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Behavioral and Psychological Symptoms of Dementia and Bipolar Spectrum Disorders: Review of the Evidence of a Relationship and Treatment Implications

Published online by Cambridge University Press:  07 November 2014

Abstract

Dementia is a neuropsychiatric disorder characterized by cognitive impairment and behavioral disturbances. The behavioral and psychological symptoms of dementia (BPSD) are common, contributing to caregiver burden and premature institutionalization. Management of BPSD is complex and often needs recourse to psychotropic drugs. Though widely prescribed, there is a lack of consensus concerning their use, and serious side effects are frequent. This is particularly the case with antidepressant treatment based on the assumption that BPSD is depressive in nature. A better understanding of BPSD etiology could lead to better management strategies. We submit that some BPSD could be the consequence of both dementia and an undiagnosed comorbid bipolar spectrum disorder, or a pre-existing bipolar diathesis pathoplastically altering the clinical expression of dementia. The existence of such a relationship is based on clinical observation, as far as the high frequency of bipolar spectrum disorders in the general population, with a prevalence estimated to be between 5.4% and 8.3%, and the psychopathological similarities between BPSD and mood disorder episodes in bipolar illness. We will review the concept of the bipolar spectrum and explain BPSD before proposing clinical pointers of a possible bipolar spectrum contaminating the phenomenology of dementia, which could lead to the targeted prescription of mood-stabilizing agents in lieu of antidepressant monotherapy. These considerations are of heuristic interest in reconceptualizing the origin of the behavioral manifestations of dementia, with important implications for geriatric practice.

Type
Review Articles
Copyright
Copyright © Cambridge University Press 2008

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References

REFERENCES

1.Lyketsos, CG, Steinberg, M, Tschanz, JT, et al.Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry. 2000;157:708714.CrossRefGoogle Scholar
2.Steinberg, M, Sheppard, JM, Tschanz, JT, et al.The incidence of mental and behavioural disturbances in dementia: the cache county study. J Neuropsychiatry Clin Neurosci. 2003;15:340345.CrossRefGoogle Scholar
3.Zuidema, S, Koopmans, R, Verhey, F. Prevalence and predictors of neuropsychiatric symptoms in cognitively impaired nursing home patients. J Geriatr Psychiatry Neurol. 2007;20:4149.CrossRefGoogle ScholarPubMed
4.Finkel, SI, Costa e Silva, J, Cohen, G, et al.Behavioral and psychological signs of dementia: a consensus statement on current knowledge and implications for research and treatment. Int Psychogeriatr. 1996;8:497500.CrossRefGoogle ScholarPubMed
5.Steele, C, Rovner, B, Chase, GA, Folstein, M. Psychiatric symptoms and nursing home placement of patients with Alzheimer's disease. Am J Psychiatry. 1990;147:10491051.Google ScholarPubMed
6.Clyburn, LD, Stones, MJ, Hadjistavropoulos, T, Tukko, H. Predicting caregiver burden and depression in Alzheimer's disease. J Gerontol B Psychol Sci Soc Sci. 2000;55:S2S13.Google ScholarPubMed
7.Mittelman, MS, Haley, WE, Clay, OJ, Roth, DL. Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. Neurology. 2006;67:15921599.CrossRefGoogle ScholarPubMed
8.Sink, MS, Hodden, KF, Yaffe, K. Pharmacological treatment of neuropsychiatric symptoms of dementia. A review of the evidence. JAMA. 2005;293:596608.CrossRefGoogle ScholarPubMed
9.Dunner, DL, Gershon, ES, Goodwin, FK. Heritable factor and the severity of the affective illness. Biol Psychiatry. 1976;11:3142.Google ScholarPubMed
10.Akiskal, HS, Djenderedjian, AH, Rosenthal, RH, Khani, MK. Cyclothymic disorder: Validating criteria for inclusion in the bipolar affective group. Am J Psychiatry. 1977;134:12271233.Google ScholarPubMed
11.Klerman, GL. The spectrum of mania. Compr Psychiaty. 1981;22:1120.CrossRefGoogle ScholarPubMed
12.Akiskal, HS, Mallya, G. Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol. 1987;23:6873.Google ScholarPubMed
13.Akiskal, HS, Pinto, O. The evolving bipolar spectrum: prototypes I, II, II, and IV. Psychiatr Clin North Am. 1999;22:517534.CrossRefGoogle ScholarPubMed
14.Akiskal, HS, Bourgeois, ML, Angst, J, et al.Re-evaluating the prevalence and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord. 2000;59:S5S30.CrossRefGoogle ScholarPubMed
15.Akiskal, HS, Hantouche, EG, Allilaire, JF, et al.Validating antidepressant-associated hypomania (bipolar III): a systematic comparison with spontaneous hypomania (bipolar II). J Affect Disord. 2003;73:6574.CrossRefGoogle ScholarPubMed
16.Regier, DA, Myers, JK, Kramer, M, et al.The NIMH Epidemiologic Catchment Area (ECA) Program: Historical context, major objectives and study population characteristics. Arch Gen Psychiatry. 1984;41:934941.CrossRefGoogle ScholarPubMed
17.Kessler, RC, Mc Gonagle, KA, Zhao, S, et al.Life-time and 12 month prevalence of DSM-II-R psychiatric disorders in the United states: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:819.CrossRefGoogle Scholar
18.Angst, J. The emerging epidemiology of hypomania and bipolar II disorder. J Affect Disord. 1998;50:143151.CrossRefGoogle ScholarPubMed
19.Judd, LL, Akiskal, HS. The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthresh-old cases. J Affect Disord. 2003;73:123131.CrossRefGoogle Scholar
20.Merikangas, KR, Simon, GE, Wang, PS. Prevalence and effects of mood disorders on work performance in a nationally representative sample of US workers. Am J Psychiatry. 2006;163:15611568.Google Scholar
21.Gorwood, P. Confusing clinical presentations and differential diagnosis of bipolar disorder. Encephale. 2004;30:182193.CrossRefGoogle ScholarPubMed
22.Akiskal, HS, Benazzi, F. Optimizing the detection of bipolar II in outpatient private practice: Toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry. 2005;66:914921.CrossRefGoogle Scholar
23.Akiskal, HS. Delineating irritable-choleric and hyperthymic temperaments as variants of cyclothymia. J Person Disord. 1992;6:326342.CrossRefGoogle Scholar
24.Hantouche, EG, Akiskal, HS, Lancrenon, S, et al.Systematic clinical methodology for validating bipolar-ll disorder: data in mid stream from a French national multi-site study (EPIDEPI. J Affect Disord. 1998;50:163173.CrossRefGoogle Scholar
25.Allilaire, JF, Hantouche, EG, Sechter, D, et al.Frequency and clinical aspect of BP-II: data from the French multisite study EDIDEP. Encephale. 2001;27:149158.Google Scholar
26.Akiskal, HS, Akiskal, KK, Lancrenon, S, et al.Validating the bipolar spectrum in the French National EPIDEP Study: Overview of the phenomenology and relative prevalence of its clinical prototypes. J Affect Disord. 2006;96:197205.CrossRefGoogle ScholarPubMed
27.Akiskal, HS. Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatr Scand. 2004;110:401407.Google ScholarPubMed
28.Akiskal, HS, Chen, S, David, G, et al.Borderline: an adjective in search of a noun. J Clin Psychiatry. 1985;46:4148.Google ScholarPubMed
29.Perugi, G, Akiskal, HS, Toni, C, Simonini, E, Gemignani, A. The temporal relationship between anxiety disorders and (hypo)mania: a retrospective examination of 63 panic, social phobic and obsessive compulsive patients with comorbid mood disorder. J Affect Disord. 2001;67:199206.CrossRefGoogle Scholar
30. The ICD-10 classification of mental and behavioral disorders. Geneva Switzerland: World Health Organization; 1992.Google Scholar
31.Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text rev. Washington, DC: American Psychiatric Association; 2000.Google Scholar
32.Akiskal, HS, Placidi, GF, Signoretta, S, et al.TEMPS-I: Delineating the most discriminant traits of cyclothymic, depressive, irritable and hyperthymic temperaments in a non patient population. J Affect Disord. 1998;51:719.CrossRefGoogle Scholar
33.Akiskal, HS, Akiskal, KK. Special Issue: TEMPS: Temperament Evaluation of Memphis, Pisa, Paris and San Diego. J Affect Disord. 2005;85:1242.CrossRefGoogle Scholar
34.Helmer, C, Peres, K, Letenneur, Let al.Dementia in subjects aged 75 years or over within the PAQUID cohort: prevalence and burden by severity. Dement Geriatr Cogn Disord. 2006;22:8794.CrossRefGoogle ScholarPubMed
35.Benoit, M, Brocker, P, Clement, JP, et al.Behavioral and psychological symptoms in dementia: description and management. Rev Neurol. 2005;161:357366.CrossRefGoogle ScholarPubMed
36.Benoit, M, Staccini, P, Brocker, P, et al.Behavioural and psychologic symptoms in Alzheimer's disease: results of the REALFR study. Rev Med Interne. 2003;24:319s324s.CrossRefGoogle Scholar
37.Stern, Y, Tang, MX, Albert, MS, et al.Predicting time to nursing home care and death in individuals with Alzheimer disease. JAMA. 1997;277:806812.CrossRefGoogle ScholarPubMed
38.Gonzalez-Salvador, MT, Arango, C, Lyketsos, CG, Barba, AC. The stress and psychological morbidity of the Alzheimer patient caregiver. Int J Geriatr Psychiatry. 1999;14:701710.3.0.CO;2-#>CrossRefGoogle ScholarPubMed
39.Bird, M, Jones, RH, Korten, A, Smithers, H. A controlled trial of a predominantly psychosocial approach to BPSD: treating causality. Int Psychogeriatr. 2007;19:120.CrossRefGoogle ScholarPubMed
40.Birks, J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006;25:CD005593.Google Scholar
41.Gauthier, S, Wirth, Y, Mobius, HJ. Effects of memantine on behavioural symptoms in Alzheimer's disease patients: an analysis of the Neuropsychiatric Inventory (NPI) data of two randomised, controlled studies. Int J Geriatr Psychiatry. 2005;10:459464.CrossRefGoogle Scholar
42.Schneider, LS, Tariot, PN, Dagerman, KS, et al.Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. N Engl J Med. 2006;335:15251538.CrossRefGoogle Scholar
43.Galland, F, Vaille-Perret, E, Jalenques, I. Bipolar disorders in the elderly. Psychol Neuropsychiatr Vieil. 2005;3:115123.Google ScholarPubMed
44.Akiskal, HS, Pinto, O, Lara, DR. Bipolarity in the setting of dementia: bipolar type VI? Medscape Family Medicine/Primary Care. Available at: http://www.medscape.com/viewarticle/495795. Accessed August 21, 2008.Google Scholar
45.Cummings, JL, Mega, M, Gray, K, et al.The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994;44:23082314.CrossRefGoogle ScholarPubMed
46.Depp, CA, Jeste, DV. Bipolar disorder in older adults: a critical review. Bipolar Disorder. 2004;6:343367.CrossRefGoogle ScholarPubMed
47.Sajatovic, S. Treatment of bipolar disorder in older adults. Int J Geriatr Psychiatry. 2002;17:865873.CrossRefGoogle ScholarPubMed
48.Evans, DL, Byerly, MY, Greer, RA. Secondary mania: diagnosis and treatment. J Clin Psychiatry. 1995;56:3137.Google ScholarPubMed
49.Goldberg, JF. Treatment guidelines: current and future management of bipolar disorder. J Clin Psychiatry. 2000;61:1218.Google ScholarPubMed
50.Meinhold, JM, Blake, LM, Mini, LJ, et al.Effect of divalproex sodium on behavioural and cognitive problems in elderly dementia. Drugs Aging. 2005;22:615626.CrossRefGoogle ScholarPubMed
51.Tariot, PN, Schneider, LS, Mintzer, J, et al.Safety and tolerability of divalproex sodium in the treatment of signs and symptoms of mania in elderly patients with dementia: results of a double blind controlled trial. Curr Ther Res Clin Exp. 2001;62:5167.CrossRefGoogle Scholar
52.Porsteinsson, AP, Tariot, PN, Erb, R, et al.Placebo-controlled study of divalproex sodium for agitation in dementia. Am J Geriatr Psychiatry. 2001;9:5866.CrossRefGoogle ScholarPubMed
53.Sival, RC, Haffmans, PM, Jansen, PA, Duursma, SA, Eikelboom, P. Sodium valproate in the treatment of aggressive behavior in patients with dementia: a randomized placebo controlled clinical trial. Int J Geriatr Psychiatry. 2002;17:865873.CrossRefGoogle ScholarPubMed
54.Tariot, PN, Raman, R, Jakimovich, L. Divalproex sodium in nursing home residents with possible or probable Alzheimer disease complicated by agitation: a randomized, controlled trial. Am J Geriatr Psychiatry. 2005;13:942949Google ScholarPubMed
55.Lonergan, ET, Cameron, M, Luxenberg, J. Valproic acid for agitation in dementia. Cochrane Database Syst Rev. 2004;2:CD003945.CrossRefGoogle Scholar
56.Ng, B, Camacho, A, Lara, DR, et al.A case series on the hypothesized connection between dementia and bipolar spectrum disorders: Bipolar type VI? J Affect Disord. 2008;107:307315.CrossRefGoogle ScholarPubMed