Carol Bannister

Quetiapine and rivastigmine and cognitive decline in Alzheimer's disease: randomised double blind placebo controlled trial.

Abstract Objectives To determine the respective efficacy of quetiapine and rivastigmine for agitation in people with dementia in institutional care and to evaluate these treatments with respect to change in cognitive performance. Design Randomised double blind (clinician, patient, outcomes assessor) placebo controlled trial. Setting Care facilities in the north east of England. Participants 93 patients with Alzheimers disease, dementia, and clinically significant agitation. Intervention Atypical antipsychotic (quetiapine), cholinesterase inhibitor (rivastigmine), or placebo (double dummy). Main outcome measures Agitation (Cohen-Mansfield agitation inventory) and cognition (severe impairment battery) at baseline and at six weeks and 26 weeks. The primary outcome was agitation inventory at six weeks. Results 31 patients were randomised to each group, and 80 (86%) started treatment (25 rivastigmine, 26 quetiapine, 29 placebo), of whom 71 (89%) tolerated the maximum protocol dose (22 rivastigmine, 23 quetiapine, 26 placebo). Compared with placebo, neither group showed significant differences in improvement on the agitation inventory either at six weeks or 26 weeks. Fifty six patients scored > 10 on the severe impairment battery at baseline, 46 (82%) of whom were included in the analysis at six week follow up (14 rivastigmine, 14 quetiapine, 18 placebo). For quetiapine the change in severe impairment battery score from baseline was estimated as an average of -14.6 points (95% confidence interval -25.3 to -4.0) lower (that is, worse) than in the placebo group at six weeks (P = 0.009) and -15.4 points (-27.0 to -3.8) lower at 26 weeks (P = 0.01). The corresponding changes with rivastigmine were -3.5 points (-13.1 to 6.2) lower at six weeks (P = 0.5) and -7.5 points (-21.0 to 6.0) lower at 26 weeks (P = 0.3). Conclusions Neither quetiapine nor rivastigmine are effective in the treatment of agitation in people with dementia in institutional care. Compared with placebo, quetiapine is associated with significantly greater cognitive decline.

The prevalence, associations and symptoms of depression amongst dementia sufferers

OBJECTIVE To examine the prevalence rates of RDC major and RDC minor depression in dementia sufferers, to compare the prevalence rates and symptoms of depression between different dementias and to look at the associations of RDC major depression. DESIGN Case control. SETTING Referrals to clinical services. SUBJECTS 124 patients with DSM-III-R dementia. MEASURES The patients were assessed using the GMS/HAS package and the Cornell Depression Scale. Depression was diagnosed according to RDC criteria. RESULTS 25.0% of patients had RDC major depression and 27.4% had RDC minor depression. Major depression occurred significantly more often and was significantly more severe in patients with vascular dementia than patients with Alzheimers disease. Severe visual impairment was significantly associated with RDC major depression in Alzheimers disease and physical health problems were significantly associated with depression in vascular dementia. Most symptoms of depression including suicidal thoughts were common. CONCLUSIONS Major depression is more common and more severe in patients with vascular dementia. The associations of depression may be different in these patients.

Prevalence, symptom profile, and aetiology of depression in dementia sufferers.

Ninety-two consecutive attenders at a day hospital for the assessment of dementia were assessed using the CAMDEX schedule. The prevalence of depression in the 58 dementia sufferers who fulfilled the entry criteria for the study was 24.1%. The prevalence of depression was similar in patients with senile dementia of Alzheimers type and those with vascular dementia. Patients with minimal dementia were significantly more likely to suffer from depression than those with mild or moderate dementia but there was no significant association with insight. The symptom profile of patients with minimal dementia was significantly correlated to that of patients with mild dementia and both were similar to the symptom profiles previously described amongst the elderly with functional depression. Physical illness was not associated with depression in the current sample. The implications of the findings are discussed.

Classification of psychotic symptoms in dementia sufferers

Little attention has been payed to the classification of psychotic symptoms in dementia sufferers. This article compares the etiology of delusions, visual hallucinations and delusional misidentification and examines the value of factors generated from principal components analysis as a possible classificatory system in a group of 125 patients with DSM‐III‐R dementia in contact with clinical services who were prospectively evaluated using standardized instruments to describe in detail individual psychotic symptoms. The assessment also included the Geriatric Mental State Schedule, the History and Aetiology Schedule and the CAMCOG. Delusions and visual hallucinations had a distinct cognitive profile as did delusions and delusional misidentification, although there was an overlap between visual hallucinations and delusional misidentification. Four factors were generated from principal components analysis. Three of these closely mirrored the 3 symptom groups delusions, visual hallucinations and delusional misidentification, although the phantom‐boarder delusion was correlated with the visual hallucination factor and not delusional misidentification. The fourth factor included visual hallucinations of relatives and delusions that relatives were in the house. This factor was strongly inversely associated with emotional distress and could perhaps best be seen as a comfort phenomena. The pattern of cognitive deficits and etiological associations of each of the factors were independent of one another, supporting the notion that it is useful to consider them as separate entities.

Depression in dementia sufferers

A large number of studies concerning depression in dementia sufferers have appeared in the literature over the last few years and have added to our knowledge considerably. The prevalence rate of concurrent depression and dementia among clinical samples is approximately 20% with lower rates in the community. There is relatively little information available regarding patients in nursing homes, which is a priority for research along with the study of milder depression. Although there have been a number of interesting developments regarding possible neurochemical associations of depression among these patients, there has been little study of psychosocial factors. The symptoms of depression are similar to those seen in patients without cognitive impairment. Concurrent depression creates considerable excess disability. More information is required about the natural course of these disorders and treatment strategies.

August: the killing season. Other measures of quality are needed.

EDITOR,—Paul Aylin and F Azeem Majeed point out that they did not have data on admission rates or bed occupancy during the …