Objective
Neuropsychiatric symptoms (NPS) in dementia are frequent and challenging for patients, carers, and the health care system, but few long‐term studies exist. We analyse the longitudinal ...course of NPS in patients with mild dementia.
Methods
A longitudinal cohort study of 223 patients with mild dementia and annual assessments using the Neuropsychiatric Inventory (NPI) for 5 years.
Results
A total 1043 NPI assessments, representing 97% of all possible measurements of living cohort members, were analysed. Neuropsychiatric symptoms were common at baseline, and only a moderate increase in total NPS score from 15 to 17 with no increase in the proportion with high NPI total scores. Ninety seven percent scored ≥16, and 49% scored ≥36 on NPI total score at least once during follow‐up. Individual NPS fluctuated and often reappeared. The most common symptoms ever reported was apathy (83%), depression (63%), appetite (63%), and aberrant motor behavior (60%). Cognitive decline was associated with higher NPI total score and several NPI items, but only the frequency of apathy increased significantly with time. Lewy body dementia was associated with higher NPI total score and psychotic symptoms. Alzheimer's disease was associated with increase in apathy.
Conclusions
Severe NPS are already common at time of dementia diagnosis, and the increase in overall severity over 5 years was moderate. Individual symptoms tend to fluctuate over time within patients and correspond to states rather than traits. These findings highlight the need to focus on, and plan for, NPS as part of dementia pathway, and are relevant for clinical trial design.
Understanding the natural course of neuropsychiatric symptoms (NPS) in dementia is important for planning patient care and trial design, but few studies have described the long-term course of NPS in ...individuals.
Primary inclusion of 223 patients with suspected mild dementia from general practice were followed by annual assessment, including the Neuropsychiatric Inventory (NPI), for up to 12 years. Total and item NPI scores were classified as stable, relapsing, single episodic or not present based on 4.96 (s.d. 2.3) observations (98% completeness of longitudinal data) for 113 patients with Alzheimer's disease and 84 patients with LBD (68 dementia with Lewy bodies and 16 Parkinson's disease dementia).
We found that 80% had stable NPI total ≥1, 50% had stable modest NPI total ≥12 and 25% had stable NPI total ≥24 scores. Very severe NPS (≥48) were mostly single episodes, but 8% of patients with Alzheimer's disease had stable severe NPS. Patients with Alzheimer's disease and the highest 20% NPI total scores had a more stable or relapsing course of four key symptoms: aberrant motor behaviour, aggression/agitation, delusions and irritability (odds ratio 55, P < 0.001). This was not seen in LBD. Finally, 57% of patients with Alzheimer's disease and 84% of patients with LBD had reoccurring psychotic symptoms.
We observed a highly individual course of NPS, with most presenting as a single episode or relapsing; a stable course was less common, especially in LBD. These findings demonstrate the importance of an individualised approach (i.e. personalised medicine) in dementia care.
BACKGROUND/OBJECTIVES
Functional status is one of the most important markers of well‐being in older adults, but the drivers of functional decline in dementia are not well known. The aim of our work ...was to study the association of neuropsychiatric symptoms (NPSs) with functional decline over 5 years in newly diagnosed people with Alzheimer´s disease (AD) and Lewy body dementia (LBD).
DESIGN
Secondary analysis of the Dementia Study of Western Norway longitudinal cohort study.
SETTING
Multicenter study conducted in memory clinics in western Norway.
PARTICIPANTS
We included a total of 196 patients newly diagnosed with AD (n = 111) and LBD (n = 85), followed up annually for 5 years.
MAIN OUTCOMES AND MEASURES
The outcome was the rapid disability rating scale (items 1–13). Linear mixed‐effects models were used for analysis with the total score of the Norwegian Neuropsychiatric Inventory (NPI) as a predictor measured either at baseline or longitudinally, adjusted for potential confounders, including cognition. Effect modification was checked by introducing interactions with NPI score and stratifying by diagnosis.
RESULTS
The total NPI score longitudinal course was associated with functional decline in both AD and LBD. At baseline, the total NPI score predicted functional decline in AD.
CONCLUSION
NPSs were associated with the rate of functional decline in people with AD and LBD, independent of cognitive impairment. These results highlight the relevance of early detection and intervention of NPSs, which may also reduce functional decline. J Am Geriatr Soc 68:2257–2263, 2020.
Objectives
We aim to study the effects of the prescription of benzodiazepines and antidepressants on cognitive and functional decline in older adults living with Alzheimer's disease (AD) and Lewy ...body dementia (LBD) over a 5‐year follow‐up.
Methods
This is a longitudinal analysis of a Norwegian cohort study entitled “The Dementia Study of Western Norway” (DemVest). We included 196 patients newly diagnosed with AD (n = 111) and LBD (n = 85), followed annually for 5 years. Three prescription groups were defined: only benzodiazepines (BZD), only antidepressants (ADep), and the combination of benzodiazepines and antidepressants (BZD‐ADep). Linear mixed‐effects models were conducted to analyze the effect of the defined groups on the outcomes. The outcomes were functional decline, measured by the Rapid Disability Rating Scale—2, and cognition measured with the Mini‐Mental State Examination.
Results
Prescription of the combination of benzodiazepines and antidepressants in LBD was associated with faster functional decline. In AD, the prescription of BZD and BZD‐ADep was associated with greater functional deterioration. ADep alone did not show positive or negative significant associations with the studied outcomes.
Conclusions
BZD and especially the combination of BZD and ADep are associated with functional decline in AD and LBD and should be used cautiously.
Key Points
Combination of benzodiazepines and antidepressants in Lewy body dementia was associated with faster functional decline
Benzodiazepines and the combination of benzodiazepines and antidepressants in Alzheimer's disease were associated with greater functional deterioration
The consumption of antidepressants alone did not show positive or negative significant associations with cognitive or functional decline
Introduction
Neuropsychiatric symptoms (NPS) in dementia are associated with poor cognitive outcomes in longitudinal studies. Whether this is due to differences in symptom burden between persons (BP) ...or changes within persons (WP) is unknown.
Methods
Patients with mild Alzheimer's disease (AD, n = 111) and Lewy‐body dementia (LBD, n = 85) were assessed annually for 8 years. We modelled the association between NPS assessed by the Neuropsychiatric Inventory (NPI) and Mini‐Mental State Examinations (MMSE) using Tobit mixed‐effects model with NPS as individual means over time (BP) and its deviance (WP).
Results
The association between higher NPS and poorer cognitive outcomes was mostly due to BP differences for the NPI‐total score, and in particular for delusions, hallucinations, agitation, aberrant motor behavior, and apathy scores.
Discussion
The NPS trait (BP) effect on cognitive decline is considerably stronger than the state effect (WP). Clinically, long‐term rather than episodic NPS better identifies patients with poor cognitive outcomes.
Introduction: The aim of the study is to describe the frequency of frailty in people with a new diagnosis of mild dementia due to Alzheimer’s disease (AD) and dementia with Lewy bodies (DLB). ...Methods: This is a secondary analysis of the Dementia Study of Western Norway (Demvest). For this study, we analysed a sample of 186 patients, 116 with AD and 70 with DLB. Subjects were included at a time in which mild dementia was diagnosed according to consensus criteria after comprehensive standardized assessment. Frailty was evaluated retrospectively using a frailty index generated from existing data. The cut-off value used to classify an older adult as frail was 0.25. Results: The prevalence of frailty was 25.81% (n = 48). In the DLB group, 37.14% (n = 26) were classified as frail, compared to 18.97% (n = 22) of those with AD (p < 0.001). The adjusted multivariate analysis revealed an OR of 2.45 (1.15–5.23) for being frail in those with DLB when using AD as the reference group. Conclusion: Frailty was higher than expected in both types of dementia. The prevalence of frailty was higher in those with DLB compared to AD. This new finding underscores the need for a multi-systems approach in both dementias, with a particular focus on DLB.
Psychiatric syndromes in dementia are often derived from the Neuropsychiatric Inventory (NPI) using principal component analysis (PCA). The validity of this statistical approach can be questioned, ...since the excessive proportion of zeros and skewness of NPI items may distort the estimated relations between the items. We propose a novel version of PCA, ZIBP-PCA, where a zero-inflated bivariate Poisson (ZIBP) distribution models the pairwise covariance between the NPI items. We compared the performance of the method to classical PCA under zero-inflation using simulations, and in two dementia-cohorts (N = 830, N = 1349). Simulations showed that component loadings from PCA were biased due to zero-inflation, while the loadings of ZIBP-PCA remained unaffected. ZIBP-PCA obtained a simpler component structure of "psychosis," "mood" and "agitation" in both dementia-cohorts, compared to PCA. The principal components from ZIBP-PCA had component loadings as follows: First, the component interpreted as "psychosis" was loaded by the items delusions and hallucinations. Second, the "mood" component was loaded by depression and anxiety. Finally, the "agitation" component was loaded by irritability and aggression. In conclusion, PCA is not equipped to handle zero-inflation. Using the NPI, PCA fails to identify components with a valid interpretation, while ZIBP-PCA estimates simple and interpretable components to characterize the psychopathology of dementia.
Background
Neuropsychiatric symptoms (NPS) are often overlooked and under-identified symptoms associated with dementia, despite their significant impact on the prognosis of individuals living with ...the disease. The specific role of certain NPS in functional prognosis remains unclear.
Aims
To determine the association of different NPS with functional decline in people living with Alzheimer’s disease (AD) or Lewy body dementia (LBD).
Methods
This is an analysis of data from the Dementia Study of Western Norway (DemVest) with 196 patients included of which 111 had AD and 85 LBD. The Neuropsychiatric Inventory (NPI) and the Rapid Disability Rating Scale (RDRS-2) for activities of daily living were administered annually for 5 years. NPI total score and individual items with RDRS-2 trajectories were analyzed with linear mixed models.
Results
The LBD group exhibited higher levels of functional impairment and a greater burden of NPS at baseline. Over the 5-year follow-up, hallucinations, aggression, depression, anxiety, apathy, disinhibition, aberrant motor behavior, nighttime behavior disturbances, and abnormal eating patterns were significantly associated with the decline in functional abilities in individuals with AD, as well as irritability and aberrant motor behavior in those with LBD.
Discussion
These results highlight the relevance of early detection and intervention of these particularly relevant NPS, due to its potential of also impacting physical function. Better detection and management of these NPS could improve functional prognosis in people living with dementia.
Conclusion
Specific NPS demonstrate relevant distinct associations with Longitudinal trajectories of functional decline in AD and LBD.
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