Behavioral and psychological signs and symptoms of dementia (BPSD) include disorders of behavior, mood, thought content and perception (Burns et al., 1990a, b, c, d; Foli and Shah, 2000). BPSD are common (Foli and Shah, 2000) and can cause distress to patients, informal carers and professionals, and lead to institutionalization and over-medication (Shah, 1999). Both non-pharmacological and pharmacological treatment strategies have been utilized to improve BPSD. Despite the recent controversy surrounding the use of olanzapine and risperidone for BPSD, a case for judicious use of these drugs is rehearsed below.

Background:Reports in the literature on the effects of behavioral problems in patients with dementia on the decision to institutionalize the patient have shown conflicting results. Few studies have taken into account the possibility that specific behavioral problems may have differential effects on the decision to institutionalize the patient. Moreover, it is probably not patient behavior itself that causes nursing home placement (NHP), but caregivers’ emotional reaction to it. The aim of the present study was to examine the impact of specific behavioral subsyndromes and caregivers’ emotional reaction on NHP.

Methods:A total of 119 patients with dementia and their informal caregivers were followed up for 2 years. Time to NHP was measured in months from the date of the baseline interview to the date of NHP. Behavioral disturbances in the patient and caregivers’ emotional reactions were measured with the Neuropsychiatric Inventory (NPI). Cox regression analyses were used to determine the probability that caregivers would institutionalize the patient when patient behavioral problems or caregiver distress were present at baseline.

ResultsForty-one percent of the patients were institutionalized during the 2-year follow-;up. Caregiver distress related to patient behavior was a significant predictor of NHP, while behavior in itself did not predict NHP. Contrary to our expectations, we did not find a differential impact of specific aspects of problem behavior. Children caregivers, especially daughters, were associated with shorter time to NHP compared to spouses.

Conclusions:Our findings indicate that the caregiver's emotional reaction to patient behavior is more important than problem behaviors per se in the decision to institutionalize patients. Interventions aimed at teaching caregivers strategies to better manage difficult patient behaviors may provide caregivers with the necessary resources to continue care at home. Future interventions need to account for the specific needs and problems of different caregiver groups.

Background and aims: Data on antipsychotic use were collected in two Canadian long-term care (LTC) facilities. During the one-year study, residents in one facility were relocated to a new facility, allowing examination of the changes in antipsychotic use associated with relocation.

Method: A comparative descriptive design was used. Pharmacy and chart data on antipsychotic use were gathered for three separate one-month periods during one year. Data were collected both in a facility experiencing relocation of all residents to a new facility, and in a facility not undergoing relocation. The three one-month data collection periods covered a one-month period before the relocation, immediately after the relocation, and six months after the relocation.

Results: In the facility not experiencing relocation, an average of 31.3% of all residents were receiving antipsychotics. Residents in this facility received antipsychotics for an average length of 0.81 years, and 20.8% of all antipsychotic prescriptions reflected dose reductions within six months of the start of the prescription. Only 8.1% of prescriptions had accompanying documentation on the behavioral indication for the use of antipsychotics. A total of 73.4% of all antipsychotics were ‘atypical’ antipsychotics, and 13.5% of all antipsychotic prescriptions were written as ‘p.r.n.’ (as needed). While the use of antipsychotics remained relatively constant in the non-relocation facility (between 30.3% and 33.1% of all residents), the percentage of residents receiving antipsychotics in the facility experiencing a relocation climbed significantly; from 21.5% six months before the move, to 32.6% immediately after the move, to 36.9% six months after the move.

Conclusion: These findings, when compared with the U.S. standards on antipsychotic use (OBRA), suggest the need for additional research on antipsychotic use in Canadian LTC facilities.

Owing to an unfortunate oversight, the conflict of interest declaration was omitted from the Debate section in the March 2005 issue of International Psychogeriatrics (Volume 17, Part 1). Please find this information below.

Ballard and Cream, henceforth referred to as the “noes”, and Shah and Suh (the “ayes”), express differing views on the matter of prescribing atypical antipsychotics to patients with dementia. They provide new and useful information which demonstrates that the psychogeriatric community is striving conscientiously to improve the management of BPSD. Despite some strong words, the “noes” ultimately admit that “long-term treatment with neuroleptics should (only) be considered in extreme circumstances and with the informed consent of next of kin”. Although this conflicts with their assertion that “there is clearly no rational reason for prescribing…(neuroleptics),” it suggests that the debate is really about defining where the threshold for prescribing neuroleptics to people with dementia should lie, rather than whether we should or shouldn't use the drugs at all. The “ayes” proffer the liberal opinion that clinicians should offer details about efficacy and side-effects to patients and carers in order that they might “weigh up carefully the risks and benefits” of treatment. It is not said in what proportion of cases with BPSD this avenue should be taken, nor is it clear how the final decision will be reached. This is too simplistic a solution. We cannot deal with this issue just by passing the buck to the patient and carer.

A group of neurodegenerative diseases is outlined that affect cortical and subcortical areas of the brain. These diseases give rise to atypical forms of dementia and, unlike Alzheimer's disease (AD), are often associated with neurological symptoms. Clinical symptoms reflect the localization of the degenerative process rather than the nature of the underlying histopathology. Degeneration of the frontal and anterior temporal lobe presents initially with behavioral alterations, but later in the course, impairment of cognition and activities of daily living develops. Posterior cortical atrophy affects the parietal and occipital association cortices and causes complex visual disturbances. In corticobasal degeneration (CBD) the focus of pathology includes the frontoparietal cortex and several subcortical nuclei, causing symmetrical rigidity, bradykinesia, myoclonus and dystonia. Progressive supranuclear palsy (PSP) involves the frontal, temporal and parietal cortex as well as parts of the brain stem. Clinical features include a hypokinetic rigid syndrome with nuchal dystonia and vertical gaze palsy. Huntington's disease is a prototypical autosomal dominant disorder that affects the extrapyramidal system and causes choreatic movements in combination with personality changes and cognitive deterioration. Amyotrophic lateral sclerosis (ALS) with dementia is a neurodegeneration of the frontotemporal cortex and of the anterior horn of the spinal cord. Behavioral change similar to frontotemporal dementia (FTD) is paralleled or followed by the classic features of motor neuron disease.

Background: Dementia is associated with progressive cognitive impairment and behavioral and psychological symptoms. Sleep–wake cycle disturbances are common in patients with dementia. This study evaluated the efficacy and safety of risperidone in the treatment of the behavioral and psychological symptoms of dementia (BPSD) and associated sleep–wake cycle disturbances.

Methods: In this open-label, 12-week, observational, prospective study, the effects of risperidone were assessed using the Neuropsychiatric Inventory (NPI) total and subscale scores. Sleep–wake cycle disturbances were rated by patients/caregivers using a newly developed sleep behavior questionnaire that included assessment of sleep duration, quality, awakenings, and effects on daily activities. Tolerability assessments included the Udvalg for Kliniske Undersogelser (UKU) subscale for extrapyramidal symptoms (EPS) and the recording of adverse events.

Results:A total of 338 patients entered the study, with 321 patients completing. Following 12 weeks of risperidone treatment (mean dose 1.49 mg/day at end-point), the mean NPI score was reduced to 10.6 from a baseline score of 28.7. Compared with baseline, patients/caregivers reported significant improvements following 12 weeks of risperidone in total sleep hours at night (5.5 vs. 7.1 hours), hours awake in bed at night (2.3 vs. 1.2 hours), insomnia (40.1% vs. 8.4%), and other sleep-related variables. Six patients reported a total of 10 adverse events, including somnolence (n = 3) and sialorrhea (n = 2). Scores on the UKU subscale of EPS improved significantly (mean 4.0 at baseline vs. 1.7 at week 12).

Conclusions: Risperidone is effective and well tolerated in the treatment of BPSD and associated sleep disturbances.

Background: A variety of interventions are available to support the caregivers of dementia patients. For the purposes of service planning, we developed an instrument to assess the needs of these caregivers and to determine whether needs are met. The reliability and validity of this new instrument was also investigated.

Methods: The development of the Carers' Needs Assessment for Dementia (CNA-D), was based on in-depth interviews and a focus group. The combined inter-rater and test–retest reliability was investigated among 45 dementia caregivers. Correlations of the CNA-D with the Zarit Burden Inventory were used to analyze concurrent validity. Content validity was investigated by performing a separate survey among 40 caregivers and 40 professionals.

Results: The CNA-D is a semi-structured research interview including 18 problem areas. For each problem area, the CNA-D offers several possible interventions. The relevance of the problem areas and the interventions (content validity) was confirmed by most of the study participants. Significant positive associations were found between the total score of the Zarit Burden Inventory and the number of problems and the number of unmet needs according to the CNA-D. The agreement between the interviewers was “excellent” (κ above 0.75) in 73.7% of the problem areas and in 69.9% of the interventions.

Conclusions: The CNA-D is a valid and reliable instrument for comprehensively assessing the needs of dementia caregivers.

Background: Dementia among nursing home residents is often accompanied by high care dependency and behavioral disturbances, resulting in an increased workload for the caregivers. Snoezelen, integrated into 24-hour dementia care, is an approach that might improve the quality of working life of dementia caregivers. This study aims to investigate the effectiveness of integrated snoezelen on work-related outcomes (workload and psychological outcomes) of caregivers in psychogeriatric nursing homes.

Methods: A quasi-experimental pre- and post-test design was used, comparing six psychogeriatric wards that implemented snoezelen in 24-hour care to six control wards that continued giving usual care. One hundred and twenty-nine Certified Nursing Assistants (CNAs) were included in the pre-test and 127 CNAs in the post-test. The six intervention wards received a 4-day in-house training program. The intervention further consisted of implementation activities on the ward (e.g. stimulus preference screening, workgroup), three in-house follow-up meetings and two general meetings. Measurements on workload, perceived problems, stress reactions, job satisfaction and burnout were performed at baseline and after 18 months.

Results: A significant treatment effect in favor of the experimental group was found for time pressure, perceived problems, stress reactions and emotional exhaustion. CNAs of the experimental group also improved on their overall job satisfaction score. In particular, they were more satisfied with the quality of care and with their contact with residents.

Conclusion: The implementation of snoezelen improved the quality of the working life of dementia caregivers.

Background: Patients with dementia often receive poor end-of-life care, with inadequate pain control and without access to the palliative care services that patients with cancer are offered. This has been identified as an area of need in recent U.K. Government reports and by the Alzheimer's Society (U.K.). Our objective was to perform a systematic review of the scientific literature regarding the efficacy of a palliative care model in patients with dementia.

Methods: A systematic review was carried out to identify controlled trials that investigated the efficacy of palliative care in patients with dementia. Data sources included were Medline, EMBASE, PsycINFO, CINAHL, British Nursing Index, AMED, Cochrane Database of Systematic Reviews, Web of Science, Cochrane Central Register of Controlled Trials, International Standard Randomised Controlled Trial register, the NHS Economic Evaluation Database and the System for Information on Grey Literature in Europe. Other data was sourced from hand searches of papers identified on electronic databases and review articles.

Results: The search identified 30 review articles, but only four papers were eligible for full appraisal and only two of these met the full criteria for inclusion. These papers gave equivocal evidence of the efficacy for a palliative model of care in dementia.

Conclusion: Despite the increased interest in palliative care for patients with dementia there is currently little evidence on which to base such an approach. This may in part be due to the ethical difficulties surrounding such research, prognostic uncertainty in clinicians and the lack of clear outcome measures for patients who are unable to express their needs or wishes. Further systematic research is urgently needed to educate an important and developing area of clinical practice.

Background: The concept of Binswanger's disease (BD) remains unclear and may not constitute a useful diagnostic category. However, cognitive decline may be present in a proportion of patients with subarachnoid hemorrhages (SAH) or subdural hematomas (SH).

Method: We provide a critical review of the concept of BD and summarize the main findings on the association between SAH, SH and cognitive decline.

Results and conclusions: BD was originally identified as a type of dementia different from neurosyphilis and with characteristic white matter atrophy. The phenomenology of BD is currently construed around the concept of frontosubcortical dementia, but the validity of this construct is unclear. Patients with SAH frequently develop a variety of cognitive and behavioral problems that usually result in poor psychosocial adjustment and poor quality of life. SH is a rare cause of progressive cognitive impairment. A proportion of patients (particularly functionally impaired old individuals) are at a high risk for cognitive deficits after surgical drainage of the hematoma.

Background: Risperidone significantly improves behavioral and psychological symptoms of dementia (BPSD), including aggression, agitation and psychosis, as shown by randomized, placebo-controlled trials.

MethodsAn 8-week, multicenter, naturalistic, open-label study was carried out to examine whether the benefits of risperidone apply to clinical practice. A total of 4499 patients were treated with risperidone at flexible doses chosen by physicians, and were included in the safety evaluation. Of these, 3909 patients met the intended study criteria (at least 65 years of age, dementia, and the presence of BPSD) and were included in the efficacy analyses.

Results:At the end of the study (after 8 weeks of treatment), risperidone (average final dose 1.6 mg/day) significantly improved all symptoms studied (agitation, aggressiveness, disturbance of the sleep–wake rhythm, social withdrawal, suspiciousness and delusions) as rated by physicians on a five-point scale of severity. On a four-point scale of global efficacy, more than 90% of patients were rated improved by both physicians and caregivers after 8 weeks of treatment. A significant improvement in sleep-wake cycle disturbances was also noted. A total of 422 adverse events were documented in 346 of the 4499 patients (7.7%); these included insufficient efficacy (2.6%), extrapyramidal symptoms (0.89%), deterioration of psychiatric symptoms (0.73%), sedation (0.56%), gastrointestinal disturbances (0.49%), cardiovascular disorders (0.38%), and cerebrovascular adverse events (0.36%).

Conclusions: Risperidone is an effective and well-tolerated treatment for BPSD in routine clinical practice.

Background: People with behavioral and psychological symptoms of dementia (BPSD) are often prescribed psychotropic medications. There is little evidence that one class of medication is more effective and safer than another and so expert opinion plays an important role in shaping local practice. In an earlier U.S. survey of psychiatrists and neurologists, limited consensus emerged regarding the pharmacological management of BPSD. We repeated this study to check consensus levels in Australia and New Zealand, following the introduction of newer atypical neuroleptics, antidepressants and cholinesterase inhibitors, and to identify areas where drug trials will be of greatest benefit.

Methods: A brief structured survey, similar to one used in the U.S.A., was posted to a random sample of members of the Australian and New Zealand Faculty of Psychiatry of Old Age.

Results: We received 106 replies (71% response). Respondents, who had 14 years' experience on average, rated atypical neuroleptics as their treatment of choice for dementia complicated by psychosis, verbal aggression, physical aggression, sundowning and persistent yelling. Opinions varied widely regarding the management of other symptoms and the role of second-line treatments.

Conclusion: Atypical neuroleptics were preferred by most respondents for treatment of most BPSD. These views, while based on considerable clinical experience, have only limited backing from published reports, and head-to-head studies of available treatments are required to ensure that clinical practice has scientific support.

At the turn of the last century, infectious diseases represented an important cause of health morbidity and behavioral changes. Neurosyphilis, for example, was relatively common at the time and often led to the development of cognitive impairment and dementia. With the advent of effective antibiotic treatment, the association between infectious diseases and dementia became increasingly less frequent, although a resurgence of interest in this area has taken place during the past 15 years with the emergence of acquired immunodeficiency syndrome (AIDS) and variant Creutzfeldt–Jakob disease (vCJD). This paper reviews the most frequent infectious causes of dementia, including prion diseases, as well as infections caused by herpes virus, human immunodeficiency virus (HIV), toxoplasmosis, cryptococcus, cytomegalovirus, syphilis, borrelia and cysticercosis.

Objective: In this study, we examined 204 older depressed individuals for up to 64 months to determine factors related to depression outcome. We hypothesized that both presence of vascular brain lesions seen on baseline magnetic resonance imaging (MRI) scans and lower baseline social support measures would be related to worse depression outcome.

Method: At study entry, all subjects were at least 59 years old, had a diagnosis of major depression, and were free of other major psychiatric illness and primary neurological illness, including dementia and stroke. Depression was diagnosed via structured interview and clinical assessment by a geriatric psychiatrist who completed a Montgomery Asberg Depression Rating Scale (MADRS) to determine severity of depression. Subjects provided self-report data on social support variables and ability to perform basic and instrumental activities of daily living (ADL, IADL). All subjects agreed to have a baseline standardized MRI brain scan. Ratings of severity of hyperintensities were determined for the periventricular white matter, deep white matter, and subcortical gray matter by two readers who decided by consensus. Treatment was provided by geropsychiatrists following clinical guidelines. Using mixed models to analyze the data, we determined the effect of a variety of demographic, social and imaging variables on the trajectory of MADRS score, the outcome variable of interest.

Results: MADRS scores decreased steadily over time. In a final HLM model, in which time since entry, a baseline time indicator, age, gender, education and Mini-mental State Examination score were controlled, subjective social support, instrumental ADL impairment, subcortical gray matter severity, and the interactions of time with social network and with subcortical gray matter lesions remained significantly associated with MADRS score.

Conclusions: Both social and biological factors at baseline are associated with longitudinal depression severity in geriatric depression.

Background and objectives: The use of risperidone or olanzapine to treat behavioral problems associated with dementia is no longer recommended in the U.K. because of the increased risk of cerebrovascular adverse effects (CVAEs) and/or mortality. To evaluate the risks and benefits of antipsychotics, we measured the rate of mortality in patients with dementia, Alzheimer's disease (AD) and vascular/mixed dementia and compared mortality rates between those who had received antipsychotics and those who had not received antipsychotics.

Methods: A total of 273 subjects were assessed at baseline, 6 months and 12 months using a 1-year prospective follow-up design. Mortality rates between groups were compared using a Kaplan–Meier curve and log-rank statistics. Relative risks (RRs) were examined by the Cox proportional-hazards model.

Results: The overall 1-year mortality rate in dementia was 23.8%. The mortality rate in those who had not received antipsychotics (26.8%) was higher than that in those who had received antipsychotics (20.6%). RR and 95% confidence interval (CI) of mortality, when we compared those who had not received antipsychotics with those who had received antipsychotics, was 1.277 (95% CI 1.134–1.437) after controlling for age, severity of dementia, medical comorbidities, cognitive impairment (measured by the Korean version of the Mini-mental State Examination (MMSE)) and behavioral and psychological symptoms of dementia (BPSD), measured by the Behavioral Pathology in Alzheimer's Disease Rating Scale, Korean version (BEHAVE-AD-K). When those who had not received antipsychotics were compared with those who had received both risperidone and haloperidol, RR (95% CI) was 1.225 (1.101–1.364).

Conclusion: This study does not support reports that antipsychotics increase mortality in dementia.