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Background: The aim of the study was to examine whether staff distress and aspects of the nursing home environment were associated with psychotropic drug use (PDU) in patients with dementia.Methods: This was a cross-sectional study of 1289 nursing home patients with dementia from 56 Dementia Special Care Units (SCUs) in the Netherlands. The primary outcome was PDU. Potential correlates of PDU were staff distress, environmental correlates (the number of patients per unit or per living room, staff/patient ratio, and the presence of a walking circuit), and patient factors (gender, age, dementia severity, and neuropsychiatric symptoms (NPS)). Multilevel logistic regression analysis was used to estimate the relative contributions of predictor variables in explaining PDU.Results: Staff distress, aspects of the physical nursing home environment and patients' neuropsychiatric symptoms were independently associated with PDU. Staff distress at patients' agitation was associated with antipsychotic and anxiolytic drug use (OR 1.66, 95% CI (1.16-2.36) and 1.62 (1.00-2.61), respectively). SCUs with more patients per living room had higher hypnotic drug use (OR 1.08, 95% CI (1.02-1.14)). Low staff/patient ratio was associated with high antidepressant drug use (OR 0.13, 95% CI (0.04-0.47)). The effects of nursing home environment on study outcome were smallest for antidepressant use (intra-SCU correlation 0.005) and highest for hypnotic use (intra-SCU correlation 0.171).Conclusion: Staff distress and other environmental aspects are independently associated with PDU. These findings raise questions about the appropriateness of psychoactive drug prescriptions for nursing home patients with dementia. [ABSTRACT FROM AUTHOR]

Context: Delirium is a common and serious complication in elderly patients. Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease.Objective: To assess the association between delirium in elderly patients and long-term poor outcome, defined as mortality, institutionalization, or dementia, while controlling for important confounders.Data Sources: A systematic search of studies published between January 1981 and April 2010 was conducted using the databases of MEDLINE, EMBASE, PsycINFO, and CINAHL.Study Selection: Observational studies of elderly patients with delirium as a study variable and data on mortality, institutionalization, or dementia after a minimum follow-up of 3 months, and published in the English or Dutch language. Titles, abstracts, and articles were reviewed independently by 2 of the authors. Of 2939 references in the original search, 51 relevant articles were identified.Data Extraction: Information on study design, characteristics of the study population, and outcome were extracted. Quality of studies was assessed based on elements of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies.Data Synthesis: The primary analyses included only high-quality studies with statistical control for age, sex, comorbid illness or illness severity, and baseline dementia. Pooled-effect estimates were calculated with random-effects models. The primary analysis with adjusted hazard ratios (HRs) showed that delirium is associated with an increased risk of death compared with controls after an average follow-up of 22.7 months (7 studies; 271/714 patients [38.0%] with delirium, 616/2243 controls [27.5%]; HR, 1.95 [95% confidence interval {CI}, 1.51-2.52]; I(2), 44.0%). Moreover, patients who had experienced delirium were also at increased risk of institutionalization (7 studies; average follow-up, 14.6 months; 176/527 patients [33.4%] with delirium and 219/2052 controls [10.7%]; odds ratio [OR], 2.41 [95% CI, 1.77-3.29]; I(2), 0%) and dementia (2 studies; average follow-up, 4.1 years; 35/56 patients [62.5%] with delirium and 15/185 controls [8.1%]; OR, 12.52 [95% CI, 1.86-84.21]; I(2), 52.4%). The sensitivity, trim-and-fill, and secondary analyses with unadjusted high-quality risk estimates stratified according to the study characteristics confirmed the robustness of these results.Conclusion: This meta-analysis provides evidence that delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia. [ABSTRACT FROM AUTHOR]

Objective: Given the hazards of knowledge about performance validity tests (PVTs) being proliferated among the general public, there is a continuous need to develop new PVTs. The purpose of these studies was to validate the newly developed Visual Association Test-Extended (VAT-E)., Method: The VAT-E consists of 24 pairs of line drawings; it is partly based on Green's Word Memory Test (WMT) paradigm. In study 1, we compared VAT-E total scores of healthy controls (n = 226), patients with mild cognitive impairment (MCI) (n = 76), patients with Alzheimer's disease (AD) (n = 26), and persons instructed to feign memory deficit (n = 29). In study 2, we compared litigating patients classified by Slick's criteria as Malingering of Neurocognitive Dysfunction (MND) (n = 26) or non-MND (n = 67). In addition, we compared the VAT-E to the Test of Memory Malingering (TOMM) (study 1) and the WMT (study 2)., Results: Results showed that the VAT-E differentiated patients with MCI (specificity 93-100%) or patients with AD (specificity 92-100%) from persons instructed to feign (sensitivity 86-100%). The VAT-E also differentiated MND from non-MND (sensitivity 54%, specificity 97%). The VAT-E was in perfect agreement with the TOMM in classifying healthy controls and persons instructed to feign, and it was in moderate agreement with the WMT in classifying non-MND and MND., Conclusion: Preliminary evidence shows that the VAT-E may be a useful PVT based on the ability to differentiate between those with genuine memory impairment, persons instructed to feign memory impairment, and a group suspected of malingering cognitive deficits.

Repeated measurements of episodic memory are needed for monitoring amnestic mild cognitive impairment (aMCI) and mild Alzheimer's disease (AD). Most episodic memory tests may pose a challenge to patients, even when they are in the milder stages of the disease. This cross-sectional study compared floor effects of the Visual Association Test (VAT) and the Rey Auditory Verbal Learning Test (RAVLT) in healthy elderly controls and in patients with aMCI or AD (N = 125). A hierarchical multiple regression analysis was used to examine whether linear or quadratic trends best fitted the data of cognitive test performance across global cognitive impairment. Results showed that VAT total scores decreased linearly across the range of global cognitive impairment, whereas RAVLT total scores showed a quadratic trend, with total scores levelling off for 90% of aMCI patients and 94% of AD patients. We conclude that the VAT shows few if any floor effects in patients with aMCI and mild AD and is therefore a potentially promising cognitive test for monitoring episodic memory impairment.

Background: A neuroinflammatory response is suggested to play an important role in delirium, a common complication in older hospitalized patients. We examined whether hip fracture patients who develop postoperative delirium have a different proteome in cerebrospinal fluid (CSF) prior to surgery., Methods: Patients (≥ 75 years) were admitted for hip fracture surgery. CSF was collected during spinal anaesthesia; proteins were separated using gel electrophoresis and identified with mass spectrometry. We compared the proteome of patients with and without postoperative delirium. Findings were validated in an independent, comparable cohort using immuno-assays., Results: In the derivation cohort 53 patients were included, 35.8% developed postoperative delirium. We identified differences in levels of eight CSF proteins between patients with and without subsequent delirium: complement factor C3, contactin-1, fibulin-1 and I-beta-1,3-N-acetylglucosaminyltransferase were significantly lower in patients with postoperative delirium, while neural cell adhesion molecule-2, fibrinogen, zinc-α-2-glycoprotein and haptoglobin levels were significantly higher. In the validation cohort 21.2% of 52 patients developed postoperative delirium. Immuno-assays confirmed contactin-1 results although not statistically significant. Complement factor C3 was significantly higher in patients with postoperative delirium., Conclusion: Our results show the complexity of pathophysiological mechanisms involved in delirium and emphasizes the need of independent validation of findings., General Significance: This study highlights the challenges and inconsistent findings in studies of delirium, a serious complication in older patients. We analysed proteins in CSF, the most proximal fluid to the brain. All patients were free from delirium at the time of sampling.

Background: Neuropsychiatric symptoms (NPS) are highly prevalent in dementia. The recently developed Neuropsychiatric Inventory - Clinician rating scale (NPI-C) includes clinical judgment and new symptom domains. Our objective was to evaluate NPI-C reliability and to compare caregiver and clinician ratings across the range of mild to severe cognitive impairment., Methods: This is a cross-sectional observational study. Participants were geriatric memory clinic patients and nursing-home residents (n = 30) with an established diagnosis of dementia or Mild Cognitive Impairment (MCI). A psychiatrist (MK) interviewed caregiver-patient dyads using the NPI-C. Neuropsychological tests and Mini-Mental State Examination (MMSE) were used to assess cognitive impairment. Two NPI-C caregiver interviews were videotaped and rated by psychologists and geriatricians. Intra-class correlations (ICCs) were used to examine inter-rater agreement. Correlation coefficients were calculated to evaluate caregiver and psychiatrist NPI-C ratings. Disagreement between caregiver and clinician was expressed in delta scores and examined across the range of mild to severe cognitive impairment, using Levene's homogeneity of variances tests., Results: Inter-rater agreement on ratings of two caregiver videos was high (ICC = 0.99-1.0). Clinician-caregiver concordance on NPI-C total severity ratings was high (r = 0.77). Variability in clinician-caregiver concordance was associated with cognitive impairment: MMSE (P = 0.02), CAMCOG-R (Cambridge Cognitive Examination-revised) total scores (P = 0.02), CAMCOG-R Memory scores (P = 0.04) and Language scores (P = 0.01)., Conclusions: The NPI-C is a reliable measure of NPS in patients with MCI or dementia. Clinician-caregiver agreement on NPS severity may vary with cognitive impairment, underlining the importance of clinician-based measures of NPS.

The Delirium Motor Subtype Scale (DMSS) was developed to capture all the previous different approaches to delirium motor subtyping into one new instrument and emphasize disturbances of motor activity rather than associated psychomotoric symptoms. We investigated reliability and validity of the DMSS Dutch version. Elderly patients who had undergone hip fracture surgery received the DMSS and the Delirium Rating Scale Revised-98 (DRS-R-98). A diagnosis of delirium was defined according to the Confusion Assessment Method (CAM). Among 146 patients, 46 (32%) patients were diagnosed with delirium (mean age 86.3 years; SD 5.2). The internal consistency of the DMSS was acceptable (Cronbach's alpha=0.72). If an item was removed at random the internal consistency of the scale remained the same. Similarly the concurrent validity of DMSS was good (Cohen's kappa=0.73) while for each motor subtype the Cohen's kappa ranged from 0.58 to 0.85. The sensitivity and specificity of DMSS to detect each subtype ranged from 0.56 to 1 and from 0.88 to 0.98, respectively. This study suggests that the Dutch version of the DMSS is a reliable and valid instrument. The DMSS has scientific validity that could allow for greater precision in further research on motor subtypes., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Aging and neurodegenerative disease predispose to delirium and are both associated with increased activity of the innate immune system resulting in an imbalance between pro- and anti-inflammatory mediators in the brain. We examined whether hip fracture patients who develop postoperative delirium have altered levels of inflammatory mediators in cerebrospinal fluid (CSF) prior to surgery., Methods: Patients were 75 years and older and admitted for surgical repair of an acute hip fracture. CSF samples were collected preoperatively. In an exploratory study, we measured 42 cytokines and chemokines by multiplex analysis. We compared CSF levels between patients with and without postoperative delirium and examined the association between CSF cytokine levels and delirium severity. Delirium was diagnosed with the Confusion Assessment Method; severity of delirium was measured with the Delirium Rating Scale Revised-98. Mann-Whitney U tests or Student t-tests were used for between-group comparisons and the Spearman correlation coefficient was used for correlation analyses., Results: Sixty-one patients were included, of whom 23 patients (37.7%) developed postsurgical delirium. Concentrations of Fms-like tyrosine kinase-3 (P=0.021), Interleukin-1 receptor antagonist (P=0.032) and Interleukin-6 (P=0.005) were significantly lower in patients who developed delirium postoperatively., Conclusions: Our findings fit the hypothesis that delirium after surgery results from a dysfunctional neuroinflammatory response: stressing the role of reduced levels of anti-inflammatory mediators in this process., Trial Registration: The Effect of Taurine on Morbidity and Mortality in the Elderly Hip Fracture Patient., Registration Number: NCT00497978. Local ethical protocol number: NL16222.094.07.

Objectives: Delirium is common in older patients admitted to hospital. Information obtained from patient's relatives or caregivers may contribute to improved detection. Our aim was to develop a caregiver based questionnaire, the Informant Assessment of Geriatric Delirium (I-AGeD), to assist in better recognition of delirium in elderly patients., Methods: A cross-sectional observational study using a scale construction patient cohort and two validation cohorts was conducted at geriatric departments of two teaching hospitals in The Netherlands. Delirium status, based on DSM-IV criteria, was assessed directly on admission by a geriatric resident and evaluated within the first 48 h of admission. Caregivers filled out a 37-item questionnaire of which 10 items were selected reflecting delirium symptoms, based on their discriminatory abilities, internal consistency and inter-item correlations., Results: A total of 88 patients with complete study protocols in the construction cohort were included. Average age was 86.4 (SD 8.5), and 31/88 patients had delirium on admission. Internal consistency of the 10-item I-AGeD was high (Cronbach's alpha = 0.85). At a cut-off score of >4 sensitivity was 77.4% and specificity 63.2%. In patients without dementia, sensitivity was 100% and specificity 65.2%. Validation occurred by means of two validation cohorts, one consisted of 59 patients and the other of 33 patients. Sensitivity and specificity in these samples ranged from 70.0% to 88.9% and 66.7% to 100%, respectively., Conclusion: The newly constructed caregiver based I-AGeD questionnaire is a valid screening instrument for delirium on admission to hospital in geriatric patients.

Background: Delirium is a risk factor for long-term cognitive impairment and dementia. Yet, the nature of these cognitive deficits is unknown as is the extent to which the persistence of delirium symptoms and presence of depression at follow-up may account for the association between delirium and cognitive impairment at follow-up. We hypothesized that inattention, as an important sign of persistent delirium and/or depression, is an important feature of the cognitive profile three months after hospital discharge of patients who experienced in-hospital delirium., Methods: This was a prospective cohort study. Fifty-three patients aged 75 years and older were admitted for surgical repair of acute hip fracture. Before the surgery, baseline characteristics, depressive symptomatology, and global cognitive performance were documented. The presence of delirium was assessed daily during hospital admission and three months after hospital discharge when patients underwent neuropsychological assessment., Results: Of 27 patients with in-hospital delirium, 5 were still delirious after three months. Patients with in-hospital delirium (but free of delirium at follow-up) showed poorer performance than patients without in-hospital delirium on tests of global cognition and episodic memory, even after adjustment for age, gender, and baseline cognitive impairment. In contrast, no differences were found on tests of attention. Patients with in-hospital delirium showed an increase of depressive symptoms after three months. However, delirium remained associated with poor performance on a range of neuropsychological tests among patients with few or no signs of depression at follow-up., Conclusion: Elderly hip fracture patients with in-hospital delirium experience impairments in global cognition and episodic memory three months after hospital discharge. Our results suggest that inattention, as a cardinal sign of persistent delirium or depressive symptomatology at follow-up, cannot fully account for the poor cognitive outcome associated with delirium.

Delirium's characteristic fluctuation in symptom severity complicates the assessment of test-retest reliability of scales using classical analyses, but application of modelling to longitudinal data offers a new approach. We evaluated test-retest reliability of the delirium rating scale (DRS) and delirium rating scale-revised-98 (DRS-R98), two widely used instruments with high validity and inter-rater reliability. Two existing longitudinal datasets for each scale included DSM-IV criteria for delirium diagnosis and repeated measurements using the DRS or DRS-R98. To estimate the reliability coefficients RT and RΛ for each scale we used a macros provided by Dr. Laenen at http://www.ibiostat.be/software/measurement.asp. For each dataset a linear mixed-effects model was fitted to estimate the variance-covariance parameters. A total of 531 cases with between 4 and 9 measurement points across studies including both delirious and non-delirious patients. Comorbid dementia in the datasets varied from 27% to 55%. Overall RT for the DRS were 0.71 and 0.50 and for DRS-R98 0.75 and 0.84. RΛ values for DRS were 0.99 and 0.98 and for DRS-R98 were 0.92 and 0.96. Individual RT measures for DRS-R98 and DRS across visits within studies showed more range than overall values. Our models found high overall reliability for both scales. Multiple factors impact a scale's reliability values including sample size, repeated measurements, patient population, etc in addition to rater variability., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Delirium is often accompanied by changes in motor activity but the longitudinal expression of these features and etiological and prognostic significance of clinical subtypes defined by motor activity is unclear., Methods: This is a prospective cohort study of elderly patients undergoing hip fracture surgery. Baseline characteristics were assessed preoperatively. During hospital admission presence of delirium was assessed daily according to CAM criteria. This study compared baseline characteristics and outcomes according to a longitudinal pattern of motor subtype expression (predominantly hyperactive, predominantly hypoactive, predominantly mixed, no motor subtype and variable). Motor subtype categorization was performed with the DRS-R98. We also investigated the longitudinal stability of motor subtypes across the delirium episode., Results: 62 patients had experienced in-hospital delirium postoperatively. The full course of the delirium episode could be defined for 42/62 (67.7%) patients. Of the patients with multiple days of delirium only 4/30 (13.3%) patients had a consistent motor subtype profile throughout the delirium episode, while 26/30 (86.7%) patients had a variable course. Of the patients with multiple days of delirium, 5/30 (16.7%) were predominantly hypoactive in profile, 7/30 (23.3%) predominantly hyperactive, 6/30 (20%) predominantly mixed, 1/30 (3.3%) had no motor subtype and 11/30 (36.7%) had a variable profile. Baseline characteristics and outcomes did not differ between the groups., Conclusion: The majority of elderly hip fracture patients in this homogenous sample experienced variable expression of motor subtype over the course of their delirium episodes. The subtype categorization according to dominant motor subtype across the delirium episode identified groups with similar characteristics and outcomes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Delirium in elderly patients is associated with various long-term sequelae that include cognitive impairment and affective disturbances, although the latter is understudied., Methods: For a prospective cohort study of elderly patients undergoing hip fracture surgery, baseline characteristics and affective and cognitive functioning were assessed preoperatively. During hospital admission, presence of delirium was assessed daily. Three months after hospital discharge, affective and global cognitive functioning was evaluated again in patients free from delirium at the time of this follow-up. This study compared baseline characteristics and affective functioning between patients with and without in-hospital delirium. We investigated whether in-hospital delirium is associated with increased anxiety and depressive levels, and post-traumatic stress disorder (PTSD) symptoms three months after discharge., Results: Among 53 eligible patients, 23 (43.4%) patients experienced in-hospital delirium after hip fracture repair. Patients who had experienced in-hospital delirium showed more depressive symptoms at follow-up after three months compared to the 30 patients without in-hospital delirium. This association persisted in a multivariate model controlling for age, baseline cognition, baseline depressive symptoms, and living situation. The level of anxiety and symptoms of PTSD at follow-up did not differ between both groups., Conclusion: This study suggests that in-hospital delirium is associated with an increased burden of depressive symptoms three months after discharge in elderly patients who were admitted to the hospital for surgical repair of hip fracture. Symptoms of depression in patients with previous in-hospital delirium cannot be fully explained by persistent (sub)syndromal delirium or baseline cognitive impairment.

Patients with mild cognitive impairment (MCI) do not always convert to dementia. In such cases, abnormal neuropsychological test results may not validly reflect cognitive symptoms due to brain disease, and the usual brain-behavior relationships may be absent. This study examined symptom validity in a memory clinic sample and its effect on the associations between hippocampal volume and memory performance. Eleven of 170 consecutive patients (6.5%; 13% of patients younger than 65 years) referred to memory clinics showed noncredible performance on symptom validity tests (SVTs, viz. Word Memory Test and Test of Memory Malingering). They were compared to a demographically matched group (n = 57) selected from the remaining patients. Hippocampal volume, measured by an automated volumetric method (Freesurfer), was correlated with scores on six verbal memory tests. The median correlation was r = .49 in the matched group. However, the relation was absent (median r = -.11) in patients who failed SVTs. Memory clinic samples may include patients who show noncredible performance, which invalidates their MCI diagnosis. This underscores the importance of applying SVTs in evaluating patients with cognitive complaints that may signify a predementia stage, especially when these patients are relatively young.

Background. Features that may allow early identification of patients at risk of prolonged delirium, and therefore of poorer outcomes, are not well understood. The aim of this study was to determine if preoperative delirium risk factors and delirium symptoms (at onset and clinical symptomatology during the course of delirium) are associated with delirium duration. Methods. This study was conducted in prospectively identified cases of incident delirium. We compared patients experiencing delirium of short duration (1 or 2 days) with patients who had more prolonged delirium (≥3 days) with regard to DRS-R-98 (Delirium Rating Scale Revised-98) symptoms on the first delirious day. Delirium symptom profile was evaluated daily during the delirium course. Results. In a homogenous population of 51 elderly hip-surgery patients, we found that the severity of individual delirium symptoms on the first day of delirium was not associated with duration of delirium. Preexisting cognitive decline was associated with prolonged delirium. Longitudinal analysis using the generalised estimating equations method (GEE) identified that more severe impairment of long-term memory across the whole delirium episode was associated with longer duration of delirium. Conclusion. Preexisting cognitive decline rather than severity of individual delirium symptoms at onset is strongly associated with delirium duration.

Background: The goal of this study is to determine patterns of psychotropic drug use (PDU), the association with neuropsychiatric symptoms (NPS), and the variability across dementia types in nursing home residents with dementia. In addition, PDU was analyzed across multiple indications., Methods: This was a prospective cohort study over a two-year period from 2006 to 2008, which involved 14 dementia special care units in nine nursing homes. A total of 117 residents with dementia participated in the study, of whom 35% had Alzheimer's dementia (AD) and 11% vascular dementia (VaD). PDU was classified according to anatomical therapeutic chemical-classification as either "present" or "absent"., Results: The majority of residents had moderately severe to severe dementia. At all successive assessments, almost two-thirds of residents received any psychotropic drug (PD) and almost one-third continued to receive any PD. Of all PDs, antipsychotics (APs) were prescribed most frequently. Fewer residents started with antidepressants, but continued to receive antidepressants at higher percentages. Anxiolytics showed an intermittent course, but a subgroup of 9% showed two-year continuation. Once started on PDs at baseline, residents continued to use PDs at high percentages: three-quarters continued to receive APs for at least six months. Half of residents received at least one PD; one-fifth received at least two PDs simultaneously. Residents with AD received more hypnotics and antidementia drugs; residents with VaD received more antipsychotics, antidepressants, anxiolytics and anticonvulsants., Conclusions: PDs have different utilization patterns, but overall, consistently high continuation rates were found. These results warrant scrutiny of continuous PDU.

Objectives: To examine the effects of general anesthesia on the risk of incident postoperative delirium in older adults undergoing hip surgery., Design: Secondary analysis of haloperidol prophylaxis for delirium clinical trial data. Predefined risk factors for delirium were assessed prior to surgery. Primary outcome was postoperative delirium. Study outcome was compared across patient groups who received either general or regional anesthesia, and for individuals receiving various perioperative medications (benzodiazepines, anticholinergics, and opioids), using multivariable logistic regression after controlling for potential confounders. Subgroup analyses based on baseline cognitive impairment and delirium risk were also undertaken., Setting: Large medical school-affiliated general hospital in Alkmaar, the Netherlands., Participants: Five hundred twenty-six adults aged 70 and older undergoing hip surgery., Measurements: The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria)., Results: Sixty participants (11.4%) had incident postoperative delirium. One hundred eighty-nine (35.9%) received general anesthesia, 18 (9.5%) of whom developed postoperative delirium, and 337 (64.1%) received regional anesthesia, 42 (12.5%) of whom developed postoperative delirium (adjusted odds ratio=0.81, 95% confidence interval=0.43-1.52, P=.51). Results were stratified for baseline cognitive impairment, age, acute admission, perioperative medication and other delirium risk factors. Delirium was not independently associated with specific drugs or the medication classes opioids, benzodiazepines, and anticholinergics., Conclusion: General anesthesia has no distinct effect on incident postoperative delirium in older adults undergoing hip surgery. This also holds for individuals suffering from cognitive impairment or who are otherwise at risk for postoperative delirium. Perioperative use of narcotics, benzodiazepines, and anticholinergic agents was not associated with incident delirium in this cohort of older adults undergoing hip surgery., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Objectives: To examine the association between cerebrospinal fluid (CSF) β-amyloid (Aβ1-42), tau, and hyperphosphorylated tau (Ptau) and risk of delirium in older adults with hip fracture., Design: Prospective cohort study., Setting: University-affiliated general hospital in Alkmaar, the Netherlands., Participants: Seventy-six participants aged 75 and older admitted for surgical repair of acute hip fracture., Measurements: Presurgical baseline screening and assessment included the Informant Questionnaire on Cognitive Decline-short form (IQCODE-N), Mini-Mental State Examination, standardized Snellen test for visual impairment, Geriatric Depression Scale, Barthel Index (BI), and Lawton Instrumental Activity of Daily Living (IADL) scale. The number of medical comorbidities and medications at home, American Society of Anesthesiologists score, and Acute Physiology and Chronic Health Evaluation II score were determined according to chart review. Delirium was diagnosed using the Confusion Assessment Method. CSF was collected at the onset of spinal anesthesia., Results: Postoperative delirium occurred in 30 (39.5%) participants. Participants with delirium were older, showed more signs of cognitive decline, were more dependent at home in activity of daily living and IADL functioning, and used more medications before admission. Preoperative CSF Aβ1-42, tau, and Ptau levels were not significantly different in participants who did and did not develop delirium during subsequent hospitalization. In contrast, prefracture cognitive decline (IQCODE-N) was significantly related to delirium (odds ratio=9.43, 95% confidence interval=2.45-36.31)., Conclusion: Cognitive impairment predisposes to delirium, but in this study, postoperative delirium was not associated with baseline CSF Aβ1-42, tau, and Ptau levels. These findings suggest that CSF markers for plaque and tangle formation are not strongly associated with delirium risk in older adults with hip fracture., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Background: delirium after hip-surgery is associated with poor outcome. Few studies examined the mortality risk associated with delirium in elderly hip-surgery patients after 1 year or more. Aim of this study was to examine the hazard risk associated with delirium in elderly hip-surgery patients at 2-year follow-up, controlling for baseline risk factors and interaction effects., Methods: this is a secondary analysis based on data from a controlled clinical trial evaluating efficacy of haloperidol prophylaxis for delirium conducted in a large medical school-affiliated general hospital in Alkmaar, The Netherlands. Randomised and non-randomised patients (n = 603) were followed-up for 2 years. Predefined risk factors and other potential risk factors for delirium were assessed prior to surgery. Primary outcome was time of death during the follow-up period. Cox proportional hazards were estimated and compared across patients who had postoperative delirium during hospitalisation and those who did not., Results: a total of 90/603 patients (14.9%) died during the study period and 74/603 (12.3%) had postoperative delirium. Incidence of delirium was higher in patients who died (32.2%) compared with those who survived (8.8%). The interaction effect of delirium by illness severity on mortality was significant after adjusting for predefined delirium risk factors and other potential covariates including study intervention (adjusted Hazard risk = 1.05, 95% CI 1.02-1.08). A total of 14/27 delirium patients who were severely ill on admission died during follow-up versus 15/47 delirium patients who were not (RR 1.63 CI 0.93-2.83)., Conclusions: delirium does not independently predict mortality at 2-year follow-up in elderly hip-surgery patients. However, outcome from delirium is particularly poor when other risk factors are present.

Objective: The aim of the study was to estimate inter-observer and test-retest reliability of the Neuropsychiatric Inventory Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), and to establish their Reliable Change Index (RCI). Reliable Change methodology is a practical method for estimating the least change acquired in outcome measures., Methods: Nursing home physicians and certified nurses assessed 105 patients with dementia (in five nursing homes) at baseline and after 2 weeks. Spearman rank correlations were calculated and Reliable Change Difference Scores (S(diff) (80))., Results: NPI-NH inter-observer correlations ranged 0.14-0.70. NPI-NH test-retest correlations ranged 0.23-0.80. CMAI inter-observer correlations ranged -0.10 to 0.72. CMAI test-retest correlations ranged 0.32-1.00 (CMAI total score, ρ=0.89). S(diff) (80) for NPI-NH items ranged 1.7-5.0. A change of 11 points on the NPI-NH total score can be considered a true behavioral change. S(diff) (80) for CMAI total score was 8 and factor analysis based sub-scale scores physically aggressive behavior, physically non-aggressive behavior, and verbally agitated behavior were 3, 6, and 4, respectively., Conclusion: Reliability estimates and RCI for the NPI-NH were modest, seriously challenging its reliability and sensitivity to change over time. NPI-NH may only be useful for monitoring behavioral changes in individual patients with dementia, when symptoms are moderate to severe, or when effect sizes are large. Reliability of the CMAI was good, supporting its usefulness in clinical practice. Poor inter-observer agreement on behavioral observations poses a real challenge in nursing homes. Reliable scales are needed that include unambiguously formulated items., (Copyright © 2010 John Wiley & Sons, Ltd.)

Objective: The MoCA is a new screening test to detect Mild Cognitive Impairment (MCI). Purpose of this study is validating the Dutch version (MoCA-D)., Method: We administered the MoCA-D to healthy control subjects and to elderly with MCI or dementia from a memory disorder outpatient clinic and a geriatric (outpatient) clinic (n = 30, 32, 37 respectively, age > or = 60). Neuropsychological testing was part of the standard procedure for patients to diagnose MCI. Sensitivity, specificity and predictive values (positive: PPV and negative: NPV) of the MoCA-D were assessed., Results: A significant effect of group was found on MoCA-D total score (F (2.95) =67.9; p < 0.01). With a cutoff score of < or = 25, sensitivity and specificity to detect MCI in relation to healthy controls were 72% and 73%, respectively. PPV and NPV were 84% and 56%, respectively. With a cut-off score of < or = 20, sensitivity to detect dementia in relation to MCI was 100% for severe dementia and 75% for mild dementia. Specificity for dementia was 81%, PPV 94% and NPV 55%., Conclusion: The MoCA-D distinguishes between healthy elderly, MCI patients and dementia patients. However, in this study, insufficient sensitivity and poor specificity were found. For the present, applying a broader and flexible screening procedure in order to detect MCI seems a more useful method than the interpretation of one test result in particular.

Objective: To determine the course of neuropsychiatric symptoms (NPSs) in nursing home residents with dementia and to determine their variability across diagnosis., Design: Prospective cohort study over 2 years., Setting: Fourteen dementia special care units in nine nursing homes in The Netherlands., Participants: One hundred seventeen residents with dementia., Measurements: NPSs were measured using the Neuropsychiatric Inventory-Nursing Home version (NPI-NH)., Results: The majority of residents had moderately severe to severe dementia. All but a few residents (97%) showed any NPS, and co-occurrence of NPSs was high. Agitation, irritability, and aberrant motor behavior were the most prevalent over the 2 years. Depression and anxiety as well as NPI total score decreased over time, whereas apathy tended to increase. Agitation and aberrant motor behavior were the most persistent symptoms. In asymptomatic residents, highest incidence rates were found for apathy, aggression/ agitation, irritability, and aberrant motor behavior. Anxiety and apathy were more prevalent in Alzheimer disease (AD) compared with vascular disease (VaD); vice versa, aggression and depression were more prevalent in VaD. Differences in change over time between AD and VaD were found for irritability and disinhibition., Conclusion: This is the first study examining the 2-year course of NPSs in a large group of nursing home residents with dementia. Virtually all residents demonstrated and/or developed NPSs. Although affective symptoms decreased, apathy tended to increase. Agitated behaviors were particularly persistent. Our data may contribute to improve mental healthcare for demented nursing home residents.

Objective: The aim of the study was to estimate the influence of environmental correlates of neuropsychiatric symptoms in nursing home patients with dementia., Methods: 1289 patients in 56 Dementia Special Care Units (SCUs) in the Netherlands were assessed using the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI). Potential correlates of the neuropsychiatric symptoms studied were gender and age of the patient, dementia severity, psychoactive medication use and environmental correlates such as the number of patients per unit or per living room, staff size/patient ratio, time spent on care activities and presence of a walking circuit. Multilevel logistic regression analysis was used to estimate the relative contribution of the different factors in explaining neuropsychiatric symptoms variability., Results: The prevalence of neuropsychiatric symptoms differed between SCUs, also after correcting for patient factors. Patient-related factors explained 7-21% of the total variance of neuropsychiatric symptoms. Intra Class Correlation (the correlation of symptoms of patients within SCUs) ranged from 0.039 (psychosis) to 0.163 (apathy). The variance in SCU symptom prevalence (variance between SCUs) accounted for 3.5-14.8% of the total variance in neuropsychiatric symptoms. In SCUs of which the staff spent more time on care activities did the patients show lower levels of apathy. Other environmental correlates did not predict neuropsychiatric symptoms., Conclusion: The substantial variation of prevalence rates between SCUs in combination with the clustering of symptoms within SCUs is strong evidence for the environmental contribution to neuropsychiatric symptoms and the multifactorial nature of behaviour in dementia., ((c) 2009 John Wiley & Sons, Ltd.)

Aims: The goal of this study is to assess the relationship between quality of life (QoL), neuropsychiatric symptoms (NPS), psychotropic drug use (PDU) and patient characteristics in a large group of nursing home residents with dementia., Methods: This cross-sectional observational study included 288 individuals with dementia who reside in 14 special care units in 9 nursing homes. The following measures were used: the Qualidem scale to assess QoL, the Neuropsychiatric Inventory-Nursing Home version, the Global Deterioration Scale (GDS), the Severe Impairment Battery-short version, an Activities of Daily Living scale and PDU. Associations between QoL and NPS were examined using multivariate linear regression models with corrections for potential covariates., Results: The average age of the residents was 84 years (SD = +/-7). Agitation, depression, psychosis, psychomotor agitation and psychotropic drugs were independently associated with poor QoL. In patients with mild to moderately severe dementia (GDS 4-6), NPS, PDU and cognitive impairment explained almost half of the variance in QoL scores. Agitation and depression were particularly strong predictors of poor QoL. In patients with severe dementia (GDS 7), agitation, depression, psychosis and cognitive impairment were associated with poor QoL., Conclusions: NPS, cognition and PDU independently impair QoL for patients in both the moderate and advanced stages of dementia. These results challenge existing pharmacological intervention strategies and highlight the need for psychosocial interventions in the treatment of NPS., (2010 S. Karger AG, Basel.)

Introduction: The aim of the study was to assess the influence of dementia severity and gender on neuropsychiatric symptoms in demented nursing home patients., Methods: Neuropsychiatric symptoms were assessed in a large sample of 1319 Dutch nursing home patients using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). The influence of gender and severity of cognitive decline, assessed with the Global Deterioration Scale (GDS), was investigated using logistic regression analysis and subsequently corrected for possible confounders, such as age, duration of institutionalization and psychoactive medication use., Results: While physically aggressive behaviour was more common in patients with very severe cognitive deterioration (GDS stage 7), disinhibition, irritability, physically non-aggressive and verbally agitated behaviour were more common in patients in GDS stage 5 or 6. Physically aggressive behaviour was more common in men, whereas female patients demonstrated more verbally agitated behaviour. With respect to other neuropsychiatric symptoms, delusions and depression were also more common in patients in GDS stage 5 and 6, while prevalences of anxiety and apathy further increased in severely demented patients (GDS stage 7). Apathy was more prevalent in male patients, while depression and anxiety were more common in females., Conclusion: In nursing home patients, neuropsychiatric symptoms were associated with the severity of dementia, with most symptoms occurring in patients showing (moderately) severe cognitive decline. Only physical aggression, anxiety and apathy were more common in patients with very severe cognitive decline. Dementia severity and gender were important predictors of neuropsychiatric symptoms in this patient cohort., (Copyright (c) 2009 John Wiley & Sons, Ltd.)

Patient A, 58 years, is referred by the Rheumatologist to the Geriatrician concerning apathy. History reviews skipping arthritis, reddened and inflamed eyes, apathy and loss of interest. Physical examination revealed red tearing eyes, bradyphrenia and bradykinesia. Laboratory examination showed inflammation markers. The patient develops fever and bilateral reddened and inflamed ears. Diagnosis of relapsing polychondritis is made, the patient is treated with prednisone and the symptoms disappear. Relapsing polychondritis is a chronical disease associated with inflammation and destruction of cartilaginous structures and proteoglycan rich structures. We diagnosed Relapsing Polychondritis with a reversible dementia, probably due to cerebral vasculitis.

Background: Efficient neuropsychological tests are needed to measure cognitive impairment in moderate to severe dementia., Objective: To examine construct validity of the Severe Impairment Battery Short Version (SIB-S) in nursing home patients with moderate to severe dementia, and to examine potential floor effects for the SIB-S., Methods: Cross-sectional comparison of cognitive measures, dementia severity and functional dependency., Results: A total of 290 patients were included 264 of whom had complete SIB-S protocols. Internal consistency of the SIB-S was very high (Cronbach alpha = 0.97). Principal-component analysis produced three factors, the first of which explained more than 50% of common score variance. Semantic memory items loaded highly on the first factor. Total SIB-S scores were associated with cognitive impairment (SIB-S--Mini Mental State Examination (MMSE) rho = 0.91, p<0.001), and with functional dependency (SIB-S--ADL scale rho = -0.61, p<0.001). SIB-S total scores differentiated between dementia stages as measured with the Global Deterioration Scale (F = 164.6; df 3,260, p<0.001). Comparisons of SIB-S total score variance across patients with moderate to severe dementia and patients with below or above average Mini Mental State Exam scores indicate an absence of large floor effects., Conclusion: In this first study examining an independently administered SIB-S, the scale proved to be a homogeneous and valid measure of cognitive impairment. The SIB short version can be used to assess moderately to severely demented patients, who may find it difficult to complete traditional, lengthier neuropsychological tests.

Objective: To study psychiatric consultation referrals of nursing home patients with dementia and to compare referral reasons with normative data on prevalence of neuropsychiatric symptoms., Methods: This is part of a cross-sectional study of 787 patients residing in 14 nursing homes in the Netherlands. Nursing home physicians (NHP) noted the primary reasons for psychiatric consultation according to the Neuropsychiatric Inventory items and two extra domains. Patients were subsequently assessed by an old-age psychiatrist. Eligible patients were those that had dementia. Reasons for referral were compared with independent data on prevalence of neuropsychiatric symptoms in nursing home patients with dementia., Results: A total of 325/787 (41.3%) patients had dementia. Agitation, disinhibition and aberrant motor behaviour were frequent reasons for referral (>25%). Psychotic symptoms, apathy and eating behaviour changes were infrequent reasons (<10%) for seeking consultation. Agitation and disinhibition were more often primary reasons for consultation than would have been expected based on normative prevalence estimates of these symptoms. In contrast, delusions, euphoria, apathy, irritability and eating behaviour changes were less often reasons for referral compared with prevalence estimates., Conclusions: This study is the first to examine psychiatric consultation for dementia patients in Dutch nursing home. Large differences exist between referral reasons and normative data on symptom prevalence. Specialized mental health service was provided for the agitated and disinhibited patient in particular. Chances are that this is at the expense of the apathetic, retarded and quietly 'not causing any trouble' patient., (Copyright (c) 2008 John Wiley & Sons, Ltd.)

Objective: To study the outcome of delirium in elderly hip surgery patients., Design: Prospective matched controlled cohort study. Hip surgery patients (n = 112) aged 70 years and older, who participated in a controlled clinical trial of haloperidol prophylaxis for delirium, were followed for an average of 30 months after discharge. Patients with a diagnosis of dementia or mild cognitive impairment (MCI) were identified using psychiatric interviews. Proportions of patients with dementia/MCI were compared across patients who had postoperative delirium and selected control patients matched for preoperatively assessed risk factors who had not developed delirium during index hospitalization. Other outcomes were mortality rate and rate of institutionalization., Results: During the follow-up period, 54.9% of delirium patients had died compared to 34.1% of the controls (relative risk = 1.6, 95% CI = 1.0-2.6). Dementia or MCI was diagnosed in 77.8% of the surviving patients with postoperative delirium and in 40.9% of control patients (relative risk = 1.9, 95% CI = 1.1-3.3). Half of the patients with delirium were institutionalized at follow-up compared to 28.6% of the controls (relative risk = 1.8, 95% CI = 0.9-3.4)., Conclusion: The risk of dementia or MCI at follow-up is almost doubled in elderly hip surgery patients with postoperative delirium compared with at-risk patients without delirium. Delirium may indicate underlying dementia., (Copyright 2008 S. Karger AG, Basel.)

Objectives: The authors investigated prodromal delirium symptoms in elderly patients undergoing hip surgery., Methods: This was a prospective cohort study in the setting of a large medical school-affiliated general hospital in Alkmaar, The Netherlands. Participants were patients undergoing hip surgery aged 70 and older at risk for delirium. Before surgery, patients were randomized to low-dose prophylactic haloperidol treatment or placebo. Daily assessments were based on patient interviews with the Mini-Mental State Examination and Digit Span test. The Delirium Rating Scale-Revised (DRS-R-98) was used to measure early symptoms during the prodromal phase before the onset of delirium., Results: Data of 66 patients with delirium were compared with those of 35 at-risk patients who did not develop delirium: 14 of 66 patients (21%) had delirium on the day of surgery or early the day after, 32 of 66 (48%) on the second day, 14 of 66 on the third, and six of 66 (9%) on the fourth. The average DRS-R-98 total scores on day -4 to day -1 before delirium were 1.9 for the comparison group patients and 5.0, 4.3, 5.8, and 10.7 for patients with postoperative delirium. Multivariate analysis showed that the early symptoms memory impairments, incoherence, disorientation, and underlying somatic illness predict delirium., Conclusions: Most elderly patients undergoing hip surgery with postoperative delirium already have early symptoms in the prodromal phase of delirium. These findings are potentially useful for screening purposes and for optimizing prevention strategies targeted at reducing the incidence of postoperative delirium.

Background/aims: To examine the influence of dementia stage and psychoactive medication use on the factor structure of the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) in Dutch nursing home patients., Methods: The NPI-NH was administered to a large sample of 1,437 patients with mild to severe dementia receiving nursing home care. Exploratory factor analysis was used to examine behavioural dimensions underlying neuropsychiatric symptoms indicated by the NPI-NH across dementia stages (as assessed with the Global Deterioration Scale - GDS) and in patients with or without psychoactive medication prescribed., Results: In GDS stages 4/5, 6 and 7, a 4- or 5-factor solution was found, with factors referred to as agitation/aggression, depression, psychosis, psychomotor agitation and apathy. These symptom clusters were replicated in the group of drug-naive patients, but only partially in the group of patients on psychoactive medication., Conclusion: The factor structure of the NPI-NH in nursing home patients is consistent with the clinical taxonomy of symptoms, is relatively stable across dementia stages, and is only moderately influenced by psychoactive medication use. The division of depression and apathy into separate behavioural dimensions - also in patients with severe dementia - may have important therapeutic consequences., (2007 S. Karger AG, Basel)

Background/aims: To establish the construct validity of the Dutch version of the Cohen-Mansfield Agitation Inventory (CMAI-D) in institutionalized patients with dementia., Methods: The CMAI-D was administered to a large sample of 1,437 patients with moderate to severe dementia, receiving nursing home or outreaching nursing home care. Exploratory factor analysis was used to examine the behavioral dimensions underlying CMAI-D observations., Results: A restricted 3-factor solution showed 3 factors, i.e. physical aggression, physically nonaggressive behavior and verbally agitated behavior, with prevalences of 62, 67 and 62%, respectively. An unrestricted factor solution revealed 3 additional behavioral dimensions: hiding/hoarding, vocal agitation and a factor of miscellaneous items (i.e. repetitious mannerisms, spitting), which occurred in 30, 28 and 35% of the patients, respectively., Conclusion: The 3-factor solution of physical aggression, physically nonaggressive behavior and verbally agitated behavior corroborates earlier findings in other patient samples and therefore establishes the construct validity in institutionalized patients with severe dementia. The robustness of these findings across different care settings suggests that agitated behaviors have a common basis. In addition, unrestricted factor analysis showed 3 other important independent behavioral symptoms in dementia, but they are in fact too small to be used as a subscale. These findings might add to the taxonomy of agitation and aggression in dementia., (Copyright 2007 S. Karger AG, Basel)

Objectives: To evaluate risk factors for postoperative delirium in a cohort of elderly hip-surgery patients and to validate a medical risk stratification model., Design: Prospective cohort study., Setting: Medical school-affiliated general hospital in Alkmaar, the Netherlands., Participants: Six hundred three hip-surgery patients aged 70 and older screened for risk factors for postoperative delirium., Measurements: Predefined risk factors for delirium were assessed on admission. One point was assigned for each of four risk factors present, resulting in three groups: low, intermediate, and high risk. Baseline screening and assessment included the Mini-Mental State Examination, the standardized Snellen test for visual impairment, chart review to determine Acute Physiological and Chronic Health Evaluation II score, and blood urea nitrogen to creatinine ratio. The primary outcome was postoperative delirium, as defined using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria. All patients were screened daily for delirium., Results: Incidence of delirium was 3.8% in the low-risk group (P<.001), 11.1% in the intermediate-risk group (P=.27, relative risk (RR)=3.0), and 37.1% in the high-risk group (P<.001, RR=9.8). Cognitive impairment at admission had the highest predictive value for postoperative delirium (coefficient of determination=0.15). Contrary to previous findings, age was an independent predictive factor for delirium. Moreover, postoperative delirium was four times as frequent in acute patients as in elective hip-replacement patients., Conclusion: The medical risk factor model is valid for elderly hip-surgery patients. Cognitive impairment, age, and type of admission are important risk factors for delirium in this surgical population.

Background: Delirium is a common psychiatric disorder in general hospital elderly patients. Several delirium screening tests exist. Few nurse based delirium severity measures are available. The aim of this study was to evaluate the Delirium-O-Meter, a new nurses' behavioural rating scale that is an efficient and sensitive measure of delirium severity., Methods: Analysis of cross sectional and repeated assessments data. Participants were 92 elderly general hospital patients; 56 with delirium, 24 with dementia or other cognitive disturbances (no delirium) and 12 with other psychiatric disorders or no mental disorder. Measures were the Delirium-O-Meter (DOM), Delirium Rating Scale-Revised version (DRS-R-98), Delirium Observation Scale (DOS), Behavioural observation scale for geriatric inpatients (GIP) and Mini Mental State Examination (MMSE)., Results: The majority of DOM items show a (near-) normal score distribution. Reliability of the DOM was high; Cronbach's alpha values ranged from 0.87-0.92; Intra Class Correlation (ICC) range was 0.84-0.91 for total scores and 0.40-0.97 for item scores. Factor analysis produced a 'Cognitive/Motivational' factor explaining almost half of variance and a smaller 'Psychotic/Behavioural' factor. The two-factor model results support the conceptual distinction between hyperactive and hypoactive delirium. DOM observations differentiated delirium from non delirium patients. DOM total scores were highly related to the DRS-R-98, DOS, MMSE and GIP apathy and cognitive sub scales, but less so to the GIP affective disturbances subscale, indicating convergent and divergent validity. Temporal difference scores calculated for DRS-R-98 and DOM assessments on subsequent days were also highly related (rho = 0.80-0.95)., Conclusions: The newly constructed DOM is a brief and valid nurses' behavioural rating scale that can be useful for measuring different aspects of delirium and for efficiently monitoring delirium severity in elderly patients., (Copyright (c) 2005 John Wiley & Sons, Ltd.)

Delirium is a severe psychiatric syndrome that is highly prevalent in elderly patients in a general hospital. Primary prevention is important to prevent delirium. This article reviews recent developments with regard to multifactorial intervention trials for primary prevention of delirium. The review process involved a systematic search in MEDLINE, The Cochrane Database and CINAHL Database and subsequent examination of reference lists. Six studies were selected. Four studies showed that systemic interventions regarding medical-, nurse-led, environmental-, and educational items, were effective in preventing delirium. In one study a reduction was found in duration and severity of duration only. One study showed no effect on delirium at all. Despite the methodological weaknesses of the studies, conclusions are that different kinds of non-pharmacological interventions can be effective in preventing delirium.

Objectives: To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk for delirium., Design: Randomized, double-blind, placebo-controlled trial., Setting: Large medical school-affiliated general hospital in Alkmaar, The Netherlands., Participants: A total of 430 hip-surgery patients aged 70 and older at risk for postoperative delirium., Intervention: Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients., Measurements: The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version-98 (DRS-R-98)), the duration of delirium, and the length of hospital stay., Results: The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk=0.91, 95% confidence interval (CI)=0.6-1.3); the mean highest DRS-R-98 score+/-standard deviation was 14.4+/-3.4 and 18.4+/-4.3, respectively (mean difference 4.0, 95% CI=2.0-5.8; P<.001); delirium duration was 5.4 versus 11.8 days, respectively (mean difference 6.4 days, 95% CI=4.0-8.0; P<.001); and the mean number of days in the hospital was 17.1+/-11.1 and 22.6+/-16.7, respectively (mean difference 5.5 days, 95% CI=1.4-2.3; P<.001). No haloperidol-related side effects were noted., Conclusion: Low-dose haloperidol prophylactic treatment demonstrated no efficacy in reducing the incidence of postoperative delirium. It did have a positive effect on the severity and duration of delirium. Moreover, haloperidol reduced the number of days patients stayed in the hospital, and the therapy was well tolerated.

Objective: To explore the phenomenology and prevalence of Self-Injurious Behaviour (SIB) in nursing home patients with dementia., Method: Cross-sectional study of 110 nursing home patients with dementia. Nurses' ratings of SIB and other behavioural disturbances were compared to independent resident physician ratings of medical charts data pertaining to dementia type, dementia severity, prescribed psychotropic drugs, immobility and measures to restrain the patient. Instruments used were the Overt Aggression Scale (OAS, modified), Behaviour Rating Scale for Psychogeriatric Inpatients (GIP), Rating scale for Older Patients (BOP)., Results: SIB was observed in 22% of the dementia patients. Pinching or scratching oneself and banging one's fist against objects were most frequently reported. Five patients showed a combination of two types of SIB. As expected, SIB was modestly related to Aimless repetitive behaviour and Aggression and no association was found between SIB and Apathy. Correlates of SIB were prescribed psychotropics (i.e. benzodiazepines), immobility and measures to restrain the patient., Conclusions: Preliminary data suggest that SIB is a specific psychopathological phenomenon that is highly prevalent in nursing home patients with dementia. Future research should focus on the aetiology and treatment of SIB., (Copyright 2005 John Wiley & Sons, Ltd.)

Delirium is commonly encountered in elderly patients in general hospitals. Most patients with delirium respond well within 12 days of commencement of treatment with haloperidol. A significant number of patients, however, does not improve. Three elderly male patients aged 85, 79 and 81 respectively suffering from prolonged delirium and unresponsive to haloperidol or atypical anti-psychotic drugs, responded well within days to treatment with rivastigmine--a cholinesterase-inhibitor. It was very well tolerated. In The Netherlands cholinesterase inhibitors are registered for the symptomatic treatment of Alzheimer's disease. There is some evidence, both from animal and human experiments, that cholinergic deficiency plays a role in certain types of delirium. Therefore treatment of delirium with a cholinesterase-inhibitor seems logical. Controlled studies are needed to evaluate the effects of these types of drugs in patients with prolonged delirium.

Objective: To examine different conceptual models of negative symptoms in Alzheimer's disease., Design: Confirmatory factor analysis of cross-sectional data., Subjects: Alzheimer patients (n=281) admitted to a psychogeriatric observation ward., Materials: Nurses' Behavioural observation scale for psychogeriatric inpatients (GIP). Global clinical ratings of severity of dementia and depression based on the Cambridge Examination for Mental Disorders of the Elderly-Dutch version (CAMDEX-N)., Results: A unidimensional model of dementia fitted the data poorly. Multidimensional models produced better results. In two- and three-factor models negative symptoms were separated from cognitive impairment and mood disturbances. The more severe the memory impairment, the more socially withdrawn patients were. In this sense negative symptoms may have been secondary to cognitive decline. However, no association was found between negative symptoms and mood disturbances., Conclusions: Negative symptoms are a prominent clinical feature of Alzheimer's disease and they are related to memory impairment but not to mood disturbances., (Copyright 2003 John Wiley & Sons, Ltd.)

Unlabelled: The Neuropsychiatric Inventory is a clinical instrument for assessing behavioral and psychological symptoms in dementia. It is based on an interview with the primary caregiver. A brief questionnaire form of the NPI was developed, intended for use in routine clinical practice (NPI-Q). This study evaluates the validity of the NPI-Q Dutch form. The NPI-Q was compared to other questionnaires, i.e. the Revised Memory and Behavioural Problems Checklist (RMBPC), the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-N), the 15 items Geriatric Depression Scale (GDS-15) and the Cognitive Screening Test (CST-20). A data set was used of geriatric outpatients who were referred for neuropsychological assessment (n = 29). Correlations between the NPI-Q and RMBPC Depression- and Disinhibition subscales were relatively high. No relationship was found between the NPI-Q and the RMBPC Memory related behavioral changes subscale, or between the NPI-Q and the IQCODE-N and the CST-20. Informant ratings on the NPI-Q depression-item were related with patient ratings on the GDS-15, especially when patients were relatively mildly cognitive impaired. Caregiver distress was strongly associated with NPI-Q symptom assessment., In Conclusion: our preliminary results support validity of the NPI-Q Dutch form. It is a practical rating scale for assessing neuropsychiatric symptoms in dementia and associated caregiver distress.

Behavioral and psychological symptoms are highly prevalent in dementia. The Neuropsychiatric Inventory was constructed to measure these symptoms. Data from three studies are presented concerning psychometric aspects of the NPI Dutch version. The NPI was compared to the Revised Memory and Behavioral Problems Checklist (RMBPC) and the Mini Mental State Examination (MMSE). In the three selected patient samples prevalence of behavioral or psychological symptoms was as high as 90%. Interrater agreement (n = 19) was very high (kappa > .90). Factor analysis (n = 199) supports NPI construct validity. The NPI items correlated reasonably high (R = .35 - .60) with the relevant RMBPC subscales (n = 24). Although some NPI items did, the NPI total score was not significantly related to the MMSE. The NPI Dutch version can be scored objectively and it is a valid rating scale for measuring a wide range of behavioral and psychological symptoms of dementia.

This study focused on the relationship between attention and dementia screening test performance, using the adapted Wechsler's Digit Span test for elderly patients, the Cognitive Screening Test (CST) and the Amsterdam Dementia Screening Test (ADS6). Participants were dementia patients and psychiatric patients (n = 147). In both groups no floor-effect was found on the Digit Span test. Principal components analysis showed that CST and ADS6-scores had relatively high loadings on one factor, in contrast to digit span scores that loaded on a second factor. On average, psychiatric patients did hardly worse than normal controls. Attention deficits were more apparent in dementia patients. Considering a maximum of r = .41, these more or less subtle deficits were only moderately related to dementia screening test performance. It is concluded that the adapted Digit Span test is suitable for measuring attention deficits in elderly patients. However, Digit Span predicts performance on dementia screening test only to a modest degree.

This study evaluated some psychometric qualities of the Dutch short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-N). The score profile on the short form IQCODE-N was comparable in two outpatient populations. Short form and regular IQCODE-N are equivalent, as they were highly correlated (r = 0.97). However, using IQCODE-N cut-off scores the short form appeared to be more strict in defining 'decline'. A moderately high correlation was found between informant ratings and dementia screening tests CST (r = -0.47) and ADS (r = -0.46). Informant ratings were not influenced by patient's age or level of education. The short form IQCODE-N describes cognitive change in everyday activities of elderly patients and can be an efficient rating scale for clinical assessment of dementia.