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Keywords:

  • Alzheimer’s disease;
  • BPSD;
  • functional assessment staging;
  • severity;
  • untreated patients

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Background:  To ascertain the prevalence of psychotic symptoms and behavioral disturbances of dementia patients is useful for families and health care professionals in order to anticipate the progression of Alzheimer’s disease (AD) and to recognize deterioration. This study aimed to determine whether behavioral and psychological symptoms of dementia (BPSD) are related to severity of untreated AD.

Methods:  Two hundred and two patients were classified into three groups by Functional Assessment Staging score as follows: mild group (n = 92) was at stages 3 or 4; moderate group (n = 80) was at stage 5; and severe group (n = 30) was at stages 6 or 7. We then compared the prevalence of BPSD among the groups. Psychiatric symptoms of BPSD were defined as including hallucinations, delusions, delusional misidentification syndrome and depressive mood; while behavioral disturbances included physical aggression, wandering, adverse sleep and hyperphagia.

Results:  In our study, depressive mood, physical aggression and wandering were statistically associated with the severity of AD.

Conclusion:  These results are meaningful for caregivers in helping them to understand the anticipated progression of AD and to recognize deterioration. In the care of AD patients, it is necessary to be aware of characteristics of each BPSD.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Psychiatric symptoms and behavioral disturbances occur in 50–70% of patients with Alzheimer’s disease (AD).1 These symptoms and behavioral problems result in a loss of quality-of-life for the patients, their families and their caregivers, increase the costs of care, and may lead to premature institutionalization.2–4 Nevertheless, they have been regarded as secondary or concomitant symptoms due to cognitive impairment. However, their importance has been increasingly recognized since 1990, with the publication of studies describing the prevalence of psychiatric symptoms and behavioral disturbances.5,6 The International Psychogeriatric Association recognizes behavioral and psychological symptoms of dementia (BPSD) as ‘symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia’.7

Treating the core symptoms of cognitive impairment is difficult, therefore elucidating the characteristics of BPSD and their association with disease progression is useful for families and health care professionals in order to anticipate the progression of AD and to recognize deterioration.

Psychotropics are thought to be a factor influencing BPSD.8 Few reports have described the relationship between the prevalence of BPSD and the severity of untreated AD patients. When BPSD components are assessed, we should presume altered pharmacokinetics due to the degeneration of the brain itself and explore the use of medicines with patients accordingly. For this reason, the study included only patients who had not received psychotropic medication in the past.

The aim of this study was to confirm whether BPSD are related to the severity of untreated AD.

METHOD

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Of 541 outpatients seen at Yokufukai Geriatric Hospital between June 1998 and August 2001, a diagnosis of ‘probable AD’, based on the criteria of the National Institute for Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA),9 was made in 202 untreated outpatients. Forty-one men and 161 women were recruited for this study after eliminating ‘possible AD’ (n = 16, based on the NINCDS-ADRDA criteria), vascular dementia (n = 57), dementia with Lewy bodies (n = 16), frontotemporal dementia (n = 9), alcoholic dementia (n = 4), other dementia (n = 75), age-associated cognitive decline (n = 20),10 delirium (n = 4), psychiatric disorder (n = 15) and mood disorder (n = 27). Probable AD patients with past histories of psychotropic drug use (n = 96) were also excluded in order to eliminate drug-induced BPSD. The remaining 202 patients were classified into three groups by Functional Assessment Staging (FAST)11 score as follows: mild group (n = 92) was at stages 3 or 4; moderate group (n = 80) was at stage 5; and severe group (n = 30) was at stages 6 or 7.

We then compared the following parameters among the groups: gender, age, age of onset, duration of illness and score on Mini-Mental State Examination (MMSE).12 The demographic characteristics of the study patients in each group are presented in Table 1. Psychiatric symptoms of BPSD were defined as including hallucinations (visual and auditory), delusions, delusional misidentification syndrome (DMS) and depressive mood; while behavioral disturbances included physical aggression, wandering, adverse sleep and hyperphagia. According to the definitions used by Burns et al. and Christodoulou,5,13 DMS was evaluated as the ‘phantom boarder syndrome’ consisting of the belief that other (nonexistent) people are living in the house and presenting a marked paranoid component (e.g. preparing meals for these other people), Capgras syndrome, Fregori syndrome, Mirror sign. The BPSD components studied were present in patients for at least the previous 4 weeks. The severity of BPSD was assessed as the degree to which certain medications were clinically required to control symptoms, as assessed by general psychiatrists.

Table 1.  Demographic characteristics of 202 study subjects
 Mild (n = 92)Moderate (n = 80)Severe (n = 30)Total (n = 202)
  1. MMSE, Mini-Mental State Examination.

Sex (men/women), n17/7517/637/2341/161
Age (years; mean ± SD)78.68 ± 5.0682.43 ± 5.9484.43 ± 6.7381.02 ± 6.08
Age of onset (years; mean ± SD)75.99 ± 5.3178.65 ± 5.9980.10 ± 7.4077.65 ± 6.61
Duration of disease (years; mean ± SD) 2.70 ± 1.56 3.78 ± 2.42 4.33 ± 2.28 3.37 ± 2.14
MMSE (mean ± SD)19.08 ± 3.9215.46 ± 4.3910.63 ± 5.8916.39 ± 5.30

The Yokufukai Geriatric Hospital Ethics Committee approved the safeguards, protocols and informed consent procedures of this study. FAST scores and BPSD were assessed by three psychiatrists and one neurologist, whereas MMSE was performed by one psychiatrist or one psychologist. Statistical analysis was conducted using the χ2 test and Fisher’s exact test for each categorical variable of BPSD. Significance was identified at the P < 0.05 level. We used the Statistical Package for the Social Sciences (SPSS) Version 11 for Windows to conduct all analyses.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Demographic characteristics of the patients

Among the three groups of patients with untreated AD, each group had more women than men (Table 1).

Psychiatric symptoms and behavioral disturbances

Table 2 shows the characteristics of BPSD and findings in each group. Delusion was reported by 29.7% of patients; the most common delusion was of stealing (Table 3). DMS was found in 21.8% of patients, most commonly as a ‘phantom boarder syndrome’ (Table 3). Overall, 29.7% of patients experienced depressive moods (most frequently found in patients in the mild group). Wandering was observed in 31.19% of patients, with almost half of the patients in the severe group having experienced this symptom. The prevalence of behavioral disturbances increased as the severity of AD increased.

Table 2.  Characteristics of behavioral and psychological symptoms of dementia
CharacteristicsMild (n = 92)Moderate (n = 80)Severe (n = 30)Total (n = 202)χ2P
  1. Statistical analysis was conducted using χ2 test and Fisher’s exact test. For each categorical variables of BPSD *P < 0.05, d.f. = 2.

  2. DMS, delusional misidentification syndrome.

Hallucination, N (%) 5 (5.43%) 9 (11.25%) 3 (10.00%)17 (8.42%)1.990.369
Visual hallucination 4 (4.35%) 8 (10.00%) 3 (10.00%)15 (7.43%)2.330.312
Auditory hallucination 1 (1.09%) 5 (6.25%) 0 (0%) 6 (2.97%)5.070.081
Delusion, N (%)26 (28.26%)26 (32.50%) 8 (26.67%)60 (29.70%)0.520.77
DMS, N (%)13 (14.13%)22 (27.50%) 9 (30.00%)44 (21.78%)5.890.053
Depressive mood, N (%)36 (39.13%)21 (26.25%) 3 (10.00%)60 (29.70%)9.950.007*
Physical aggression, N (%) 3 (3.26%) 5 (6.25%) 6 (20.00%)14 (6.93%)9.920.007*
Wandering, N (%)19 (20.65%)30 (37.50%)14 (46.67%)63 (31.19%)9.590.008*
Adverse sleep, N (%) 3 (3.26%) 9 (11.25%) 3 (10.00%)15 (7.43%)4.310.116
Hyperphagia, N (%) 6 (6.52%) 8 (10.00%) 5 (16.67%)19 (9.41%)2.790.248
Table 3.  Details of delusion and delusional misidentification syndrome (DMS)
 N
Delusion (n = 60)
 Delusion of injury53
 Stealing42
 Poisoning3
 Observation1
 Persecution1
 Others7
 Delusion of jealousy4
DMS (n = 44)
 Phantom boarder40
 Capgras syndrome3
 Fregoli syndrome0
 Mirror sign1

Statistical analysis

The χ2 test and Fisher’s exact test demonstrated a significant difference between depressive mood (χ2 = 9.95, P = 0.007), physical aggression (χ2 = 9.92, P = 0.007), wandering (χ2 = 9.59, P = 0.008) and the severity of AD.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

To our knowledge, few studies of untreated AD patients have described the relationship between the characteristics of BPSD and the severity of AD. The authors therefore sought to determine whether prevalence of BPSD is related to the severity of untreated AD. Our findings indicated that certain BPSD were associated with increasing disease severity while others were not. Specifically, depressive mood decreased with increasing disease severity, hallucinations and delusions frequently increased in the moderate group and declined in the severe group, while behavioral abnormalities and DMS increased with increasing disease severity. Throughout the three stages of disease, depressive mood, physical aggression and wandering were statistically associated with the severity of AD.

With respect to the relationship between BPSD and cognitive impairment, some studies have shown a lack of association,14,15 others described that BPSD was associated with cognitive impairment,16,17 a constant conclusion has not been found. The present data are in line with the latter studies. The prevalences of hallucination and delusion in our study were less than those reported by other studies,18,19 which may be due to variations in the definition of DMS.20 For example, ‘phantom boarder syndrome’ may be defined as a part of a misidentification syndrome with ‘confusion concerning the presence or identity of people in the house’18 and ‘consisting of the belief, based on misrecognition, that others are living in the house’,21 or the phenomenon may alternatively be classified as a hallucination and delusion of injury rather than as DMS. Our definition included actions, often accompanied by paranoid interpretation, not simply the misidentification alone.13,22

Our study also considered the effect of the environment on the patients and medication on the prevalence of BPSD. How does the prevalence of BPSD, particularly behavioral abnormalities, vary between inpatients and outpatients? A patient’s surroundings contain myriad influences, including the amount of physical contact a patient receives from caregivers, the amount of freedom a patient has to move about outdoors and who is responsible for the management of a patient’s meals. Steele et al. attempted to discern environmental effects by comparing the performance of 25 patients who were institutionalized for 3 years with the performance of 25 patients who were not institutionalized,23 with respect to the Psychogeriatric Dependency Rating Scale,24 the Hamilton Rating Scale for Depression,25 and the Brief Psychiatric Rating Scale,26 and reported that the patients who had been institutionalized scored higher on standardized psychiatric rating scales. The identification of environmental influences in studies of BPSD will make comparisons between studies more meaningful.

Subjects were also limited to cases at one facility and only BPSD that were present in the previous 4 weeks were evaluated.

In conclusion, the prevalence of BPSD as a broad group of symptoms did not increase with increasing disease severity. In particular, depressive mood, hallucinations, delusions, DMS and behavioral disturbances exhibited different tendencies throughout the progression of AD. These results are meaningful for caregivers in helping them to understand the anticipated progression of AD and to recognize deterioration. It is necessary to be cognizant of the characteristics of each BPSD in the treatment and care of AD patients.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The authors wish to thank Shungyoku Ryo for help with statistical analysis in the present study.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES
  • 1
    Wragg RE, Jeste DV. Overview of depression and psychosis in Alzheimer’s disease. Am J Psychiatry 1989; 146: 577587.
  • 2
    Aarsland D, Cummings JL, Yenner G et al. Relationship of aggressive behavior to other neuropsychiatric symptoms in patients with Alzheimer’s disease. Am J Psychiatry 1996; 153: 243247.
  • 3
    Deutsch LH, Bylsma FW, Rovner BW et al. Psychosis and physical aggression in probable Alzheimer’s disease. Am J Psychiatry 1991; 148: 11591163.
  • 4
    Ryden MB. Aggressive behavior in persons with dementia who live in the community. Alzheimer Dis Assoc Disord 1988; 2: 342355.
  • 5
    Burns A, Jacoby R, Levy R. Psychiatric phenomena in Alzheimer’s disease. I: Disorders of thought content. Br J Psychiatry 1990; 157: 7276.
  • 6
    Teri L, Larson EB, Reifler BV. Behavioral disturbance in dementia of the Alzheimer’s type. J Am Geriatr Soc 1988; 36: 16.
  • 7
    International Psychogeriatric Association. An Introduction to BPSD. Educational Pack. Cheshire: Gardiner-Caldwell Communications, 2000.
  • 8
    Skoog I. The prevalence of psychotic depressive and anxiety syndromes in demented and non-demented 85-year-olds. Int J Geriatr Psychiatry 1993; 8: 247253.
  • 9
    McKhann G, Drachman D, Folstein M et al. Clinical diagnosis of Alzheimer’s: report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s disease. Neurology 1984; 34: 939944.
  • 10
    Levy R. Aging-associated cognitive decline. Int Psychogeriatr 1994; 6: 6368.
  • 11
    Reisberg B, Ferris SH, Anand R et al. Functional staging of dementia of the Alzheimer type. Ann N Y Acad Sci 1984; 435: 481483.
  • 12
    Folstein MF, Folstein SE, McHugh PR. ‘Mini mental test’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189198.
  • 13
    Christodoulou GN. The delusional misidentification syndromes. Br J Psychiatry 1991; 159: 6569.
  • 14
    Wagner AW, Teri L, Orr-Rainey N. Behavior problems among dementia residents in special care units: changes over time. J Am Geriatr Soc 1995; 4: 784787.
  • 15
    Kortla KJ, Chacko RC, Harper RG et al. Clinical variables associated with psychosis in Alzheimer’s disease. Am J Psychiatry 1995; 152: 13771379.
  • 16
    Harwood DG, Barker WW, Ownby RL et al. Relationship of behavioral and psychological symptoms to cognitive impairment and functional status in Alzheimer’s disease. Int J Geriatr Psychiatry 2000; 15: 393400.
  • 17
    Cummings JL. Cognitive and behavioral heterogeneity in Alzheimer’s disease: seeking the neurobiological basis. Neorobio Aging 2000; 21: 845861.
  • 18
    Rubin EH, Wayne CD, William JB. The nature of psychotic symptoms in senile dementia of the Alzheimer type. J Geriatr Psychiatry Neurol 1988; 1: 1620.
  • 19
    Teri L, Borson S, Kiyak HA et al. Behavioral disturbance, cognitive dysfunction, and functional skill. Prevalence and relationship in Alzheimer’s disease. J Am Geriatr Soc 1989; 37: 109116.
  • 20
    Forstl H, Almeida OP, Owen A et al. Psychiatric, neurological, and medical aspects of misidentification syndromes: a review of 260 cases. Psychol Med 1991; 21: 905910.
  • 21
    Burns A, Jacoby R, Levy R. Psychiatric phenomena in Alzheimer’s disease. II: Disorders of perception. Br J Psychiatry 1990; 157: 7681.
  • 22
    Forstl H, Besthorn C, Burns A et al. Delusional misidentification in Alzheimer’s disease: a summary of clinical and biological aspects. Psychopathology 1994; 27: 194199.
  • 23
    Steele C, Rovner B, Chase GA et al. Psychiatric symptoms and nursing home placement of patients with Alzheimer’s disease. Am J Psychiatry 1990; 147: 10491051.
  • 24
    Wilkinson IM, Graham-White J. Psychogeriatric Dependency Rating Scales (PGDRS): a method of assessment for use by nurses. Br J Psychiatry 1980; 137: 558565.
  • 25
    Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967; 6: 278296.
  • 26
    Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep 1962; 10: 799812.