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Questions and Answers

Which intervention showed the greatest mean difference in reducing symptoms of depression in dementia compared to usual care?

Occupational therapy

Massage + touch therapy

Cognitive stimulation + cholinesterase inhibitor

Exercise + social interaction + cognitive stimulation (correct)

What is the mean difference reported for cognitive stimulation alone in reducing symptoms of depression in dementia?

−2.93 (correct)

−1.98

−12.37

−9.03

Which of the following treatments for depression in dementia showed no significant difference when compared to placebo?

Fluoxetine

Mirtazapine (correct)

Sertraline

Citalopram

Agitation in dementia is best described as which of the following?

Inappropriate verbal or motor activity Signup and view all the answers

What is a potential consequence of agitation in dementia patients?

Care breakdown Signup and view all the answers

Which of the following statements about antidepressant use in people with dementia is correct?

People with Alzheimer's disease use antidepressants at a rate 3 times higher than those without dementia. Signup and view all the answers

When assessing agitation in a person with dementia, which of the following should be considered?

Physical comfort and hunger Signup and view all the answers

What was the mean difference for multidisciplinary care in reducing symptoms of depression?

−1.98 Signup and view all the answers

What are neuropsychiatric symptoms in relation to dementia?

Disturbed perception, thought, mood, or behavior Signup and view all the answers

What does the Neuropsychiatric Inventory (NPI) assess?

Neuropsychiatric symptoms across 12 domains Signup and view all the answers

What is the main focus of the Tailored Activity Program (TAP) for people with dementia?

Using activities tailored to interests and abilities Signup and view all the answers

Which neuropsychiatric symptom has the highest odds ratio of progressing to Mild Cognitive Impairment (MCI)?

Agitation Signup and view all the answers

Which of the following symptoms is NOT included in the Neuropsychiatric Inventory assessment?

Memory loss Signup and view all the answers

Which intervention showed a moderate effect on improving the quality of life for individuals with dementia?

Activity Intervention Program Signup and view all the answers

What is one key outcome reported in the study by Ballard regarding the WHELD intervention?

Improved neuropsychiatric symptoms Signup and view all the answers

How are the severity scores calculated in the Neuropsychiatric Inventory?

By multiplying frequency and severity scores Signup and view all the answers

What percentage of individuals with Mild Cognitive Impairment experience significant neuropsychiatric symptoms?

25% Signup and view all the answers

What was the effect size regarding the reduction of carer burden found in the TAP systematic review?

0.68 Signup and view all the answers

Which of the following symptoms tends to persist the longest in individuals with Mild Cognitive Impairment?

Delusions Signup and view all the answers

Which of the following was NOT identified as a method of intervention while the issue is happening?

Cognitive behavioral therapy Signup and view all the answers

Which intervention design used a single-blind, parallel RCT study to assess outcomes?

TAP for veterans Signup and view all the answers

What is the term used to describe behavioral and psychological symptoms of dementia?

BPSD Signup and view all the answers

What is one reported outcome of the TAP interventions regarding behavioral symptoms?

Decreased behavioral symptoms Signup and view all the answers

What type of training did carers receive in the Tailored Activity Program?

Using activities tailored to individual needs Signup and view all the answers

What is the effect of Citalopram 30mg on agitation in dementia patients?

Decreases general agitation Signup and view all the answers

Which intervention is most effective in reducing agitation in care homes?

Individualized multicomponent interventions Signup and view all the answers

What is the expected excess cost associated with agitation in individuals with Alzheimer's Disease per year?

£4,091 Signup and view all the answers

What action should be considered when medications are not effective for agitation?

Attempt alternative non-drug therapies Signup and view all the answers

What did the RCT in German primary care demonstrate regarding neuropsychiatric symptoms?

Decreased neuropsychiatric symptoms with no quality of life impact Signup and view all the answers

Which statement accurately reflects the impact of communication and listening on agitation in dementia?

They may alleviate some symptoms of agitation Signup and view all the answers

What is the role of activity in managing agitation in care homes?

Targeted interventions combined with activity are necessary Signup and view all the answers

Which medication has been found to be ineffective for agitation in dementia patients?

Valproate Signup and view all the answers

What was the main objective of the TAP program mentioned in the study?

To reduce the agitation and aggression in individuals with dementia Signup and view all the answers

What demographic differences were observed in the benefits of the TAP program?

More benefits for Black dyads than White dyads Signup and view all the answers

What was the result regarding cognitive impairment in the exercise group of the DAPA trial?

Cognitive impairment increased in the exercise group Signup and view all the answers

Which aspect was NOT positively affected by the interventions in the Sanders study?

Social interaction Signup and view all the answers

Which intervention was part of the TAP program?

Behavioral activities tailored to each dyad Signup and view all the answers

What was the sample size of the TAP study focusing on individuals with moderate dementia?

250 participants Signup and view all the answers

What type of study design was used in the TAP trial?

Single-blind RCT Signup and view all the answers

What was the significant finding regarding hospitalizations in the TAP group?

Fewer deaths/hospitalizations in the TAP group Signup and view all the answers

What percentage of individuals with Dementia with Lewy Bodies (DLB) experienced sleep disturbances while living at home?

49% Signup and view all the answers

What sleep-related behavior is commonly observed in individuals with dementia?

Difficulty initiating sleep Signup and view all the answers

What is a potential consequence of sleep disturbances in patients with dementia for family caregivers?

Increased risk of care home admission Signup and view all the answers

What environmental factors can contribute to sleep problems in individuals with dementia?

Noise, light, and temperature Signup and view all the answers

What type of therapy has been identified as potentially helpful when combined with sleep education in dementia?

Cognitive Behavioral Therapy (CBT) Signup and view all the answers

Which medication is commonly used for sleep disturbances in dementia but may have adverse effects?

Melatonin Signup and view all the answers

What is one significant risk associated with the use of hypnotics in dementia patients?

Increased risk of falls Signup and view all the answers

What hormonal change is implicated in the sleep-wake cycle impairment in dementia?

Degeneration of the suprachiasmatic nucleus Signup and view all the answers

Study Notes

Neuropsychiatric Symptoms of Dementia

Neuropsychiatric symptoms (NPS) are disturbances in perception, thought, mood, or behaviour, associated with dementia.
Also known as behavioral and psychological symptoms of dementia (BPSD)
Symptoms can occur clustered or separately
Cluster analyses commonly categorize NPS into subgroups like agitation, psychosis, and mood disorders.

Neuropsychiatric Inventory (NPI)

The NPI is a semi-structured instrument used to assess NPS in dementia.
It is administered to caregivers.
The NPI has 12 domains: delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, euphoria/elation, apathy/indifference, disinhibition, irritability/lability, aberrant motor behavior, sleep disturbance, and appetite disturbance.
Each symptom is rated by frequency and severity. The overall score is the product of these two ratings.

Delusions

Individuals with dementia may have beliefs that are not true.
Examples include, insisting that people are trying to harm them, or that family members are not who they say they are.
This differs from simple suspiciousness which is a normal part of aging.

Mild Cognitive Impairment (MCI)

25% of people with MCI have significant neuropsychiatric symptoms.
75% of symptoms persist for 6 months.
Delusions, agitation, apathy, and sadness were the most persistent symptoms in more severe baseline cases.
Clinically significant NPS negatively impact quality of life.

Pre-cognitive Impairment

New neuropsychiatric symptoms in older people without impairment may be a pre-dementia disorder.
New onset agitation is associated with a higher likelihood of escalating to MCI.
Neuropsychiatric symptoms in pre-dementia are strongly linked to tau and amyloid neuropathology.
The neurobiological mechanisms behind these symptoms could be linked to increased vulnerability to stressors or triggers including genetics, personal history, comorbidities and environmental factors such as carer response.

Prevalence of NPS in Dementia

75% of people with Alzheimer's disease (AD) have at least one clinically significant symptom.
80% of clinically significant symptoms persist for 6 months.
Apathy, aberrant motor behavior, and agitation are the most common types.
Persistence of symptoms is predicted by the severity of symptoms at baseline.
Symptoms like apathy, agitation and delusions tend to be the most persistent.
NPS deterioration often correlates with declining MMSE scores.

Prevalence of NPS in Nursing Homes

Over 90% of patients in nursing homes have one or more clinically significant NPS.
Irritability, agitation, and disinhibition are the most frequent and persistent symptoms.
NPS can be a reason for admission to a nursing home.
Persistent symptoms such as delusions, agitation, apathy and irritability are common reasons for enduring symptoms.
88% without agitation did not develop it over 16 months, and 70% in those present, remained so.
Those without agitation did not develop it over the 16 month testing period.

Summary of NPS

NPS increase from MCI and mild to moderate dementia.
The prevalence of clinically significant symptoms increase from 25% with MCI to ~90% in nursing homes.
At-home settings may show different rates compared to nursing homes.
75% of agitation and apathy persist over a year with proper management.
Agitation and apathy are persistent across all severities.

Psychosis in Dementia

Prevalence of psychosis in dementia is ~18% across various stages.
Prevalence increases from mild to moderate dementia before plateauing.
Psychotic symptoms typically persist for at least several months.

Psychosis in Dementia-Symptoms

Delusions (more common) - usually are simple, not systematic or bizarre, like beliefs of theft, abandonment, infidelity, or poisoning.
Misidentification symptoms: belief that someone's identity has changed, or "phantom boarder"
Visual hallucinations (much more common than auditory)
Auditory hallucinations: usually sounds, single words or phrases, rarely commenting or commanding voices.

Assessment and Management

Assessment: Determine if it's a delusion vs memory loss , and consider delirium.
Management should begin with non-pharmacological approaches and use antipsychotics as a last resort at the lowest dose possible and shortest duration possible .
Consider contributory factors like sensory impairment, loneliness or isolation, for example.

Risk Factors

Misinterpretations of reality in dementia are often tied to sensory deprivation.
Visual and auditory impairment, isolation can contribute.
DLB has a greater tendency for well-formed visual hallucinations.
No genetic contribution identified despite familiar aggregation.
Gray matter changes in the neocortical regions, rather than the temporal lobe structures are seen in AD and psychosis.

Significance of Psychosis in Dementia

Significant distress in some patients compared to others.
Psychotic symptoms often signal a faster decline in cognitive function compared to patients without psychotic symptoms.
Family care burden is also higher when psychosis is present.
More severe general health problems and mortality are often observed in those with psychosis.

Antipsychotic Use

Individual antipsychotics have differing mortality risks.
Antipsychotics in dementia are associated with 1% mortality.
Increased risk observed of stroke and cognitive decline.
Perhaps less risk with delusions than agitation.
General antipsychotic side effects include cognitive worsening, falls, immobility and CVA (cerebrovascular accident).
Use when benefit outweighs the risks.

Agitation in Dementia

Agitation is inappropriate verbal, vocal, or motor activity, including purposeless activity, shouting, physical and verbal aggression, and wandering.
It's a behavioural manifestation, rather than purely emotional.
The person is usually distressed. Often this is seen as a form of communication.

Importance of Agitation Research

Agitation may be a more crucial indicator than cognition in dementia.
Agitation is a common, persistent and distressing symptom in dementia.
80% of those with clinically significant agitation remain symptomatic 6 months later.
Agitation leads to reduced quality of life, increased costs, care breakdown.
Increased pressure on relationships within the family unit.

Assessment for Agitation

What is wrong?
Psychological distress (fright, anxiety)
Physical comfort/ needs (hunger, thirst).
Sudden onset suggests a new physical problem
Reaction to stress from others

Interventions for Agitation

Activities-focused therapy to a protocol
Music therapy and sensory interventions
Supervised person-centred care.
Supervised communication skills training
Dementia mapping with supervision

Activity Intervention

Tailored activity programs (TAP) are shown to improve QoL, reduce neuropsychiatric symptoms and reduce carer burden.

Sensory Interventions

Sensory interventions, such as massage and multisensory techniques, can help reduce symptomatic agitation during the intervention.
Therapeutic touch methods weren't shown to be better than standard care methods.

Person-Centred Care

Training staff in communication and person-centered care, or dementia mapping with supervision has positive benefits for agitation, particularly over six months.

Interventions Not Recommended

Light therapy studies show an increase in agitation.
Aromatherapy did not demonstrate positive results in studies.
Training of family caregivers in behavioural and cognitive interventions was not effective, and in some instances, was harmful when dealing with severe agitation.

Sleep and Dementia

Sleep disturbance is prevalent across all stages of dementia, including AD and DLB (higher proportion observed in DLB).
Sleep disturbances can include- impaired sleep initiation, reduced nighttime sleep, increased nighttime wandering, and excessive daytime sleep.
There are also associated behavioral changes during the night.

Sleep Disturbance in DLB

49% of people living at home with DLB experience sleep disturbance.
Difficulty staying alert (apathy, napping)
Visual hallucinations and delusions
Restlessness
Rapid eye movement (REM) sleep behavior disorder

Consequences of Sleep Disturbances in Dementia

Sleep disturbances can create distress in dementia patients.
This can significantly impact the quality of life for individuals and their support networks.
Sleep disorders that affect routine nighttime sleep can sometimes affect wellbeing, and behaviors in individuals with dementia.

Why Sleep Disturbances Matter

Sleep disturbances influence family carer's mental health and well-being, and sometimes make it harder for individuals to cope with the caregiving responsibilities.
This puts more pressure on healthcare systems, as the risk of admission to a care home increases.

Causes of Sleep Problems

Suprachiasmatic nucleus degeneration disrupts the sleep-wake cycle and circadian rhythms.
Inactivity or excessive napping can adversely impact sleep pressure.
Visual impairments can affect the brain's ability to process light cues.
Physical illness and medications also influence sleep.
Environment factors such as temperature, noise, and light can also affect sleep.

Effective Treatments for Sleep

Bright light therapy, combined with sleep education/hygiene, exercise, and daytime activities appears effective.
Cognitive Behavioral Therapy (CBT), also shows promise in improvement.

Medication for Sleep

Melatonin, mirtazapine, and analgesics are sometimes used, although RCTs have not shown consistent positive results.
Hypnotics are often ineffective, and may even cause harm.

Summary-Agitation

Agitation is often a way of communicating distress in people with dementia
Addressing underlying factors like Pain, constipation, thirst, anxiety, worry or lack of touch, loneliness or discomfort is crucial.
Good communication alongside sensory interventions can improve outcomes.
Medication is often not the most effective way to address the issue, unless other non-pharmacological means have failed.

Dementia Care Management

RCT in German primary care: weekly interdisciplinary case conferences with nurses, neurologists, psychiatrists, psychologists, and pharmacists.
Six months of care management by trained dementia nurses.
Intervention showed decreased NPS.

UK Cost of Agitation

Agitation has a significant cost associated with care, and healthcare.
£2.0 Billion per year is the estimated excess cost in the UK attributable to agitation, and this cost is a substantial burden on healthcare systems.

When to Use Medications for Dementia

Consider medications only when other treatments fail.
The risks of certain drugs outweigh the benefits.
Risks need to be discussed with the individual and care network first.

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