Background: Paratonia causes severe movement dysfunction in late stage dementia. Passive Movement Therapy (PMT) is often used to decrease high muscle tone, but the efficacy has never been shown. The objective of this study is to investigate the effect of PMT on muscle tone after two and four weeks of treatment.

Methods: This study comprised a multicenter single-blinded RCT. Nursing home residents with dementia (according to the DSM-IV-TR criteria) and moderate to severe paratonia were randomly assigned to either a PMT or control group. The PMT group received PMT three times a week over four weeks. The control group received no PMT. The primary outcome was the severity of paratonia as measured by the Modified Ashworth scale (MAS). Secondary outcomes were clinical change (Clinical Global Impression; CGI), caregiver's burden (modified patient specific complaints; PSC), and level of pain during morning care (Pain Assessment Checklist for Elderly with Limited Ability to Communicate, Dutch version; PACSLAC-D). All outcomes were assessed at baseline and after two and four weeks. The MAS, PACSLAC-D, and PSC data were subjected to multilevel mixed linear analysis, and the CGI data to cross-tabulation χ2 analysis.

Results: One-hundred-and-one patients from 12 Dutch nursing homes participated in the study; data from 47 patients in the PME group and 54 controls were analyzed. Patients receiving PMT performed no better in paratonia assessments, nor on CGI, PSC, or PACSLAC-D, than controls in two and four week's time.

Conclusion: PMT has no beneficial effects and should therefore not be recommended as an intervention in severe paratonia.

Trial registration: Current Controlled Trials ISRCTN43069940

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.

Background: Recognizing and diagnosing early onset dementia (EOD) can be complex and often takes longer than for late onset dementia. The objectives of this study are to investigate the barriers to diagnosis and to develop a typology of the diagnosis pathway for EOD caregivers.

Methods: Semi-structured interviews with 92 EOD caregivers were analyzed using constant comparative analysis and grounded theory. A conceptual model was formed based on 21 interviews and tested in 29 additional transcripts. The identified categories were quantified in the whole sample.

Results: Seven themes emerged: (1) changes in the family member, (2) disrupted family life, (3) misattribution, (4) denial and refusal to seek advice, (5) lack of confirmation from social context, (6) non-responsiveness of a general practitioner (GP), and (7) misdiagnosis. Cognitive and behavioral changes in the person with EOD were common and difficult to understand for caregivers. Marital difficulties, problems with children and work/financial issues were important topics. Confirmation of family members and being aware of problems at work were important for caregivers to notice deficits and/or seek help. Other main issues were a patient's refusal to seek help resulting from denial and inadequate help resulting from misdiagnosis.

Conclusion: EOD caregivers experience a long and difficult period before diagnosis. We hypothesize that denial, refusal to seek help, misattribution of symptoms, lack of confirmation from the social context, professionals’ inadequate help and faulty diagnoses prolong the time before diagnosis. These findings underline the need for faster and more adequate help from health-care professionals and provide issues to focus on when supporting caregivers of people with EOD.

Background: Apathy is a common and important behavioral syndrome in various neuropsychiatric diseases, such as mild cognitive impairment (MCI) and Alzheimer's disease (AD). So far, only few studies have compared the neuropsychological correlates of apathy in patients with MCI and dementia. The aim of the current study was to examine the association between apathy and neuropsychological functioning in patients with MCI and AD.

Methods: Two-hundred-and-sixty AD patients and 178 MCI patients visiting the Memory Clinic of the Maastricht University Medical Centre participated in the study. Linear regression analysis, corrected for age, gender, level of education and depression, was performed to reveal cross-sectional associations between apathy and scores on neuropsychological tests of memory, attention, psychomotor speed and executive functioning.

Results: In patients with MCI, apathy was characterized by decreased verbal fluency and psychomotor tracking. In AD, patients with apathy differed from non-apathetic patients only on a verbal fluency task.

Conclusion: Apathy is related to executive dysfunction in the early phases of cognitive decline. In particular, in the prodromal phase of AD, apathy seems to be characterized by poor initiating. In the more advanced stages of cognitive deterioration, associations between apathy and specific neuropsychological correlates may be obscured by the more severe neuropathology. Awareness of apathy in the early phase of cognitive impairment may help in early diagnosis of AD.

Background: Paratonia is a progressive motor problem that is observed in individuals with dementia and is not a well-known phenomenon. This study explores the development and risk factors of paratonia in moderate stage dementia patients.

Methods: A multi-center, longitudinal, one-year follow-up cohort study was performed. Patients with an established diagnosis of dementia, with a score of 6 or lower on the Global Deterioration Scale (GDS) were included. The participants were assessed using the Paratonia Assessment Instrument (PAI), the Timed Up and GO test, the Qualidem, the Global Deterioration Scale (Reisberg et al., 1982) and the Mini-mental State Examination. Information about each patient's diagnosis of dementia, comorbidities and use of medication were obtained from the participant's medical file. The PAI was assessed every three months, the other variables at baseline and after 12 months. Cross-tabulation χ2 and logistic regression tests were used for the statistical analyses.

Results: Baseline measures were assessed in the 204 participants – 111 (54%) female and 93 (46%) male, with a mean age of 79.8 years (56–97). Seventy-one patients (34.8%) were diagnosed with paratonia at baseline, and 51 patients developed paratonia over one year. The highest hazard ratio (3.1) for developing paratonia within one year was observed in the vascular dementia group. The logistic regression analysis revealed that the presence of diabetes mellitus (OR = 10.7) was significantly related to the development of paratonia (Wald χ2 p-value < 0.01).

Conclusions: Diabetes mellitus and likely vascular damage are risk factors for the development of paratonia.

Evince-I is a desktop expert system for the differential diagnosis of dementia, implemented on a personal computer. It is intended to assess the effectiveness of this new technology in modeling a psychiatrist who uses international guidelines for diagnosing dementia. EVINCE-I was tested in diagnosing 19 patients with varying stages of dementia and 10 patients showing other disorders except dementia. EVINCE-I and the human expert were in perfect agreement on the diagnosis of dementia and correlated highly on the diagnosis of dementia of the Alzheimer type and multiple infarct dementia. EVINCE-I thus offers important possibilities as a tool in investigating the data and procedures used by the human expert.

Background: Paratonia is one of the associated movement disorders characteristic of dementia. The aim of this study was to develop an assessment tool (the Paratonia Assessment Instrument, PAI), based on the new consensus definition of paratonia. An additional aim was to investigate the reliability and validity of the PAI.

Methods: A three-phase cross-sectional survey was conducted. In the first two phases, the PAI was developed and validated. In the third phase, the inter-observer reliability and feasibility of the instrument was tested.

Results: The original PAI consisted of five criteria that all needed to be met in order to make the diagnosis. On the basis of a qualitative analysis, one criterion was reformulated and another was removed. Following this, inter-observer reliability between the two assessors resulted in an improvement of Cohen's κ from 0.532 in the initial phase to 0.677 in the second phase. This improvement was substantiated in the third phase by two independent assessors with Cohen's κ ranging from 0.625 to 1.

Conclusion: The PAI is a reliable and valid assessment tool for diagnosing paratonia in elderly people with dementia that can be applied easily in daily practice.

Background: Post-stroke depression (PSD) frequently complicates stroke and is associated with an impaired functional outcome, more severe cognitive deficits, a reduced quality of life, and a higher mortality. The aim of this study was to assess whether general risk factors for major depressive disorder (MDD) in the community are also risk factors for PSD, and to identify additional, stroke-related risk factors.

Methods: In a hospital setting, 190 consecutively admitted patients were assessed for MDD 1 month after stroke, and at follow-up after 3, 6, 9 and 12 months. A Cox model was created with four established risk factors for MDD in the community (female sex, prior personal history of depression, positive family history of depression, and somatic comorbidity other than stroke). Five potential disease-related risk factors (disability, cognitive deterioration, inter- and intrahemispheric lesion location, and generalized vascular damage on computed tomography (CT) scan) were then added individually to this model, to see whether these would improve the significance of the overall model.

Results: The Cox model of four general risk factors for depression in the community was shown to be a valid model to predict depression in stroke patients. Of the disease-specific factors, only incorporation of “disability” in this model improved its significance.

Conclusion: Established risk factors for depression in the community are also predictors of depression in the first year after stroke. Disability is a non-specific disease-related variable that is associated with PSD. The contribution of stroke-specific factors may be less than is generally assumed.

Background: The results of studies of the association between awareness and clinical correlates in patients with dementia are inconclusive. The aims of this study were to investigate whether awareness changed during the course of dementia and to determine whether awareness was associated with certain behavioral symptoms. Specifically, it was hypothesized that relatively intact awareness was related to affective disorders.

Methods: One hundred and ninety-nine patients with dementia were included in a prospective 18-month follow-up study. Behavioral problems were assessed with the Neuropsychiatric Inventory and the Cornell Scale for Depression in Dementia. Awareness was assessed by means of the Guidelines for the Rating of Awareness Deficits.

Results: Cross-sectional analyses showed awareness to be positively associated with age, gender, education and socioeconomic status, and negatively associated with psychosis, apathy, and overall behavioral disorders at baseline. After 1 year, a higher level of awareness was related to depression and anxiety. The level of awareness at baseline also predicted depression and anxiety after 1 year. Awareness decreased during the study.

Conclusions: A higher level of awareness is associated with subsyndromal depression and anxiety, whereas lack of awareness is associated with psychosis and apathy. The level of awareness decreases as dementia progresses. Clinicians should be more alert to changes in awareness in patients with dementia because psychosocial support might help to prevent the development of affective symptoms.

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.

Dementia and depression are the two most prevalent psychiatric disorders in the elderly. Although dementia has traditionally been viewed as a disorder of cognition, and depression as a disorder of mood, this simple classification has recently been questioned, and the complex interrelationship between depression and dementia is being elucidated (Emery & Oxman, 1992; Raskind, 1998). Patients with depression may show cognitive deficits, simulating dementia (Berrios, 1989), and patients with dementing disorders may show symptoms of depression (Allen & Burns, 1995; Burns, 1991). In addition, depression may precede dementia and represent the very first signs of dementing illness, or may be a risk factor for subsequent dementia.