Depression associated with dementia.

Depression and cognitive disorders, including dementia and mild cognitive impairment, are common disorders in old age. Depression is frequent in dementia, causing distress, reducing the quality of life, exacerbating cognitive and functional impairment and increasing caregiver stress. Even mild levels of depression can significantly add to the functional impairment of dementia patients and the severity of psychopathological and neurological impairments increases with increasing severity of depression. Depressive symptoms may be both a risk factor for, as well as a prodrome of dementia. Major depressive syndrome of Alzheimer's disease may be among the most common mood disorders of older adults. Treating depression is therefore a key clinical priority to improve the quality of life both of people with dementia as well as their carergivers. Nonpharmacological approaches and watchful waiting should be attempted first in patients who present with mild to moderate depression and dementia. In cases of severe depression or depression not able to be managed through nonpharmacological means, antidepressant therapy should be considered.

Apathy in nursing home residents with dementia: results from a cluster-randomized controlled trial.

PURPOSE: Here we evaluate an interdisciplinary occupational and sport therapy intervention for dementia patients suffering from apathy. SUBJECTS AND METHODS: A prospective, controlled, rater-blinded, clinical trial with two follow-ups was conducted as part of a larger cluster-randomized trial in 18 nursing homes in Berlin. n=117 dementia patients with apathy, defined as a score of 40 or more on the apathy evaluation scale (AES) or presence of apathy on the Neuropsychiatric Inventory (NPI), were randomly assigned to intervention or control group. The intervention included 10 months of brief activities, provided once a week. The primary outcome measure was the total score on the AES scale measured directly after the intervention period and again after 12 months. RESULTS: We found significant group differences with respect to apathy during the 10 month intervention period (F2,82=7.79, P<0.01), which reflected an increase in apathy in the control group, but not in the intervention group. Within one year after the intervention was ceased, the treatment group worsened and no longer differed significantly from the control group (P=0.55). CONCLUSIONS: Our intervention was effective for the therapy of apathy in dementia, when applied, but not one year after cessation of therapy.

[Guideline compliance in the treatment of schizophrenic patients. Introduction of a computer-assisted treatment pathway]. / Leitlinienkonformität in der Behandlung schizophrener Patienten. Einführung eines IT-gestützten Behandlungspfades.

BACKGROUND: The goal of S3 Guidelines for the Treatment of Schizophrenia was to improve the care of patients with schizophrenic psychoses. However, the publication of guidelines alone does not ensure their consistent implementation. The use of treatment pathways represents one possible approach to help implement the complex treatment recommendations contained in the S3 Guidelines. The first computer-assisted treatment pathway for patients with schizophrenic psychoses was successfully incorporated into the everyday routine of psychiatric hospitals. The aim of the present study was to systematically analyse the impact of this measure on guideline compliance. MATERIALS AND METHODS: Based on the S3 Guidelines for the Treatment of Schizophrenia developed by the German Association of Psychiatry, Psychotherapy and Neurology (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde; DGPPN), diagnostic and treatment procedures were defined by a multiprofessional working group with members from five different hospitals and subsequently incorporated into an existing hospital information system. In one of the five hospitals, the impact of this measure was analysed in a pilot study in a systematic manner. In the year 2007, approximately 100 patients in each of two wards in the hospital received in a parallel group design either standard care or care based on a computer-assisted treatment pathway. Based on their place of residence, patients were assigned to the two units consecutively. Both groups were analysed to determine the extent to which the care they received conformed to treatment guidelines. Data available from the years 2004 and 2005 served as a historical comparison to the present results. RESULTS: The differences in guideline compliance between the two wards were heterogeneous and, in certain respects, counterintuitive. As expected, the treatment pathway group showed an increased number of laboratory tests, more frequent drug screening at hospital admission and more appropriate dosing of neuroleptics. However, the rate of participation in psychoeducational interventions was disappointing. A conspicuous finding was the negative relationship between initial disease severity and compliance with guidelines on psychopharmacological treatment. In contrast, the historical comparison revealed that guideline compliance had increased slightly in both the treatment pathway and standard treatment groups. CONCLUSION: Developing computer-assisted treatment pathways based on S3 Guidelines and incorporating them into existing hospital information systems is feasible and well accepted by users. The initial effects on guideline compliance are mostly positive, but not strongly so. Moreover, there was a reduction in duration of hospital stay. Disease-related factors such as disease severity appear to compromise guideline compliance.

[MCI-plus: mild cognitive impairment with rapid progression. Part II: Biomarkers and research methods]. / MCI-plus: leichte kognitive Beeinträchtigung mit rascher Progredienz. Teil II: Biomarker und Untersuchungsmethoden.

Long-term studies will be pivotal in order to examine the efficacy of preventive and early therapeutic interventions during the preclinical phase of dementia. Biomarkers will be of importance due to the large sample sizes and the necessary logistic efforts, high drop-out rates and slow clinical progression. The validity of functional and even structural imaging methods is currently investigated with early and promising results; it is presently unclear whether conventional csf-markers of Alzheimer's disease (beta-amyloid and tau-proteins) are sufficiently sensitive to monitor the effects of early interventions. It also remains doubtful whether modifications of these methods will ever be useful and available for practical purposes.

[MCI-plus: mild cognitive impairment with rapid progression. Part I: prevention and therapy]. / MCI-plus: leichte kognitive Beeinträchtigung mit rascher Progredienz. Teil I: Prävention und Therapie.

Mild Cognitive Impairment (MCI) is a prevalent problem in the elderly and many patients show predictors of rapid cognitive decline ("MCI-plus"). MCI-plus represents a syndrome with growing importance in an ageing society, which will increasingly affect primary medicine and most other clinical specialties. We will have to face the dilemma of fast progress in the field of neurodiagnostics with innovative therapeutic strategies lagging behind. Psychological and medical co-morbidity in MCI-plus will therefore offer important opportunities to delay and to avoid the manifestation of dementia. We will review and discuss current training and treatment options including symptomatic and causal interventions.

[Reasons for referral to a gerontopsychiatric department]. / Gründe für die Einweisung in eine gerontopsychiatrische Klinik.

BACKGROUND: The need of specific gerontopsychiatric wards has not been estimated thus far, although psychiatric disorders are very common among the elderly. AIM: The purpose of this study was to describe reasons for referral of old patients to a psychiatric department providing full services for 252,000 inhabitants. METHODS: All 975 admissions within 2 years were evaluated in this prospective study. RESULTS: During the study period 645 patients aged over 64 years were admitted 830 times to the gerontopsychiatric wards. About half of them were referred by physicians in private practice, about 30% came via the emergency room, and 18% were transferred from other departments or hospitals. The most frequent reasons for referral were disorientation, confusion, or delirious states (31.9%), hallucinations or delusion (21.6%), aggression or excitation (17.7%), depression (17.6%), refusal of feeding or drinking (14.4%), agitation or restlessness (13.9%), suicidality or suicide attempt (13.3%), and disruptive behaviour (13.0%). In 81.8% of the cases, behaviour endangering themselves or others was an important cause of referral. The amount of specific gerontopsychiatric beds needed in hospital was estimated as ten beds per 10,000 inhabitants aged 65 or more. CONCLUSIONS: The greatest proportion of the patients referred to gerontopsychiatric wards showed behaviour endangering themselves or others-typical indications for psychiatric inpatient treatment.

[The nursing phenomenon "chronic confusion" in relation to the diagnosis "dementia"]. / Das Pflegephänomen "Chronische Verwirrtheit" im Kontext der Diagnose "Demenz"--Eine Literaturstudie.

This article is about the results of a literature analysis, focusing on the two questions: 1) What is the understanding of "Chronic confusion"? and 2) How is the nursing diagnosis "Chronic confusion" delineated from the diagnosis "Dementia"? The review is based on the databases CINAHL, MEDLINE and GEROLIT. A review of the literature revealed that there is basic agreement regarding the characteristic "cognitive impairment" but there are differences in the question as to how this cognitive impairment manifests itself in practice. Moreover most authors described socially and emotionally altered behaviors which accompany the phenomenon. There is, however, no clear vision on the status of such socially and emotionally altered behaviors: Do they have to be present for "Chronic confusion" to be diagnosed or not? In addition, it seems inconsistent to include the mild stage of Dementia in the "Chronic confusion" diagnosis. This analysis indicates that much work remains to be done to validate the characteristics of "Chronic confusion". As long as the diagnosis is not clear, imprecise labeling of patients and ineffective interventions cannot be avoided.

[Micro-Mental Test - a short method of dementia screening]. / Mikro-Mental-Test Ein Kurzverfahren zum Demenzscreening.

Especially in outpatient settings, dementia is still an underdiagnosed syndrome. The Micro-Mental Test has been developed as a short version of the Mini-Mental-Status Examination (MMSE). We examined the reliability and diagnostic validity of a German version (Mikro-Mental Test). We administered the MMSE and the German version of the Micro-Mental Test to 20 inpatients of a geriatric psychiatry hospital (mean age 74.8+/-8.1 years), 55 patients from a cognitive clinic (mean age 71.9+/-9.1 years), and 27 healthy older adults (mean age 68.5+/-4.1 years). Diagnoses made by an experienced psychiatrist according to ICD-10 criteria served as external criteria. The mean duration for testing with the Micro-Mental Test was 8 min, and with the MMSE 15 min. Test-retest analyses showed satisfactory reliability. With regard to sensitivity and specificity, we found comparable diagnostic validity for the MMSE and the Micro-Mental Test. We suggest that, due to its brevity and diagnostic validity, the Micro-Mental Test is a useful tool for dementia screening in an outpatient setting.

Safety and efficacy of idebenone versus tacrine in patients with Alzheimer's disease: results of a randomized, double-blind, parallel-group multicenter study.

This study evaluated the safety and efficacy of idebenone vs. tacrine in a prospective, randomized, double-blind, parallel-group multicenter study in patients suffering from dementia of the Alzheimer type (DAT) of mild to moderate degree. Diagnosis was based on DSM-III-R (primary degenerative dementia) and NINCDS-ADRDA criteria (probable Alzheimer's disease). A total of 203 patients of both sexes aged between 40 and 90 years were randomized to either idebenone 360 mg/day (n = 104) or tacrine up to 160 mg/day (n = 99) and treated for 60 weeks. The primary outcome measure was the Efficacy Index Score (EIS). The EIS combines dropout as well as the relevant improvements individually across the three levels of assessment (cognitive function, activities of daily living, global function). Secondary outcome measures were the ADAS-Cog score, the NOSGER-IADL score and the clinical global response (CGI-Improvement). After 60 weeks of treatment, 28.8 % of the patients randomized to idebenone, but only 9.1 % of the patients randomized to tacrine were still on the drug. In the LOCF analysis, 50 % of the patients randomized to idebenone but only 39.4 % of the patients randomized to tacrine showed an improvement in the Efficacy Index Score or at least one of the secondary outcome variables. The primary efficacy measurement was the change of the Efficacy Index Score from baseline to the assessment after 60 weeks treatment. The analysis was done on intention-to-treat (ITT) in a before-and-after test design. Patients randomized to idebenone showed a higher benefit from treatment than patients randomized to tacrine. We conclude that the benefit-risk ratio is favorable for idebenone compared to tacrine, and furthermore, that this ratio is likely to be similar when comparing idebenone to other cholinesterase inhibitors.

Invasions of personal space in demented and nondemented elderly persons.

Personal space has been a research issue in both social psychology and nursing in the past 20 years. In the context of behavioral and psychological signs and symptoms in dementia (BPSSD), however, personal space and other basic paradigms of social psychology sparsely play a role. In order to assess personal space in demented (n = 10) and nondemented (n = 10) elderly participants, we replicated the original study addressing personal space by Felipe and Sommer (1966). The two groups differed in the overall number of participants showing a specific reaction, in the mean duration until specific reactions occurred, and in the percentage of participants within a group showing a specific reaction at a given point in time. The argument is being made that such findings might reflect situational as well as disease-specific changes in the perception of and reactions to invasions of personal space in demented patients. We suggest that further research in that field could bring about more information on the nature of dementia, and especially BPSSD. Implications for therapy and care of dementia patients are being discussed.

[Diagnosis and therapy of depression in advanced age]. / Diagnostik und Therapie der Depression im höheren Lebensalter.

Depressive symptoms and dementia are the most frequent psychiatric disorders in late life. Somatic diseases, social isolation, and functional disability, interfering with the activity of daily life and social participation are among the relevant risk factors. The elderly are particularly prone to subsyndromal depression because of their increased tendency to alexithymia and somatisation, which masks the depression. There is a strong association between comorbid physical illnesses and depressive symptoms for a number of common medical disorders. Antidepressive therapy is proven to be as effective as in younger age groups. Medical treatment should consider the special pharmacological features of old age and should be combined with psychotherapy. When the notion that depression in older people is "justified" is no longer common sense, then successful treatment will be more likely.

[Are psychiatric illnesses adequately considered in distribution of nursing care levels according to the nursing care insurance law? Evaluation using a new scale for evaluating need for nursing care by senior citizens]. / Werden psychische Erkrankungen in der Vergabe von Pflegestufen nach dem Pflegeversicherungsgesetz hinreichend berücksichtigt? Evaluation mit Hilfe einer neuer Skala zur Beurteilung der Pflegebedürftigkeit von Senioren (BPS).

The object of our study is the evaluation of care needs of senior citizens and the adjustment of certain stage of care according to the German Health Care Act ("Pflegeversicherungsgesetz"). For assessment of care needs we developed a new rating scale (BPS). Factor analysis of the rating scale showed 5 dimensions: (1) "Psychoorganic Syndrome" (Dementia), (2) "Physical Care Needs", (3) "Lack of Social Skills", (4) "Aggressiveness" and (5) "Depression". The sample size is N = 1739, mean age 82.5 years. A statistically significant partial correlation of the extent of care needs as indicated by the stage of care described by BPS dimensions was found only for dimension (2) "Physical Care Needs" (r = 0.50). Cluster analysis resulted in distribution of the whole sample into 6 discriminable groups, according to their syndrome specificity (BPS profiles). Additionally clusters are different regarding the severity of need for care. It is obvious, analyzing the adjustment of stages of care within clusters, that psychiatric relevant disturbances contribute substantially to this adjustment. Nevertheless this finding is valid only for aged people, who receive regular care by ambulant or home services, and can not be transferred to senior citizens cared by their families.

Sustained efficacy and safety of idebenone in the treatment of Alzheimer's disease: update on a 2-year double-blind multicentre study.

The 2-year efficacy and safety of idebenone were studied in a prospective, randomized, double-blind multicentre study in 3 parallel groups of patients with dementia of the Alzheimer type (DAT) of mild to moderate degree. A total of 450 patients were randomized to either placebo for 12 months, followed by idebenone 90 mg tid for another 12 months (n = 153) or idebenone 90 mg tid for 24 months (n = 148) or 120 mg tid for 24 months (n = 149). The primary outcome measure was the total score of the Alzheimer's Disease Assessment Scale (ADAS-Total) at month 6. Secondary outcome measures were the ADAS cognitive (ADAS-Cog) and noncognitive score (ADAS-Noncog), the clinical global response (CGI-Improvement), the SKT neuropsychological test battery, and the Nurses' Observation Scale for Geriatric Patients (NOSGER-Total and IADL subscale). Safety parameters were adverse events, vital signs, ECG and clinical laboratory parameters. During the placebo controlled period (the first year of treatment), idebenone showed statistically significant dose-dependent improvement in the primary efficacy variable ADAS-Total and in all the secondary efficacy variables. There was no evidence for a loss of efficacy during the second year of treatment, as a further improvement of most efficacy variables was found in the second year in comparison to the results at the 12 months visit. Also, a clear dose effect relationship (placebo/90 mg < idebenone 90 mg < idebenone 120 mg) was maintained throughout the second year of treatment. This suggests that idebenone exerts its beneficial therapeutic effects on the course of the disease by slowing down its progression. Safety and tolerability of idebenone were good and similar to placebo during the first year of treatment and did not change during the second year.

Lisuride treatment of Alzheimer's disease. A preliminary placebo-controlled clinical trial of safety and therapeutic efficacy.

In this article, the authors examine the effect of lisuride on 22 patients with probable Alzheimer's disease (NINCDS/ADRDA criteria) in a randomized double-blind, placebo-controlled, parallel group design. Ten patients received lisuride and 12 patients received placebo. Lisuride was administered in a dose-finding phase of four weeks and an efficacy phase of eight weeks, with a maximum dose of 0.3 mg daily. Outcome measures included global clinical impression, general cognitive function, mood, verbal and visual memory, attention, and psychomotor function. Average decline in Mini-Mental State Examination score after 12 weeks treatment was less often statistically significant in lisuride treated patients than in patients receiving a placebo (p < 0.05). Patients treated with lisuride improved their average total score and short-delay cued recall score on the California Verbal Learning Test, a test of verbal memory, whereas placebo-treated patients showed worse performance compared with baseline. These differences approached statistical significance, with p = 0.06 and p = 0.05, respectively. No other differences between the treatment groups were evident. The authors failed to find a consistent effect of lisuride on symptoms of Alzheimer's disease. However, this study's sample size was relatively small, and larger studies are needed to ascertain the treatment effects of serotonergic antagonists on Alzheimer's disease.

Measuring the efficacy of psychopharmacological treatment of psychomotoric restlessness in dementia: clinical evaluation of tiapride.

A major problem in psychogeriatrics is the treatment of demented patients suffering from severe restlessness and aggressive behavior. There have been few controlled studies of the efficacy of antipsychotic drugs in the treatment of this condition. Therefore, a multi-centre, double-blind, randomized study, measuring the efficacy and safety of tiapride vs. melperone in hospitalized dementia patients suffering from psychomotoric agitation, was conducted in 24 psychiatric hospitals in Germany. A total of 176 patients were enrolled: 175 of them were included in the safety analysis and 156 were evaluated for efficacy. Both treatment groups were comparable regarding the severity of disease and demographic data as well as with regard to the neuropsychological baseline assessment. The CGI (item, 2) was the primary efficacy parameter. Both groups yielded an identical response rate of 74.36%. The secondary efficacy parameters (NOSIE, AIMS, RAPSU, BePU, VAS) showed correspondingly a marked improvement for both groups. No significant changes of the safety parameters (blood pressure, pulse rate, ECG, clinical examination) occurred in the study. The overall number of adverse events was slightly higher in the tiapride group, serious events occurring less frequently. This study demonstrates that tiapride is as effective and as safe as melperone. These results are consistent with international experience on tiapride.

Organic mental disorders (Fo). Results from the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries.

The results of the ICD-10 Diagnostic Criteria for Research (DCR) field trial in German-speaking countries concerning section F0 (organic mental disorders) are reported. On the comparatively small data basis of the study, acceptance and interrater-reliability cannot be estimated satisfactorily. Despite this general problem, it can be said that section F0 of ICD-10 DCR maintains a high degree of continuity with respect to ICD-10. Some categories caused diagnostic disturbances and needed further specification, especially the criteria regarding the temporal relationship between the onset of an organic disorder and the psychiatric symptomatology. The recently published definite DCR seem to avoid most of the problems of the earlier version used in this study.

Potential of cognitive plasticity as a diagnostic instrument: a cross-validation and extension.

Examination of the range and limits of cognitive developmental reserve capacity (plasticity) by means of cognitive training has been proffered as a promising diagnostic strategy for the early identification of Alzheimer's disease. Previous findings of differential gains after cognitive training for healthy older persons and older persons at risk for dementia were supported, rendering cognitive plasticity a criterion by which the overlap in performance distributions between healthy older persons and older persons at risk can be reduced. Stepwise hierarchical regression analyses demonstrated that posttraining scores, which represented developmental reserve capacity, explained significantly more variance in mental health status than pretest or baseline performance. Older persons at risk profited significantly less from training in 2 components of fluid intelligence, figural relations, and inductive reasoning. The authors discuss the possibilities of turning this testing-the-limits procedure into an instrument for screening purposes in clinical practice.

Improving the Clinical Recognition of Very Mild Dementia Using Multiple Levels of Assessment.

Neuropsychological test batteries alone are often unable to differentiate very mild dementia from both normal aging and mild dementia of the Alzheimer type (DAT). The authors hypothesized that some of the difficulties of neuropsychological tests in the identification of very mild dementia could be overcome by the inclusion of additional levels of assessment (activities of daily living, psychopathology, and subjective complaints). Three groups (very mild dementia, mild-to-moderate DAT, and healthy control subjects) of community-dwelling older persons were assessed on cognitive and noncognitive variables. Results indicated that noncognitive variables improved prediction of group assignment. For accurate identification of all patients with very mild dementia, in addition to neuropsychological variables, subjective complaints of impaired orientation and disturbances of apperception were necessary and sufficient.