Psychiatric symptoms in patients with dementia predict the later development of behavioural abnormalities

BACKGROUND: Cross-sectional studies of non-cognitive symptoms in dementia show that patients with psychotic symptoms tend to have more disturbed behaviour. However, it is not known whether individuals who experience psychiatric symptoms early in dementia are more prone to develop behavioural problems later in the illness. METHOD: The behaviour of 86 community-dwelling subjects with dementia was intensively studied for 4 years or until death, using an informant interview which was administered every 4 months on a median of eight occasions. The extent to which psychiatric symptoms, age, sex and cognitive function predicted clinically significant physical aggression or motor hyperactivity was assessed. RESULTS: Physical aggression was predicted by sad appearance and motor hyperactivity was predicted by persecutory ideas. These associations were robust, remaining significant over 2, 3 and 4 years of follow-up and were independent of cognitive function, age, sex and duration of illness. CONCLUSIONS: There may be two distinct longitudinal syndromes of non-cognitive symptoms in dementia. This suggests that important aberrant behaviours in late dementia may share pathophysiological mechanisms with psychiatric symptoms in early dementia.     

Depression in elders with dementia: implications for home healthcare practice

In addition to severe cognitive decline, depressive symptoms occur in almost 50% of patients with dementia. Depressive symptoms can be treated successfully, thereby reducing clinical manifestations of coexisting dementia and improving quality of life for these patients and their families. Practical assessment, interventions, and referral guidelines are presented for home healthcare nurse generalists whose caseloads include elders with both cognitive decline and depressive symptoms.     

Psychiatric aspects of temporal arteritis: a case report and review of the literature

Temporal arteritis may present with atypical manifestations that can hamper its diagnosis. We report a case presenting with predominantly psychiatric symptoms including psychotic features and affective symptoms both on a background of cognitive impairment. Such clear-cut psychotic symptoms have not been described previously in the literature. Corticosteroid treatment was followed by full remission of psychotic and affective symptoms; treatment with antipsychotic medication was unnecessary. Temporal arteritis should be considered in the differential diagnosis of psychosis and affective disorder in the elderly. The erythrocyte sedimentation rate is a valuable parameter in the assessment of old-age psychiatry patients presenting both with functional and neurologic disorders.     

Psychopathology in younger versus older persons with very mild and mild dementia of the Alzheimer type

OBJECTIVE: The psychopathology associated with early-onset dementia of the Alzheimer type was investigated by comparing the prevalence of psychiatric symptoms in younger subjects (mean age = 59 years) who had very mild or mild dementia with that in older adults (mean age = 72) whose dementia was of equivalent severity. METHOD: Nondemented comparison subjects and persons with very mild or mild dementia of the Alzheimer type were recruited to participate in longitudinal studies. All subjects met strict inclusion and exclusion criteria. Information pertaining to personality changes, affective symptoms, and psychotic symptoms was included in the 90-minute semistructured, physician-administered interview, which was used to assign a clinical dementia rating according to published guidelines. The younger group were age 64 or younger and consisted of 20 nondemented subjects, 11 subjects with very mild dementia, and 18 subjects with mild dementia. The older group, described previously, were 64-83 years old and consisted of 83 nondemented subjects, 41 persons with very mild dementia, and 68 subjects with mild dementia. RESULTS: The psychopathology in the younger subjects was similar to that in the older group. Personality changes occurred in over 80% of the younger persons with very mild illness. Psychotic symptoms were present in over 40% of the younger persons with mild illness but were rare in the group with very mild dementia. CONCLUSIONS: Similar patterns of psychopathology in younger and more elderly persons with dementia of the Alzheimer type support the suggestion that these changes are direct effects of the illness on the CNS. Increased attention to documenting these noncognitive symptoms and studying various treatments is urgently needed.     

Mental disorders of drug addicts in treatment: a study of prevalence with retrospective evaluation by means of structured diagnostic interviews

The aim of this research is to evaluate current and lifetime psychiatric morbidity according to ICD-10 criteria of subjects in treatment for psychoactive substance dependence. It is a cross-sectional clinical-epidemiological study also collecting retrospective information by means of structured diagnostic interviews. Ninety-nine outpatients fulfilling criteria of eligibility were recruited by systematic sampling at 8 Italian National Health Service's Drug Dependence Units. Criteria of inclusion were the presence of clinical diagnosis of psychoactive substance dependence according to ICD-10 and age 18-45, while criteria of exclusion were pharmacological distress related to acute withdrawal from street drugs and the presence of severe cognitive impairment, delirium or acute psychoses in order to assure reliability of the interviews. Only 75 patients accepted to participate, were enrolled in the study and interviewed by means of a European adaptation of the Addiction Severity Index. Finally, the Composite International Diagnostic Interview was completed in 65 cases. The prevalence of current psychiatric morbidity for any disorder in addition to substance use disorders was 22.2%, and lifetime prevalence was 35.4% (but, if drop-out cases are excluded from calculation, the prevalence rates grow up to 30-35% and 50-55% respectively). Psychiatric morbidity is more frequent among females and is unrelated to age or lifetime duration of substance use. In almost one-half of the cases mental disorders arose before the beginning of substance use. By order of frequence, anxiety, affective, and schizophrenic syndromes are the most common comorbid diagnoses. Affective disorders are more often secondary, since they mostly develop after the beginning of psychotropic substance use and are uncommon among currently abstinent subjects. Finally, outpatients affected by psychotic disorders are not likely to abstain from psychotropic drugs during the treatment. Psychiatric comorbidity is a considerable point in the clinical management of drug dependence, and for primary and secondary prevention of substance use disorders.     

Syndromes of psychosis and nonpsychosis: Factor analysis of a systems analysis.

Factor analyzed the ratings of 924 psychotic and nonpsychotic patients on the Boston City Hospital-Behavior Checklist, a 100-item behavior rating scale derived from a recent systems analysis of traditional psychiatric diagnostic procedures. The Biomedical Computer Program BMDX72 was used to factor the matrix of intercorrelations, with 13 factors being defined by an oblique rotation. Discussion of results centers on the degree to which the present factors define dimensions of psychopathology similar to those defined by other analyses of symptom data. The value of factor analysis as a means of assessing the validity of traditional psychiatric syndromes is also discussed. (24 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Postnatal depression: how can midwives help?

The results of recent neuropathologic and genetic studies in Alzheimer's disease led to a renewed interest in differentiations within the dementia syndrome. New disease-entities can be distinguished (Lewy Body Dementia, Frontal Lobe Dementia) and other criteria have been put forward for vascular dementia. Hachinski's Ischemic Score, for many years the diagnostic criterium for vascular dementia, has been cancelled. Instead a CT- or MRI scan must demonstrate the vascular pathology in the brain. For clinical practice, the differentiation between cortical and subcortical dementia is still important. For reasons of management it appears useful to distinguish between early-onset and late-onset Alzheimer's disease. The amyloid cascade hypothesis for the pathogenesis of Alzheimer's disease is credible for the early-onset as well as the late-onset type, because results from epidemiological as well as from neurobiological studies might be fit in. Moreover, this hypothesis is promising from the point of view of developing specific therapies. Finally, the breakdown of the dementia syndrome in separate disease-entities stimulated interest in the psychiatric symptoms in these patients and activated the development of rational and symptomatic therapeutics.     

Psychiatric hospitalization of senile and arteriosclerotic dementia patients by commitment order under the 1991 Israeli Mental Health Act

Data regarding commitment orders issued by district psychiatrists for elderly patients aged 65 years or older were obtained from the national psychiatric case register. Out of a total of 2,284 commitment orders issued in Israel in the period 1 January 1992 to 30 June 1993 under the 1991 Mental Health Act, 191 (8.3%) involved patients aged 65 and over; these orders were issued for the commitment of 169 patients who suffered from the following ICD-9-CM diagnoses on discharge: senile and arteriosclerotic dementia; transient organic psychotic conditions; schizophrenic disorders; affective psychoses; paranoid states; or other psychiatric disorders. Demographic and clinical characteristics of the senile and arteriosclerotic dementia patients were compared with the same variables in the other diagnostic categories. Results showed that (a) involuntary commitment of senile and arteriosclerotic dementia patients involved a small minority of dementia sufferers; (b) it was usually the patients' first psychiatric admission; (c) most of the patients were discharged within a one-month period; and (d) most of the patients were referred for continuation of treatment in non-psychiatric institutions. Findings (c) and (d) characterized other diagnostic categories as well. The relevance of these findings to the Mental Health Act is discussed.     

Tumor necrosis factor inhibits the transcriptional rate of glucose-6-phosphatase in vivo and in vitro

OBJECTIVE: After Alzheimer's disease, vascular dementia (VaD) and frontotemporal dementia (FTD) are among the most common dementing illnesses. FTD may have a neuropsychological profile similar to that of VaD, and patients with these dementias may be difficult to distinguish on clinical examination. The purpose of this study was to elucidate distinct cognitive profiles of a large group of FTD and VaD patients on a brief, clinical mental status examination. DESIGN: A comparison of 39 FTD patients and 39 VaD patients on a brief, clinical mental status examination. SETTING: A Dementia Research Center and affiliated, university hospitals. METHODS: The FTD patients were diagnosed by noncognitive clinical and neuroimaging criteria, and the VaD patients met NINDS-AIREN criteria for vascular dementia. The two dementia groups were comparable on three dementia assessment scales. MEASUREMENTS: The mental status measures included the neuropsychological battery from the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), plus supplementation from the Neurobehavioral Cognitive Status Examination (NCSE) for cognitive areas not assessed by the CERAD). RESULTS: The FTD and VaD groups differed significantly on the mental status examination measures. FTD patients performed significantly better than the VaD patients on digit span and constructions, despite comparable performance by both groups on calculations. Although not statistically significant, the FTD group performed worse than the VaD group on verbal fluency and abstractions. These differences were not explained by group differences in age and education. CONCLUSION: These results suggest that cognitive differences between FTD and VaD groups reflect greater frontal pathology in contrast to relative sparing of posterior cortex and subcortical white matter in FTD. These cognitive differences as measured by a mental status examination may help distinguish between these two dementia syndromes.     

Occurrence and clinical correlates of psychiatric comorbidity in patients with psychotic disorders

BACKGROUND: The aim of this study was to explore patterns and clinical correlates of psychiatric comorbidity in patients with schizophrenia spectrum disorders and mood spectrum disorders with psychotic features. METHOD: Ninety-six consecutively hospitalized patients with current psychotic symptoms were recruited and included in this study. Index episode psychotic diagnosis and psychiatric comorbidity were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Psychopathology was assessed by the SCID-P, Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, and Hopkins Symptom Checklist. Awareness of illness was assessed with the Scale to Assess Unawareness of Mental Disorders. RESULTS: The total lifetime prevalence of psychiatric comorbidity in the entire cohort was 57.3% (58.1% in schizophrenia spectrum disorders and 56.9% in mood spectrum psychoses). Overall, panic disorder (24%), obsessive-compulsive disorder (24%), social phobia (17.7%), substance abuse (11.5%), alcohol abuse (10.4%), and simple phobia (7.3%) were the most frequent comorbidities. Within the group of mood spectrum disorders, negative symptoms were found to be more frequent among patients with psychiatric comorbidity than among those without comorbidity, while such a difference was not detected within the group of schizophrenia spectrum disorders. Social phobia, substance abuse disorder, and panic disorder comorbidity showed the greatest association with psychotic features. An association between earlier age at first hospitalization and comorbidity was found only in patients with unipolar psychotic depression. Patient self-reported psychopathology was more severe in schizophrenia spectrum patients with comorbidity than in those without, while such a difference was less pronounced in mood spectrum psychoses. CONCLUSION: These findings suggest that psychiatric comorbidity is a relevant phenomenon in psychoses and is likely to negatively affect the phenomenology of psychotic illness. Further studies in larger psychotic populations are needed to gain more insight into the clinical and therapeutic implications of psychiatric comorbidity in psychoses.     

No increased incidence of Alzheimer's disease in elderly schizophrenics

There is currently controversy as to the morphological basis of cognitive impairment in elderly schizophrenics. In contrast to previous findings, recent studies have found no increased frequency of Alzheimer's disease (AD) pathology in elderly schizophrenics. We examined 99 consecutive autopsy cases of patients over the age of 55 years from a psychiatric hospital who met the DSM-III-R and ICD.10 criteria for schizophrenia (mean age 69.5 +/- 8.25 years; mean duration of illness 35.15 +/- 10.1 years), 56% showing moderate to severe dementia. All brains were blindly reviewed for evidence of AD using CERAD criteria and Braak staging of neuritic AD lesions. "Definite" AD (CERAD C, Braak stage V) was seen in 2 cases aged 56 and 67 years, respectively [2% of total or 1/68 (1.4%) of those over age 65]. "Probable" AD (CERAD B, Braak stages IV-V) were seen in 5 cases aged 71-89 years (mean 79 years; 5% of total or 7.3% of those over age 65), and 1 case each with multiple cerebral infarcts and with Parkinson's disease pathology. In addition, 2 females aged 82 and 89 years, respectively, revealed senile dementia with tangles (NIA, CERAD negative; Braak stage IV), 1 with hippocampal sclerosis. The total incidence of definite and probable AD in this cohort was 7.1% or 8.7% for those over age 65. This is in line with other recent studies showing that the frequency of AD in elderly schizophrenics may be equal or even less than in the general population. The reasons for this negative association and the basis of cognitive deficits in elderly schizophrenics--those with dementia usually showing significantly lower brain weight--await further elucidation.     

Treatment of the psychiatric manifestations of Huntington''s disease: a review of the literature

OBJECTIVE: To review the clinical management of the psychiatric aspects of Huntington's disease (HD), namely the mood disorders, psychotic disorders, anxiety symptoms, sleep disorders, disorders of sexuality, and the behavioural changes of apathy, irritability, and aggression. Emphasis is on pharmacologic and psychotherapeutic intervention strategies. In addition, the role of psychiatric intervention in presymptomatic testing is explored. METHOD: English language literature on the pharmacologic and psychotherapeutic management of the psychiatric manifestations of HD between 1976 and 1996 was critically reviewed. RESULTS: Few sound studies address the clinical management of the psychiatric aspects of HD; thus, only the broadest conclusions can be drawn. Pharmacologic strategies for the treatment of psychiatric aspects of HD were organized according to the therapeutic agent and class, and psychotherapeutic strategies were discussed. CONCLUSION: The clinical management of the psychiatric manifestations of HD requires much more complete and systematic study before any definite conclusions as to efficacy of various approaches can be drawn.     

Non-cognitive aspects of dementia

OBJECTIVE: To observe the frequency of various psychiatric disorders (depressive disorders, anxiety state and paraphrenic-paranoid disorders). PATIENTS AND METHODS: This study includes the 'cases' of dementia detected in an epidemiological field study done door-to-door, double phased and including non-institutionalized persons aged over 69 years in a rural area. All diagnoses were done by CAMDEX and on these criteria. RESULTS: Depressive disorder was diagnosed in 26.5% studied, paraphrenic or paranoid disorder in 14% and anxiety state in 6.5%. Depression and paraphrenic-paranoid disorder were not associated with the severity of the dementia, whilst anxiety state was more commonly seen in mild dementia. Paraphrenic-paranoid disorders were commoner in women than in men. CONCLUSION: The considerable prevalence of other psychiatric diagnoses in persons with dementia shows that non-cognitive symptoms are common in these patients.     

Heterogeneity of cognitive profiles in dementias of the Alzheimer type: theoretical aspects and clinical consequences

Presently, Alzheimer's disease can only be diagnosed with the coexistence of clinical symptoms and the presence of neuropathological alterations. Thus, in the absence of pre mortem biological markers, cognitive deficits form the starting point and the basis of inclusion criteria on which the clinician relies in order to make a putative diagnose of dementia of the Alzheimer type (DTA). Cognitive deficits should thus be accurately described through neuropsychological testing since it is essential to identify the cognitive deterioration patterns of the patients--in terms of selective impairment of cognitive functions--as well as the evolution of these patterns. Regarding this issue, the classical teaching of the Geneva school has proposed a homogeneous deterioration of the aphasic-apraxicagnosic syndrome into four stages. However, recent work does not support this hypothesis. On the contrary, these studies tend to show the presence of heterogeneity in neuropsychological manifestations of the disease. The aim of the present paper is to provide a critical review of this topic through a brief survey of the classical work and research that have recently been conducted. An analysis of the possible candidates responsible for the existence of this heterogeneity of cognitive profiles is presented. Finally, theoretical implications and clinical repercussions are discussed.     

Velogenic Newcastle disease virus in captive wild birds

This study investigated the correlates of change in behavioral disturbance in geropsychiatric inpatients with dementia. It was hypothesized that improvement in specific psychiatric symptoms, such as psychosis and depression, contribute to the improvement of specific behavioral disturbances. All admissions between October 1993 and May 1995 were reviewed to identify those patients admitted to the Houston VA geropsychiatry unit with a diagnosis of dementia; 233 patients were included in the study. Improvement in behavioral disturbance symptoms was associated with decreases in depression, thought disorder, and hostility. However, the relative importance of depressive and psychotic symptoms varied depending upon the type of behavioral disturbance examined. These results may support a focused approach employing therapies specific to the type of behavioral disturbance.     

Dementias--diagnosis, differential diagnosis and therapy

The most common cause of primary (degenerative) dementia in old age is Alzheimer's disease, with vascular forms of dementia taking second place. Endocrinopathies, normal pressure hydrocephalus and space-occupying lesions are frequent causes of secondary dementia. A multitude of further, more rare clinical presentations results in a wide differential diagnostic spectrum necessitating a careful diagnostic work-up of the demential syndrome before considering treatment. This work-up must include clinical, laboratory and equipment-based investigations. The multimodal therapeutic approach to dementia covers not only the elimination of treatable underlying causal conditions and the medical treatment of cognitive symptoms and psychiatric accompanying symptoms, but also non-medicamentous aspects.     

Alzheimer's disease and its Lewy body variant: a clinical analysis of postmortem verified cases

OBJECTIVE: The authors compared clinical findings of Alzheimer's disease and the so-called Lewy body variant of Alzheimer's disease. METHOD: Available data were analyzed on the clinical features of 58 patients with Alzheimer's disease and 24 patients with the Lewy body variant of Alzheimer's disease who underwent postmortem examination. RESULTS: The proportion of men was significantly larger in the Lewy body variant group than in the Alzheimer's disease group (66.7% versus 34.5%), and, concordantly, the Lewy body variant group was slightly taller. The prevalence of hallucinations and delusions was significantly higher in Lewy body variant subjects than the Alzheimer's disease subjects, but there were no significant differences between the two groups in educational attainment, family history of dementia, age at onset, duration of illness, cognitive impairment, overall severity of illness, or neuropsychological findings. Patients with the Lewy body variant of Alzheimer's disease tended to experience more frequent extrapyramidal side effects of neuroleptics than did the patients with Alzheimer's disease, but for patients in the two groups who were not exposed to neuroleptics, there was little difference in frequency of extrapyramidal side effects. CSF concentration of homovanillic acid (HVA) was significantly lower in the Lewy body variant patients, even when correction was made for height. CONCLUSIONS: The Lewy body variant of Alzheimer's disease may be suspected in elderly male dementia patients who otherwise meet criteria for Alzheimer's disease but who manifest significant psychiatric symptoms and neuroleptic-induced extrapy-ramidal side effects and have low levels of CSF HVA.     

Brain infarction and the clinical expression of Alzheimer disease. The Nun Study

OBJECTIVE: To determine the relationship of brain infarction to the clinical expression of Alzheimer disease (AD). DESIGN: Cognitive function and the prevalence of dementia were determined for participants in the Nun Study who later died. At autopsy, lacunar and larger brain infarcts were identified, and senile plaques and neurofibrillary tangles in the neocortex were quantitated. Participants with abundant senile plaques and some neurofibrillary tangles in the neocortex were classified as having met the neuropathologic criteria for AD. SETTING: Convents in the Midwestern, Eastern, and Southern United States. PARTICIPANTS: A total of 102 college-educated women aged 76 to 100 years. MAIN OUTCOME MEASURES: Cognitive function assessed by standard tests and dementia and AD assessed by clinical and neuropathologic criteria. RESULTS: Among 61 participants who met the neuropathologic criteria for AD, those with brain infarcts had poorer cognitive function and a higher prevalence of dementia than those without infarcts. Participants with lacunar infarcts in the basal ganglia, thalamus, or deep white matter had an especially high prevalence of dementia, compared with those without infarcts (the odds ratio [OR] for dementia was 20.7, 95% confidence interval [95% CI], 1.5-288.0). Fewer neuropathologic lesions of AD appeared to result in dementia in those with lacunar infarcts in the basal ganglia, thalamus, or deep white matter than in those without infarcts. In contrast, among 41 participants who did not meet the neuropathologic criteria for AD, brain infarcts were only weakly associated with poor cognitive function and dementia. Among all 102 participants, atherosclerosis of the circle of Willis was strongly associated with lacunar and large brain infarcts. CONCLUSION: These findings suggest that cerebrovascular disease may play an important role in determining the presence and severity of the clinical symptoms of AD.     

Psychiatric symptoms in patients with dementia treated in a psychogeriatric day hospital

Sixty-five consecutive patients with dementia, treated at a psychogeriatric day hospital, were studied regarding prevalence of psychiatric symptoms. The clinical diagnoses were dementia of the Alzheimer type (n = 19), vascular dementia (n = 27), mixed Alzheimer's disease and vascular dementia (n = 13), vascular dementia of frontal type (n = 2), and other diseases (n = 4). Mean age at referral was 75.6 +/- 6.6 years and the average treatment time was 21 +/- 14 months. About 90% of the patients showed one or several significant psychiatric symptoms during the course of dementia. Most common were delirious episodes, anxiety, sleep disturbances, and depressed mood. The relationship between clinical features and the type and duration of dementia was analyzed. Sleep disturbances and depressed mood often appeared early, whereas misidentification and delusions became more prevalent later in the course of dementia. The results indicate that the psychogeriatric day hospital may offer effective and flexible care and support to demented persons living at home.     

EEG spectral abnormalities and psychosis as predictors of cognitive and functional decline in probable Alzheimer's disease

We examined whether either psychotic features (e.g., delusions and hallucinations) or EEG abnormalities are associated with more rapid progression of Alzheimer's disease (AD). AD patients with psychosis have exhibited more EEG abnormalities than those without psychosis, and both abnormal EEG and psychosis have been noted to be predictors of functional and cognitive decline in AD. Ninety-five probable AD patients participating in a longitudinal study of dementia had an EEG and a semistructured psychiatric interview at baseline. Using EEG spectral analysis, we classified records as normal/abnormal based on the parasagittal mean frequency. Patients with abnormal EEGs were more functionally (e.g., Blessed Rating Scale for activities of daily living) and cognitively (e.g., Mini-Mental State) impaired than patients with normal EEG. AD patients with psychosis were only more functionally impaired than patients without psychosis. A two-factor analysis showed no interaction between abnormal EEG and psychosis. In addition, using a Cox proportional hazard model adjusted for age and education, the presence of an abnormal EEG or psychotic symptom at study entry was associated with higher risk of reaching severe cognitive and functional impairment during follow-up. Neither abnormal EEG nor the presence of psychosis predicted death. These results indicate that both abnormal EEG and psychosis are independent predictors of disease progression but not of physical survival.