Knut Engedal

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

BACKGROUNDnNeuropsychiatric symptoms (NPS) are prevalent in nursing-home (NH) patients with dementia, but little is known about the long-term course of these symptoms.nnnMETHODSnIn 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.nnnRESULTSnMild, 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.nnnCONCLUSIONnNearly 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 reliability and validity of the Norwegian version of the Neuropsychiatric Inventory, Nursing Home Version (NPI-NH)

BACKGROUNDnPsychiatric symptoms and behavioral disturbances are highly prevalent in the residents of nursing homes. The Neuropsychiatric Inventory (NPI) is a commonly used scale for the assessment of such symptoms in diverse settings. We have conducted a study of the reliability and the validity of the Norwegian version of the NPI nursing home version (NPI-NH).nnnMETHODSnThe reliability study comprised 41 patients. We established inter-rater reliability between raters with various levels of health education using kappa statistics. Fifty patients were included in the validity study. The patients were examined by a physician, who also rated the patients behavior using behavioral pathology in Alzheimers disease (BEHAVE-AD). Subsequently, a research nurse performed a standardized interview using the NPI and the Cornell scale. Concurrent validity of the NPI and the BEHAVE-AD was analyzed.nnnRESULTSnInternal consistency, as measured by Cronbachs alpha was above 0.8. Inter-rater reliability was, except for one item, between 0.85 and 1.0 across assessors with different levels of health education. All correlations between the NPI and the BEHAVE-AD were significant, ranging from 0.38 to 0.72. The weakest correlations were between items assessing affective and anxiety symptoms.nnnCONCLUSIONnThe Norwegian version of the NPI-NH is a reliable and valid instrument for assessing psychiatric symptoms and behavioral disturbances in the residents of nursing homes. The investigation of depressive symptoms merits particular attention.

The course of neuropsychiatric symptoms in patients with dementia in Norwegian nursing homes.

BACKGROUNDnNeuropsychiatric symptoms (NPS) are common in patients with dementia, and cause distress for patients. Studies on the prevalence, incidence, persistence and resolution of NPS in patients living in nursing homes are sparse. The aim of this study was to evaluate the course of NPS in patients with dementia living in Norwegian nursing homes.nnnMETHODSn169 patients from seven Norwegian nursing homes were assessed five times over a period of 16 months with the Neuropsychiatric Inventory (NPI). The severity and the frequency of the NPI were analyzed.nnnRESULTSn91.7% of the patients had at least one clinically significant NPS at one or more assessments over the 16 months. Irritability (63.5%), agitation (51.0%) and disinhibition (50.0%) had the highest cumulative prevalence, while irritability (42.6%), disinhibition (37.8%) and depression (31.5%) showed the highest cumulative incidence. Delusion, agitation and irritability were enduring symptoms while the other symptoms had high resolution rates. The severity of the NPS did not vary significantly over time.nnnCONCLUSIONnAlmost every patient in Norwegian nursing homes had at least one clinically significant NPS over 16 months, but individual NPS show a fluctuating course. This should influence how we monitor and treat NPS in patients with dementia.

The quality of life and factors associated with it in the medically hospitalised elderly.

Aim: The present study describes the quality of life (QOL) and explores health-related factors associated with domains of the QOL in the acutely ill and hospitalised elderly. Method: In all, 484 elderly (65–101 years, 241 men) patients hospitalised in an acute medical unit participated. Their QOL (in its overall and physical, psychological, social and environmental domains) was assessed with the World Health Organisations WHOQOL-BREF. The QOL was explored with multiple linear regression analysis. Health-related variables controlled for socio-demographic background were the independent variables. Results: The overall QOL was good in two-thirds of the elderly patients. In multiple linear regression models, lower physical QOL was significantly associated with a number of medications, impaired personal activities of daily living (PADL), impaired cognition, depression and anxiety. Lower psychological QOL was significantly associated with impaired PADL, impaired cognition, depression and anxiety. Lower social QOL was significantly associated with depression and anxiety. Lower environmental QOL was significantly associated with female gender, impaired PADL, depression and anxiety. Conclusion: Our results indicate that improvement in the medical state, functional status and/or emotional condition of elderly medically hospitalised patients may improve their QOL.

Factors associated with perceived health in elderly medical inpatients: A particular focus on personal coping recourses

Aim: We wanted to unveil associations between perceived health and physical health, function in activity of daily living, anxiety, depression and coping resources in terms of sense of coherence (SOC) in elderly (≥65 years) in-hospital patients without cognitive impairment. Method: In a cross-sectional study, we evaluated 217 hospitalized elderly patients with an age range 65–95 (mean 77.9) years. Perceived health was rated on a four-point scale. Physical health was measured with the Charlson index; functional status was rated using the Lawton and Brodys scale for self-maintaining and instrumental activities of daily living; and, anxiety and depression were rated using the Hospital Anxiety and Depression scale. Finally, the 13-item version of the SOC scale was used to assess coping, and cognitive state was assessed using the Mini-mental State Examination. Results: In all, 40% of the patients reported good perceived health. In an adjusted logistic regression analysis, the main outcome good perceived health was associated with increasing age: odds ratio (OR) 1.06 (95% CI 1.01–1.11); good physical health: OR 2.49 (95% CI 1.22–5.07); and, medium high and high SOC: OR 2.48 (95% CI 1.20–5.13), and OR 2.43 (95% CI 1.11–5.28), respectively. Explained variance was 22.2%. Conclusion: Good coping resources and low severity of co-morbid disorders are the two most important factors that explain why elderly inpatients rate their health as good. Since coping may be equally important as poor physical health for perception of health, coping should be recognized and measured in clinical practice.

Development of residential care services facilitated for persons with dementia in Norway

Background: In the 1980s, special care units devoted to persons with dementia (SCU) were established, and in the 1990s, a new system of sheltered housing for persons with dementia (SH) was inaugurated. Aim: The aim of this study was to examine the establishment of SCUs and SH units and to explore the effects of varying patient-staff ratios and unit sizes. Method: On five occasions (1996/1997, 2000/2001, 2004/2005, 2008, 2010/2011), a detailed questionnaire was sent by post to all Norwegian municipalities. It contained questions about the provision of services for persons with dementia. Results: In 1996/1997, 70% of the municipalities had SCUs and 13.3% of the beds in Norwegian nursing homes were in SCUs. In 2010/11, 87% of the municipalities had such services, which filled 23.8% of the beds in nursing homes. The number of beds in SH units increased from 856 beds in 1996/1997 to 2181 beds in 2010/11. SCUs have on average three patients per carer on an ordinary weekday day-time shift. These numbers have been quite stable throughout the study period. The ratio is about 3.5 patients per carer in the SH units and is also stable. Conclusions: The rate of increase in the provision of institutional beds facilitated for persons with dementia has been slow in Norway over the last 14 years. Both SCUs and SH units seem to have stable staffing ratios and the number of beds in each unit is also stable.

Factor Analysis of the Brief Agitation Rating Scale in a Large Sample of Norwegian Nursing Home Patients

Background: Agitation and aggression are prevalent in dementia and put heavy strains on caregivers. Validated assessment tools measuring these symptoms are required to evaluate patients before therapy and during the follow-up period. Given the daily routine in nursing homes, abbreviated instruments are preferable. The Brief Agitation Rating Scale (BARS) is a short form of the Cohen-Mansfield Agitation Inventory. Our aim was to examine the Norwegian version of the BARS by performing a factor analysis. Methods: The data came from 1,870 nursing home patients. The primary caregivers were interviewed by research nurses using the Clinical Dementia Rating Scale, Lawton’s Physical Self-Maintenance Scale and the BARS. Results: The exploratory factor analysis of the BARS revealed 3 dimensions: physically aggressive behavior, physically nonaggressive behavior and verbal agitation. Linear regression analysis showed that reduced functioning in activities of daily living was associated with physically aggressive behavior and verbal agitation, whereas increased severity of dementia and better functioning in activities of daily living were related to physically nonaggressive behavior. In addition, verbal agitation was positively related to a higher number of drugs being taken per day. Conclusions: The factor analyses confirmed that the Norwegian version of the BARS measures the clinically relevant dimensions of agitation in dementia.

Sense of coherence and quality of life in older in-hospital patients without cognitive impairment- a 12 month follow-up study

BackgroundThe relation between sense of coherence (SOC) and quality of life (QoL) among older persons has been found in some, but not all, studies and mostly in studies with cross-sectional design. We wanted to study if SOC was associated with domains of QoL at hospitalization and one year later among persons 65xa0years and above without cognitive impairment.MethodAt hospitalization (T1) and 12xa0month follow-up (T2) QoL and cognitive status were assessed using the WHOQOL-BREF and the Mini-Mental State Examination. At baseline, the 13-item version of the SOC scale was used to assess coping, the Hospital Anxiety and Depression Scale (HADS) was used to assess depressive and anxiety symptoms. Level of functioning was rated using Lawton and Brody’s scales for physical self-maintenance and instrumental activities of daily living (personal and instrumental ADL).ResultsIn total, 165 (80 men) persons with a mean age of 77.7 (SD 6.9) years were included. The proportion of people rating their overall QoL as high had decreased from T1 to T2. The mean score on QoL- physical domain had increased, while the mean score of QoL-environmental domain had decreased. In adjusted regression analyses at T1, a high level of SOC was positively associated with QoL in three of four domains, i.e. physical, psychological and environmental, but level of SOC assessed at T1 was not associated with any domain of QoL at T2. Personal ADL was associated with some domains of QOL at T1 and T2.ConclusionThe SOC level was associated with older adult’s QoL during hospitalization but not their QoL one year after the hospital stay.

A comparison of depressive symptoms in elderly medical inpatients and the elderly in a population-based health study (the Nord-Trøndelag Health Study 3)

Aim: To compare depression in a sample of the medically hospitalized elderly with elderly people participating in a population-based health study in Norway and further to study the odds for depression, controlling for demographic and health differences between the two samples. Method: This cross-sectional observational study evaluated 484 medical inpatients from rural areas and 10,765 drawn from the Nord-Trøndelag Health Study 3 (HUNT-3 Study) including participants from rural and urban areas. All participants were elderly (≥65 years) with a mean (± standard deviation) age of 80.7 ± 7.4 and 73.3 ± 6.3 years, respectively. Symptoms of depression were screened by the Hospital Anxiety and Depression Scale (HAD). Results: The prevalence of symptoms indicating mild, moderate or more severe depression (depression score ≥8) was about the same in both groups. In regression analyses, adjusting demographic and health differences, the odds for depression was lower for the elderly in the hospital sample than in the HUNT-3 Study. Older age, male gender, perceiving general health as poor, having impaired ability to function in daily life, previous consultation or treatment for emotional problems and anxiety (anxiety score ≥8) were associated with increased odds for depression in the elderly independent of being hospitalized or not. Conclusion: Surprisingly, we found the odds for depression after controlling for demographic and health variables to be lower in the hospitalized elderly individuals than in the elderly participating in the population-based health study. The health variables that were most strongly associated with an increased risk of depression were poor physical health and anxiety.

Electroencephalography, visual evoked potentials, and cerebral CAT- scan as diagnostic tools in senile dementia of Alzheimer type

The usefulness of a cerebral computed tomogram (CAT-scan), an electroencephalogram (EEG), and flash visual evoked responses (FVER) as diagnostic tools in dementia was studied in 36 mentally impaired and 32 unimpaired persons aged 75 yr and above, who were recruited from a random sample of elderly people living at home. The clinical diagnosis of dementia was made after a full psychogeriatric assessment supplemented by a follow-up 18 mo later. When the measures of cortical atrophy from a cerebral CAT-scan, the presence/absence of diffuse slow activity on a standard EEG, and FVER P200 and FVER P100 latencies were introduced in a logistic regression model, the clinical diagnoses being the dependent variable, an effective prediction of senile dementia of Alzheimer type (SDAT) was obtained (sensitivity 93%, specificity 86%, misclassification rate 12%). We conclude that the use of FVER, an EEG, and a cerebral CAT-scan may facilitate the diagnosis of senile dementia of Alzheimer type.