Clinician and caregiver agreement on neuropsychiatric symptom severity: a study using the Neuropsychiatric Inventory - Clinician rating scale (NPI-C).

BACKGROUND: Neuropsychiatric symptoms (NPS) are highly prevalent in dementia. The recently developed Neuropsychiatric Inventory - Clinician rating scale (NPI-C) includes clinical judgment and new symptom domains. Our objective was to evaluate NPI-C reliability and to compare caregiver and clinician ratings across the range of mild to severe cognitive impairment. METHODS: This is a cross-sectional observational study. Participants were geriatric memory clinic patients and nursing-home residents (n = 30) with an established diagnosis of dementia or Mild Cognitive Impairment (MCI). A psychiatrist (MK) interviewed caregiver-patient dyads using the NPI-C. Neuropsychological tests and Mini-Mental State Examination (MMSE) were used to assess cognitive impairment. Two NPI-C caregiver interviews were videotaped and rated by psychologists and geriatricians. Intra-class correlations (ICCs) were used to examine inter-rater agreement. Correlation coefficients were calculated to evaluate caregiver and psychiatrist NPI-C ratings. Disagreement between caregiver and clinician was expressed in delta scores and examined across the range of mild to severe cognitive impairment, using Levene's homogeneity of variances tests. RESULTS: Inter-rater agreement on ratings of two caregiver videos was high (ICC = 0.99-1.0). Clinician-caregiver concordance on NPI-C total severity ratings was high (r = 0.77). Variability in clinician-caregiver concordance was associated with cognitive impairment: MMSE (P = 0.02), CAMCOG-R (Cambridge Cognitive Examination-revised) total scores (P = 0.02), CAMCOG-R Memory scores (P = 0.04) and Language scores (P = 0.01). CONCLUSIONS: The NPI-C is a reliable measure of NPS in patients with MCI or dementia. Clinician-caregiver agreement on NPS severity may vary with cognitive impairment, underlining the importance of clinician-based measures of NPS.

Mortality associated with delirium after hip-surgery: a 2-year follow-up study.

BACKGROUND: delirium after hip-surgery is associated with poor outcome. Few studies examined the mortality risk associated with delirium in elderly hip-surgery patients after 1 year or more. Aim of this study was to examine the hazard risk associated with delirium in elderly hip-surgery patients at 2-year follow-up, controlling for baseline risk factors and interaction effects. METHODS: this is a secondary analysis based on data from a controlled clinical trial evaluating efficacy of haloperidol prophylaxis for delirium conducted in a large medical school-affiliated general hospital in Alkmaar, The Netherlands. Randomised and non-randomised patients (n = 603) were followed-up for 2 years. Predefined risk factors and other potential risk factors for delirium were assessed prior to surgery. Primary outcome was time of death during the follow-up period. Cox proportional hazards were estimated and compared across patients who had postoperative delirium during hospitalisation and those who did not. RESULTS: a total of 90/603 patients (14.9%) died during the study period and 74/603 (12.3%) had postoperative delirium. Incidence of delirium was higher in patients who died (32.2%) compared with those who survived (8.8%). The interaction effect of delirium by illness severity on mortality was significant after adjusting for predefined delirium risk factors and other potential covariates including study intervention (adjusted Hazard risk = 1.05, 95% CI 1.02-1.08). A total of 14/27 delirium patients who were severely ill on admission died during follow-up versus 15/47 delirium patients who were not (RR 1.63 CI 0.93-2.83). CONCLUSIONS: delirium does not independently predict mortality at 2-year follow-up in elderly hip-surgery patients. However, outcome from delirium is particularly poor when other risk factors are present.

Long-term cognitive outcome of delirium in elderly hip surgery patients. A prospective matched controlled study over two and a half years.

OBJECTIVE: To study the outcome of delirium in elderly hip surgery patients. DESIGN: Prospective matched controlled cohort study. Hip surgery patients (n = 112) aged 70 years and older, who participated in a controlled clinical trial of haloperidol prophylaxis for delirium, were followed for an average of 30 months after discharge. Patients with a diagnosis of dementia or mild cognitive impairment (MCI) were identified using psychiatric interviews. Proportions of patients with dementia/MCI were compared across patients who had postoperative delirium and selected control patients matched for preoperatively assessed risk factors who had not developed delirium during index hospitalization. Other outcomes were mortality rate and rate of institutionalization. RESULTS: During the follow-up period, 54.9% of delirium patients had died compared to 34.1% of the controls (relative risk = 1.6, 95% CI = 1.0-2.6). Dementia or MCI was diagnosed in 77.8% of the surviving patients with postoperative delirium and in 40.9% of control patients (relative risk = 1.9, 95% CI = 1.1-3.3). Half of the patients with delirium were institutionalized at follow-up compared to 28.6% of the controls (relative risk = 1.8, 95% CI = 0.9-3.4). CONCLUSION: The risk of dementia or MCI at follow-up is almost doubled in elderly hip surgery patients with postoperative delirium compared with at-risk patients without delirium. Delirium may indicate underlying dementia.

Reasons for psychiatric consultation referrals in Dutch nursing home patients with dementia: a comparison with normative data on prevalence of neuropsychiatric symptoms.

OBJECTIVE: To study psychiatric consultation referrals of nursing home patients with dementia and to compare referral reasons with normative data on prevalence of neuropsychiatric symptoms. METHODS: This is part of a cross-sectional study of 787 patients residing in 14 nursing homes in the Netherlands. Nursing home physicians (NHP) noted the primary reasons for psychiatric consultation according to the Neuropsychiatric Inventory items and two extra domains. Patients were subsequently assessed by an old-age psychiatrist. Eligible patients were those that had dementia. Reasons for referral were compared with independent data on prevalence of neuropsychiatric symptoms in nursing home patients with dementia. RESULTS: A total of 325/787 (41.3%) patients had dementia. Agitation, disinhibition and aberrant motor behaviour were frequent reasons for referral (>25%). Psychotic symptoms, apathy and eating behaviour changes were infrequent reasons (<10%) for seeking consultation. Agitation and disinhibition were more often primary reasons for consultation than would have been expected based on normative prevalence estimates of these symptoms. In contrast, delusions, euphoria, apathy, irritability and eating behaviour changes were less often reasons for referral compared with prevalence estimates. CONCLUSIONS: This study is the first to examine psychiatric consultation for dementia patients in Dutch nursing home. Large differences exist between referral reasons and normative data on symptom prevalence. Specialized mental health service was provided for the agitated and disinhibited patient in particular. Chances are that this is at the expense of the apathetic, retarded and quietly 'not causing any trouble' patient.

Early symptoms in the prodromal phase of delirium: a prospective cohort study in elderly patients undergoing hip surgery.

OBJECTIVES: The authors investigated prodromal delirium symptoms in elderly patients undergoing hip surgery. METHODS: This was a prospective cohort study in the setting of a large medical school-affiliated general hospital in Alkmaar, The Netherlands. Participants were patients undergoing hip surgery aged 70 and older at risk for delirium. Before surgery, patients were randomized to low-dose prophylactic haloperidol treatment or placebo. Daily assessments were based on patient interviews with the Mini-Mental State Examination and Digit Span test. The Delirium Rating Scale-Revised (DRS-R-98) was used to measure early symptoms during the prodromal phase before the onset of delirium. RESULTS: Data of 66 patients with delirium were compared with those of 35 at-risk patients who did not develop delirium: 14 of 66 patients (21%) had delirium on the day of surgery or early the day after, 32 of 66 (48%) on the second day, 14 of 66 on the third, and six of 66 (9%) on the fourth. The average DRS-R-98 total scores on day -4 to day -1 before delirium were 1.9 for the comparison group patients and 5.0, 4.3, 5.8, and 10.7 for patients with postoperative delirium. Multivariate analysis showed that the early symptoms memory impairments, incoherence, disorientation, and underlying somatic illness predict delirium. CONCLUSIONS: Most elderly patients undergoing hip surgery with postoperative delirium already have early symptoms in the prodromal phase of delirium. These findings are potentially useful for screening purposes and for optimizing prevention strategies targeted at reducing the incidence of postoperative delirium.

The emotional impact of psychiatric symptoms in dementia on partner caregivers: do caregiver, patient, and situation characteristics make a difference?

This study aims to investigate the emotional impact of psychiatric symptoms of patients with dementia on their caregiving partners, and to explore if caregiver, patient, and situation factors predict this emotional impact on caregivers. A cross-sectional design was used. Partners of patients with slight to moderately severe dementia who live in the community (n = 85) were interviewed. In a subgroup (n = 58) potential predictors of emotional impact of psychiatric symptoms on caregivers were studied. Agitation, irritability, apathy, and disinhibition produced the highest mean emotional impact scores in caregivers. Besides the neuropsychiatric symptoms themselves, the emotional impact of these symptoms on caregivers was predicted by sense of competence, degree of care needed by the patient, and financial expenditure due to the caregiving situation. The emotional impact of psychiatric symptoms on caregivers is predicted by several patient, caregiver, and situation factors. Interventions aimed at decreasing the experienced burden of caregivers should therefore not only focus on the psychiatric symptoms of the patient, but also on the sense of competence of the caregiver and the financial burden due to the caregiving situation.

Delirium-O-Meter: a nurses' rating scale for monitoring delirium severity in geriatric patients.

BACKGROUND: Delirium is a common psychiatric disorder in general hospital elderly patients. Several delirium screening tests exist. Few nurse based delirium severity measures are available. The aim of this study was to evaluate the Delirium-O-Meter, a new nurses' behavioural rating scale that is an efficient and sensitive measure of delirium severity. METHODS: Analysis of cross sectional and repeated assessments data. Participants were 92 elderly general hospital patients; 56 with delirium, 24 with dementia or other cognitive disturbances (no delirium) and 12 with other psychiatric disorders or no mental disorder. Measures were the Delirium-O-Meter (DOM), Delirium Rating Scale-Revised version (DRS-R-98), Delirium Observation Scale (DOS), Behavioural observation scale for geriatric inpatients (GIP) and Mini Mental State Examination (MMSE). RESULTS: The majority of DOM items show a (near-) normal score distribution. Reliability of the DOM was high; Cronbach's alpha values ranged from 0.87-0.92; Intra Class Correlation (ICC) range was 0.84-0.91 for total scores and 0.40-0.97 for item scores. Factor analysis produced a 'Cognitive/Motivational' factor explaining almost half of variance and a smaller 'Psychotic/Behavioural' factor. The two-factor model results support the conceptual distinction between hyperactive and hypoactive delirium. DOM observations differentiated delirium from non delirium patients. DOM total scores were highly related to the DRS-R-98, DOS, MMSE and GIP apathy and cognitive sub scales, but less so to the GIP affective disturbances subscale, indicating convergent and divergent validity. Temporal difference scores calculated for DRS-R-98 and DOM assessments on subsequent days were also highly related (rho = 0.80-0.95). CONCLUSIONS: The newly constructed DOM is a brief and valid nurses' behavioural rating scale that can be useful for measuring different aspects of delirium and for efficiently monitoring delirium severity in elderly patients.

Negative symptoms in Alzheimer's disease: a confirmatory factor analysis.

OBJECTIVE: To examine different conceptual models of negative symptoms in Alzheimer's disease. DESIGN: Confirmatory factor analysis of cross-sectional data. SUBJECTS: Alzheimer patients (n=281) admitted to a psychogeriatric observation ward. MATERIALS: Nurses' Behavioural observation scale for psychogeriatric inpatients (GIP). Global clinical ratings of severity of dementia and depression based on the Cambridge Examination for Mental Disorders of the Elderly-Dutch version (CAMDEX-N). RESULTS: A unidimensional model of dementia fitted the data poorly. Multidimensional models produced better results. In two- and three-factor models negative symptoms were separated from cognitive impairment and mood disturbances. The more severe the memory impairment, the more socially withdrawn patients were. In this sense negative symptoms may have been secondary to cognitive decline. However, no association was found between negative symptoms and mood disturbances. CONCLUSIONS: Negative symptoms are a prominent clinical feature of Alzheimer's disease and they are related to memory impairment but not to mood disturbances.