Luis Agüera-Ortiz

Diagnostic criteria for apathy in clinical practice.

Apathy is an important and distressing behavioural symptom in Alzheimers disease and in various neuropsychiatric disorders. Recently, diagnostic criteria for apathy have been proposed.

Neuropsychiatric symptoms as early manifestations of emergent dementia: Provisional diagnostic criteria for mild behavioral impairment

Neuropsychiatric symptoms (NPS) are common in dementia and in predementia syndromes such as mild cognitive impairment (MCI). NPS in MCI confer a greater risk for conversion to dementia in comparison to MCI patients without NPS. NPS in older adults with normal cognition also confers a greater risk of cognitive decline in comparison to older adults without NPS. Mild behavioral impairment (MBI) has been proposed as a diagnostic construct aimed to identify patients with an increased risk of developing dementia, but who may or may not have cognitive symptoms. We propose criteria that include MCI in the MBI framework, in contrast to prior definitions of MBI. Although MBI and MCI can co‐occur, we suggest that they are different and that both portend a higher risk of dementia. These MBI criteria extend the previous literature in this area and will serve as a template for validation of the MBI construct from epidemiologic, neurobiological, treatment, and prevention perspectives.

GREATER RISK OF ALZHEIMER’S DISEASE IN OLDER ADULTS WITH INSOMNIA

ACKNOWLEDGMENTS Conflict of Interest: This work was supported by the Fundamental Research Grant Scheme, Ministry of Higher Education, Malaysia. Dr. Noran N. Hairi’s work on this study was supported by the Public Service Department of Malaysia. The authors would like to express their appreciation to Dr. Siti Halimah Shaikh and all healthcare providers of Masjid Tanah Health Clinic, Ministry of Health, Malaysia, for their contributions to this research. Author Contributions: NNH: study concept, chief investigator, designing research protocol, data analysis, interpretation of data, and writing manuscript. AB, IM: conceptualization of research and data collection. RGC, VN, AB: critically editing of the manuscript. All authors read and approved the final manuscript. Sponsor’s Role: None.

Pain as a symptom of depression: Prevalence and clinical correlates in patients attending psychiatric clinics

BACKGROUND The need to assess the prevalence and characteristics of painful symptoms among depressed patients attended by psychiatrists in their regular clinical practice. METHODS A multi-centre, cross-sectional study was carried out in a large sample (n=3566) of patients attending out-patient psychiatric facilities in Spain. All types of DSM-IV-TR depressive disorders were included. Data on the diagnosis, specific symptoms, intensity of depression and antidepressant and analgesic drug treatments were collected. The presence and characteristics of significant pain (visual analogue scale score>40) at the time of the study were also recorded. RESULTS The prevalence of pain in depressed patients was 59.1% (CI 95%: 57.7%; 60.7%). Factors associated independently with the existence of significant pain were: being female, presence of loss of energy and the diagnosis of dysthymia or depression induced by physical disorders. In addition, age and the intensity of depression were two risk factors, where each year of age and each point in the Hamilton scale increased the risk of having pain by 2% and 8% respectively. The presence of anhedonia and the diagnosis of depression induced by illegal drugs were factors inversely related to pain. LIMITATIONS The cross-sectional naturalistic characteristics of the study. CONCLUSION Our data show a high prevalence of pain among depressive patients attending psychiatric clinics. Painful symptoms are modulated differently depending on the type of depression and the presence of specific symptoms, such as loss of energy or anhedonia. Psychiatrists should ask their depressive patients for the presence of pain on a regular basis.

Apathy associated with neurocognitive disorders: Recent progress and future directions

Apathy is common in neurocognitive disorders (NCDs) such as Alzheimers disease and mild cognitive impairment. Although the definition of apathy is inconsistent in the literature, apathy is primarily defined as a loss of motivation and decreased interest in daily activities.

The Mild Behavioral Impairment Checklist (MBI-C): A Rating Scale for Neuropsychiatric Symptoms in Pre-Dementia Populations.

BACKGROUND Mild behavioral impairment (MBI) is a construct that describes the emergence at ≥50 years of age of sustained and impactful neuropsychiatric symptoms (NPS), as a precursor to cognitive decline and dementia. MBI describes NPS of any severity, which are not captured by traditional psychiatric nosology, persist for at least 6 months, and occur in advance of or in concert with mild cognitive impairment. While the detection and description of MBI has been operationalized in the International Society to Advance Alzheimers Research and Treatment - Alzheimers Association (ISTAART-AA) research diagnostic criteria, there is no instrument that accurately reflects MBI as described. OBJECTIVE To develop an instrument based on ISTAART-AA MBI criteria. METHODS Eighteen subject matter experts participated in development using a modified Delphi process. An iterative process ensured items reflected the five MBI domains of 1) decreased motivation; 2) emotional dysregulation; 3) impulse dyscontrol; 4) social inappropriateness; and 5) abnormal perception or thought content. Instrument language was developed a priori to pertain to non-demented functionally independent older adults. RESULTS We present the Mild Behavioral Impairment Checklist (MBI-C), a 34-item instrument, which can easily be completed by a patient, close informant, or clinician. CONCLUSION The MBI-C provides the first measure specifically developed to assess the MBI construct as explicitly described in the criteria. Its utility lies in MBI case detection, and monitoring the emergence of MBI symptoms and domains over time. Studies are required to determine the prognostic value of MBI for dementia development, and for predicting different dementia subtypes.

Social robots in advanced dementia.

Aims: Pilot studies applying a humanoid robot (NAO), a pet robot (PARO) and a real animal (DOG) in therapy sessions of patients with dementia in a nursing home and a day care center. Methods:In the nursing home, patients were assigned by living units, based on dementia severity, to one of the three parallel therapeutic arms to compare: CONTROL, PARO and NAO (Phase 1) and CONTROL, PARO, and DOG (Phase 2). In the day care center, all patients received therapy with NAO (Phase 1) and PARO (Phase 2). Therapy sessions were held 2 days per week during 3 months. Evaluation, at baseline and follow-up, was carried out by blind raters using: the Global Deterioration Scale (GDS), the Severe Mini Mental State Examination (sMMSE), the Mini Mental State Examination (MMSE), the Neuropsychiatric Inventory (NPI), the Apathy Scale for Institutionalized Patients with Dementia Nursing Home version (APADEM-NH), the Apathy Inventory (AI) and the Quality of Life Scale (QUALID). Statistical analysis included descriptive statistics and non-parametric tests performed by a blinded investigator. Results: In the nursing home, 101 patients (Phase 1) and 110 patients (Phase 2) were included. There were no significant differences at baseline. The relevant changes at follow-up were: (Phase 1) patients in the robot groups showed an improvement in apathy; patients in NAO group showed a decline in cognition as measured by the MMSE scores, but not the sMMSE; the robot groups showed no significant changes between them; (Phase 2) QUALID scores increased in the PARO group. In the day care center, 20 patients (Phase 1) and 17 patients (Phase 2) were included. The main findings were: (Phase 1) improvement in the NPI irritability and the NPI total score; (Phase 2) no differences were observed at follow-up.

Quality of life (QoL) in community-dwelling and institutionalized Alzheimer's disease (AD) patients.

The purpose of this study was to describe and compare QoL and its determinants in two groups of patients with AD that differed in place of residence: community or nursing home. This study covered 200 patients with AD (mean age 79.3 ± 8.2 years, 74% female). Fifty-four per cent of the subjects were living in a nursing home and 46% lived at home. QoL was measured using the Alzheimers Disease Related Quality of Life Scale (ADRQL). The ADRQL was answered by the family caregiver (community group) or the professional caregiver (nursing home group). Descriptive statistics, Chi-square test, Mann-Whitney test and multiple regression analysis were used to compare sociodemographic and clinical variables between the two study groups. The institutionalized patients were predominantly women (87.0% vs. 58.7%, p<0.001), were older (84 years vs. 74 years, p<0.001), and had more advanced dementia (Global Deterioration Scale (GDS)>5 79.6% vs. 19.6%, p<0.001). ADRQL total score was higher (i.e., better QoL) for patients living at home than for institutionalized patients (72.6 ± 19.9 vs. 64.8 ± 18.2, p<0.01). Neuropsychiatric symptoms, severity of dementia, depression and functional dependence were significant predictors of worst QoL. Once those variables were controlled a marginal effect of setting on QoL was found, which favored the nursing home (β=0.20, p<0.05).

Undiagnosed Mood Disorders and Sleep Disturbances in Primary Care Patients with Chronic Musculoskeletal Pain

OBJECTIVE The study aims to determine the prevalence of undiagnosed comorbid mood disorders in patients suffering chronic musculoskeletal pain in a primary care setting and to identify sleep disturbances and other associated factors in these patients, and to compare the use of health services by chronic musculoskeletal pain patients with and without comorbid mood disorders. DESIGN Cross-sectional study. SUBJECTS A total of 1,006 patients with chronic musculoskeletal pain from a representative sample of primary care centers were evaluated. OUTCOME MEASURES Pain was measured using a visual analog scale and the Primary Care Evaluation of Mental Disorders questionnaire was used to measure mood disorders. RESULTS We observed a high prevalence of undiagnosed mood disorders in chronic musculoskeletal pain patients (74.7%, 95% confidence interval [CI] 71.9-77.4%), with greater comorbidity in women (adjusted odds ratio [OR] = 1.91, 95% CI 1.37-2.66%) and widow(er)s (adjusted OR = 1.87, 95% CI 1.19-2.91%). Both sleep disturbances (adjusted OR = 1.60, 95% CI 1.17-2.19%) and pain intensity (adjusted OR = 1.02, 95% CI 1.01-1.02%) displayed a direct relationship with mood disorders. Moreover, we found that chronic musculoskeletal pain patients with comorbid mood disorders availed of health care services more frequently than those without (P < 0.001). CONCLUSIONS The prevalence of undiagnosed mood disorders in patients with chronic musculoskeletal pain is very high in primary care settings. Our findings suggest that greater attention should be paid to this condition in general practice and that sleep disorders should be evaluated in greater detail to achieve accurate diagnoses and select the most appropriate treatment.

Promoting Research in Advanced Dementia: Early Clinical Results of the Alzheimer Center Reina Sofía Foundation

The Alzheimer Center Reina Sofía Foundation (ACRSF) was envisaged to address the complex and multi-disciplinary research and care needs posed by Alzheimers disease (AD) and other neurodegenerative dementias. Patients may be admitted at ACRSF either as inpatients (i.e., nursing home) or outpatients (i.e., day-care center). The research program includes clinical, social, biochemical, genetic, and magnetic resonance investigations, as well as brain donation. We present the inception of the clinical research protocol for the ACRSF, the early results, and the amendments to the protocol. Foreseen as distinct populations, inpatient and outpatient results are presented separately. Data were collected from 180 patients (153 inpatients, 27 outpatients) (86% AD), with informed consent for participation in the research program of the ACRSF. Most patients (95%) had moderate to severe dementia. Nursing home patients were older, displayed marked gait dysfunction, and were significantly more dependent in the activities of daily living (ADL), compared to the day-care patients (p < 0.05). Some cognitive, ADL, and quality of life (QoL) scales were eliminated from the protocol due to floor effect or lack of specificity of contents for advanced dementia. New measurements were added for evaluation of cognition, apathy, agitation, depression, ADL, motor function, and QoL. The final assessment is expected to be sensitive to change in all the clinical aspects of advanced degenerative dementia, to promote multidisciplinary and, desirably, inter-center collaborative research and, eventually, to contribute to the improvement of treatment and care for these patients.