. Group similarities and differences on Neuropsychiatric Inventory Questionnaire (NPI‐Q) outcomes (NPI‐Q total score, NPI‐Q items) were evaluated using univariate ANOVAs and post hoc comparisons after controlling for sex and CDR stage. Results: Our sample consisted of 498 participants (26% AA; 30% HIW; 44% NHW). Overall, NPI‐Q total scores differed significantly between our groups, with HIW having the highest NPI‐Q total scores, and by AD stage as measured by CDR. We found no significant difference in NPI‐Q total score by sex. There were six NPI‐Q items with comparable prevalence in all groups and six items that significantly differed between the groups (Anxiety, Apathy, Depression, Disinhibition, Elation, and Irritability). Further, within the HIW group, differences were found between Puerto Rican and Cuban American Hispanics across several NPI‐Q items. Finally, Six NPI‐Q items were more prevalent in the later stages of AD including Agitation, Appetite, Hallucinations, Irritability, Motor Disturbance, and Nighttime Behavior. Conclusions: We identified differences in NPS among HIW, AA, and NHW individuals. Most striking was the high burden of NPS in HIW, particularly for mood and anxiety symptoms. We suggest that NPS differences may represent the impact of sociocultural influences on symptom presentation as well as potential genetic factors rooted in ancestral background. Given the complex relationship between AD and NPS it is crucial to discern the presence of NPS to ensure appropriate interventions. Key points: Our study sought to determine if there are differences in neuropsychiatric symptom prevalence, as measured by the Neuropsychiatric Inventory Questionnaire (NPI‐Q), among self‐declared African American (AA), Hispanic, and Non‐Hispanic White (NHW) individuals with Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI).While the prevalence of several NPI‐Q symptoms was consistent across the three groups our Hispanic participants showed a greater overall burden of neuropsychiatric symptoms—especially anxiety and mood symptoms (i.e., Anxiety, Depression, Apathy, and Irritability items). By contrast, African Americans reported significantly more behavioral problems as reflected on the Disinhibition and Elation items.The variability in the prevalence of neuropsychiatric symptoms among different populations (e.g., mood and anxiety symptoms in HIW) represents both underlying genetic factors rooted in ancestral background as well as sociocultural influences on the measurement and reporting of NPS. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the rate of occurrence of neuropsychiatric symptoms (NPS) and their relationship with age, sex and cognitive performance in subjects with Alzheimer's disease and related dementias (Alzheimer's disease and related dementias [ADRD]). Methods: This is a retrospective matched case‐control study. Data from memory clinic patients included demographic information presence of NPS, and cognitive testing of Orientation, Immediate and Delayed Memory, Visuospatial Function, Working Memory, Attention, Executive Control and Language. Participants were Individuals with subjective cognitive impairment (n = 352), mild cognitive impairment (MCI) (n = 369), vascular MCI (n = 80), Alzheimer's disease (n = 147), vascular dementia (n = 41), mixed dementia (n = 33), and healthy controls (n = 305). Logistic regression was used to investigate the relationship between the presence of NPS, age and sex. A generalised additive model was used to investigate the relationship between presence of NPS, age and cognitive impairment. Analysis of variance was used to investigate differences in cognition between younger and older groups with and without NPS. Results: We found an increased likelihood of occurrence of NPS in younger individuals and females across cohorts. Anxiety, depression, agitation, and apathy were associated with higher overall rate of NPS. We also found that individuals under 65 years of age with NPS had worse cognitive scores than their counterpart without NPS. Conclusion: The younger group with ADRD and NPS had lower cognitive scores, probably reflecting more aggressive neurodegenerative disease. Further work will be needed to elicit the degree to which imaging or mechanistic abnormalities distinguish this group. Key points: Younger individuals with Alzheimer's disease and related dementias (ADRD) were more likely to present with neuropsychiatric symptoms (NPS) than older individuals.Younger individuals with ADRD and NPS showed lower cognitive scores than individuals in the same age group without NPS, which was not observed in the older group. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of the DementiAbility Methods: The Montessori Way (DMMW) on agitation in long-term care home residents with dementia. The activities using the DMMW are hypothesized to reduce agitation in terms of its frequency and disruptiveness to greater extent than structured social activities as control.Methods: Forty-six long-term care home residents with dementia were randomly allocated to receive the DMMW (n = 23) or structured social activities as control (n = 23). Each participant received six intervention sessions of 45 minutes each within 2 weeks, at long-term care home. Agitation in terms of frequency and disruptiveness before and after the intervention were compared.Results: The results showed that the DMMW resulted in significant reduction in overall frequency and disruptiveness of agitation. The DMMW group had significant reduction in frequency and disruptiveness of verbal aggressive, physical nonaggressive, and physical aggressive behaviors after the intervention.Conclusions: The present findings support the potential of the DMMW as a safe and efficacious therapeutic intervention for addressing agitation in long-term care home residents with dementia, relevant to Hong Kong culture. [ABSTRACT FROM AUTHOR]

Background: The prevalence of neuropsychiatric symptoms (NPS) diminishes the quality of life and increases the care burden in patients with dementia. Despite the clinical importance of dementia-associated NPS, no protocols for treating NPS are already well established. Attention has turned to the effectiveness of nonpharmacological treatments for NPS since their potential safe alternative to pharmacotherapy.Objective: This study is aimed to compare the effects in older individuals with dementia living in a residential care, of two intervention programs, the gesture-verbal treatment (GVT), a treatment implemented by us on a previous method for word retrieval in individuals with aphasia, and the better-known doll therapy (DT). The GVT would act on both receptive and expressive language skills, the DT on attachment and emotional connections.Methods: We evaluated NPS by the neuropsychiatric inventory in a total of 30 patients divided into 3 groups, the GVT, the DT, and control groups, using a pre-post design. The treatment groups completed 12-week nonpharmacological interventions in addition to standard rehabilitative therapies, while the control group participated only in standard rehabilitative therapies.Results: The DT group showed significant improvements in agitation, irritability, apathy, depression, and delusions relative to controls. The GVT group showed significant improvements in apathy and depression with respect to controls. The DT intervention ameliorated symptoms of agitation compared to the GVT intervention whereas the GVT intervention improved apathy compared to the DT intervention.Conclusion: Improved understanding of the potential therapeutic benefits of different treatments for neuropsychiatric symptoms is crucial for establishing nonpharmacological interventions in dementia. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of the study are (1) to test our primary hypothesis that carers using more dysfunctional coping strategies predict lower quality of life in care home residents living with dementia, and this is moderated by levels of resident agitation, and (2) to explore relationships between carer dysfunctional coping strategy use, agitation, quality of life, and resident survival. Methods: In the largest prospective cohort to date, we interviewed carers from 97 care home units (baseline, 4, 8, 12, 16 months) about quality of life (DEMQOL‐Proxy) and agitation (Cohen‐Mansfield Agitation Inventory) of 1483 residents living with dementia. At baseline, we interviewed 1566 carers about coping strategies (Brief COPE), averaging scores across care home units. Results: Carer dysfunctional coping strategies did not predict resident quality of life over 16 months (0.03, 95% CI −0.40 to 0.46). Lower resident quality of life was longitudinally associated with worse Cohen‐Mansfield Agitation Inventory score (−0.25, 95% CI −0.26 to −0.23). Survival was not associated with carer dysfunctional coping, resident quality of life, or agitation scores. Conclusions: Carer dysfunctional coping did not predict resident quality of life. Levels of resident agitation were consistently high and related to lower quality of life, over 16 months. Lack of association between carer dysfunctional coping and resident quality of life may reflect the influence of the care home or an insensitivity of aggregated coping strategy scores. The lack of relationship with survival indicates that agitation is not explained mainly by illness. Scalable interventions to reduce agitation in care home residents living with dementia are urgently needed. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to evaluate the long-term safety and tolerability of flexible-dose brexpiprazole adjunct to antidepressant treatment (ADT) in elderly patients with major depressive disorder (MDD).Methods: Elderly patients (≥65 years) with MDD and inadequate response to ≥1 ADT during the current episode were recruited to a 26-week, interventional, open-label study (NCT02400346) at outpatient centers in the USA and Europe. All patients received brexpiprazole 1 to 3 mg/day adjunct to their current ADT. Safety outcomes included adverse events (AEs), movement disorder scales, and standard safety assessments (vital signs, laboratory safety parameters, physical examination, electrocardiograms). Exploratory efficacy outcomes included the Montgomery-Åsberg Depression Rating Scale (MADRS), Clinical Global Impressions-Severity of Illness (CGI-S), and Social Adaptation Self-Evaluation Scale (SASS).Results: Of the 132 treated patients, 88 (66.7%) completed the study and 44 (33.3%) withdrew, including 24 who withdrew because of AEs (18.2%). Overall, 102 patients (77.3%) experienced ≥1 treatment-emergent AE (TEAE), which were mostly mild or moderate in severity. Treatment-emergent AEs with the highest incidence were fatigue (15.2%) and restlessness (12.9%). The most common TEAE leading to withdrawal was fatigue (3.0%). No consistent clinically relevant findings were seen with regard to movement disorder scales or standard safety assessments. Mean (standard error) efficacy score changes from baseline to week 26 were: MADRS total, -14.5 (0.9); CGI-S, -1.8 (0.1); and SASS, 3.2 (0.5).Conclusions: Long-term (26-week) treatment with adjunctive brexpiprazole was generally well tolerated in elderly patients with MDD and inadequate response to prior ADT. Improvements were observed in depressive symptoms and social functioning. [ABSTRACT FROM AUTHOR]

Objective: Neuropsychiatric symptoms such as agitation and delusions occur frequently in Lewy body dementia and Alzheimer's disease and represent significant burden and unmet treatment need. The underlying aetiology remains poorly understood. Methods: We used a multidimensional linear model to look for associations between measurements of agitation, delusions, amyloid, tau and α‐synuclein pathology, and synaptic proteins (ZnT3, PSD95, synaptophysin, and β‐III‐tubulin) across multiple brain regions in post‐mortem tissue from a cohort of 130 Lewy body dementia and Alzheimer's disease patients and non‐demented controls. Results: We found both agitations and delusions to be significantly associated with increased tau pathology and decreased levels of ZnT3. ZnT3 packages Zn2+ into synaptic vesicles to be released as a long‐term modulator of synaptic activity. Conclusions: Our finding adds to the evidence that zinc modulating compounds are of interest for treatment or symptomatic relief in these dementias. [ABSTRACT FROM AUTHOR]

Objective: As not speaking English as a first language may lead to increased difficulties in communication with staff and other residents, we (1) tested our primary hypotheses that care home residents with dementia speaking English as a second language experience more agitation and overall neuropsychiatric symptoms, and (2) explored qualitatively how staff consider that residents' language, ethnicity, and culture might impact on how they manage agitation.Methods: We interviewed staff, residents with dementia, and their family carers from 86 care homes (2014-2015) about resident's neuropsychiatric symptoms, agitation, life quality, and dementia severity. We qualitatively interviewed 25 staff.Results: Seventy-one out of 1420 (5%) of care home residents with dementia interviewed spoke English as a second language. After controlling for dementia severity, age, and sex, and accounting for care home and staff proxy clustering, speaking English as a second language compared with as a first language was associated with significantly higher Cohen-Mansfield Agitation Inventory (adjusted difference in means 8.3, 95% confidence interval 4.1 to 12.5) and Neuropsychiatric inventory scores (4.1, 0.65 to 7.5). Staff narratives described how linguistic and culturally isolating being in a care home where no residents or staff share your culture or language could be for people with dementia, and how this sometimes caused or worsened agitation.Conclusions: Considering a person with dementia's need to be understood when selecting a care home and developing technology resources to enable dementia-friendly translation services could be important strategies for reducing distress of people with dementia from minority ethnic groups who live in care homes. [ABSTRACT FROM AUTHOR]

Objectives: The Cohen-Mansfield Agitation Inventory (CMAI; (Cohen-Mansfield and Kerin, 1986)) is a well-known tool for assessing agitated behaviours in people with dementia who reside in long-term care. No studies have evaluated the psychometric qualities and factor structure of the CMAI in acute general hospitals, a setting where people with demand may become agitated.Method: Longitudinal study investigating pain, agitation and behavioural problems in 230 people with dementia admitted to acute general hospitals in 2011-2012. Cohen-Mansfield Agitation Inventory was completed as part of a battery of assessments including PAINAD to measure pain.Results: A nine-item two-factor model of aggressive and nonaggressive behaviours proved to be the best-fitting measurement model in this sample, (χ2  = 96.3, df = 26, p<0.001; BIC [Bayesian Information Criterion] = 4593.06, CFI [Comparative Fit Index] = 0.884, TLI [Tucker Lewis Index] = 0.839, RMSEA [Root Mean Square Error of the Approximation] = 0.108). Although similar to the original factor structure, the new model resulted in the elimination of item 13 (screaming). Validity was confirmed with the shortened CMAI showing similar associations with pain as the original version of the CMAI, in particular the link between aggressive behaviours and pain.Conclusion: The factor structure of the CMAI was broadly consistent with the original solution although a large number of items were removed. Scales reflecting physical and verbal aggression were combined to form an Aggressive factor, and physical and verbal nonaggressive behaviours were combined to form the Nonaggressive factor. A shorter, more concise version of the CMAI was developed for use in acute general hospital settings. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Agitation and delirium frequently occur in cognitively impaired older people. We conducted a systematic review with narrative synthesis of the literature aiming to assess effectiveness of complementary and alternative medicine (CAM) modalities to address these conditions.Methods: Following preliminary search, we included 40 original researches on CAM treatment of delirium and agitation in older persons. Then, the quality of these studies was assessed using the Downs and Black Checklist and Quality Assessment Tool for Studies with Diverse Designs, and the effect sizes were calculated. We subsequently conducted a narrative synthesis of the main findings, including theory development, preliminary synthesis, exploration of relationships within and between studies, and assessment of synthesis robustness.Results: Forty articles that met the inclusion criteria were analyzed. Sixteen of these were randomized controlled trials. One article specifically addressed CAM treatment of delirium in patients without dementia, and the remaining 39 articles described treatments of agitated older persons with dementia. Thirty-five of the 40 included studies suggested that the investigated CAM therapies may ameliorate the severity of agitation and delirium. The physiological surrogates of agitation assessed in these studies included cortisol level, chromogranin A level, and heart rate variability. Very few of the studies systematically assessed safety issues, although no major adverse effects were reported.Conclusion: Overall, the systematic review of the literature suggests that several CAM modalities are potentially beneficial in the treatment of agitation and delirium among older persons. We suggest that promising CAM modalities should be further explored through large-scale randomized controlled trials in different clinical settings. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: The prevalence of neuropsychiatric symptoms in cognitively impaired nursing home residents is known to be very high, with depression and agitation being the most common symptoms. The possible effects of a 12-week intervention with animal-assisted activities (AAA) in nursing homes were studied. The primary outcomes related to depression, agitation and quality of life (QoL).Method: A prospective, cluster randomized multicentre trial with a follow-up measurement 3 months after end of intervention was used. Inclusion criteria were men and women aged 65 years or older, with a diagnosis of dementia or having a cognitive deficit. Ten nursing homes were randomized to either AAA with a dog or a control group with treatment as usual. In total, 58 participants were recruited: 28 in the intervention group and 30 in the control group. The intervention consisted of a 30-min session with AAA twice weekly for 12 weeks in groups of three to six participants, led by a qualified dog handler. Norwegian versions of the Cornell Scale for Depression, the Brief Agitation Rating Scale and the Quality of Life in Late-stage Dementia scale were used.Results: A significant effect on depression and QoL was found for participants with severe dementia at follow-up. For QoL, a significant effect of AAA was also found immediately after the intervention. No effects on agitation were found.Conclusions: Animal-assisted activities may have a positive effect on symptoms of depression and QoL in older people with dementia, especially those in a late stage. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: The measurement of neuropsychiatric symptoms (NPS) in dementia is often based on caregiver report. Challenges associated with providing care may bias the caregiver's recognition and reporting of symptoms. Given potential problems associated with caregiver report, clinicians may improve measurement by drawing from a wider array of available data and by applying clinical judgment.Objective: The objective of this study is to evaluate potential disagreements between caregiver report and clinician impression when rating psychopathological manifestations from the same patient with dementia.Methods: Three hundred twelve participants (156 patients with Alzheimer's disease [AD] and 156 caregivers) were studied using the Neuropsychiatric Inventory-Clinician Rating Scale. We considered disagreement to be present when caregiver ratings were significantly higher or lower (p < 0.05) than NPS ratings by clinicians of the same patient. To evaluate whether disagreements were related to dementia severity, we repeated comparisons across levels defined by the clinical dementia rating.Results: The most common disagreements involved ratings of agitation, depression, anxiety, apathy, irritability, and aberrant motor behavior especially in patients with mild dementia. There were fewer discrepancies in moderate or severe dementia. The most consistent disagreements involved global ratings of depression where caregiver scores ranged from +22.5 higher to -4.5 lower than clinician rating.Conclusions: Caregivers may have incomplete perception of patient NPS mainly in mild dementia. NPS ratings might be confounded by cultural beliefs, sometimes leading caregiver to interpret symptoms as part of "normal" aging. [ABSTRACT FROM AUTHOR]

Objective To characterize clusters of neuropsychiatric symptoms targeted for tracking the disease course in people with dementia, in relation to stage. Methods Baseline symptoms from 2922 subjects from two datasets (one clinic based, one online) were aggregated. Common neuropsychiatric symptoms identified by patients/carers as targets of treatment using a dementia SymptomGuide™ were selected. The Global Deterioration Scale was used for clinic staging, and an artificial neural network algorithm, for staging online subjects. Symptom clusters were detected using multiple correspondence analysis and connectivity graph analysis based on relative risk (RR). In a connectivity graph, each pair of nodes (representing symptoms) is connected if their co-occurrence is statistically significant; direction is indicated as positive if RR > 1 and negative otherwise. Results Neuropsychiatric symptoms were targeted for treatment in 1072 patients (37%). Agitation (37%) and sleep disturbances (28%) were most common symptoms. One cluster (in people with cognitive impairment, no dementia (CIND) or mild dementia) showed significant co-occurrence of anxiety and restlessness; decreased initiative was chiefly seen in isolation. A second cluster (in moderate/severe dementia) was defined by significant co-occurrence of delusions and hallucinations with sleep disturbances; in these subjects, decreased initiative was related to aggression. Conclusions Two analytical methods identified neuropsychiatric symptom clusters targeted to track the disease course. In CIND/mild dementia, a profile of decreased initiative distinct from depression suggests possible executive dysfunction. In moderate/severe dementia, targets more reflected psychotic symptoms. Visual data displays allow the relationships between multiple symptoms to be considered simultaneously, which commonly is how they present in patients. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Agitation and aggression are among the most frequent and disruptive behavioral complications of dementia that contribute to increased cost of care, hospitalization, caregiver burden, and risk of premature institutionalization. This current study examined the safety and efficacy of electroconvulsive therapy (ECT) as a treatment for behavioral disturbances in dementia. We hypothesized that ECT would result in reduced agitated and aggressive behaviors between baseline and discharge. Methods Twenty-three participants admitted to McLean Hospital (Belmont, MA, USA) and Pine Rest Christian Mental Health Services (Grand Rapids, MI, USA), with a diagnosis of dementia who were referred for ECT to treat agitation and/or aggression, were enrolled in the study. We administered the Cohen-Mansfield Agitation Inventory-Short Form, Neuropsychiatric Inventory-Nursing Home Version, Cornell Scale for Depression in Dementia, and the Clinical Global Impression Scale at baseline, during, and after the ECT course. Results Regression analyses revealed a significant decrease from baseline to discharge on the Cohen-Mansfield Agitation Inventory ( F(4,8) = 13.3; p = 0.006) and Neuropsychiatric Inventory ( F(4,31) = 14.6; p < 0.001). There was no statistically significant change in scores on the Cornell Scale for Depression in Dementia. The Clinical Global Impression scores on average changed from a rating of 'markedly agitated/aggressive' at baseline to 'borderline agitated/aggressive' at discharge. Treatment with ECT was well tolerated by most participants; discontinuation of ECT occurred for two participants because of recurrence of agitation and for three participants because of adverse events. Conclusions Electroconvulsive therapy may be a safe treatment option to reduce symptoms of agitation and aggression in patients with dementia whose behaviors are refractory to medication management. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective A wide range of behavioural and psychological symptoms (BPSD) are common in dementia, and it has been suggested that groups of correlated symptoms should be studied together. Here, we describe the groups of BPSD that have been identified in the literature and how they have been used to study associations, burden, treatment and underlying biology. Methods The literature database PubMed was searched for articles that identified clusters or factors of BPSD or used previously defined symptom groups. Results Sixty-two studies were included. Generally, the following symptom groups were suggested: affective symptoms, including depression and anxiety; psychosis, including delusions and hallucinations; hyperactivity, including irritability and aggression; and euphoria. Symptoms that did not show consistent results include apathy, eating disturbances, night-time behaviour disturbances, disinhibition and aberrant motor behaviour. Symptom groups differed in their associations, treatment and biology. Conclusions Studies investigating symptom groups show relatively consistent results. Studying symptom groups allows similar symptoms to be studied together, which might strengthen results and may point to differences in their aetiology and treatment. However, a large amount of the individual variability of the symptoms could not be explained by the factors, and authors should carefully address their research question and hypotheses to decide if symptoms should be studied in groups or individually. Clinicians need to consider each symptom in its own right and also to be aware of the interrelations between them when assessing patients and developing strategies for treatment. © 2013 The Authors. International Journal of Geriatric Psychiatry by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Individuals suffering from Alzheimer's disease (AD) often have impaired awareness or a lack of insight into their cognitive deficits and functional abilities, especially in the later stages of the disease. Previous research has documented a relationship between depression and insight in AD, such that greater awareness of one's disease has been associated with a higher degree of depression. However, little is known about the relationship between insight, cognitive decline, and other psychiatric or behavioral problems associated with AD. Methods This study included 107 outpatients who met criteria for probable AD. Instruments included the Neurobehavioral Rating Scale, the Apathy Evaluation Scale, and the mini mental state exam. A series of hierarchical regression analyses were conducted to determine the relationship between insight and depressed mood, anxiety, psychosis, apathy, agitation, and behavioral retardation in AD patients after controlling for cognitive skills. Results Insight was found to significantly predict depressed mood, anxiety, and apathy even after controlling for global cognition. Greater insight was found to be associated with depressed mood and anxiety. However, impaired insight was associated with higher levels of apathy. Conclusion Insight may be differentially related to mood symptoms and apathy within AD, such that patients with intact insight are more depressed, whereas patients with impaired insight are more apathetic. This suggests that assessment of insight in AD may complement the clinical evaluation of depression and apathy in AD and help guide the most appropriate interventions. Published 2013. This article is a U.S. Government work and is in the public domain in the USA. [ABSTRACT FROM AUTHOR]

Objective This study aimed to compare the effects of music therapy with general recreational day activities in reducing agitation in people with dementia, residing in nursing home facilities. Methods In a randomised controlled design, residents with dementia ( n = 94) were allocated to either music therapy or recreational activities. Both music therapy and general activities were offered twice weekly for 4 months. Changes in agitation were measured with a modified Cohen-Mansfield Agitation Inventory (CMAI) at four intervals on each intervention day. A mixed model analysis was used to evaluate the effectiveness of music therapy, compared with general activities, on CMAI scores at 4 h after the intervention, controlled for CMAI scores at 1 h before the session and session number. Results Data were analysed for 77 residents (43 randomised to music therapy and 34 to general activities). In both groups, the intervention resulted in a decrease in agitated behaviours from 1 h before to 4 h after each session. This decrease was somewhat greater in the music therapy group than in the general activities group, but this difference was statistically not significant ( F = 2.885, p = 0.090) and disappeared completely after adjustment for Global Deterioration Scale stage ( F = 1.500; p = 0.222). Conclusions Both music therapy and recreational activities lead to a short-term decrease in agitation, but there was no additional beneficial effect of music therapy over general activities. More research is required to provide insight in the effects of music therapy in reducing agitation in demented older people. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Psychological symptoms are common in Parkinson's disease (PD). Psychological symptoms do not respond to psychotropic medications as well in patients with PD as in patients with psychiatric illnesses who do not have PD. Evidence that PD patients can be classified into distinct psychological symptom subgroups is conflicting. This study sought to examine potential psychological heterogeneity in PD with a broader range of instruments than has been used in previous studies. Methods A comprehensive battery of psychological measures assessing dysphoria, apathy, anhedonia, anxiety, and negative affect was administered to 95 PD patients without global cognitive impairment. Latent class analysis was used to identify subgroups of patients based on continuous variables derived from the psychological battery. Multinomial regression was used to examine predictors of classification. Results The latent class analysis identified three subgroups with incremental levels of psychopathology across most symptom domains. One exception was a greater level of affective flattening in the 'psychologically healthy' group compared with the 'moderate symptoms' group. Greater motor dysfunction and less education were associated with greater severity of psychological symptoms. Conclusions These results support high psychological co-morbidity in PD, which complicates the treatment of individual symptoms. In addition, emotional blunting and anhedonia may be less indicative of widespread psychological distress than anxiety, dysphoria, and cognitive aspects of apathy. Clinicians should be aware that PD patients with greater motor dysfunction and less education are at greater risk not only for depression but also for a variety of other psychological symptoms that may not be routinely assessed. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Neuropsychiatric symptoms, including agitation and aggression (A/A), are highly prevalent in Alzheimer's disease (AD) and are associated with increased disability, functional impairment, caregiver distress, and institutionalization. Previous psychometric work suggests that individual items of agitation, irritability, disinhibition, and aberrant motor behavior from the Neuropsychiatric Inventory (NPI) may be a valid measure of A/A in AD. We provide additional confirmation of this subscale, as well as preliminary validation of it as a measure of A/A (the NPI-4-A/A). Methods The sample included 641 individuals identified from the South Carolina Alzheimer's Disease Registry and assessed to be at a nursing home level of care. Demographic and medical data were extracted from the Registry, and phone interviews were conducted with caregivers to collect additional information not included in the Registry. The primary statistical analysis was confirmatory factor analysis of the NPI-12 factor structure. Results The standardized root mean residual and root mean square error of approximation (90% CI) values of 0.060 and 0.043 (0.030, 0.057), respectively suggest adequate model fit of the data, whereas the Tucker-Lewis index estimate of 0.779 is below the criteria for adequate model fit. All but two normalized residuals ( NR) suggested adequate model fit of the data (| NR| < 2.58). NPI-4-A/A scores were higher in patients residing in nursing homes and were correlated with caregiver burden. Conclusions The NPI-4-A/A is proposed as a measure of A/A in AD. The utility and validity of this measure should be explored further. Improved measurement and focus on subgroups of neuropsychiatric symptoms should be integrated into interventions for AD. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To compare physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) regarding their approach to dementia-associated behavior problems in nursing home residents. Methods A web-based questionnaire solicited information about symptoms, assessment methods, suspected etiologies, and interventions with respect to the last resident treated for dementia-associated behavior problems. Results Responses were obtained from 108 MDs, 38 PhDs, and 100 NPs. All groups relied similarly on information from the nursing staff, speaking with nursing assistants, and care team meetings in assessment; NPs were more likely to consult with family members. A standard assessment instrument was used most frequently by PhDs (50%), but this generally assessed cognitive status rather than problem behaviors. PhDs most frequently noted depression in residents. Groups were similar in attributing the behavioral symptoms to dementia and to underlying medical conditions, but PhDs were more likely to indicate depression, loneliness/boredom, staff-resident communication, and insufficient activities as etiologies. Use of pharmacological and nonpharmacological interventions of MDs and NPs were similar. PhDs reported least satisfaction with treatment. Conclusion Awareness of similarities and differences in the approaches of different health professionals can facilitate interdisciplinary interaction in providing care for dementia-associated behavior problems in nursing home residents. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Advancing age is associated with high prevalence of both dementia and pain. Dementia is frequently accompanied by distressing behavioral and psychological symptoms, including agitation and aggression, particularly in nursing home patients. The etiology of agitation is multifactorial. It has been suggested that un-diagnosed and untreated pain may contribute to agitation in people with dementia. If this is correct, individual pain treatment could be of benefit in ameliorating agitation and other behavioral changes in people with dementia. Objective The objective of this paper is to conduct a systematic review of studies of whether pain medication can improve agitation in people with dementia. Methods A systematic search of the PubMed and Cochrane databases for the period 1992-2010 was performed, using dementia, agitation, aggression, depression, behavioral disturbances, behavioral and psychological symptoms (BPSD), pain, pain assessment, pain treatment, pain management, and analgesics as search terms. Inclusion criteria were: prospective studies including patients with dementia, interventions focusing on pain reduction, inclusion of a control condition, and outcome measures including agitation or other related behavioral disturbances. Results Only three controlled trials were identified; all were cross-over trials, and two included small sample sizes (<50). Findings were inconsistent, and although some correlations were reported, these did not support the hypothesis that pain management reduced agitation. Conclusion There is a profound dearth of rigorous studies of the effect of pain treatment in patients with dementia and agitation. The available studies do not support the hypothesis that pain management reduces agitation in nursing-home patients with dementia. Randomized, controlled parallel-group studies are needed. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: This study explored the effectiveness of group music intervention against agitated behavior in elderly persons with dementia. Methods: This was an experimental study using repeated measurements. Subjects were elderly persons who suffered from dementia and resided in nursing facilities. In total, 104 participants were recruited by permuted block randomization and of the 100 subjects who completed this study, 49 were in the experimental group and 51 were in the control group. The experimental group received a total of twelve 30-min group music intervention sessions, conducted twice a week for six consecutive weeks, while the control group participated in normal daily activities. In order to measure the effectiveness of the therapeutic sessions, assessments were conducted before the intervention, at the 6th and 12th group sessions, and at 1 month after cessation of the intervention. Longitudinal effects were analyzed by means of generalized estimating equations (GEEs). Results: After the group music therapy intervention, the experimental group showed better performance at the 6th and 12th sessions, and at 1 month after cessation of the intervention based on reductions in agitated behavior in general, physically non-aggressive behavior, verbally non-aggressive behavior, and physically aggressive behavior, while a reduction in verbally aggressive behavior was shown only at the 6th session. Conclusions: Group music intervention alleviated agitated behavior in elderly persons with dementia. We suggest that nursing facilities for demented elderly persons incorporate group music intervention in routine activities in order to enhance emotional relaxation, create inter-personal interactions, and reduce future agitated behaviors. [ABSTRACT FROM AUTHOR]

Objective: Circadian rhythm disturbances, like sundowning, are seen in dementia. Because the circadian rhythm is regulated by the biological clock, melatonin might be effective in the treatment of these disturbances. We systematically studied the effect of melatonin treatment in patients with dementia. In addition, we elaborate on the possible effects one might expect of melatonin treatment in patients with delirium, since dementia and delirium are strongly related. Moreover, some evidence exists that sundowning in patients with dementia and the alterations in the sleep/wake cycle, seen in patients with delirium both originate from circadian rhythm disturbances. Design: A systematic search of the literature, published between 1985 and April 2009, was performed using PubMed and other databases. All papers on melatonin treatment in dementia were retrieved. Effects of melatonin on circadian rhythm disturbances were scored by means of scoring sundowning/ agitated behaviour, sleep quality and daytime functioning. Results: Nine papers, including four randomised controlled trials (RCTs) (n¼243), and five case series (n¼87) were reviewed. Two of the RCTs found a significant improvement on sundowning/agitated behaviour. All five case series found an improvement. The results on sleep quality and daytime functioning were inconclusive. Conclusion: Sundowning/agitated behaviour improves with melatonin treatment in patients with dementia. There are several arguments that sundowning in patients with dementia and the alterations in the sleep/wake cycle in patients with delirium have a common background, namely a disturbance of the circadian rhythm. This suggests that melatonin treatment could also have the same positive effects in patients with delirium. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of ambient bright light therapy (BLT) on agitation among institutionalized persons with dementia. Methods High intensity, low glare ambient lighting was installed in activity and dining areas of a state psychiatric hospital unit in North Carolina and a dementia-specific residential care facility in Oregon. The study employed a cluster-unit crossover design involving four ambient lighting conditions: AM bright light, PM bright light, All Day bright light, and Standard light. Sixty-six older persons with dementia participated. Outcome measures included direct observation by research personnel and completion by staff caregivers of the 14-item, short form of the Cohen-Mansfield Agitation Inventory (CMAI). Results Analyses of observational data revealed that for participants with mild/moderate dementia, agitation was higher under AM light (p = 0.003), PM light (p < 0.001), and All Day light (p = 0.001) than Standard light. There was also a trend toward severely demented participants being more agitated during AM light than Standard light (p = 0.053). Analysis of CMAI data identified differing responses by site: the North Carolina site significantly increased agitation under AM light (p = 0.002) and PM light (p = 0.013) compared with All Day light while in Oregon, agitation was higher for All Day light compared to AM light (p = 0.030). In no comparison was agitation significantly lower under any therapeutic condition, in comparison to Standard lighting. Conclusions Ambient bright light is not effective in reducing agitation in dementia and may exacerbate this behavioral symptom. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Understanding the underlying mechanisms and risk factors leading to agitation is crucial to reduce the severity of agitation and increase quality of life. International comparative studies offer special advantages in elucidating environmental risk factors by providing a wider diversity of environmental exposures such as nursing home structures, health care systems and genetic diversity. Methods Baseline data for three different intervention studies in Austria (n = 38), England (n = 302) and Norway (n = 163) were combined posthoc. Patients were grouped according to their dementia severity using the global deterioration scale (GDS), functional assessment staging (FAST) and clinical dementia rating (CDR) scales. For the measurement of agitation, the Cohen-Mansfield Agitation Inventory (CMAI) was used. Data analysis was performed using one-way ANOVA, multivariate and linear regression analysis. Results CMAI scores were available for 503 subjects with dementia. There were significant differences between the nursing home residents in the three countries regarding age, gender and dementia severity (all p values < 0.001). In the multivariate analyses, the level of agitation differed with higher mean scores in the Austrian (mean (SD) score 51.9(21.8)) compared to UK (43.3(16.1)) and Norwegian (41.6(13.2)) nursing homes (p = 0.002). Similarly, the use of psychotropic drugs differed significantly, with a higher proportion of neuroleptics in UK (48%, p < 0.001) and Austrian (52.6%; p = 0.001) compared to Norwegian (19%) nursing homes. Conclusion We found differences in agitation and antipsychotic drug use which are likely related to structural and cultural differences in nursing homes in three European countries. These findings suggest that structural changes can improve quality of care and quality of life for nursing home residents. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Alzheimer's disease (AD) is a neurodegenerative disorder that is the most common cause of dementia in the elderly and is frequently accompanied by emotional disorder, including agitation. Although evidence of neuroendocrine immune and inflammatory functions during emotional changes has been accumulated, the pathogenic mechanisms in the development of agitation accompanied by AD remain to be elucidated. Methods To clarify the involvement of neuroendocrine and immune and inflammatory systems in agitation in AD, we examined agitation levels, circadian rhythms of behavior, cortisol, interleukin-1β (IL-1β), and natural killer cell activity (NKCA) in controls without dementia and 16 AD patients who were recognized to be easily agitated in their nursing homes. These behavioral and blood indicators were assessed according to the progress of the stage of agitation in 16 AD patients (stable, pre-agitation, and agitation stages). Results Elevations in night behavior and blood cortisol, IL-1β and an reduced blood NKCA level in the evening were observed not only in the agitation stage, but also when stable in AD patients as compared to the control. Increased IL-1βand decreased NKCA occurred in both the morning and evening in pre-agitation and agitation stages in AD. Conclusions The increased IL-1βand decreased NKCA with the progress of agitation in AD suggest that inflammation produces agitation and aggravates AD. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Depression is frequent in elderly stroke patients, and the pathophysiology may involve psychological as well as organic mechanisms. Aim To explore construct validity of the Montgomery Aasberg Depression Rating Scale using factor analysis and investigate whether symptom clusters of depression after stroke are associated with patient characteristics. Methods A sample of 163 stroke patients was assessed by the Montgomery Aasberg Depression Rating Scale. Pre-stroke assessment was accomplished by means of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Barthel ADL Index and patient's medical history. Post-stroke assessment was performed with the Mini Mental State Examination (MMSE), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), the Star Cancellation Test, the Barthel ADL Index, the modified Rankin Scale (mRS) and the National Institute of Health Stroke Scale (NIHSS). Information was collected from the patients' records. A principal components factor analysis followed by oblique rotation was performed. Results Among the patients, 56.4% scored between 7 and 19 on the Montgomery Aasberg Depression Rating Scale, and 13% had a score above 19. The factor analysis resulted in three factors, called anhedonia (lassitude, inability to feel, suicidal thoughts, loss of appetite), sadness (observed sadness, reported sadness, pessimism) and agitation (inner tension, lack of concentration, disturbed sleep). Anhedonia correlated with cognitive impairment, whereas sadness correlated with sensorimotor and cranial nerve deficits. Agitation had low internal reliability and did not correlate with any systematic patients characteristics. Conclusion We found three distinct factors. The factor anhedonia is related to cognitive impairment, sadness to neurological impairment due to the stroke and agitation to somatic factors not directly related to the stroke. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Context Despite a growing literature on effective interventions for Alzheimer's disease (AD) and agitation, the management of these conditions in long term care (LTC) often is inadequate. The goals of the present study were: (a) to evaluate existing beliefs about evidence based practices (EBP) for the management of Alzheimer's disease and agitation among LTC staff; and (b) to evaluate the contribution of demographic and attitudinal variables to LTC staff beliefs about these EBP. Method A cross sectional study of 371 LTC staff members completed an EBP questionnaire, a short demographic questionnaire, and an attitudinal questionnaire about AD and agitation. Results Paraprofessional caregivers, those of lower educational level, and ethnic minorities were more likely to be in disagreement with the EBP views examined in this study. Those in disagreement with the EBP views also reported a preference towards not working with residents with AD and agitation and a sense of helplessness associated with such work. Disagreement with EBP views was associated with both normalization and stigmatization of AD and agitation. Conclusions Paraprofessional caregivers, ethnic minorities, and people of lower educational level are most at need for educational activities about AD and neuropsychiatric symptoms. Educational efforts geared towards changing the belief system of LTC staff should target not only EBP but also information about AD and agitation as conditions that are deviant from the normal aging process, yet non-stigmatizing. It is expected that following EBP will empower staff and improve staff motivation to work with residents with AD and agitation. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective A pilot study was performed to examine the efficacy of indoor gardening on sleep, agitation and cognition of dementia patients. Method Twenty-three institutionalized dementia patients who had sleep disturbance and/or agitation participated in a 5-week study protocol of 1 week of baseline and 4 weeks of treatment. The study design was a one group repeated measures study. For the first and fifth week of the study period, sleep patterns, agitation, and cognition were evaluated using a sleep diary, Modified Cohen-Mansfield Agitation Inventory and revised Hasegawa Dementia Scale respectively. Results Significant improvement in wake after sleep onset, nap, nocturnal sleep time, and nocturnal sleep efficiency was identified. On the contrary sleep onset time, wake-up time, total sleep time did not change after indoor gardening. Agitation and cognition score was significantly improved. Conclusion Indoor gardening was found to be effective for sleep, agitation, and cognition of dementia patients. Randomized controlled studies of larger sample size are needed to confirm treatment effect. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Behavioural and psychological symptoms in dementia (BPSD) are common and distressing to both patients and carers. The use of antipsychotics to treat BPSD is associated with a high burden of side-effects and alternative strategies are required. Aromatherapy is an option that has been recommended for use in dementia. We aimed to review the evidence supporting the use of aromatherapy in BPSD. Methods We searched Medline, Cochrane and EMBASE for randomised controlled trials of aromatherapy in patients with dementia. Results Eleven prospective randomised studies of aromatherapy in BPSD were identified. The aromatherapy oils tested, method of administration and outcome measures used varied widely across the studies. Most of the studies included very small numbers of patients and were designed in such a way that made interpretation of the findings difficult. Conclusion Data supporting the efficacy of aromatherapy are scarce; available studies reported positive and negative consequences for both people with dementia and their carers. The side-effect profile of commonly used oils is virtually unexplored. Although a potentially useful treatment for BPSD, the expectations of clinicians and patients with respect to the efficacy and tolerability of conventional medicines should equally apply to aromatherapy. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Agitated behaviours among persons with dementia are distressing to both patients and their caregivers. As pharmacological interventions may be limited by their potentially adverse effects, the use of complementary therapies for treatment of agitation has become more popular and aromatherapy is the fastest growing one. Objectives This study investigates the effectiveness of lavandula angustifolia (lavender) in treating agitated behaviours of demented people in Hong Kong. Methods It was a cross-over randomized trial. Seventy Chinese older adults with dementia were recruited; half were randomly assigned to the active group (lavender inhalation) for three weeks and then switched to control group (sunflower inhalation) for another three weeks; the other half did the opposite. Clinical response was evaluated using the Chinese versions of Cohen-Mansfield Agitation Inventory (CCMAI) and Neuropsychiatric Inventory (CNPI). Results The mean CCMAI total scores decreased from 24.68 to 17.77(t = 10.79, df = 69, p < 0.001). The CNPI scores changed from 63.17 (SD = 17.81) to 58.77 (SD = 16.74) (t = 14.59, df = 69, p < 0.001) after receiving Treatment A (Lavandula Angustifolia). There were no period and sequential effects noted. Conclusion In summary, lavender is effective as an adjunctive therapy in alleviating agitated behaviours in Chinese patients with dementia. In a patient population particularly vulnerable to side effects of psychotropic medications, aromatherapy using lavender may offer an alternative option. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives Although routine activities are important to normal functioning across all phases of life, their expression in older people may be associated with cognitive and psychological vulnerability. Methods The relationship between these variables was explored in 235 elderly French participants from the PAQUID cohort study. Results Cross-sectional positive associations were found between preferences for routines, anxiety and depression levels, and cognitive complaints. General cognitive decline over a three-year time span was also associated with a greater desire for routines at the end of this period. Conclusions The progressive routinization of behaviors and activities in older people is discussed as a marker of affective and cognitive vulnerability, and its understanding has potential for improving the early detection of adaptation difficulties and overall care in this population. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Behavioural and psychological symptoms of dementia (BPSD) cannot be regarded as a single clinical syndrome, but rather as a heterogeneous group of symptoms, each of which can be considered as possible targets for therapy. Objective To compare the efficacy of risperidone and haloperidol on specific manifestations of BPSD. Methods A post-hoc analysis was conducted using data from an 18-week, randomized, double-blind, crossover head-to-head trial of risperidone vs haloperidol in treating 114 nursing-home residents with BPSD. Dependent variables were item scores of the Korean versions of the Behavioural Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD-K) and Cohen-Mansfield Agitation Inventory (CMAI-K). Results On the BEHAVE-AD-K, risperidone was significantly more effective than haloperidol in treating wandering (p = 0.0496), agitation (p = 0.0091), diurnal rhythm disturbances (p = 0.0137), anxiety regarding upcoming events (p = 0.0002), and other anxieties (p = 0.0088). On the CMAI-K, risperidone was significantly more effective in treating physical sexual advances (p = 0.0202), pacing and aimless wandering (p = 0.0123), intentional falling (p = 0.0398), hoarding things (p = 0.0499), performing repetitious mannerisms (p = 0.0048), repetitive sentence or questions (p = 0.0025), complaining (p = 0.0101), and negativism (p = 0.0027). Haloperidol was not significantly superior to risperidone on any individual item in either scale. Conclusions When comparing treatment effects on individual symptoms frequently occurring in patients with dementia, risperidone significantly improved symptoms of agitation, wandering, diurnal rhythm disturbance and anxieties, among other symptoms, compared with haloperidol. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Anxiety and depressive symptoms encountered in acute stroke influence the patients' neurological outcome and the psychosocial burden of family members. These emotional changes may be caused by the patients' brain damage per se or by psychological reactions. The aims of the present study were to assess the prevalence of anxiety and depressive symptoms in the acute stage of ischemic stroke, and to identify the factors associated with such problems. Methods Anxiety and depressive symptoms were evaluated in 178 patients with acute ischemic stroke using the Hospital Anxiety and Depression Scale (HADS) between day 3 and 7 after admittance to the stroke unit. Factors associated with anxiety and depressive symptoms were identified using logistic regression analyses. Results 26.4% of the patients suffered from anxiety symptoms, 14.0% from depressive symptoms and 7.9% from both. Anxiety symptoms were associated with single marital state (OR 2.53, 95% CI 1.18–5.41) and a low Mini Mental State Examination (MMSE) score (< 26 points) (OR 0.53, 95% CI 0.31–0.87) whereas depressive symptoms were related to a low Barthel Activities of Daily Living index (BI) (score < 90 points) (OR 0.37, 95% CI 0.15–0.88). Conclusion The present study indicates that anxiety symptoms are more frequent than depressive symptoms in the acute stage of ischemic stroke. It is important to focus on both anxiety and depressive symptoms throughout the rehabilitation phase in order to ease the patients' personal anguish and improve neurological outcome after stroke. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives This study examines the correlation between actigraphic measures and a validated assessment scale of agitated behaviour in dementia, the Cohen-Mansfield Agitation Inventory (CMAI). Methods A total of 110 patients were included. Patients either suffered from Alzheimer dementia (AD), mixed dementia (MXD), frontotemporal dementia (FTD) or diffuse Lewy body disease (DLB). All patients underwent actigraphic recordings for 48 h. CMAI was scored by professional caretakers, who were responsible for the patient during his or her actigraphic recording. Results Patients with high total CMAI scores (≥ 50) clearly had higher levels of activity during the day as measured by means of actigraphy than patients with low total CMAI scores (ANOVA, F = 126.75, p < 0.0001). Patients with low MMSE scores (< 20) also had higher activity levels during the day than patients with higher MMSE scores (ANOVA, F = 85.74, p < 0.0001). Correlations between actigraphic data and CMAI total scores were moderate but highly significant. Conclusion We conclude that actigraphy is a useful tool to examine agitated behaviour in dementia. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

IntroductionBehavioural symptoms are common in moderate to severe Alzheimer's disease (AD). We have analysed the databases of two randomised studies with regard to the effects of memantine treatment on behavioural symptoms, measured using the 12-item version of the Neuropsychiatric Inventory (NPI). SubjectsThe monotherapy study (memantine only) reported by Reisberg et al. (2003) involved 252 patients with baseline MMSE total score of between 3 and 14, whereas the combination study (memantine and donepezil) reported by Tariot et al. (2004) comprised 404 patients with MMSE scores of between 5 and 14. In both studies, patients received 10 mg memantine b.i.d. or matching placebo, and lived in the community. MethodsFor both studies NPI total and individual domains scores were analysed in the ITT population. For the monotherapy study a dichotomised analysis was performed separately for patients who had behavioural symptoms at baseline and for those without pre-existing symptoms. Furthermore, a factor analysis was used to identify any behavioural clusters within the patient population. ResultsIn both studies, the change in NPI total scores at endpoint was consistently in favour of memantine treatment, reaching statistical significance in the combination study (p = 0.002). Memantine treatment showed a significant beneficial effect in comparison to placebo treatment in the NPI agitation/aggression domain in both studies (p = 0.008; p = 0.001). The dichotomised analysis of the monotherapy study showed that there was significantly less agitation/aggression emerging in the memantine-treated group compared to placebo (p = 0.003). Factor analysis showed that hyperactivity accounted for 27% of the data variance. ConclusionsMemantine has a beneficial effect on the behavioural symptoms of patients with moderate to severe AD, with the most pronounced effect on agitation/aggression. Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to examine the occurrence of the noncognitive behavioral and psychological symptoms and signs of dementia in a geriatric chronic-care hospital and to separate agitated and affective components of behavioral pathology using factor analysis. Methods The frequency and severity of Alzheimer's disease, vascular dementia, mixed dementia and Lewy Body dementia was assessed in 145 consecutive residents of a chronic-care hospital. The presence of noncognitive behavioral symptoms was evaluated with the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) and the Cohen-Mansfield Agitation Inventory (CMAI). A Factor analysis on the BEHAVE-AD subscores was performed to create symptom clusters. Analysis of covariance and post hoc tests were used to compare means of factor variables between different types of dementia. Results Statistical analysis showed a significant correlation between severity of dementia and BEHAVE-AD total score and between severity of dementia and CMAI total score. Factor analysis with Varimax rotation revealed the presence of three behavioral subsyndromes: agitation, affectivity and day/night disturbances. Conclusions The finding of three factors of behavioral pathology in demented patients reflects the possibility that different etiological mechanisms could explain the expression of the symptoms and signs of psychosis in demented patients. Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Behavioural disturbance, such as agitation, is a common feature of dementia, and causes significant problems and distress for carers. Snoezelen is increasingly used with people who have dementia, but there is limited evidence of its efficacy. Objective This crossover randomised controlled study aimed to evaluate the effect of Snoezelen on the mood and behaviour of patients with dementia, in comparison to the effect of an established and accepted intervention, reminiscence therapy. Methods Twenty patients with dementia and significant agitated behaviour, received three sessions each of Snoezelen and reminiscence. The effects were assessed using measures of observed agitated behaviour and heart rate over the course of the sessions, and mood and behaviour during the sessions. Results Both interventions had a positive effect. Snoezelen was no more beneficial than reminiscence in terms of effecting a significant reduction in agitated behaviour or heart rate. There was considerable variation in the way individuals responded to each intervention. Snoezelen may have a more positive effect than reminiscence, but due to the observed differences between the interventions being small, and the small number of subjects, this advantage was not demonstrated statistically. Conclusions Further research, with larger numbers of subjects, and an appropriate control is required to establish the benefits of Snoezelen for people at different stages of dementia, and to identify any benefits additional to those derived from increased staff attention. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

ObjectiveTo determine whether individualized advice on non-pharmacological strategies for hospitalized older patients with confusion and behavioral problems can improve levels of agitation and reduce the use of psychotropic medication. MethodPragmatic randomized controlled trial in two metropolitan teaching hospitals in South Australia. Seventy-one older patients with confusion and a behavioral disturbance were randomly allocated to receive either an assessment and ongoing individualized advice from an extended practice nurse on non-pharmacological strategies or usual care. Usual care included an assessment by a geriatrician. MeasurementsPrimary outcomes were levels of agitation (Pittsburgh Agitation Scale), appropriateness of psychotropic medication prescribing (Medication Appropriateness Index) and levels of psychotropics administered (chlorpromazine and diazepam dose equivalents). Secondary outcomes were length of stay, discharge destination, number of falls, restraint use and satisfaction from nursing staff and next of kin. ResultsLevels of agitation were modest at baseline with mean PAS intervention group 3.4 (SD = 0.5) and control group 4.0 (SD = 0.4) and both groups improved over time to 1.7 (SD = 0.4) for the intervention group and 1.8 (SD = 0.3) for the control group on the final day of data collection. Median length of follow-up was nine days. There was no effect of the intervention on levels of agitation, amount and appropriateness of psychotropic medication prescribed and administered, falls, length of stay, discharge destination, restraint use and nursing and next of kin satisfaction. ConclusionA nursing consultation service providing individualized non-pharmacological advice does not improve patient agitation or use of psychotropic medication for older patients with confusion and behavioral problems in an acute hospital. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Assessment of behavior problems in elderly persons with dementia is important for understanding and managing those behaviors. The most common method for assessing agitation is the use of informant ratings; however, these ratings may be affected by staff bias, inaccurate or insufficient memory, or stress. An alternative method is direct observation, which is more objective, but very costly and necessitates time sampling, thereby limiting the period covered by the assessment. To date, little research attention has been given to the degree to which these two methods converge. Methods In the present study, 175 elderly persons with dementia who manifested problem behaviors were recruited from 11 nursing home facilities in Maryland. The average age for the participants was 87 years; 78% were female. Two methods were employed for assessing agitation: the Agitated Behaviors Mapping Instrument (ABMI), which is based upon direct observations, and the Cohen-Mansfield Agitation Inventory (CMAI), which is a frequency rating scale completed by a formal caregiver. The ABMI and CMAI contain some identical items for tapping behavior problems. Results Data analysis revealed significant Pearson correlations between identical items on the two assessment instruments, as well as significant correlations of summary measures based on these different instruments, demonstrating a strong convergence between informant ratings and direct observations. Conclusions Informant ratings can achieve moderate agreement with direct observation when valid instruments and informants are used. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To analyze the factor structure, the criterion validity, the internal consistency, inter–rater reliability and test–retest reliability of the Korean version of Cohen-Mansfield Agitation Inventory, to provide data on the frequency and distribution of agitated behaviours, and to compare patterns of agitated behaviours among the institutionalized elderly with Alzheimer's disease (AD) or Vascular dementia (VaD). Methods The Korean version of the Cohen-Mansfield Agitation Inventory (CMAI-K) was administered to a total of 257 elderly with AD or VaD in a nursing home in Seoul, Korea. Three kinds of reliability and criterion validity were tested. Factor analysis using principal component analysis with the varimax rotation was performed. To identify different patterns of agitated behaviours, multiple logistic regression analysis was used. Results This study demonstrated satisfactory reliability and validity for the CMAI-K as an instrument measuring agitation in Korean dementia sufferers in nursing homes. Eighty-three percent of the subjects manifested one or more agitated behaviours at least once a week. Factor analysis yielded four subtypes of agitation: physically aggressive behaviours, physically nonaggressive behaviours, verbally agitated behaviours, and hiding/hoarding behaviours. Conclusion These results indicate that the CMAI-K is a reliable and valid instrument to measure agitated behaviours in Korean elderly with AD or VaD. These results validate and expand previous research on the agitation in dementia, and guide in the development of interventions. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Some patients with advanced dementia cannot convey the experience of pain verbally and may react to pain with aggressive and agitated behaviors. We hypothesized that unrecognized pain could contribute to agitation and that low dose opioid therapy might reduce agitation by reducing pain. We therefore attempted to determine the effect of opioids on agitation in demented patients. Methods We administered placebo for 4 weeks and a long-acting opioid for another 4 weeks to nursing home patients with advanced dementia and severe agitation despite treatment with psychotropic drugs. Patients and study nurses did not know if the medication administered was placebo or opioid. We measured the Cohen-Mansfield Agitation Inventory (CMAI) score at baseline and every two weeks. Results Among 47 patients who entered the study, 25 completed the two phases. The median age for the 25 patients was 85.5 years. Analyses of the data of these 25 patients and of the patients <85 years-old showed no significant differences in agitation level between the placebo and opioid phases. However, among the 13 patients who completed the study and were ≥85 years old, the agitation level at the end of the opioid phase was significantly lower than at the end of the placebo phase (mean change in CMAI score: -6.4; 95% confidence interval (CI): -10.96, -1.8). The decrease in agitation in the patients ≥85 years old persisted after adjusting for sedation. The results remained unchanged when we expanded the analyses to include four ≥85 patients who dropped out of the study after the second week of the opioid phase. Conclusion Low dose, long-acting opioids can lessen agitation that is difficult to control in very old (≥85) patients with advanced dementia. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Delusions constitute one of the most prominent psychiatric complications in Alzheimer's disease (AD). However, there is little consensus of the prevalence and associated factors for delusions in AD. To reveal the characteristics of delusions among Japanese patients with AD. 112 consecutive patients with AD were recruited over a one year period and administered the Neuropsychiatric Inventory (NPI). Delusions were present in 53 patients (47.3%). Delusions of theft were the most common type of delusion (75.5% of patients with delusions), followed by misidentification delusions and delusions of suspicion. More hallucination, agitation, and female gender were found in the delusions group. The authors found a high frequency of delusions, particularly of delusions of theft and suggested that gender was associated with the expression of delusions in Japanese patients with AD. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To determine whether aromatherapy with lavender oil is effective in the treatment of agitated behaviour in patients with severe dementia. Design A placebo controlled trial with blinded observer rater. Setting A long-stay psychogeriatric ward. Patients Fifteen patients meeting ICD-10 diagnostic criteria for severe dementia and suffering from agitated behaviour defined as a minimum score of three points on the Pittsburgh Agitation Scale (PAS). Intervention A 2% lavender oil aromatherapy stream was administered on the ward for a two hour period alternated with placebo (water) every other day for a total of ten treatment sessions. Assessments For each subject 10 total PAS scores were obtained. Five during treatment and five during placebo periods. Results Nine patients (60%) showed an improvement, five (33%) showed no change and one patient (7%) showed a worsening of agitated behaviour during aromatherapy compared with placebo. A comparison of the group median PAS scores during aromatherapy showed a significant improvement in agitated behaviour during aromatherapy compared with placebo (median PAS scores 3 c.f. 4; Wilcoxon Signed-Ranks test p = 0.016 (one-tailed)). Conclusions Lavender oil administered in an aroma stream shows modest efficacy in the treatment of agitated behaviour in patients with severe dementia. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective This case series describes the various contributors of disruptive behavior in demented nursing home residents and outlines the necessary steps to identify and treat them. Design Evaluation of overall clinical improvement and agitation at discharge from the hospital and at follow-up. Setting Nursing home residents consecutively admitted to the geriatric psychiatry service of a psychiatric university hospital in the New York metropolitan area. Patients 15 elderly demented nursing home residents with agitation. Measures Overall clinical improvement was assessed with the ‘global assessment of functioning scale’. Agitation was evaluated with the ‘brief agitation rating scale’ and the ‘nursing home scale for agitation’. Medication side-effects were measured with the ‘Simpson–Angus scale’ and the ‘abnormal involuntary movement scale’. Results The patients showed significantly more overall clinical improvement at discharge compared with admission. Additionally, agitation scores were significantly lower at discharge and at follow-up compared with admission. Conclusion A comprehensive medical and neurological assessment, an accurate identification of comorbid psychopathology, evaluation of drug toxicity, and a thorough history of psychotropic medication trials are essential steps for a successful treatment. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]