Rebecca G. Logsdon

Assessment of behavioral problems in dementia: the revised memory and behavior problems checklist.

The Revised Memory and Behavior Problems Checklist (RMBPC), a 24-item, caregiver-report measure of observable behavioral problems in dementia patients, provides 1 total score and 3 subscale scores for patient problems (memory-related, depression, and disruptive behaviors) and parallel scores for caregiver reaction. Data were obtained from 201 geriatric patients and their caregivers. Factor analysis confirmed 3 first-order factors, consistent with subscales just named, and 1 general factor of behavioral disturbance. Overall scale reliability was good, with alphas of .84 for patient behavior and .90 for caregiver reaction. Subscale alphas ranged from .67 to .89. Validity was confirmed through comparison of RMBPC scores with well-established indexes of depression, cognitive impairment, and caregiver burden. The RMBPC is recommended as a reliable and valid tool for the clinical and empirical assessment of behavior problems in dementia patients.

Assessing quality of life in older adults with cognitive impairment

Objective This article discusses theoretical, psychometric, and practical considerations of quality of life assessment in older adults with cognitive impairment. It describes a new measure of quality of life in dementia, the QOL-AD, and examines the reliability and validity of patient and caregiver reports of patient quality of life. Methods Subjects were 177 patient/caregiver dyads. Patient Mini Mental State Exam scores ranged from 0 to 29, with a mean score of 16 (SD = 7). Each patient and caregiver rated the patient’s quality of life on the QOL-AD. Patient functional and cognitive status, psychological state, physical function, and behavior problems were also assessed. Reliability and validity of patient QOL-AD reports were examined across three levels of cognitive impairment. Results One hundred, fifty-five patients were able to complete the QOL-AD. Completers scored between 4 and 29 on the Mini Mental State Exam, whereas noncompleters all scored 10 or lower. Reliability for both patient and caregiver reports on the QOL-AD was good (&agr; values ranged from 0.83 to 0.90). Validity of patient and caregiver reports across cognitive levels was supported by correlation with measures of depression (r = −0.41 to −0.65), day-to-day functioning (r = −0.10 to −0.45), and pleasant events frequency (r = 0.18 to 0.51). Intraclass correlation between patient and caregiver reports was positive across all cognitive levels (r = 0.14 to 0.39). Conclusions The QOL-AD seems to be reliable and valid for individuals with MMSE scores greater than 10. Further research is needed to clarify the relationship between patient and caregiver reports of patient quality of life and to identify factors that influence quality of life throughout the progression of dementia.

Treatment of agitation in AD A randomized, placebo-controlled clinical trial

Background: Treatment of agitation is a crucial problem in the care of patients with AD. Although antipsychotic and antidepressant medications and behavior management techniques (BMT) have each been used to treat agitation, clinical trials of these treatments have been characterized by small sample sizes and uncontrolled treatment designs. Objective: To compare haloperidol, trazodone, and BMT with placebo in the treatment of agitation in AD outpatients. Methods: A total of 149 patients with AD and their caregivers participated in a randomized, placebo-controlled, multicenter trial. Blind assessment was conducted at baseline and after 16 weeks of treatment. The three active treatments were haloperidol, trazodone, and BMT. The Alzheimer’s Disease Cooperative Study Clinical Global Impression of Change was the primary outcome measure. Secondary outcomes included patient agitation, cognition, and function, and caregiver burden. Results: Thirty-four percent of subjects improved relative to baseline. No significant differences on outcome were obtained between haloperidol (mean dose, 1.8 mg/d), trazodone (mean dose, 200 mg/d), BMT, or placebo. Significantly fewer adverse events of bradykinesia and parkinsonian gait were evident in the BMT arm. No other significant difference in adverse events was seen. Symptoms did not respond differentially to the different treatments. Conclusions: Comparable modest reductions in agitation occurred in patients receiving haloperidol, trazodone, BMT, and placebo. More effective pharmacologic, nonpharmacologic, and combination treatments are needed.

Ambulatory Physical Activity Performance in Youth With Cerebral Palsy and Youth Who Are Developing Typically

Background and Purpose Assessment of walking activity in youth with cerebral palsy (CP) has traditionally been “capacity-based.” The purpose of this study was to describe the day-to-day ambulatory activity “performance” of youth with CP compared with youth who were developing typically. Subjects Eighty-one youth with CP, aged 10 to 13 years, who were categorized as being in Gross Motor Function Classification System (GMFCS) levels I to III and 30 age-matched youth who were developing typically were recruited. Methods Using a cross-sectional design, participants wore the StepWatch monitor for 7 days while documenting average daily total step counts, percentage of time they were active, ratio of medium to low activity levels, and percentage of time at high activity levels. Results The youth with CP demonstrated significantly lower levels of all outcomes than the comparison group. Discussion and Conclusion Daily walking activity and variability decreased as functional walking level (GMFCS level) decreased. Ambulatory activity performance within the context of the daily life for youth with CP appears valid and feasible as an outcome for mobility interventions in CP.

Nighttime Insomnia Treatment and Education for Alzheimer's Disease: A Randomized, Controlled Trial

Objectives: To evaluate whether a comprehensive sleep education program (Nighttime Insomnia Treatment and Education for Alzheimers Disease (NITE‐AD)) could improve sleep in dementia patients living at home with their family caregivers.

Characteristics of sleep disturbance in community-dwelling Alzheimer's disease patients.

This study examined the frequency, predictors, and impact of sleep problems in a population-based sample of 205 Alzheimers disease (AD) patients. Sleeping more than usual and early morning awakenings were the most common sleep problems reported but were the least disturbing behaviors for caregivers. Night-time awakenings were less common but were most disturbing to caregivers. Using logistic regression analyses, the factors most strongly asso ciated with night awakenings among patients were male gender, greater memory problems, and decreased functional status. Patient depression increased the risk for caregivers to rate patient sleep problems as more disturbing over all. Cluster analyses revealed three characteristic groups of patients who awakened caregivers: one group was inactive during the day but had few other behavior problems; one group had increased levels of fearfulness, fid geting, and occasional sadness; and the third group had multiple behavior problems, including frequent episodes of sadness, fearfulness, inactivity, fidgeting, and hallucinations. These findings indicate that the nature of sleep problems in AD is multifaceted; future research on the occurrence and treatment of sleep disturbance in dementia patients should consider the patterns of individual differences that may influence its development. (J Geriatr Psychiatry Neurol 1999; 12:53-59).

Associations Between Physical Performance and Executive Function in Older Adults With Mild Cognitive Impairment: Gait Speed and the Timed “Up & Go” Test

Background Older adults with amnestic mild cognitive impairment (aMCI) are at higher risk for developing Alzheimer disease. Physical performance decline on gait and mobility tasks in conjunction with executive dysfunction has implications for accelerated functional decline, disability, and institutionalization in sedentary older adults with aMCI. Objectives The purpose of this study was to examine whether performance on 2 tests commonly used by physical therapists (usual gait speed and Timed “Up & Go” Test [TUG]) are associated with performance on 2 neuropsychological tests of executive function (Trail Making Test, part B [TMT-B], and Stroop-Interference, calculated from the Stroop Word Color Test) in sedentary older adults with aMCI. Design The study was a cross-sectional analysis of 201 sedentary older adults with memory impairment participating in a longitudinal intervention study of cognitive function, aging, exercise, and health promotion. Methods Physical performance speed on gait and mobility tasks was measured via usual gait speed and the TUG (at fast pace). Executive function was measured with the TMT-B and Stroop-Interference measures. Results Applying multiple linear regression, usual gait speed was associated with executive function on both the TMT-B (β=−0.215, P=.003) and Stroop-Interference (β=−0.195, P=.01) measures, indicating that slower usual gait speed was associated with lower executive function performance. Timed “Up & Go” Test scores (in logarithmic transformation) also were associated with executive function on both the TMT-B (β=0.256, P<.001) and Stroop-Interference (β=0.228, P=.002) measures, indicating that a longer time on the TUG was associated with lower executive function performance. All associations remained statistically significant after adjusting for age, sex, depressive symptoms, medical comorbidity, and body mass index. Limitations The cross-sectional nature of this study does not allow for inferences of causation. Conclusions Physical performance speed was associated with executive function after adjusting for age, sex, and age-related factors in sedentary older adults with aMCI. Further research is needed to determine mechanisms and early intervention strategies to slow functional decline.

Anxiety and Alzheimer's disease.

This study investigated symptoms of anxiety in two samples of clinic outpatients diagnosed with Alzheimers dis ease (AD). Clinician and caregiver reports were obtained using standardized measures to characterize a broad array of anxiety symptoms. Anxiety symptoms were reported for a substantial proportion of subjects, regardless of whether clinician or caregiver ratings were used. Anxious or worried appearance was most common (68% to 71%), followed by fearfulness, tension, restlessness, and fidgeting (37% to 57%). Sleep disturbance and various somatic symptoms were less common (8% to 34%). Although anxiety symptoms were prevalent, only 5% to 6% of subjects met Diagnostic and Statistical Manual of Mental Disorders criteria for the diagnosis of generalized anxiety disorder. In both sam ples, anxiety symptoms were associated with depression, behavioral disturbances, and increased cognitive impairment. Study findings support a high occurrence of anxiety in patients with dementia, and treatments for anxiety might therefore be helpful in reducing the psychiatric burden of AD. (J Geriatr Psychiatry Neurol 2001; 14:52-58).

Evidence-based psychological treatments for disruptive behaviors in individuals with dementia.

In this article, the authors review the literature regarding evidence-based psychological treatments (EBTs) for behavioral disturbances in older adults with dementia, as proposed by the American Psychological Associations Committee on Science and Practice of the Society for Clinical Psychology. Fifty-seven randomized clinical trials were reviewed for inclusion on the basis of titles or abstract information. Forty-three were excluded either because they did not meet EBT methodological criteria or because they involved environmental or psychoeducational nursing interventions in which the psychological component could not be separately evaluated. Fourteen studies were considered for inclusion as EBTs; of these, 8 showed significant differences between treatment and control groups. Results of this review indicate that behavioral problem-solving therapies that identify and modify antecedents and consequences of problem behaviors and increase pleasant events and individualized interventions based on progressively lowered stress threshold models that include problem solving and environmental modification meet EBT criteria. Additional randomized clinical trials are needed to evaluate the generalizability and efficacy of these and other promising psychological interventions in a variety of settings with individuals who have a range of cognitive, functional, and physical strengths and limitations.

Depression in Alzheimer's Disease Patients: Caregivers as Surrogate Reporters

OBJECTIVE: To evaluate the use of caregivers as surrogate reporters of depressive symptoms in Alzheimers disease (AD) patients on five depression measures.