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EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ PSYCHOLOGICAL AND BEHAVIORAL SYMPTOMS IN A SAMPLE OF ELDERLY INDIVIDUALS WITH DEMENTIA By Amr Makram EL-Sherbini Department of Neurology and Psychiatry, EL-Minia Faculty of Medicine ABSTRACT: Introduction: Behavioral and psychological symptoms are common in individuals with dementia and affect the patients negatively and cause distress to the caregivers. Aim of Work: The aim of the current study is to assess the prevalence of behavioral and psychological symptoms in a sample of individuals with dementia and to determine the effect of such symptoms on the patients and the caregivers. Methods: Twenty eight individuals diagnosed with dementia were assessed using the Neuropsychiatric Inventory (NPI), Mini Mental State Examination (MMSE), the Activity of Daily Living tool (ADL) and the Instrumental activity of daily living (IADL). Results: Of the 28 individuals 24 (85.7%) had neuropsychological symptoms as assessed with the NPI. The most common symptoms were those of depression occurring in 32.1% of the sample followed by apathy or indifference which was diagnosed in eight individuals (28.6%) and irritability found in 21.4% of the patients. Caregiver distress was correlated with the NPI scores and functional disability was correlated with MMSE scores. In conclusion: Psychological and behavioral symptoms are very prevalent in individuals with dementia and these symptoms cause significant family distress and negatively affect the functional ability of the patients. It is recommended that such symptoms should be diagnosed and managed effectively to decrease their negative effect on the patients and the caregivers. KEY WORDS: Dementia Activities of Daily living Psychological symptoms persons and this number is expected to increase to 63 million in 2030, 41 million in less developed regions2. INTRODUCTION: Dementia is a generic term that describes a chronic or progressive dysfunction of cortical and subcortical functions. This dysfunction is characterized by impairment of memory and of at least one other cognitive function (aphasia, apraxia, agnosia, executive dysfunction)1. Today, dementia is considered one of the major social burdens in developing countries and it was estimated that the worldwide number of persons with dementia in the year 2000 was about 25 million Since the first description of Alzheimer’s disease it has been recognized that the disease is multidimensional in nature and is characterized clinically by cognitive decline, psychiatric and behavioral disturbances, and an impaired ability to perform activities of daily living3. Dementia is associated with a diverse array of behavioral changes, and the 16 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ nature of the psychiatric and behavioral disturbances varies among patients with dementia4. It is not clear whether behavioral and psychological symptoms of dementia (BPSD) are epiphenomena of the neurodegenerative process or are the symptoms of specific, biologically distinct subtypes of dementing disorders 5. ability to perform daily activity as well as the effect of such symptoms on the caregivers of these patients. SUBJECTS AND METHODS: This cross sectional study involved patients with dementia assessed for the presence of neuropsychiatric symptoms. A patient was considered eligible for inclusion in the study only if he or she had a responsible caregiver who knows the patient well and can reliably give account on the patient behavior. Exclusion criteria:1- Patients with previous psychiatric disorder prior to the onset of dementia. 2- Patients with chronic pulmonary disease, renal failure, advanced hepatic disease and brain tumors or other brain pathology that may result in reversible dementia. Behavioral and psychiatric symptoms associated with dementia include apathy, psychosis, and aggression6. Delusions are observed in high proportion of dementia patients, and their onset is predictive of a rapid cognitive deterioration7,8. Symptoms of depression and anxiety are also common in patients with dementia and may be among the first signs of dementia9. Agitation and depression exacerbate functional and cognitive deficits.10 Other psychiatric and behavioral disturbances are also common in dementia, including agitation, and labile affect 5. Patients were recruited from the outpatient clinic of the hospital of Bahrain. The sample was collected over a period of ten months starting from June 2010 till March 2011. All patients presented with symptoms suggestive of dementia had a routine brain CT scan and were subjected to: The majority of dementia patients are cared for at home by family members, including both spouses and adult children11-12. The psychiatric and behavioral disturbances of an individual with dementia greatly impact on both the patient and the caregiver13-14, such disturbances can compromise the patient’s social functioning and safety. The frequency and severity of psychiatric and behavioral disturbances exhibited by a dementia patient may influence caregiver burden as well as distress 15-16. Socio-demographic questionnaire sheet which was intended to obtain personal history mainly; name, age, sex, address, marital status and medical history. Clinical Psychiatric Assessment concentrating on the clinical diagnosis of dementia using DSM-1V criteria1. AIM OF WORK: The aims of the current study are to determine the prevalence of behavioral and psychiatric symptoms in a sample of outpatient elderly with dementia. In addition, we tried to detect the effect of behavioral and psychiatric symptoms on the patient’s Mini-Mental State Examination (MMSE) This tool was used to determine the degree of cognitive impairment17. Activities of Daily Living (ADL)18 Which is a tool used to detect the patient ability to perform basic life 17 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ tasks as bathing, dressing,.. Each item is scored on a 3-point scale, reflecting independence, the need for assistance, or dependence with higher scores reflecting greater functioning independence. The NPI contain an integral part for measurement of family distress which is rated separately, the total caregiver distress score is generated by adding the item-related distress scores20. STATISTICAL ANALYSIS: Data were analyzed by using SPSS version 10.0 software. Means with standard deviations or percentages were used to describe the sample. Group differences were assessed using the unpaired student t- test, for categorical variables the chi-square test was used. We also determined the Pearson linear correlation between certain variables. A P value below 0.05 was considered to indicate statistical significance. The aim of the study was explained to the patient and to the caregiver and they gave a written consent to participate in the study. Instrumental Activity of Daily Living (IADL) A tool used to assess individual ability to handle more complex tasks as shopping, handling finance... Each item is scored on a 3point scale, reflecting independence, the need for assistance, or dependence with higher scores reflecting greater functioning independence 19. The Neuropsychiatric Inventory (NPI) psychological and behavioral symptoms were assessed using the Neuropsychiatric Inventory (NPI), a widely used instrument in dementia research. It is an informant-based interview that is well validated with excellent interrater reliability. The NPI was administered to caregivers or to persons very familiar with the participants. The NPI covers 10 domains: delusions, hallucinations, agitation/aggression, dysphoria/ depression, anxiety, euphoria/elation, apathy/indifference, disinhibition, irritability/lability, and aberrant motor behaviors. Each domain has a screening question, with a positive answer being followed up by a detailed set of questions about the domain. Symptom severity was assessed by then asking the informant to rate both the frequency and severity of symptoms which produces a composite domain-specific frequency x severity score. Since no participants endorsed the euphoria/elation domain, it was excluded from the analyses. Total NPI score was calculated by summing the composite domain specific severity ratings for the remaining nine domains. Higher scores indicate greater overall neuropsychiatric symptom severity. RESULTS: The results of the current study show that out of 32 individuals eligible for inclusion in the study 28 individuals completed the study. Two refused to participate in the study and two had no consistent reliable caregiver. Description of the participants: The sample was formed of 15 females (53.6%) and 13 males (46.4%) the mean age of individuals included in the study was 71.3± 6.9. The MMSE mean score was 19.4±2.3 while the ADL mean score was 7.2±2.9 and the IADL score was 6.7±3.5. There were no statistically significant differences between males and females in any of the above mentioned parameters. (Table 1) Activities of daily living: The functional level of individuals included in the study was measured using the ADL and the 18 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ IADL. Description of these activities are given in table 2 and table 3 in which it could be seen that 85.7% of individuals with dementia were unable to bath without help and that 71.4% needed help for dressing and that 75% needed assistance in toileting and transferring (Table2). As regards instrumental activity of daily living it was found that more than two thirds of individuals with dementia (85.6%) are unable of shopping alone and that 92.9% cannot use transportation alone, 75% cannot be responsible for their own medications and that about one third (32.1%) can handle financial issues independently (table 3). patients while delusions occurred in 17.9% of the sample followed by aberrant motor behavior and anxiety each occurring in 14.3% of the individuals; finally hallucination was found in 3 patients (10.7%) and disinhibition in 2 patients (7.1%) . The highest score on the NPI scale was for depression (mean=1.2±2.6) followed by delusions (mean=0.9±1.9), apathy and indifference (Mean=0.79±1.3), irritability (Mean=0.6±1.8), agitation and aggression (Mean=0.62±1.6) and anxiety (Mean=0.58±1.6). The total mean INP score was 6.1±4.2 and the total mean distress score was 1.8±1.1. Psychological and behavioral symptoms: The prevalence of different psychiatric and behavioral symptoms is given in table 4 in which it could be seen that the total number of individuals with any neuropsychological symptoms was 24 representing 85.7% of the total sample. The most common symptoms were those of depression observed in 9 individuals (32.1%) followed by apathy or indifference which was diagnosed in 8 individuals (28.6%), irritability was found in 21.4% of the Correlation between different variables: Correlation studies shows that scores on the NPI were correlated negatively with scores on the IADL indicating that higher NPI score is associated with worse instrumental activities, there were positive correlations between scores on the NPI and both family distress (R=0.35 P=0.01) and MMSE scores (R=0.3 P=0.05). On the other hand, scores of the MMSE were correlated positively with the ADL score (R=0.9 P=0.000) and age of the patient (R=0.6 P=0.000). Table I: Description of individuals of the study Variable Sex Age MMSE ADL IADL Males= 13 (46.4%) Mean=71.3 Mean=19.4 Mean=7.2 Mean= 6.7 Females= 15(53.6%) SD=6.9 SD=2.3 SD=2.9 SD=3.5 19 Difference between both sex Chi sq=1.1 P=0.2 T=0.08 P=0.93 T=0.1 P=0.89 T=0.2 P=0.81 T=0.02 P=0.98 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ Table II: Activities of Daily Living Bathing Dressing Toileting Transferring Continence Feeding Without help 4(14.3%) 8(28.6%) 7(25%) 7(25%) 8(28.6%) 15(53.5%) With some help 17 (60.7%) 15(53.5%) 17(60.7%) 16(57.1%) 17(60.7%) 10(35.7) Unable completely 7 (25%) 5 (17.9%) 4 (14.2%) 5 (17.9%) 3 (10.7%) 3 (10.7%) Table III: Instrumental Activities of Daily Living Without help 8(28.6%) Use telephone 4(14.3%) Shopping 8(28.6%) Food preparation 5(17.9%) Do house work 4(14.3%) Laundry 2(7.1%) Transportation 7(25%) Responsible for medications 9 (32.1%) Handle finance With some help Unable completely 11 (39.3%) 9 (32.1%) 9(32.1%) 15(53.5%) 7(25%) 13 (46.4%) 9(32.1%) 14 (50%) 8(28.6%) 16 (57.1%) 8 (28.6%) 18 (64.3%) 7(25%) 14 (50%) 11 (39.3%) 8 (28.6%) Table IV: Neuropsychiatric Inventory Delusions Hallucinations Agitation/aggression Depression Anxiety Apathy/indifference Irritability Disinhibition Aberrant motor behavior Total individuals with any symptom Total INP score Total Distress score Number (%) 5(17.9%) 3(10.7%) 5(17.9%) 9(32.1%) 4(14.3%) 8(28.6%) 6(21.4%) 2(7.1%) 4(14.3%) N=24 (85.7%) Score 0.9± 1.9 0.39± 1.1 0.62± 1.6 1.2± 2.6 0.58±1.6 0.79±1.3 0.6±1.8 0.16± 0.6 0.53± 1.4 Mean= 6.1± 4.2 Mean= 1.8 ± 1.1 Table V: Correlation studies between different variables NPI Scores MMSE Family distress ADL R=-0.27 P=0.07 R= 0.9 P=0.000* R=0.26 P=-0.08 IADL R=-0.6 P=0.000* R=0.3 P=0.05* R=0.2 P=0.1 Family distress R=0.35 P=0.01* R= -0.28 P=0.07 - 20 Age R= 0.03 P=0.8 R=0.6 P=0.000* R=0.2 P=0.1 MMSE R=0.3 P=0.05* R= -0.28 P=0.07 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ depression as a risk factor for cognitive deterioration28,29. The current prevalence in our study of depression is comparable to those reported in previous studies5,21. DISCUSSION: In this study we tried to assess the prevalence of psychiatric and behavioral symptoms in a sample of patients with dementia as well as their effect on family distress and activities of daily living. The NPI was the main tool used to assess the presence of psychiatric and behavioral symptoms while the MMSE was used to determine the degree of cognitive impairment. Apathy was the second most common symptom in the current study occurring in 28.6% of the population, the reported prevalence of apathy in different studies ranged from 17.6% to 56.7%30,31 and some studies found apathy as the most common psychopathology in individuals with dementia6 but this was not the case in our study although using the same tool, this might be due to difference in sampling. Psychotic symptoms occurred in considerable proportion of individuals in the current study with delusions occurring in 17.9% of the sample and hallucination in 10.7%, these rates are in line with those reported in other studies7,8. As mentioned before the scores of NPI are the result of multiplication of the severity of the symptom by its frequency, in this regard depression showed the highest score (mean=1.4) followed by delusions (mean=0.9); although delusions were not the second most common symptom its mean score come next to depression indicating that delusions when present is either severe or persistent resulting in their high mean score. In the current study females were slightly more represented than males and most of the individuals were in the moderate dementia severity as indicated by a mean score on the MMSE of 19.4 this findings reflect the clinical setting of the study compared to community studies in which females constitute the majority of cases with better scores on the MMSE5-21. Activities of daily living and instrumental activities of daily living were significantly impaired in our sample as indicated by scores on both scales. Comparable results were reported in studies using the same tools in patients assessed in a clinical setting22,21 where as individuals assessed in community studies show better scores on the same scales 23,24. Individuals functioned better in the basic activity of daily living than in the more complicated instrumental activities this finding was reported in previous studies24,25. As regards correlations between different variables, scores of the MMSE was correlated positively with age, increased cognitive dysfunction with advancing of age is one of the most consistent finding in different studies32,33. In addition, MMSE scores were correlated significantly with ADL and less significantly with IADL where as scores on the NPI was correlated negatively only with IADL. This might indicate that more complicated skills As regards psychiatric and behavioral symptoms the most common symptoms found in our sample was that of depression occurring in 32.1% of the sample. High association between depression and dementia is reported in several studies26, 21 and some studies views depression as a predictor of dementia in the elderly9 while others see 21 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ are more impaired with the occurrence of neuropsychiatric symptoms this might reflect increased disease severity or that there are an underlying common mechanism for both conditions. This debate as whether behavioral and psychological symptoms of dementia are epiphenomena of the neurodegenerative process or are the symptoms of specific, biologically distinct subtypes of dementing disorders is still not settled5. negatively affect the functional ability of the patients and causes significant family distress. It is recommended that such symptoms should be promptly probed for and managed to decrease their negative effect on the patients and the care givers. REFERENCES: 1American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders, 4. Ed. (DSM-IV). Washington DC:14 3-147. 2- Wimo A, Winblad B, AgueroTorres H, et al. (2003) The magnitude of dementia occurrence in the world. Alzheimer Dis Assoc Disord;17:63-67. 3- Morris J. (2005) Dementia Update. Alzheimer Dis Assoc Disord; 19: 100-117. 4- Ritchie K, Lovestone S. (2002) The dementias. Lancet;360:1759-1766. 5-Savaa GM, Mthews F, Julie E, Brayne C (2009) Prevalence, correlates and course of behavioral and psychological symptoms of dementia in the population. Br. J. of Psychiatry 194:212-219. 6-Landes AM, Sperry SD, Strauss ME, (2005) Prevalence of Apathy, Dysphoria, and Depression in Relation to Dementia Severity in Alzheimer’s Disease. J Neuropsychiatry Clin Neurosci 17:342-349 7-Scarmeas N, Brandt J, Albert M, Dubios B (2005) Delusions and Hallucinations Are Associated With Worse Outcome in Alzheimer Disease. Arch Neurol, 62(10): 1601 - 1608. 8-Ropacki SA, and Jeste DJ (2005) Epidemiology of and Risk Factors for Psychosis of Alzheimer’s Disease: A Review of 55 Studies Published From 1990 to 2003 Am J Psychiatry 162: 2022-2030. 9- Van Reekum R, Simard M, Clarke D, Binns MA, Conn D (1999) Late-life depression as a possible predictor of dementia: cross-sectional As regards family distress, the results of the current study shows that family distress was correlated with the scores on NPI, increased family distress with increased psychological and behavioral symptoms had been reported in several studies15,16. In the current study family distress was not correlated with the degree of cognitive dysfunction or functional disability, this is contrary to results reported in most studies conducted in western communities23.24 and this difference might be due to the availability of help and care from personal nurses available to many patients included in the current study, while psychological and behavioral symptoms affect directly family members and are not mitigated by external help leading to increased family distress. This study has its own limitations most importantly is the small sample size, the clinical orientation of the study which might not reflect the true extent of the problem in the society, and the absence of differentiation of subtypes of dementia which would have required more investigations to determine. In conclusion psychological and behavioral symptoms are very prevalent in individuals with dementia affecting 86% of the patients included in the study. These symptoms 22 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ and short-term follow-up results. Am J Geriatr Psychiatry. (2):151-9. 10-Nygaard HA (1991) Who cares for the caregiver? Factors exerting influence on nursing home admissions of demented elderly. Scand J Caring Sci; 5:157-162 11- Aneshensel CS, Pearlin LI, Schuler RH (1993) Stress, role captivity, and the cessation of caregiving. J Health Soc Behav; 34: 54–70 12- Stommel M, Collins CE, Given BA (1994) The costs of family contributions to care of persons with dementia. Gerontologist; 34:199–205 13- Borson S, Raskind MA (1997) Clinical features and pharmacologic treatment of behavioral symptoms of Alzheimer’s disease. Neurology; 48(Suppl 6):Sl7-S24. 14- Hamel M, Gold DP, Andres D (1990) Predictors and consequences of aggressive behavior by communitybased dementia patients. Gerontologist; 30:206-211. 15- Schoenmakers B, Buntinx F and De Lepeleire J (2009) Can pharma-cological treatment of behavioural disturbances in elderly patients with dementia lower the burden of their family caregiver? Family Practice; 26: 279–286. 16- Steele C, Rovner B, Chase GA, Folstein M (1990) Psychiatric problems and nursing home placement of patients with Alzheimer’s disease. Am J Psychiatry; 147:1049-1051. 17- Folstien MF, Folestein S, McHugh PR, (1975) MINI-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res.; 12:189. 18- Katz S, Ford AB, Moskowitz RW, Jackson BS, Jaffe MW (1963) Studies of illness in the aged. the Index of ADL: A Standardized measure of biological and psychosocial function JAMA.;185(12):914-919. 19- Lawton MP and Brody EM. (1969) Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist; 9(3):179-86. 20- Cummings JL, Mega M, Gray K (1994) The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology; 44:2308–2314. 21- M Ikeda, R Fukuhara, K Shigenobu, K Hokoishi, N Maki, A Nebu, K Komori, H Tanabe (2004) Dementia associated mental and behavioural disturbances in elderly people in the community: findings from the first Nakayama study. J Neurol Neurosurg Psychiatry; 75:146–148 22- Davis JD and Tremont G (2007) Impact of Frontal Systems Behavioral Functioning in Dementia on Caregiver Burden. J Neuropsychiatry Clin Neurosci 19:43-49 23-Desai AK, Grossberg GT, Sheth DN (2004) Activities of Daily Living in Patients with Dementia: Clinical Relevance, Methods of Assessment and Effects of Treatment.CNS Drugs 18; 853-875 24- Sikkes SA, de Klerk SM, Pijnenburg YA, Scheltens P (2009) A systematic review of Instrumental Activities of Daily Living scales in dementia: room for improvement J Neurol Neurosurg Psychiatry 80;7-12. 25- Liu K P, Chan C C, Chu M M, Chu L, Hui F S, Yuen H K, Fisher A G (2007) Activities of daily living performance in dementia. Acta Neurologica Scandinavica; 116: 91-95. 26- Ballard CG, Bannister C, Solis M (1996) The prevalence, associations and symptoms of depression amongst dementia sufferers. J Affect Disord; 36:135–144 27- Jason M. Stroud JM, Victoria S, Cletus L (2008) Predictors of depression among older adults with dementia. Dementia; 7: 127-138 28- Forsell Y, Winblad B (1998) Major depression in a population of demented and nondemented older 23 EL-MINIA MED., BUL., VOL. 22, NO. 2, JUNE 2011 El-Sherbini __________________________________________________________________________________ people: prevalence and correlates. JAm Geriatr Soc; 46:27-30. 29- Payne JL, Lyketsos CG, Steele C (1998) Relationship of cognitive and functional impairment to depressive features in Alzheimer’s disease and other dementias. J Neuropsychiatry Clin Neurosci. 10:440-447. 30- Rao V, Rosenberg P, Miles Q, Patadia D, (2010) neuropsychiatric Symptoms in Dementia Patients With and Without a History of Traumatic Brain Injury J Neuropsychiatry Clin Neurosci 22:166-172 31- Cummings JL, Nadel A, )Masterman D, Cyrus PA (2001 Efficacy of Metrifonate in Improving the Psychiatric and Behavioral Disturbances of Patients with Alzheimer’s disease . J Geriatr Psy-chiatry Neurol 14: 101 32- Dong MJ, Peng B, Lin XT, et al. (2007) The prevalence of dementia in the People's Republic of China: a systematic analysis of 1980–2004 studies. Age & Ageing; 36:619–24. 33- Nitrini R, Caramelli P, Herrera E, Jr, et al. (2004) Incidence of dementia in a community-dwelling Brazilian population. Alzheimer Dis Assoc Disord.; 18:241–46. األعراض النفسية والسلوكية في عينة من المسنين المصابين بمرض عته الشيخوخة عمرو مكرم الشربيني قسم األمراض العصبية و النفسية كلية الطب جامعة المنيا الملخص العربي تنتشر األعراض النفسية والسلوكية بين مرضى عته الشيخوخة وتأثر بالسلب على المرضى كما تؤدى الى زيادة الضغط على من يقومون برعاية المريض .الهدف من هذا البحث هو التعرف على مدى أنتشار األعراض النفسية و السلوكية في مرضى عته الشيخوخة والوقوف على أثر هذه األعراض على المرضى واألهل .فى هذا البحث تم تقييم ثماني وعشرين مريض مصابين بمرض عته الشيخوخه و قد تم تحديد وجود األعراض النفسية والسلوكية عن طريق أستخدام جداول األعراض النقسية والسلوكية باألضافة الى أستخدام أختبار الحالة العقلية المصغر ,أختبار النشاطات اليومية وأختبار النشاطات اليومية األلية .أظهرت نتائج هذه الدراسة أن %85.7من العينة يعانون من أعراض نفسية وسلوكية .كما أظهرت النتائج أن األكتئاب كان العرض األكثر شيوعا بين المرضى حيث تم تشخيصه في %32.1من العينة متبوعا بعدم األهتمام %28.6ثم القلق .%21.4وأظهرت النتائج أن معاناة األهل كانت مرتبطة يشدة األعراض النفسية والسلوكية في حين أرتبط التدهور الوظيفي بأختبار الحالة العقلية المصغر .و قد خلص البحث الى أن األعراض النفسية والسلوكية واسعة األنتشار في مرضى عته الشيخوخة و يجب تشخيص هذه األعراض ومعالجتها بشكل فعال للتقليل من أثرها السلبي. 24