Development of an abbreviated version of the delirium motor subtyping scale (DMSS-4).

BACKGROUND: Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Identification of clinical subtypes can allow for more targeted clinical and research efforts. We sought to develop a brief method for clinical subtyping in clinical and research settings. METHODS: A multi-site database, including motor symptom assessments conducted in 487 patients from palliative care, adult and old age consultation-liaison psychiatry services was used to document motor activity disturbances as per the Delirium Motor Checklist (DMC). Latent class analysis (LCA) was used to identify the class structure underpinning DMC data and also items for a brief subtyping scale. The concordance of the abbreviated scale was then compared with the original Delirium Motor Subtype Scale (DMSS) in 375 patients having delirium as per the American Psychiatric Association's Diagnostic and Statistical Manual (4th edition) criteria. RESULTS: Latent class analysis identified four classes that corresponded closely with the four recognized motor subtypes of delirium. Further, LCA of items (n = 15) that loaded >60% to the model identified four features that reliably identified the classes/subtypes, and these were combined as a brief motor subtyping scale (DMSS-4). There was good concordance for subtype attribution between the original DMSS and the DMSS-4 (κ = 0.63). CONCLUSIONS: The DMSS-4 allows for rapid assessment of clinical subtypes in delirium and has high concordance with the longer and well-validated DMSS. More consistent clinical subtyping in delirium can facilitate better delirium management and more focused research effort.

[Development and validation of the Informant Assessment of Geriatric Delirium Scale (I-AGeD). Recognition of delirium in geriatric patients]. / Ontwikkeling en validering van de Informant Assessment of Geriatric Delirium Scale (I-AGeD). Herkenning van delier bij geriatrische patiënten.

OBJECTIVES: Delirium is common in older patients admitted to hospital. Information obtained from patient's relatives or caregivers may contribute to improved detection. Our aim was to develop a caregiver based questionnaire, the Informant Assessment of Geriatric Delirium (I-AGeD), to assist in better recognition of delirium in elderly patients. METHODS: A cross-sectional observational study using a scale construction patient cohort and two validation cohorts was conducted at geriatric departments of two teaching hospitals in The Netherlands. Delirium status, based on DSM-IV criteria, was assessed directly on admission by a geriatric resident and evaluated within the first 48 h of admission. Caregivers filled out a 37-item questionnaire of which 10 items were selected reflecting delirium symptoms, based on their discriminatory abilities, internal consistency and inter-item correlations. RESULTS: A total of 88 patients with complete study protocols in the construction cohort were included. Average age was 86.4 (SD 8.5), and 31/88 patients had delirium on admission. Internal consistency of the 10-item I-AGeD was high (Cronbach's alpha = 0.85). At a cut-off score of >4 sensitivity was 77.4% and specificity 63.2%. In patients without dementia, sensitivity was 100% and specificity 65.2%. Validation occurred by means of two validation cohorts, one consisted of 59 patients and the other of 33 patients. Sensitivity and specificity in these samples ranged from 70.0% to 88.9% and 66.7% to 100%, respectively. CONCLUSION: The newly constructed caregiver based I-AGeD questionnaire is a valid screening instrument for delirium on admission to hospital in geriatric patients.

Prescribing pattern of psychotropic drugs in nursing home residents with dementia.

BACKGROUND: The goal of this study is to determine patterns of psychotropic drug use (PDU), the association with neuropsychiatric symptoms (NPS), and the variability across dementia types in nursing home residents with dementia. In addition, PDU was analyzed across multiple indications. METHODS: This was a prospective cohort study over a two-year period from 2006 to 2008, which involved 14 dementia special care units in nine nursing homes. A total of 117 residents with dementia participated in the study, of whom 35% had Alzheimer's dementia (AD) and 11% vascular dementia (VaD). PDU was classified according to anatomical therapeutic chemical-classification as either "present" or "absent". RESULTS: The majority of residents had moderately severe to severe dementia. At all successive assessments, almost two-thirds of residents received any psychotropic drug (PD) and almost one-third continued to receive any PD. Of all PDs, antipsychotics (APs) were prescribed most frequently. Fewer residents started with antidepressants, but continued to receive antidepressants at higher percentages. Anxiolytics showed an intermittent course, but a subgroup of 9% showed two-year continuation. Once started on PDs at baseline, residents continued to use PDs at high percentages: three-quarters continued to receive APs for at least six months. Half of residents received at least one PD; one-fifth received at least two PDs simultaneously. Residents with AD received more hypnotics and antidementia drugs; residents with VaD received more antipsychotics, antidepressants, anxiolytics and anticonvulsants. CONCLUSIONS: PDs have different utilization patterns, but overall, consistently high continuation rates were found. These results warrant scrutiny of continuous PDU.

Determinants of quality of life in nursing home residents with dementia.

AIMS: The goal of this study is to assess the relationship between quality of life (QoL), neuropsychiatric symptoms (NPS), psychotropic drug use (PDU) and patient characteristics in a large group of nursing home residents with dementia. METHODS: This cross-sectional observational study included 288 individuals with dementia who reside in 14 special care units in 9 nursing homes. The following measures were used: the Qualidem scale to assess QoL, the Neuropsychiatric Inventory-Nursing Home version, the Global Deterioration Scale (GDS), the Severe Impairment Battery-short version, an Activities of Daily Living scale and PDU. Associations between QoL and NPS were examined using multivariate linear regression models with corrections for potential covariates. RESULTS: The average age of the residents was 84 years (SD = +/-7). Agitation, depression, psychosis, psychomotor agitation and psychotropic drugs were independently associated with poor QoL. In patients with mild to moderately severe dementia (GDS 4-6), NPS, PDU and cognitive impairment explained almost half of the variance in QoL scores. Agitation and depression were particularly strong predictors of poor QoL. In patients with severe dementia (GDS 7), agitation, depression, psychosis and cognitive impairment were associated with poor QoL. CONCLUSIONS: NPS, cognition and PDU independently impair QoL for patients in both the moderate and advanced stages of dementia. These results challenge existing pharmacological intervention strategies and highlight the need for psychosocial interventions in the treatment of NPS.

[Applicability and validity of the Dutch version of the Montreal Cognitive Assessment (moCA-d) in diagnosing MCI]. / Bruikbaarheid en validiteit van de Nederlandse versie van de Montreal Cognitive Assessment (MoCA-D) bij het diagnosticeren van Mild Cognitive Impairment.

OBJECTIVE: The MoCA is a new screening test to detect Mild Cognitive Impairment (MCI). Purpose of this study is validating the Dutch version (MoCA-D). METHOD: We administered the MoCA-D to healthy control subjects and to elderly with MCI or dementia from a memory disorder outpatient clinic and a geriatric (outpatient) clinic (n = 30, 32, 37 respectively, age > or = 60). Neuropsychological testing was part of the standard procedure for patients to diagnose MCI. Sensitivity, specificity and predictive values (positive: PPV and negative: NPV) of the MoCA-D were assessed. RESULTS: A significant effect of group was found on MoCA-D total score (F (2.95) =67.9; p < 0.01). With a cutoff score of < or = 25, sensitivity and specificity to detect MCI in relation to healthy controls were 72% and 73%, respectively. PPV and NPV were 84% and 56%, respectively. With a cut-off score of < or = 20, sensitivity to detect dementia in relation to MCI was 100% for severe dementia and 75% for mild dementia. Specificity for dementia was 81%, PPV 94% and NPV 55%. CONCLUSION: The MoCA-D distinguishes between healthy elderly, MCI patients and dementia patients. However, in this study, insufficient sensitivity and poor specificity were found. For the present, applying a broader and flexible screening procedure in order to detect MCI seems a more useful method than the interpretation of one test result in particular.

Validity of the Severe Impairment Battery Short Version.

BACKGROUND: Efficient neuropsychological tests are needed to measure cognitive impairment in moderate to severe dementia. OBJECTIVE: To examine construct validity of the Severe Impairment Battery Short Version (SIB-S) in nursing home patients with moderate to severe dementia, and to examine potential floor effects for the SIB-S. METHODS: Cross-sectional comparison of cognitive measures, dementia severity and functional dependency. RESULTS: A total of 290 patients were included 264 of whom had complete SIB-S protocols. Internal consistency of the SIB-S was very high (Cronbach alpha = 0.97). Principal-component analysis produced three factors, the first of which explained more than 50% of common score variance. Semantic memory items loaded highly on the first factor. Total SIB-S scores were associated with cognitive impairment (SIB-S--Mini Mental State Examination (MMSE) rho = 0.91, p<0.001), and with functional dependency (SIB-S--ADL scale rho = -0.61, p<0.001). SIB-S total scores differentiated between dementia stages as measured with the Global Deterioration Scale (F = 164.6; df 3,260, p<0.001). Comparisons of SIB-S total score variance across patients with moderate to severe dementia and patients with below or above average Mini Mental State Exam scores indicate an absence of large floor effects. CONCLUSION: In this first study examining an independently administered SIB-S, the scale proved to be a homogeneous and valid measure of cognitive impairment. The SIB short version can be used to assess moderately to severely demented patients, who may find it difficult to complete traditional, lengthier neuropsychological tests.

[Reversible cognitive decline in a patient with relapsing polychondritis]. / Passagère cognitieve achteruitgang bij een patient met relapsing polychondritis.

Patient A, 58 years, is referred by the Rheumatologist to the Geriatrician concerning apathy. History reviews skipping arthritis, reddened and inflamed eyes, apathy and loss of interest. Physical examination revealed red tearing eyes, bradyphrenia and bradykinesia. Laboratory examination showed inflammation markers. The patient develops fever and bilateral reddened and inflamed ears. Diagnosis of relapsing polychondritis is made, the patient is treated with prednisone and the symptoms disappear. Relapsing polychondritis is a chronical disease associated with inflammation and destruction of cartilaginous structures and proteoglycan rich structures. We diagnosed Relapsing Polychondritis with a reversible dementia, probably due to cerebral vasculitis.

[A systematic review of multifactorial interventions for primary prevention of delirium in the elderly]. / Een systematisch overzicht van multifactoriële interventies ter primaire preventie van delier bij ouderen.

Delirium is a severe psychiatric syndrome that is highly prevalent in elderly patients in a general hospital. Primary prevention is important to prevent delirium. This article reviews recent developments with regard to multifactorial intervention trials for primary prevention of delirium. The review process involved a systematic search in MEDLINE, The Cochrane Database and CINAHL Database and subsequent examination of reference lists. Six studies were selected. Four studies showed that systemic interventions regarding medical-, nurse-led, environmental-, and educational items, were effective in preventing delirium. In one study a reduction was found in duration and severity of duration only. One study showed no effect on delirium at all. Despite the methodological weaknesses of the studies, conclusions are that different kinds of non-pharmacological interventions can be effective in preventing delirium.

[Successful treatment of three elderly patients suffering from prolonged delirium using the cholinesterase inhibitor rivastigmine]. / Succesvolle behandeling van 3 langdurig delirante oudere patiënten met de cholinesteraseremmer rivastigmine.

Delirium is commonly encountered in elderly patients in general hospitals. Most patients with delirium respond well within 12 days of commencement of treatment with haloperidol. A significant number of patients, however, does not improve. Three elderly male patients aged 85, 79 and 81 respectively suffering from prolonged delirium and unresponsive to haloperidol or atypical anti-psychotic drugs, responded well within days to treatment with rivastigmine--a cholinesterase-inhibitor. It was very well tolerated. In The Netherlands cholinesterase inhibitors are registered for the symptomatic treatment of Alzheimer's disease. There is some evidence, both from animal and human experiments, that cholinergic deficiency plays a role in certain types of delirium. Therefore treatment of delirium with a cholinesterase-inhibitor seems logical. Controlled studies are needed to evaluate the effects of these types of drugs in patients with prolonged delirium.

[Neuropsychiatric inventory questionnaire (NPI-Q): A validity study of the Dutch form]. / Neuropsychiatric inventory vragenlijstversie (NPI-Q): validiteitsaspecten van de Nederlandse versie.

UNLABELLED: The Neuropsychiatric Inventory is a clinical instrument for assessing behavioral and psychological symptoms in dementia. It is based on an interview with the primary caregiver. A brief questionnaire form of the NPI was developed, intended for use in routine clinical practice (NPI-Q). This study evaluates the validity of the NPI-Q Dutch form. The NPI-Q was compared to other questionnaires, i.e. the Revised Memory and Behavioural Problems Checklist (RMBPC), the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-N), the 15 items Geriatric Depression Scale (GDS-15) and the Cognitive Screening Test (CST-20). A data set was used of geriatric outpatients who were referred for neuropsychological assessment (n = 29). Correlations between the NPI-Q and RMBPC Depression- and Disinhibition subscales were relatively high. No relationship was found between the NPI-Q and the RMBPC Memory related behavioral changes subscale, or between the NPI-Q and the IQCODE-N and the CST-20. Informant ratings on the NPI-Q depression-item were related with patient ratings on the GDS-15, especially when patients were relatively mildly cognitive impaired. Caregiver distress was strongly associated with NPI-Q symptom assessment. IN CONCLUSION: our preliminary results support validity of the NPI-Q Dutch form. It is a practical rating scale for assessing neuropsychiatric symptoms in dementia and associated caregiver distress.

[Neuropsychiatric symptoms of dementia: psychometric aspects of the Dutch Neuropsychiatric Inventory (NPI)]. / Neuropsychiatrische symptomen bij dementie: psychometrische aspecten van de Nederlandse Neuropsychiatric Inventory (NPI).

Behavioral and psychological symptoms are highly prevalent in dementia. The Neuropsychiatric Inventory was constructed to measure these symptoms. Data from three studies are presented concerning psychometric aspects of the NPI Dutch version. The NPI was compared to the Revised Memory and Behavioral Problems Checklist (RMBPC) and the Mini Mental State Examination (MMSE). In the three selected patient samples prevalence of behavioral or psychological symptoms was as high as 90%. Interrater agreement (n = 19) was very high (kappa > .90). Factor analysis (n = 199) supports NPI construct validity. The NPI items correlated reasonably high (R = .35 - .60) with the relevant RMBPC subscales (n = 24). Although some NPI items did, the NPI total score was not significantly related to the MMSE. The NPI Dutch version can be scored objectively and it is a valid rating scale for measuring a wide range of behavioral and psychological symptoms of dementia.

[Is 'attention' important for the results of dementia screening? Relation among Digit Span Test, CST amd ADS in elderly patients]. / Is 'aandacht' belangrijk voor de resultaten van dementiescreening? Samenhang tussen de Cijferreeksentest, CST en ADS bij oudere patiënten.

This study focused on the relationship between attention and dementia screening test performance, using the adapted Wechsler's Digit Span test for elderly patients, the Cognitive Screening Test (CST) and the Amsterdam Dementia Screening Test (ADS6). Participants were dementia patients and psychiatric patients (n = 147). In both groups no floor-effect was found on the Digit Span test. Principal components analysis showed that CST and ADS6-scores had relatively high loadings on one factor, in contrast to digit span scores that loaded on a second factor. On average, psychiatric patients did hardly worse than normal controls. Attention deficits were more apparent in dementia patients. Considering a maximum of r = .41, these more or less subtle deficits were only moderately related to dementia screening test performance. It is concluded that the adapted Digit Span test is suitable for measuring attention deficits in elderly patients. However, Digit Span predicts performance on dementia screening test only to a modest degree.

[Short version of the Dutch Behavioral Rating Scale for Psychogeriatric Inpatients (GIP-28)]. / Verkorte Gedragsobservatieschaal voor de Intramurale Psychogeriatrie (GIP-28).

This study reports on a new rating scale, the short version (GIP-28) of the Dutch Behavioral Rating Scale for Geriatric Inpatients (GIP). Only a limited number of items was needed to adequately describe GIP variance in two patient samples (n = 2196 and n = 126). Based on previous results factor analysis produced three factors: 'apathy', 'cognitive' and 'affective' symptoms. This led to the construction of new subscales which showed significant differences between persons in different patient settings. Elderly patients with a cognitive disorder or schizophrenia/mood disorder according to DSM-IV criteria, were correctly classified in almost 80% of the cases. We conclude that the GIP-28 is equivalent to the GIP and describes aspects of apathy and cognitive and affective symptoms in elderly patients. A compact rating scale like this might best be used in (routine) screening of cognitive and noncognitive behavioral problems. It may also prove useful for outpatient purposes.

Differentiating between demented and psychiatric patients with the Dutch version of the IQCODE.

This study presents psychometric data on the Dutch version of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-N). We focused on differentiating between inpatients with dementia or a mood/psychotic disorder. A cutoff point of 3.9 on the IQCODE-N correctly predicted group membership in 87.8% and 78.8% respectively. Internal consistency and principal component analysis suggest that the IQCODE-N measures a unidimensional construct. Correlations with a Dementia Screening Test (r = 0.62), nurses' observations on memory disorders (r = 0.71) and a global assessment of severity of dementia (r = 0.72) support the validity of the informant ratings. Patients' age and level of education did not confound informant ratings. Only a small fraction of the informants could not complete the IQCODE-N, which makes it an easily applicable rating scale for cognitive decline.