ABSTRACT
From experimental research it appears that personality plays a role in causes and onset of aggressive behavior in adults. However, studies about the influence of premorbid personality on aggressive behavior of older persons with dementia show contradictory results. In this study we gathered data on personality and behavior of 166 residents of psychogeriatric nursing homes. Nursing staff filled out the Cohen-Mansfield Agitation Inventory (Dutch version, CMAI-D). Proxy family members completed the Hetero Anamnestic Personality questionnaire (HAP). Results showed that on the CMAI-D aggression could be distinguished from other forms of agitation. Four subscales of the HAP showed significant positive correlations with aggression as measured with the CMAI-D. These subscales were: Antagonism, Whimsical and impulsive behavior, Rigid behavior, and Being vulnerable in social interactions. Although the influence of personality decreased with increasing cognitive impairment, it was still present in stage 6 of the Reisberg Global Deterioration Scale. In depth analysis items of the HAP revealed a first profile of the aggression prone personality.
Subject(s)
Aggression/psychology , Dementia/psychology , Homes for the Aged , Nursing Homes , Aged , Aging/psychology , Comorbidity , Female , Geriatric Assessment , Humans , Male , Personality , Psychiatric Status Rating ScalesABSTRACT
BACKGROUND: There is still a lack of diagnostic instruments that are specifically developed to diagnose personality disorders in the elderly. OBJECTIVE: To develop a reliable and valid screening instrument to assess personality disorders in older adults. METHOD: The draft version of the screening instrument (52 items) consists of two sections: one for patients and one for informants. The diagnostic accuracy of the instrument has been assessed in the Netherlands in 159 elderly patients in an ambulatory department of geriatric psychiatry and 96 informants. RESULTS: In the patient section, sixteen items had a reasonable score for both sensitivity and specificity (approximately 70%). The internal consistency was moderate for habitual behavior (HAB; 7 items) and good for biographical information (BIO; 9 items). The test and retest reliability was moderate for HAB and excellent for BIO. The informant section, on the other hand, had a low score for sensitivity (45%) and a good score for specificity (78%). CONCLUSION: A specific instrument has been developed to diagnose personality disorders in older adults. However, further research is necessary to improve the diagnostic accuracy of the Gerontological Personality disorders Scale (GPS).
Subject(s)
Geriatric Assessment/methods , Personality Disorders/diagnosis , Psychiatric Status Rating Scales , Aged , Aged, 80 and over , Community Mental Health Services , Female , Humans , Male , Mass Screening/methods , Middle Aged , Psychometrics , Reproducibility of Results , Sensitivity and SpecificityABSTRACT
Little is known about the course of personality disorders across the life span. A major problem is that the current DSM nosology for personality disorders does not account for age-associated changes in behaviour and interpersonal functioning. This editorial will discuss the main diagnostic bottlenecks when applying the current DSM-IV-TR Axis II criteria to older adults. Subsequently, suggestions will be given for future research and the development of a geriatric sub-classification.
Subject(s)
Diagnostic and Statistical Manual of Mental Disorders , Personality Disorders/classification , Aged , Aging/psychology , Biomedical Research , Geriatric Assessment/methods , Geriatric Psychiatry/methods , HumansABSTRACT
Till now, no specific diagnostic instruments to detect personality disorders in the elderly are available. The aim of our study was to contribute to the construction of a reliable en valid instrument for the detection of personality disorders in older adults. Therefore, a draft version of the instrument was constructed both for the patient and the informant. Both the patient and the informant version of the instrument included 52 items with the same content. These items concerned Habitual behaviour (HAB), Biographical information (BIO) and Observation of actual behaviour (OBS). 159 clients of 60 years and older of a Dutch ambulatory mental health care organisation were assessed with the screening instrument. In 96 of the 159 outpatients one or more informants were included. The results indicate that the internal consistency of seven HAB items, nine BIO items and five OBS items was moderate to good with regard to both the patient and informant instrument. Test-retest reliability of the 21 items of the patient instrument was moderate with regard to HAB, excellent with regard to BIO and moderate with regard to OBS. Interrater reliability of OBS was also moderate. The criterion validity (criterion: DSM-IV TR Axis II classification) of HAB, BIO and OBS based on the 21 items of the patient instrument was fair and with regard to the same 21 items of the informant instrument insufficient. In conclusion, sixteen out of 52 potential items of the patient's draft version of the screening instrument can be used to detect a possible personality disorder. These sixteen items from the HAB and BIO scale are named the Gerontological Personality disorder Scale (GPS). Medical doctors, psychologists and nurses working in ambulatory mental health organisation can use the GPS as a resource during the diagnostic process. Whether the GPS can be used beyond mental health organisations, for example by general practitioners is a subject for future studies.
Subject(s)
Geriatric Assessment/methods , Geriatric Psychiatry , Personality Disorders/diagnosis , Psychiatric Status Rating Scales/standards , Aged , Aged, 80 and over , Female , Humans , Interview, Psychological , Male , Mass Screening , Middle Aged , Netherlands , Personality Disorders/classification , Reproducibility of Results , Sensitivity and Specificity , Surveys and QuestionnairesABSTRACT
A Delphi-technique was used as part of the development of a screening instrument to diagnose personality disorders in the elderly. Several statements regarding this subject were tested. Fifty-three Delphi-members, with expertise in the field of mental health services for the elderly and knowledge about the concept 'personality disorder', gave their opinion on the statements. In three successive rounds we aimed to get consensus as well as agreement on the contents of the statements. In the first round the Delphi-panel confirmed the importance of diagnosing personality disorders, with regard to individual therapy in older adults and psycho-educational activities. The DSM-IV Axis II criteria and related assessment-instruments do not take into account the emotional and social context of the elderly people. In the second round the Delphi-panel endorsed the importance of several information sources namely biographical information, informant information, behavioural observations and the reactions of the therapist himself. In the third round, 44 items considering diagnostics on personality were pro-pounded to the panel. There was agreement as well as consensus on 25 out of the 44 items. In conclusion, adjusting the DSM-IV Axis II criteria to the elderly will improve the quality of the diagnostics. Developments of a specific screening instrument for older adults probably will also increase the quality of the diagnostics.
Subject(s)
Delphi Technique , Geriatric Psychiatry , Personality Disorders/diagnosis , Aged , Diagnosis, Differential , Female , Geriatric Assessment , Geriatric Psychiatry/methods , Geriatric Psychiatry/standards , Humans , Male , Netherlands/epidemiology , Personality Disorders/epidemiologyABSTRACT
OBJECTIVES: To explore and quantify the relative contribution of guideline recommendations and other determinants in the family physicianamprsquos diagnostic work-up of patients suspected of dementia. STUDY DESIGN: We prospectively studied 64 family physicians in an Eastern district in the Netherlands who diagnosed dementia according to the national Dutch guidelines in primary care. Their diagnoses were compared with the reference standard embodied by the memory clinic team of the University Medical Center Nijmegen. POPULATION: The physicians evaluated 107 patients older than 55 years suspected of having dementia. OUTCOMES MEASURED: Predictive values of various clinical and demographic parameters were measured in both univariate and multivariate logistic regression analyses. RESULTS: Activities of daily living (ADL) dependency (odds ratio [OR] = 5.3, P =.03), years since symptoms first started (OR = 1.84, P =.03), and the presence of somatic comorbidity (OR = 0.48, P =.02) independently contributed to the prediction of the presence or absence of dementia. The area under the receiver-operating characteristic (ROC) curve for these 3 variables together was 0.79. The ROC area of the family physiciansamprsquo diagnosis to determine the final diagnosis was 0.74. The number of recommendations applied did not additionally contribute to the assessment of the final diagnosis. CONCLUSIONS: The diagnostic accuracy of the family physician was reasonable. For family physicians, ADL dependency is a better predictor of dementia than cognitive impairment. Family physicians should be aware of diagnostic difficulties in patients with somatic comorbidity. We were unable to confirm the diagnostic value of many of the recommendations of dementia guidelines.
Subject(s)
Dementia/diagnosis , Practice Guidelines as Topic , Activities of Daily Living , Decision Making , Family Practice , Humans , Logistic Models , Middle Aged , Netherlands , Practice Patterns, Physicians' , ROC CurveABSTRACT
BACKGROUND: Mild cobalamin (Cbl) deficiency is frequently found in older persons and is associated with cognitive and cerebral abnormalities. The effects of Cbl supplementation on these abnormalities are largely unknown. METHODS: In a single-blind, placebo-controlled intervention study, 16 healthy community-dwelling elderly subjects with low plasma Cbl concentration and no cognitive impairments were studied. Subjects underwent 1 month of treatment with placebo, followed by 5 months of treatment with intramuscular injections of hydroxycobalamin. Before and after measurements of plasma cobalamin, total homocysteine (tHcy), methylmalonic acid (MMA), quantitative electroencephalograph (qEEG), and psychometric tests were taken. RESULTS: After Cbl supplementation, plasma Cbl concentrations increased, and plasma MMA and tHcy concentrations decreased. The performance on the Verbal Word Learning Test, Verbal Fluency and Similarities improved. qEEG showed more fast activity and less slow activity. Lower plasma tHcy concentrations were related to increased fast activity on qEEG on the one hand and improved performance on the Verbal Word Learning Test and Similarities on the other. Increased fast or decreased slow activity on qEEG was associated with improved performance on the Verbal Word Learning Test, Similarities and Verbal Fluency. CONCLUSIONS: Electrographic signs of improved cerebral function and improved cognitive function were found after Cbl supplementation in older subjects with low plasma Cbl concentrations who were free of significant cognitive impairment. These improvements were related to a reduction of plasma tHcy concentration.
Subject(s)
Aging/physiology , Brain/physiopathology , Cognition/drug effects , Hydroxocobalamin/therapeutic use , Vitamin B 12 Deficiency/drug therapy , Vitamin B 12 Deficiency/physiopathology , Aged , Aged, 80 and over , Aging/psychology , Brain/drug effects , Electroencephalography , Female , Humans , Male , Methylmalonic Acid/blood , Single-Blind Method , Vitamin B 12 Deficiency/psychologyABSTRACT
OBJECTIVE: To evaluate the efficiency of the CAMDEX by exploring the contribution of its four main screening measures to the diagnosis of dementia at a memory clinic. METHODS: A retrospective descriptive study was conducted on the diagnostic practice in a memory clinic regarding all consecutively referred patients who came for a first assessment. A standardised examination based on the CAMDEX included three cognitive tests (CAMCOG, MMSE, IMCT) and a test for functional competence (BDS). The predictive value of the tests was estimated by uni- and multivariate analysis with the clinical dementia diagnosis (yes/no) as dependent variable, taking into account the patients' age, education, gender and sensory ability. RESULTS: Of the 180 patients consecutively referred, 150 completed the assessments and entered the study. Multivariate analysis revealed that the CAMCOG-score contributed most to the clinical diagnosis and was consistent with 84% of the clinical diagnoses using the conventional cutoff 79/80. The CAMCOG-score correlated best with the clinical diagnosis, however, at a cutoff score of 81/82. Forty-one patients (27%) scored closely around (+/-5 points) the CAMCOG cutoff of 79/80. In this group 19 of the total of 23 deviations from the CAMCOG cutoff (83%) occurred. The patients' age, education, gender and visual ability explained some cases where the team's diagnosis deviated from the conventional cutoff score. CONCLUSION: Among four screening measures, after control, the CAMCOG was the only significant predictor for the clinical diagnosis of dementia. To gain efficiency, the screening measures of the CAMDEX protocol may be restricted to the CAMCOG. The interpretation of CAMCOG-scores around the cut-off is problematic. This indicates the need for reference values.
Subject(s)
Dementia/diagnosis , Geriatric Assessment , Mass Screening , Aged , Cognition Disorders/diagnosis , Cognition Disorders/psychology , Female , Humans , Male , Memory Disorders/diagnosis , Memory Disorders/psychology , Middle Aged , Psychometrics , Sensitivity and SpecificityABSTRACT
Little is known about diagnosing personality disorders in elderly persons. The current Axis II nosology is not age related and the majority of psychological tests are unreliable. Three cases dealing with personality disorders are presented. In these cases loss of health, relationships and autonomy are pointed out as the age specific stressors. We studied the relation between psychological symptoms, personality, coping style and age specific stressor. It appeared that elderly persons with personality disorders often have difficulties coping with these stressors. Inadequate coping styles may luxate or exaggerate axis I disorders. Therefore we recommend to pay more attention to the axis II classification during the diagnostical process.
Subject(s)
Adaptation, Psychological , Aging/psychology , Life Change Events , Personality Disorders/diagnosis , Stress, Psychological/diagnosis , Adjustment Disorders/diagnosis , Adjustment Disorders/etiology , Aged , Aged, 80 and over , Diagnosis, Differential , Female , Humans , Male , Medical History Taking , Personality Assessment , Personality Disorders/psychologyABSTRACT
The Charles Bonnet syndrome (CBS) is characterized by the presence of complex visual hallucinations in psychologically normal people. The syndrome occurs predominantly in the visually handicapped elderly. Little is known about its etiology and pathogenesis. The aim of this study was to examine the associations of CBS with psychological and social determinants. All subjects were patients older than 64 years from a low-vision unit. Using a case-control approach, 50 patients with CBS and 80 patients without visual hallucinations were interviewed about their educational level, social circumstances, number of social contacts, and ability to cope with visual handicap. Loneliness was measured with the De Jong-Gierveld-Kamphuis loneliness scale, and personality traits were examined with the Dutch-language short version of the Minnesota Multiphasic Personality Inventory ([MMPI] Nederlandse Verkorte MMPI [NVM]). Compared with the control group, significantly more CBS patients were lonely. Mean scores on the NVM shyness scale and extraversion scale were significantly higher and lower, respectively, in CBS patients. In multiple logistic regression analysis for the three determinants simultaneously, loneliness and low extraversion were significant predictors for CBS, but shyness was not. It is concluded that loneliness, low extraversion, and shyness are risk indicators for CBS in elderly visually handicapped people. The findings suggest that CBS is associated with a low quality of social contacts.
Subject(s)
Disabled Persons , Interpersonal Relations , Personality , Social Alienation , Vision Disorders/psychology , Adaptation, Psychological , Aged , Aged, 80 and over , Case-Control Studies , Chi-Square Distribution , Demography , Female , Hallucinations/psychology , Humans , Loneliness , MMPI , Male , Psychological Tests , Sensitivity and Specificity , Severity of Illness Index , Syndrome , Vision Disorders/diagnosisABSTRACT
Research on important or stressful life events mainly refers to the causes and presence of somatic or psychiatric pathology. In most research checklists or questionnaires are used. Each item of the questionnaire corresponds with a life event. The subject has to indicate which life events had occurred in a restricted period before the onset of the illness, disorder, or behavioural changes. This method has some disadvantages, especially in use with the elderly. Other methods seem to be better for these subjects, e.g. the semi-structured interview. This method is based on the personal meaning and judgement of the subject. He or she can report important life events and the personal experience of feelings and cognitions. In our research with participants of support-groups of the elderly we used the interview-method. We asked the subjects which life events were important for them at that moment and in what way they experienced them (positively, negatively, or neutrally). This was asked before the start of the support-group and in two observations after the end of the group. The results show a change in the experience in a positive direction.
