Aspects of Rest-Activity Rhythms Associated With Behavioral and Psychological Symptoms in Moderate and Severe Dementia: Results of a Cross-sectional Analysis.

OBJECTIVE: Disturbances in rest-activity rhythms (RAR) are commonly observed in patients with dementia; however, the influence thereof on behavioral and psychological symptoms of dementia (BPSD) remains unexplored. This study aimed to determine whether there is an association between RAR and BPSD among patients with moderate and severe dementia. METHODS: RAR analyses of 64 participants were performed using actigraphy. BPSD was assessed using the Neuropsychiatric Inventory-Nursing Home (NPI-NH) scale, and other clinical variables were assessed by the Mini-Mental State Examination, Cognitive Test for Severe Dementia, and Hyogo Activities of Daily Living Scale. Correlations among RAR, sleep time, and BPSD were analyzed. A stepwise multiple linear regression analysis was conducted to examine the association of RAR and sleep time with BPSD. The demographic variables were also adjusted. Variables were compared between two groups with aberrant and nonaberrant activity peak timing. RESULTS: Correlation analysis showed that longer maximum durations of activity and shorter daytime sleep were associated with higher NPI-NH scores. Stepwise multiple linear regression analysis showed that maximum activity duration predicted the NPI-NH score after adjustment for the demographic variables. There was no significant difference in any variables between the groups with aberrant and nonaberrant activity peak timing. CONCLUSION: RAR is associated with BPSD in moderate-to-severe dementia, which should be considered with regard to treatment.

Clinical utility of an assessment scale for engagement in activities for patients with moderate-to-severe dementia: additional analysis.

BACKGROUND: We developed the assessment scale for engagement in activities (ASEA), an assessment tool used to quantify engagement in therapeutic activities for patients with moderate-to-severe dementia. In this study, we report additional analyses to confirm the viability of ASEA as a reliable measurement scale. METHODS: This study included 195 patients with moderate-to-severe dementia in a psychiatric acute-phase hospital. Additional analyses based on the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist were as follows: (i) exploratory and confirmatory factor analysis; (ii) standard error of measurement (SEM), minimal detectable change (MDC) and limit of agreement (LOA); (iii) short change score from baseline to 2 weeks; and (iv) correlation to the facial expression analysis system. RESULTS: Exploratory factor analysis yielded two factors. This two-factor model of ASEA exhibited an acceptable and validated model fit (comparative fit index = 0.954, Tucker Lewis index = 0.936, goodness-of-fit index = 0.927, adjusted goodness-of-fit index = 0.873, root mean square error of approximation = 0.091, standardised root mean square residual = 0.045) by confirmatory factor analysis. SEM and MDC were 1.29 and 3.80, respectively. The Bland-Altman plot for examining LOA showed no apparent fixed bias. From baseline to 2 weeks later, 129 participants were retested. The mean ASEA total score improved significantly (Wilcoxon signed-rank test; P < 0.01, effect size = 0.25) from baseline (14.30 ± 2.63) to 2 weeks later (15.00 ± 2.73). The correlation between each emotion value was calculated using Kokoro sensor, which is an affect analysis based on human facial expression data using deep learning. For the 36 video data samples, the total score and domains of arousal, interaction, and affect in ASEA were statistically significantly correlated with the emotion value of joy, engagement, and valence (Spearman rank correlation; P < 0.05). CONCLUSIONS: Among the few evaluation methods specific to severe dementia, ASEA is a useful scale for quantifying and evaluating the state of engagement in therapeutic activities.

Factors influencing the quality of life in patients with severe dementia.

BACKGROUND: A comprehensive understanding of the relevant factors involved in improving quality of life (QoL) is essential in patients with severe dementia; however, rating scales used in previous studies may not adequately reflect the factors that affect these patients. The purpose of this study was to identify factors that contribute to QoL using an evaluation scale suitable for patients with severe dementia. METHODS: The current cross-sectional study was conducted at a hospital for recuperation in Hyogo prefecture in Japan. The measurement scales included the QoL in Late-Stage Dementia Japanese version (QUALID-J), Cognitive Test for Severe Dementia, Neuropsychiatric Inventory-Nursing Home (NPI-NH), Physical Self-Maintenance Scale (PSMS), Pain Assessment in Advanced Dementia (PAINAD), and Special Care Unit Environment Quality Scale (SCUEQS). Multiple regression analyses were performed. RESULTS: We assessed a total of 105 patients with severe dementia (80 women; aged 87.3 ± 6.3 years). Multiple regression demonstrated that the QUALID-J total score was significantly affected by the NPI-NH and PAINAD scores. Factors 1 (expression of comfort) and 2 (expression of discomfort) of the QUALID-J were significantly affected by the PSMS and PAINAD, and the NPI-NH and PAINAD scores, respectively. CONCLUSION: Our results indicate that behavioural and psychological symptoms of dementia and pain are important factors in influencing the QoL of patients with severe dementia.

Insight Into Illness and Psychological Defense Attitudes in People With Chronic Schizophrenia Using Markova's Insight Scale.

ABSTRACT: Insight into illness is a multidimensional phenomenon, and various assessments are available. We focused on Markova's Insight Scale (IS) and investigated the relationship between insight, psychological defenses, and neurocognition in 38 patients with schizophrenia. Results showed that insight was significantly correlated with an immature defense style. Moreover, IS was significantly predicted by immature defense style after adjusting for clinical variables. Although insight is often assumed to be multidetermined with potential contributions from factors such as cognitive function and psychological defensive mechanisms, our results indicated that better insight assessed with the IS is more likely to reflect immature defenses. This may also be reflected in our result that a higher insight score correlated with earlier onset of illness. The insight score may reflect the immature psychological defensive attitudes of schizophrenia and may lead such patients to wish to comply with the views of clinicians.

Impact of Disturbed Rest-activity Rhythms on Activities of Daily Living in Moderate and Severe Dementia Patients.

PURPOSE: People with dementia exhibit disturbed rest-activity rhythms and extended sleep duration issues throughout their disease. Little is known about the effects of these issues on clinical problems for those with moderate and severe dementia. This cross-sectional study aimed to examine the associations of disturbed rest-activity rhythms and extended sleep duration with activities of daily living (ADL). METHODS: Sleep parameters were measured using an actigraphy device. Cognitive function was assessed using the Mini-Mental State Examination and Cognitive Test for Severe Dementia, the Hyogo Activities of Daily Living Scale was used to assess ADL, and behavioral and psychological symptoms of dementia were assessed using the Neuropsychiatric Inventory-Nursing Home scale. Associations among rest-activity rhythms, sleep duration, and other clinical variables were analyzed with multiple linear regression. Clinical variables were compared between 2 groups categorized by onset timing of rest peak. PATIENTS: Sixty-four participants with moderate and severe dementia were assessed. RESULTS: In the correlation analysis, unstable daily rest-activity rhythm was associated with lower ADL. In the multiple linear regression analysis, low intradaily variability, and long daytime sleep duration were associated with low ADL. Aberrant rest peak timing showed lower ADL compared with nonaberrant timing. CONCLUSIONS: Abnormal rest-activity rhythm and sleep duration in persons with moderate and severe dementia may affect ADL.

Clinical factors associated with activities of daily living and their decline in patients with severe dementia.

BACKGROUND: To identify the clinical factors affecting activities of daily living (ADL) at baseline and after 6 months. METHODS: We conducted a single-centre observational study at two time points across 6 months (baseline and after 6 months) from April 2015 to March 2017. in a 270-bed rural recuperation hospital at Hyogo prefecture in Japan. The total number of participants was 131 (male 33, female 98; mean age: 87.0 ± 7.0; mild and moderate dementia, 38; severe dementia, 93). Measurement scales used were Personal Self-Maintenance Scale (PSMS) for assessing ADL, Mini-Mental State Examination and Cognitive Test in Severe Dementia (CTSD) for cognitive function, Neuropsychiatric Inventory-Nursing Home version and Cornell Scale for Depression in Dementia (CSDD) for behavioural/psychological symptoms of dementia, Mini Nutritional Assessment Short form (MNA-SF) for nutritional status, Pain Assessment in Advanced Dementia for pain, and Charlson comorbidity index (CCI) and the number of illness categories based on Cumulative Illness Rating Scale Geriatrics for comorbidities. Multiple regression analyses identified the association between PSMS score as the dependent variable and other variables as independent variables. RESULTS: In participants with severe dementia, the PSMS scores at baseline were significantly associated with CTSD, CCI, MNA-SF, and CSDD scores. In the longitudinal analysis, only CTSD score was significantly associated with PSMS score after 6 months. It is noteworthy that for participants with severe dementia, the only factor associated with ADL after 6 months was cognitive function, as assessed by CTSD score. CONCLUSIONS: The most important factor predicting functional decline is cognitive function, even at the severe and profound stage.

Insight Into Illness and Defense Styles in Schizophrenia.

Although the psychological denial model argues that poor insight is a result of defense mechanisms, the direct relationship between the two remains unclear. This study aimed to examine the relationship between insight into illness and defense mechanisms while considering cognitive dysfunction in schizophrenia. A total of 38 patients with schizophrenia were evaluated for level of insight (Schedule for the Assessment of Insight), defense mechanisms (Defense Style Questionnaire), neurocognitive function (Brief Assessment of Cognition in Schizophrenia), and psychotic symptoms (Brief Psychiatric Rating Scale). Regarding level of insight, partial correlation analysis controlling neurocognitive and psychotic variables showed that "recognition of illness" was positively correlated with immature defense styles and negatively correlated with mature defense styles. Stepwise regression analyses revealed that "recognition of illness" was significantly predicted by immature defense styles. Our findings suggest that patients who tend to use immature defense styles are more likely to accept their own mental illness.

Clinical Utility of the Cognitive Test for Severe Dementia: Factor Analysis, Minimal Detectable Change, and Longitudinal Changes.

AIMS: This study sought to conduct additional analyses of the Cognitive Test for Severe Dementia (CTSD) using the COSMIN checklist to ensure the development of adequate outcome measures. METHODS: The following analyses were conducted: (1) factor analyses were used to evaluate construct validity; (2) the standard error of measurement (SEM) and minimal detectable change (MDC) were assessed to evaluate reliability and interpretability; and (3) longitudinal change was assessed to evaluate responsiveness. RESULTS: The CTSD factor analysis yielded 2 factors, each of which was dichotomized by the passage rate of each item. We calculated a SEM and MDC of 1.6 and 3.6 points, respectively. Finally, the mean CTSD score showed a significant reduction (p < 0.001) over time, and the change in score exceeded the SEM and MDC. CONCLUSION: Our results indicate that the CTSD could provide a reliable outcome measure in severe dementia.

Impaired Interpretation of Others' Behavior is Associated with Difficulties in Recognizing Pragmatic Language in Patients with Schizophrenia.

Much attention has been paid to the pragmatic language function in schizophrenia. This study of Japanese patients with schizophrenia examined the relationship between impaired interpretation of the behaviors of other people in social contexts and the ability to recognize metaphor and irony. We assessed 34 patients with schizophrenia and 34 normal subjects using first- and second-order theory of mind tasks, the Metaphor and Sarcasm Scenario Test, and the Dewey Story Test (which tests the ability to judge others' social behaviors). We compared the performance between the groups and analyzed correlations between the tasks. All tasks revealed significant deficits in the patients compared with the controls. In the patient group, metaphor comprehension was correlated with the ability to judge normal behaviors, and irony comprehension was correlated with the ability to judge abnormal behaviors, suggesting that deficits of social cognition in schizophrenia include these two types of factors associated with pragmatic language.

Development of the Cognitive Test for Severe Dementia.

BACKGROUND/AIMS: Existing cognitive measures for moderate-to-severe dementia have shown floor effects and an inability to assess the remaining cognitive function, especially for profound dementia. METHODS: We constructed the Cognitive Test for Severe Dementia (CTSD), which consists of 13 items covering 7 cognitive domains, and examined its reliability and validity. RESULTS: Cronbach's α in severe dementia participants was 0.896. Interrater and test-retest reliability were 0.961 and 0.969, respectively. The CTSD showed a significant correlation with 3 other measures of cognitive function (Mini-Mental State Examination, Severe Cognitive Impairment Rating Scale, and Hasegawa Dementia Scale-Revised: r values = 0.870-0.922, p values <0.001). While the other measures showed floor effects, the CTSD did not. CONCLUSION: The CTSD was able to sensitively capture the remaining cognitive function in severe dementia patients when compared with other cognitive tests.