Geir Selbæk

Dementia prevention, intervention, and care

Acting now on dementia prevention, intervention, and care will vastly improve living and dying for individuals with dementia and their families, and in doing so, will transform the future for society. Dementia is the greatest global challenge for health and social care in the 21st century. It occurs mainly in people older than 65 years, so increases in numbers and costs are driven, worldwide, by increased longevity resulting from the welcome reduction in people dying prematurely. The Lancet Commission on Dementia Prevention, Intervention, and Care met to consolidate the huge strides that have been made and the emerging knowledge as to what we should do to prevent and manage dementia. Globally, about 47 million people were living with dementia in 2015, and this number is projected to triple by 2050. Dementia affects the individuals with the condition, who gradually lose their abilities, as well as their relatives and other supporters, who have to cope with seeing a family member or friend become ill and decline, while responding to their needs, such as increasing dependency and changes in behaviour. Additionally, it affects the wider society because people with dementia also require health and social care. The 2015 global cost of dementia was estimated to be US

Loss-of-function variants in ABCA7 confer risk of Alzheimer's disease.

818 billion, and this figure will continue to increase as the number of people with dementia rises. Nearly 85% of costs are related to family and social, rather than medical, care. It might be that new medical care in the future, including public health measures, could replace and possibly reduce some of this cost.

The course of psychiatric and behavioral symptoms and the use of psychotropic medication in patients with dementia in Norwegian nursing homes--a 12-month follow-up study.

We conducted a search for rare, functional variants altering susceptibility to Alzheimers disease that exploited knowledge of common variants associated with the same disease. We found that loss-of-function variants in ABCA7 confer risk of Alzheimers disease in Icelanders (odds ratio (OR) = 2.12, P = 2.2 × 10−13) and discovered that the association replicated in study groups from Europe and the United States (combined OR = 2.03, P = 6.8 × 10−15).

The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review.

OBJECTIVE This study investigates the natural course of neuropsychiatric symptoms and the concomitant use of psychotropic medication among a large and representative sample of nursing-home patients with dementia. METHOD The authors performed two data collections with structured interviews in a 1-year follow-up cohort-study including 26 nursing homes in four counties in two Norwegian health regions. The main outcome measures were baseline and follow-up frequencies, persistence and incidence of neuropsychiatric symptoms, and the change in neuropsychiatric symptoms with regard to the use of psychotropic medication. RESULTS At baseline a representative sample of 1,163 nursing-home patients participated, of whom 933 had dementia. At the follow-up interview after 1 year, 633 of the patients who had dementia at baseline were assessed. Clinically significant neuropsychiatric symptoms were exhibited by 84% of patients with dementia at the baseline or follow-up interviews. Overall persistence of symptoms was 79%. Individual symptoms, such as depression (58%), delusions (56%), and agitation/aggression (47%) had resolved at a high rate. Persistent use of antidepressants (79%), antipsychotics (75%), or any psychotropic drug (88%) was common. There were no differences between users and nonusers of antipsychotics or antidepressants regarding the course of psychosis, agitation, or depression over the 1-year observation period. CONCLUSION Neuropsychiatric symptoms are ubiquitous in nursing home patients with dementia. Overall the symptoms are chronically present, whereas individual symptoms often show an intermittent course. Long-term use of psychotropic medication is extensive. Uncertainty about treatment effects emphasizes the need for further treatment trials.

A Reliability and Validity Study of the Cornell Scale among Elderly Inpatients, Using Various Clinical Criteria

BACKGROUND Persons with dementia frequently exhibit neuropsychiatric symptoms (NPSs). Previous studies have indicated that the prevalence is particularly high in nursing home (NH) patients. However, differences in methodology in studies of the prevalence and course of NPSs have made it difficult to compare their results. METHODS We searched the electronic databases MEDLINE, EMBASE, PsycINFO, Ovid Nursing, and AgeLine from their inception until July 2012 using medical subject headings to identify studies that reported figures on the prevalence and course of NPSs in NH patients with dementia. RESULTS A total of 28 studies met the inclusion criteria. In total, 8468 and 1458 persons participated in the prevalence and longitudinal studies, respectively. The weighted mean prevalence of having at least one NPS was 82%. Although the prevalence of individual symptoms varied, the highest prevalence figures were found for agitation and apathy. The persistence of individual NPSs varied substantially, but in these studies, having at least one NPS was highly persistent across the studies. CONCLUSION This review confirms that clinically significant NPSs are common in NH patients with dementia. Even though great variability exists across studies, recent studies applying similar methodology have made comparisons between studies feasible, revealing relatively consistent prevalence patterns for individual symptoms. The natural course of symptoms deserves closer attention. This is vital in planning prevention and treatment of NPSs in NH patients with dementia.

Quality of Life among Elderly Patients with Dementia in Institutions

Background: The validity of the Cornell Scale for Depression in Dementia is seldom studied in institutions. Method: Two reliability studies, with 103 and 32 patients, and a validity study with 231 patients in nursing homes and in hospital were performed. They were assessed by the Cornell Scale, Clinical Dementia Rating scale and Self-Maintenance scale. A psychiatrist ‘blind’ to the Cornell assessment diagnosed depression according to the ICD-10, DSM-IV-TR and the Provisional Criteria for Depression in Alzheimer’s Disease (PCD-dAD). Results: Cronbach’s α values were 0.81 and 0.95, and the mean ĸ for the Cornell items were 0.91 and 0.57, respectively. In the validity study, 164 subjects had dementia; 105 (45.5%) had depression according to the ICD-10, 68 (29.9%) according to the DSM-IV-TR and 88 (53.3%) of the demented patients had depression according to the PCD-dAD. In the receiver operating characteristic analysis, the DSM-IV-TR criteria produced the highest area under the curve, i.e. 0.81 (95% CI: 0.75–0.87). A range of cutoff points for a depressive disorder was found for the various clinical criteria. Conclusion: The Cornell Scale is reliable and a range of cutoff points should be used for various clinical criteria of depression.

The course of neuropsychiatric symptoms in nursing-home patients with dementia over a 53-month follow-up period

Aim: To study quality of life among the elderly with dementia in institutions. Methods: Patients above 60 years with dementia, 82 in nursing home and 74 in departments of geriatric psychiatry, were included. They were assessed with the Quality of Life in Late-Stage Dementia (QUALID); the Self-Maintenance scale, Mini Mental State Examination (MMSE) and Clinical Dementia Rating scale. Patient’s age, gender, previous medical and psychiatric history were recorded. Dementia was diagnosed according to ICD-10 criteria for research. Based on information in an interview with the patient and a carer and information in the patient’s record, a geriatric psychiatrist made a diagnosis of major depression according to DSM-IV, if present. Results: The patients’ mean (± SD) age was 82.9 ± 7.7 years, 103 (66%) were women. A factor analysis of the QUALID scale resulted in two factors: ‘discomfort’ and ‘comfort’. Three linear regression analyses were performed. Variables associated with lower quality of life (total QUALID score) were: a diagnosis of major depression (p < 0.001), lower score on MMSE (p = 0.032), impaired function in activities of daily living (p = 0.007) and female gender (p = 0.046). Variables associated with the ‘discomfort’ subscale score were: major depression (p < 0.001), lower score on MMSE (p = 0.006) and living in a department of geriatric psychiatry (p = 0.041). The ‘comfort’ subscale score was associated with impaired function in activities of daily living (p < 0.001). Explained variance for the three models was 34, 33 and 23%, respectively. Conclusion: Quality of life is diminished among elderly patients in institutions and the most marked correlates were a diagnosis of major depression, worse performance in activities of daily living and worse cognitive function.

Factors associated with depression in Norwegian nursing homes

BACKGROUND Neuropsychiatric symptoms (NPS) are prevalent in nursing-home (NH) patients with dementia, but little is known about the long-term course of these symptoms. METHODS In this study, 931 NH patients with dementia took part in a prospective cohort study with four assessments over a 53-month follow-up period. NPS and level of dementia were assessed with the Neuropsychiatric Inventory scale and the Clinical Dementia Rating scale, respectively. RESULTS Mild, moderate, and severe dementia was present in 25%, 33%, and 42%, respectively. There was an increase in the severity of the dementia from the first to the fourth assessment. Agitation, irritability, disinhibition, and apathy were the most prevalent and persistent symptoms during the study period. The affective subsyndrome (depression and anxiety) became less severe, whereas the agitation subsyndrome (agitation/aggression, disinhibition, and irritability) and apathy increased in severity during the follow-up period. More severe dementia was associated with more severe agitation, psychosis, and apathy, but not more severe affective symptoms. Mild dementia was associated with an increase in the severity of psychosis, whereas moderate or severe dementia was associated with decreasing severity of psychosis over the follow-up period. CONCLUSION Nearly all the patients experienced clinically significant NPS, but individual symptoms fluctuated. Affective symptoms became less severe, while agitation and apathy increased in severity. An increase in dementia severity was associated with an increase in the severity of agitation, psychosis, and apathy, but not affective symptoms. The results may have implications when planning evaluation, treatment, and the prevention of NPS in NH patients.

The Effect of Person-Centred Dementia Care to Prevent Agitation and Other Neuropsychiatric Symptoms and Enhance Quality of Life in Nursing Home Patients: A 10-Month Randomized Controlled Trial

Depression among patients in nursing homes is frequent and apparently underdiagnosed. Because depression is associated with negative outcomes, identification of groups at risk would improve the diagnosis and potentially improve the prognosis.

Stability of the factor structure of the Neuropsychiatric Inventory in a 31-month follow-up study of a large sample of nursing-home patients with dementia

Aims: We examined whether Dementia Care Mapping (DCM) or the VIPS practice model (VPM) is more effective than education of the nursing home staff about dementia (control group) in reducing agitation and other neuropsychiatric symptoms as well as in enhancing the quality of life among nursing home patients. Methods: A 10-month three-armed cluster-randomized controlled trial compared DCM and VPM with control. Of 624 nursing home patients with dementia, 446 completed follow-up assessments. The primary outcome was the change on the Brief Agitation Rating Scale (BARS). Secondary outcomes were changes on the 10-item version of the Neuropsychiatric Inventory Questionnaire (NPI-Q), the Cornell Scale for Depression in Dementia (CSDD) and the Quality of Life in Late-Stage Dementia (QUALID) scale. Results: Changes in the BARS score did not differ significantly between the DCM and the control group or between the VPM and the control group after 10 months. Positive differences were found for changes in the secondary outcomes: the NPI-Q sum score as well as the subscales NPI-Q agitation and NPI-Q psychosis were in favour of both interventions versus control, the QUALID score was in favour of DCM versus control and the CSDD score was in favour of VPM versus control. Conclusions: This study failed to find a significant effect of both interventions on the primary outcome. Positive effects on the secondary outcomes indicate that the methods merit further investigation.