Catherine S. Hurt

Neuropsychiatric syndromes in dementia - Results from the European Alzheimer Disease Consortium: Part I

Background/Aims: The aim of this study was to identify neuropsychiatric subsyndromes of the Neuropsychiatric Inventory in a large sample of outpatients with Alzheimer’s disease (AD). Methods: Cross-sectional data of 2,354 patients with AD from 12 centres from the European Alzheimer’s Disease Consortium were collected. Principal component analysis was used for factor analysis. Results: The results showed the presence of 4 neuropsychiatric subsyndromes: hyperactivity, psychosis, affective symptoms and apathy. The subsyndrome apathy was the most common, occurring in almost 65% of the patients. Conclusion: This large study has provided additional robust evidence for the existence of neuropsychiatric subsyndromes in AD.

Consistency of Neuropsychiatric Syndromes across Dementias: Results from the European Alzheimer Disease Consortium

Background/Aims: The aim of this study was to determine the consistency of neuropsychiatric subsyndromes of the Neuropsychiatric Inventory across several clinical and demographic subgroups (e.g. dementia subtypes, dementia severity, medication use, age and gender) in a large sample of outpatients with dementia. Methods: Cross-sectional data of 2,808 patients with dementia from 12 centres from the European Alzheimer’s Disease Consortium were collected. Principal component analysis was used for factor analysis. Subanalyses were performed for dementia subtypes, dementia severity, medication use, age and gender. Results: The results showed the relatively consistent presence of the 4 neuropsychiatric subsyndromes ‘hyperactivity’, ‘psychosis’, ‘affective symptoms’ and ‘apathy’ across the subanalyses. The factor structure was not dependent on dementia subtypes, age and gender but was dependent on dementia severity and cholinesterase use. The factors hyperactivity and affective symptoms were present in all subanalyses, but the presence of the factors apathy and psychosis was dependent on use of cholinesterase inhibitors and dementia severity, respectively. Conclusion: The present study provided evidence of the relative consistency of neuropsychiatric subsyndromes across dementia subtypes, age and gender, thereby stressing the importance of thinking about neuropsychiatric subsyndromes instead of separate symptoms. However, the subsyndromes apathy and psychosis were dependent on use of cholinesterase inhibitors and dementia severity.

Patient and Caregiver Perspectives of Quality of Life in Dementia An Investigation of the Relationship to Behavioural and Psychological Symptoms in Dementia

Background/Aims: Behavioural and psychological symptoms have a high prevalence amongst patients with dementia and can be a significant source of distress to both patients and carers. The present study explored the relationships between quality of life and behavioural and psychological symptoms in dementia (BPSD) from both patient and carer perspectives. Contextual factors surrounding the occurrence of BPSD were explored. Methods: Forty-six patients and 116 carers completed questionnaire measures of BPSD and quality of life. Results: BPSD were negatively associated with both patient and carer ratings of patient quality of life. The symptoms related to lower quality of life differed between patient and carer ratings: depression and irritability were found to predict lower carer ratings of quality of life, whilst delusions and apathy indicated lower patient ratings. Carers were found to be poor at identifying antecedents and consequences of BPSD. Conclusions: The presence of BPSD is associated with lower quality of life in dementia. Interventions designed to improve the quality of life for patients should focus on the BPSD specifically associated with the patient’s rating of quality of life. Information regarding the role of contextual factors in behaviour management should be made available to carers.

Depression and anxiety related subtypes in Parkinson's disease

Background Depression and anxiety are common in Parkinsons disease (PD) and although clinically important remain poorly understood and managed. To date, research has tended to treat depression and anxiety as distinct phenomena. There is growing evidence for heterogeneity in PD in the motor and cognitive domains, with implications for pathophysiology and outcome. Similar heterogeneity may exist in the domain of depression and anxiety. Objective To identify the main anxiety and depression related subtype(s) in PD and their associated demographic and clinical features. Methods A sample of 513 patients with PD received a detailed assessment of depression and anxiety related symptomatology. Latent Class Analysis (LCA) was used to identify putative depression and anxiety related subtypes. Results LCA identified four classes, two interpretable as ‘anxiety related’: one anxiety alone (22.0%) and the other anxiety coexisting with prominent depressive symptoms (8.6%). A third subtype (9%) showed a prominent depressive profile only without significant anxiety. The final class (60.4%) showed a low probability of prominent affective symptoms. The validity of the four classes was supported by distinct patterns of association with important demographic and clinical variables. Conclusion Depression in PD may manifest in two clinical phenotypes, one ‘anxious–depressed’ and the other ‘depressed’. However, a further large proportion of patients can have relatively isolated anxiety. Further study of these putative phenotypes may identify important differences in pathophysiology and other aetiologically important factors and focus research on developing more targeted and effective treatment.

Parkinson's disease motor subtypes and mood

Parkinsons disease is heterogeneous, both in terms of motor symptoms and mood. Identifying associations between phenotypic variants of motor and mood subtypes may provide clues to understand mechanisms underlying mood disorder and symptoms in Parkinsons disease. A total of 513 patients were assessed using the Hospital Anxiety and Depression Scale, and separately classified into anxious, depressed, and anxious‐depressed mood classes based on latent class analysis of a semistructured interview. Motor subtypes assessed related to age‐of‐onset, rate of progression, presence of motor fluctuations, lateralization of motor symptoms, tremor dominance, and the presence of postural instability and gait symptoms and falls. The directions of observed associations tended to support previous findings with the exception of lateralization of symptoms, for which there were no consistent or significant results. Regression models examining a range of motor subtypes together indicated increased risk of anxiety in patients with younger age‐of‐onset and motor fluctuations. In contrast, depression was most strongly related to axial motor symptoms. Different risk factors were observed for depressed patients with and without anxiety, suggesting heterogeneity within Parkinsons disease depression. Such association data may suggest possible underlying common risk factors for motor subtype and mood. Combined with convergent evidence from other sources, possible mechanisms may include cholinergic system damage and white matter changes contributing to non‐anxious depression in Parkinsons disease, while situational factors related to threat and unpredictability may contribute to the exacerbation and maintenance of anxiety in susceptible individuals.

Nonmotor versus motor symptoms: How much do they matter to health status in Parkinson's disease?

Evidence suggests that both motor and nonmotor symptoms contribute to health status in Parkinsons disease. Less clear is how much change in health status can be expected if these clinical variables change. In addition, anxiety, separate from depression, has rarely been examined as a predictor of health status. We used hierarchical multiple regression analysis and standardized beta coefficients in a prevalent cohort of 462 patients with Parkinsons disease to explore the relative impact on health status (measured using the Parkinsons Disease Questionnaire) of 5 well‐recognized symptom domains in Parkinsons disease: motor signs, depression, anxiety, cognition, and other nonmotor symptoms. In the health status scores, 19.6% of variance was explained by age, number of comorbidities, disease duration, and levodopa equivalent dose. Younger age predicted worse health status. A full regression model containing baseline variables and all 5 symptom domains explained 56% of the variance in health status. The standardized beta coefficient for depression was 2.1, 1.6, and 1.3 times that of motor signs, anxiety, and other nonmotor symptoms, respectively. Our findings provide a ranking order of clinical variables for their relative impact on health status in Parkinsons disease and show that depression has more than twice the impact of motor signs on health status. Anxiety and other nonmotor symptoms are also important separate determinants of poor health status in Parkinsons disease. Our results will help to guide the development of individual care and service planning for patients with Parkinsons disease.

Insight, cognition and quality of life in Alzheimer's disease

Background The detrimental impact of dementia upon patient health-related quality of life (HRQL) is well established, as is the importance of improving HRQL. However, relatively little is known about the natural history of HRQL in dementia and those factors influencing it. This limited knowledge potentially restricts the evaluation of the efficacy of interventions designed to improve HRQL. One such area concerns the relationship between HRQL and patient insight. It remains unclear what impact, if any, impaired insight has upon a patients HRQL. The present study aimed to investigate the relationship between insight and HRQL in a sample of patients with Alzheimers disease (AD) and their carers. Methods 256 patients with AD were recruited as part of AddNeuroMed, a multicentre European AD biomarkers study. Of these, 174 completed a quality-of-life measure in addition to a comprehensive battery of clinical and neuropsychological assessments. Results Insight was found to be differentially related to patient perceptions of HRQL in mild and moderate dementia. Within moderate dementia, impaired insight was associated with better perceived HRQL. Conversely, cognition, but not insight, was associated with impaired HRQL in mild dementia. Insight was not found to be associated with carer perceptions of patient HRQL. Conclusion Impairment of insight is associated with better HRQL in moderate dementia. This finding has implications for interventions which focus on increasing patient awareness and orientation, as impairment of insight appears to have a positive impact upon HRQL.

CLUSTERING OF BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS IN DEMENTIA (BPSD): A EUROPEAN ALZHEIMER’S DISEASE CONSORTIUM (EADC) STUDY

Abstract Objectives. This cross-sectional study investigated the relationships between behavioural and psychological symptoms of dementia (BPSD). Methods. We recruited 194 patients with dementia from the memory clinic practice of six European Alzheimer’s Disease Consortium centres. BPSD were assessed using a pre-designed questionnaire comprising the Neuropsychiatric Inventory (NPI). BPSD scores were analysed by Spearman’s correlation analysis and principal components factor analysis. Results were confirmed by performing Varimax rotation of the factors. Results. The NPI symptoms occurred very frequently: 96% of the patients displayed at least one symptom. Among them, apathy (59.6%) and depression (58.5%) were the most common abnormalities, followed by irritability (44.6%), anxiety (44%) and agitation (41.5%). Four NPIbased factors were identified (58% of the common variance): psychosis factor (irritability, agitation, hallucinations and anxiety), psychomotor factor (aberrant motor behaviour and delusions), mood liability factor (disinhibition, elation and depression) and instinctual factor (appetite disturbance, sleep disturbance and apathy). Conclusion: Psychosis, psychomotor factor, mood liability factor and instinctual factor form four distinct behavioural syndromes in dementia. We report the novel observation that depression clusters together with disinhibition and elation within a mood liability factor. This finding highlights the nature of mood, and mood oscillations, from depression to disinhibition within the cluster, and has implications for treatment by taking into consideration the poles of the mood scale and any oscillation between them.

Apathy and cortical atrophy in Alzheimer's disease

Apathy has been reported as the most prevalent behavioural symptom experienced in Alzheimers disease (AD), associated with greater functional decline and caregiver distress. The aim of the current study was to investigate structural correlates of apathy in AD using magnetic resonance imaging (MRI) regional volume and regional cortical thickness measures.

Why don't older adults with subjective memory complaints seek help?

Subjective memory complaints (SMCs) are common among older adults, often causing significant distress and showing strong relationships to future cognitive decline. However, low rates of help‐seeking for memory complaints are well documented. Little is known about the reasons behind the decision to seek or not to seek help with memory problems. The common‐sense model of illness perception proposes that the beliefs people hold about their health underlie help‐seeking behaviour. The present study investigated factors underlying the decision to seek help in people with SMCs within the framework of the common‐sense model of illness perception.