Place of psychosocial rehabilitation in psychiatry of the elderly / Place de la réhabilitation psychosociale en psychiatrie de la personne âgée

Psychosocial rehabilitation (PSR) is a practice focused on recovery of the personal processes in which the elderly subject works to maintain his autonomy for as long as possible, and to remain in control of his life and his decisions. The belief that once old, the person loses his ability to act, is often linked to cognitive biases and can have negative impacts on recovery. Indeed, compared to adults, the elderly subject is doubly stigmatized, both by mental disorders and the consequences of aging. Thus, the geriatric population requires, in the recovery process, to take into account the specificities related to aging. Moreover, PSR must go beyond the control of symptoms and aim to improve the quality of life and well-being. We thus propose to describe in this article the RPS tools adapted to the psychiatry of the elderly subject.

La réhabilitation psychosociale (RPS) est une pratique axée sur le rétablissement des processus personnels dans lesquels le sujet âgé chemine pour maintenir son autonomie le plus longtemps possible, et rester maitre de sa vie et de ses décisions. La croyance qu'une fois âgée, la personne perd de sa capacité à agir, est souvent liée à des biais cognitifs et peut avoir des impacts négatifs sur le rétablissement. En effet, par rapport à l'adulte, le sujet âgé est doublement stigmatisé, à la fois par les troubles mentaux, et les conséquences du vieillissement. Ainsi, la population gériatrique nécessite, dans le processus de rétablissement, une prise en compte des spécificités liées au vieillissement. Par ailleurs, la RPS doit aller au-delà de la maîtrise des symptômes et viser l'amélioration de la qualité de vie et du bien-être. Nous proposons ainsi de décrire dans cet article les outils de RPS adaptés à la psychiatrie du sujet âgé.

Impaired Facial Emotion Recognition and Gaze Direction Detection in Mild Alzheimer's Disease: Results from the PACO Study.

BACKGROUND: Facial emotion recognition (FER) and gaze direction (GD) identification are core components of social cognition, possibly impaired in many psychiatric or neurological conditions. Regarding Alzheimer's disease (AD), current knowledge is controversial. OBJECTIVE: The aim of this study was to explore FER and GD identification in mild AD compared to healthy controls. METHODS: 180 participants with mild AD drawn from the PACO study and 74 healthy elderly controls were enrolled. Participants were asked to complete three socio-cognitive tasks: face sex identification, recognition of facial emotions (fear, happiness, anger, disgust) expressed at different intensities, and GD discrimination. Multivariate analyses were conducted to compare AD participants and healthy controls. RESULTS: Sex recognition was preserved. GD determination for subtle deviations was impaired in AD. Recognition of prototypically expressed facial emotions was preserved while recognition of degraded facial emotions was impacted in AD participants compared to controls. Use of multivariate analysis suggested significant alteration of low-expressed fear and disgust recognition in the AD group. CONCLUSION: Our results showed emotion recognition and GD identification in patients with early-stage AD compared to elderly controls. These impairments could be the object of specific therapeutic interventions such as social cognition remediation or raising awareness of primary caregivers to improve the quality of life of patients with early AD.

Association Between Mild Neurocognitive Disorder Due to Alzheimer's Disease and Possible Attention-deficit/Hyperactivity Disorder: A Case Report.

Recent literature concerning attention-deficit/hyperactivity disorder (ADHD) underlines the persistence of this neurodevelopmental illness in older patients. Comorbidity with a neurodegenerative disease is thus possible. However, few studies have investigated this topic. To our knowledge, this is the first case report of such a possible association, which raises important questions about clinical presentation, symptoms, diagnosis, and treatment. A 72-year-old man, without any psychiatric history, presented with depression, subjective memory loss, and attention deficit and anxious symptoms, and was diagnosed with mild neurocognitive disorder due to Alzheimer's disease. However, the patient's attentional symptoms appeared to have been present since childhood. A formalized diagnostic interview assessing for ADHD did not allow for a clear diagnosis, possibly due to recall bias. The patient's anxiety symptoms also did not respond well to cognitive behavioral therapy coupled with different antidepressants. We hypothesized the presence of ADHD, with the symptoms balanced until now by the patient's high cognitive capacities, and we postulated that the onset of a neurogenerative process may have disrupted this balance. In this case report, we discuss symptom dimensionality, the interplay between neurodegenerative and neurodevelopmental diseases, and various treatment options. Attentional deficits and anxiety symptoms are frequent in mild neurocognitive disorders due to neurodegenerative illnesses. It is important to explore the time of onset of such symptoms since neurodegenerative processes can worsen neurodevelopmental conditions. Moreover, identification of a pre-existing neurodevelopmental condition can lead to alternative care and treatment options. In addition, the unexplained worsening of ADHD symptoms should prompt clinicians to assess for a neurodegenerative process.

Attention in schizophrenia: Impaired inhibitory control, faulty attentional resources, or both?

While the literature regarding the existence of difficulties in inhibition in schizophrenia is relatively consistent, it is not clear whether these difficulties reflect any specific deficit in an inhibitory control process or whether they are the result of deficits in the systems that regulate inhibitory control, such as attentional resources. This also raises the issue of attentional resources in schizophrenia, which offers a somewhat puzzling and sometimes contradictory picture. In this study, these issues were investigated by means of a paradigm in which the need for inhibitory control and the need for correct allocation of attentional resources varied parametrically. Twenty-six outpatients with a diagnosis of schizophrenia and 26 matched controls completed a visual search task during which distractors were presented and had to be inhibited. At the same time, they also completed an auditory target detection task of varying difficulty. The results show that the patients had difficulties both in inhibiting distractors and in correctly allocating attention to the two tasks. The results also show that these two difficulties were not related. This leads to the conclusion that schizophrenia involves both defective inhibitory control and faulty management of attentional resources, and that the former does not result from the latter. Furthermore, these effects seem to be neither dependent on processing speed, nor related to medication.

Association between executive function and the evolution of behavioral disorders in Alzheimer's disease.

OBJECTIVE: This study was aimed at evaluating the association between cognitive functioning and the occurrence of behavioral and psychological symptoms of dementia (BPSD) in patients with Alzheimer's disease (AD). METHODS/DESIGN: The population is derived from the PACO cohort, including 237 patients with prodromal or mild AD. A neuropsychological tests battery exploring verbal and visual memory, language, attention, and executive functions was performed at baseline. BPSD were assessed at 6-, 12-, and 18-month follow-up with neuropsychiatric inventory (NPI). RESULTS: Lower baseline performance on Stroop test interference score was associated with higher subsequent overall NPI scores (P = .006), subscores of anxiety/depression (P = .03), and apathy inventory (P = .01). Conversely, other executive functions, verbal or visual memory, and language performances were not associated with a higher risk of BPSD. CONCLUSION: Our results suggest that poorer inhibition performance would be associated with a higher risk of 18-month BPSD occurrence, including anxiety, depression, and apathy. A better knowledge of the predictive factors of the BPSDs would make it possible to better identify the patients at risk, to propose preventive strategies and an earlier adapted care. J Am Geriatr Soc 68:-, 2020.

Neuroticism-Withdrawal and Neuroticism-Volatility Differently Influence the Risk of Neuropsychiatric Symptoms in Alzheimer's Disease.

BACKGROUND: Neuroticism is recognized as the personality domain that is most strongly associated with behavioral and psychological symptoms (BPS) of Alzheimer's disease (AD). Two sub-components of neuroticism have been recently isolated. Neuroticism-withdrawal (N-withdrawal) refers to the tendency to internalize negative emotion, whereas neuroticism-volatility (N-volatility) reflect the predisposition to externalize negative emotions. OBJECTIVE: The objective of the current study was to investigate the specific influence of these two sub-components of neuroticism on BPS. METHODS: One hundred eighty-seven patients with prodromal or mild AD were drawn from the PACO study (Personalité Alzheimer COmportement). Neuroticism and its facets were assessed at baseline using the NEO-PI-R inventory. N-withdrawal and N-volatility were isolated using a principal component analysis led on the six facets composing neuroticism. BPS were measured with the short version of Neuropsychiatric Inventory (NPI-Q) and collected at baseline, then every 6 months over an 18-month follow-up. Linear mixed-effect analyses were conducted to investigate the association between N-withdrawal, N-volatility, and the severity of BPS over the follow-up. RESULTS: Mean age of the participant was 79.2±6.5; 59% were female; mean MMSE was 24.5±2.5. Both N-volatility and N-withdrawal were related with the NPI-Q (p < 0.001; p = 0,004). N-withdrawal was positively associated with anxiety (p = 0.001) and depression (p = 0.002), while N-volatility was positively related to delusions (p = 0.004), agitation/aggression (p < 0.001), irritability/volatility (p = 0.037), and apathy (p = 0.021). CONCLUSION: The present study demonstrates that N-volatility and N-withdrawal influence the risk of developing BPS in a different way. These results highlight the relevance of considering sub-components of neuroticism when studying links between personality and BPS.

Brain Volume Predicts Behavioral and Psychological Symptoms in Alzheimer's Disease.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are frequent and troublesome for patients and caregivers. Considering possible preventive approaches, a better understanding of underlying neural correlates of BPSD is crucial. OBJECTIVE: The aim is to assess whether brain regional volume predicts behavioral changes in mild AD. METHODS: This work took part from the PACO study, a multicenter and prospective study that included 252 patients with mild AD from 2009 to 2014. Fifty-three patients were retained. Forty healthy matched control subjects from the ADNI cohort were included as controls. Voxel-based morphometry analysis was conducted to assess regional brain volume using baseline MRI scans as a predictor of future behavioral changes over a period of 18 months. Behavior was assessed at baseline and longitudinally at 6-month intervals using the shortened form of the Neuropsychiatric Inventory (NPI). RESULTS: The volume of 23 brain structures in frontal, temporal, parietal, occipital, subcortical regions and cerebellum predicted the evolution of NPI scores. Frontal volume was the most powerful predictor with frontal gyri, anterior cingulate cortex, and orbital gyri being particularly involved. CONCLUSION: To our knowledge, this is the first study assessing regional brain volumes as predictors of behavioral changes considered at earlier stages of AD. Up to 23 brain structures were associated with an increased risk of developing BPSD. Frontal lobe volume was the strongest predictor of future evolution of NPI. The involvement of multiple structures in the prediction of behavior suggests a role of the main large-scale networks involved in cognition.

Personality Traits are Related to Selective Cognitive Impairment in Early Alzheimer's Disease.

BACKGROUND: A link between personality traits and cognitive performance has been shown in normal adults and elderly individuals. Very few studies have evaluated this link in Alzheimer's disease (AD). OBJECTIVE: To better understand cognitive performance as regards to personality traits, our study was aimed to evaluate the role of premorbid personality on cognitive functioning in a population of patients presenting prodromal or mild AD. METHODS: 181 elderly with prodromal or mild AD participated in a cross-sectional, prospective cohort study. The participants completed a personality inventory and a neuropsychological battery exploring memory, attention, executive function, language, and praxis. Cognitive performance were compared according to the level of each personality trait, using multivariate MANOVA models. RESULTS: A higher level of neuroticism was associated with lower performance at similarities test (D = 9.49, p = 0.003), delayed Free and Cued Selective Reminding test (D = 5.22, p = 0.02), and digit span score (D = 7.99, p = 0.006). A higher level of openness was related to better performance at similarities (D = 4.33, p = 0.04), letter fluency (D = 11.45, p = 0.001), and category fluency test (D = 5.85, p = 0.02). Neuroticism interfered negatively with cognitive functioning at the prodromal stage; the association between openness and cognitive function was observed at both prodromal and mild AD stage. CONCLUSION: These results suggest that personality traits, in particular neuroticism and openness, modulate cognitive abilities in patients with early AD. These results encourage the development of stress management programs to prevent its negative effects on cognitive aging.

Does Personality Predict Behavioral and Psychological Symptoms of Dementia? Results from PACO Prospective Study.

BACKGROUND: Premorbid personality could play a role in the onset of behavioral and psychological symptoms (BPS) in Alzheimer's disease (AD) but prospective studies are lacking. OBJECTIVE: The present study aimed at prospectively assessing the influence of premorbid personality traits on BPS evolution in a population of patients with prodromal or mild AD. METHODS: We used a multicenter prospective cohort study of 237 patients followed-up for 18 months. The influence of personality traits on BPS evolution, measured with Neuropsychiatric Inventory (NPI), was assessed using linear mixed-effect models. RESULTS: A principal components analysis of the 12 NPI behavioral domains yielded five factors labelled as psychotic symptoms, affective symptoms, behavioral dyscontrol, apathy/appetite symptoms, and sleep disorders. During the follow-up, higher neuroticism was significantly associated with a higher progression of affective symptoms (p < 0.0001), apathy/appetite symptoms (p = 0.002), sleep disorders (p = 0.001) as well as global NPI scores (p < 0.0001). Greater conscientiousness was related to a lower evolution of psychotic (p = 0.002), affective (p = 0.02) and apathy/appetite symptoms (p = 0.02), and global NPI score (p < 0.0001). Higher openness was associated with lower affective symptoms evolution (p = 0.01). A significant relationship was found between higher extraversion, lower affective symptoms (p = 0.02), and higher behavioral dyscontrol (p = 0.04). CONCLUSION: The present analysis suggests that premorbid personality may influence the evolution of BPS in prodromal or mild AD. Given these results, it seems important to give more importance to personality assessment in early AD, in order to better identify and manage patients at risk of adverse behavioral changes.

Behavioral and psychological symptoms in Lewy body disease: a review.

Dementia with Lewy bodies (DLB) is a common neurodegenerative disease, second in terms of prevalence after Alzheimer's disease (AD). DLB may be suspected according to three core features which are cognitive and motor fluctuations, early visual hallucinations and parkinsonism; and more recently, according to the new criteria, REM sleep behavior disorder (RBD). Behavorial and psychological symptoms associated with DLB are more frequent, more severe and appear earlier than those found in other neurodegenerative diseases. They may be at the forefront and are a major diagnostic and therapeutic challenge. An improved knowledge of the pathophysiology and phenomenology associated to these symptoms can facilitate their identification as well as eliminating differential diagnoses. Managing these symptoms may require drugs when hallucinations are overwhelming and induce behavorial disorders. However, psychotropic medications are not well tolerated in this specific population and some antipsychotic drugs cannot be prescribed due to their side effects. Although further studies are needed on this subject, non-interventional treatments such as therapeutic strategies based on the patients and their caregivers appear to be essential. This paper offers a review which aims to help clinicians to identify behavioral and psychological symptoms in DLB and treat them in their daily practice.

Prefrontal cortex and impulsivity: Interest of noninvasive brain stimulation.

INTRODUCTION: Impulsivity has been reported in many psychiatric conditions and includes deficits in several cognitive functions such as attention, inhibitory control, risk taking, delay discounting and planning. Many studies have shown that noninvasive brain stimulation (NIBS) techniques modulate the activity of the prefrontal cortex and the functions involved in impulsivity. OBJECTIVE: This article aims to review the literature on the effect of NIBS on impulsivity in healthy subjects aged 18-65 years old, and to highlight research avenues to develop therapeutic alternatives for such disorders. METHOD: We performed a systematic review of the literature in the PubMed database following PRISMA method with "transcranial magnetic stimulation", "repetitive transcranial magnetic stimulation", "transcranial direct current stimulation", "inhibition", "risk", "impulsive behavior", "attention", "reward", "delay discounting", "delay task", "planning", "prefrontal cortex" as key words. RESULTS: We selected fifty-six studies showing modulation of the cognitive functions involved in impulsivity through NIBS. CONCLUSIONS: The data led us to consider new therapeutic alternatives in impulsive disorders by modulating prefrontal cortex activity through NIBS.

Neuroanatomical Correlates of Recognizing Face Expressions in Mild Stages of Alzheimer's Disease.

Early Alzheimer's disease can involve social disinvestment, possibly as a consequence of impairment of nonverbal communication skills. This study explores whether patients with Alzheimer's disease at the mild cognitive impairment or mild dementia stage have impaired recognition of emotions in facial expressions, and describes neuroanatomical correlates of emotion processing impairment. As part of the ongoing PACO study (personality, Alzheimer's disease and behaviour), 39 patients with Alzheimer's disease at the mild cognitive impairment or mild dementia stage and 39 matched controls completed tests involving discrimination of four basic emotions-happiness, fear, anger, and disgust-on photographs of faces. In patients, automatic volumetry of 83 brain regions was performed on structural magnetic resonance images using MAPER (multi-atlas propagation with enhanced registration). From the literature, we identified for each of the four basic emotions one brain region thought to be primarily associated with the function of recognizing that emotion. We hypothesized that the volume of each of these regions would be correlated with subjects' performance in recognizing the associated emotion. Patients showed deficits of basic emotion recognition, and these impairments were correlated with the volumes of the expected regions of interest. Unexpectedly, most of these correlations were negative: better emotional facial recognition was associated with lower brain volume. In particular, recognition of fear was negatively correlated with the volume of amygdala, disgust with pallidum, and happiness with fusiform gyrus. Recognition impairment in mild stages of Alzheimer's disease for a given emotion was thus associated with less visible atrophy of functionally responsible brain structures within the patient group. Possible explanations for this counterintuitive result include neuroinflammation, regional ß-amyloid deposition, or transient overcompensation during early stages of Alzheimer's disease.

Personality, Alzheimer's disease and behavioural and cognitive symptoms of dementia: the PACO prospective cohort study protocol.

BACKGROUND: Alzheimer's disease is characterised by a loss of cognitive function and behavioural problems as set out in the term "Behavioural and Psychological Symptoms of Dementia". These behavioural symptoms have heavy consequences for the patients and their families. A greater understanding of behavioural symptoms risk factors would allow better detection of those patients, a better understanding of crisis situations and better management of these patients. Some retrospective studies or simple observations suggested that personality could play a role in the occurrence of behavioural symptoms. Finally, performance in social cognition like facial recognition and perspective taking could be linked to certain personality traits and the subsequent risks of behavioural symptoms. We propose to clarify this through a prospective, multicentre, multidisciplinary study. Main Objective: -To assess the effect of personality and life events on the risk of developing behavioural symptoms. Secondary Objectives: -To evaluate, at the time of inclusion, the connection between personality and performance in social cognition tests; -To evaluate the correlation between performance in social cognition at inclusion and the risks of occurrence of behavioural symptoms; -To evaluate the correlation between regional cerebral atrophy, using brain Magnetic Resonance Imaging at baseline, and the risk of behavioural symptoms. METHODS/DESIGN: Study type and Population: Prospective multicentre cohort study with 252 patients with Alzheimer's disease at prodromal or mild dementia stage. The inclusion period will be of 18 months and the patients will be followed during 18 months. The initial evaluation will include: a clinical and neuropsychological examination, collection of behavioural symptoms data (Neuropsychiatric-Inventory scale) and their risk factors, a personality study using both a dimensional (personality traits) and categorical approach, an inventory of life events, social cognition tests and an Magnetic Resonance Imaging. Patients will be followed every 6 months (clinical examination and collection of behavioural symptoms data and risk factors) during 18 months. DISCUSSION: This study aims at better identifying the patients with Alzheimer's disease at high risk of developing behavioural symptoms, to anticipate, detect and quickly treat these disorders and so, prevent serious consequences for the patient and his caregivers. TRIAL REGISTRATION: ClincalTrials.gov: NCT01297140.

Pain-related mood influences pain perception differently in fibromyalgia and multiple sclerosis.

In patients, the perception of pain intensity may be influenced by the subjective representation of their disease. Although both multiple sclerosis (MS) and fibromyalgia (FM) possibly include chronic pain, they seem to elicit different disease representations because of the difference in their respective etiology, the former presenting evidence of underlying lesions as opposed to the latter. Thus, we investigated whether patients with FM differed from patients with MS with respect to their perception of "own" pain as well as others' pain. In addition, the psychological concomitant factors associated with chronic pain were considered. Chronic pain patients with FM (n=13) or with MS (n=13) participated in this study. To assess specific pain-related features, they were contrasted with 12 other patients with MS but without chronic pain and 31 controls. A questionnaire describing imaginary painful situations showed that FM patients rated situations applied to themselves as less painful than did the controls. Additionally, pain intensity attributed to facial expressions was estimated as more intense in FM compared with the other groups of participants. There is good evidence that the mood and catastrophizing reactions expressed in FM differentially modulated the perception of pain according to whether it was their own pain or other's pain.

[Caring for young patients with Alzheimer's disease or associated disorders in day care centers of the Rhône-Alpes region]. / Prise en charge des patients jeunes atteints de la maladie d'Alzheimer ou maladie apparentée dans les accueils de jour de la région Rhône-Alpes.

CONTEXT: The prevalence of Alzheimer's disease and associated disorders (ADAD) increases with aging but patients younger than 65 years may also be concerned. OBJECTIVE: To assess how ADAD young patients (less than 65 years old) were managed in day care centers in the Rhône-Alpes Region (France). METHOD: A questionnaire was sent to the day care centers to specify the number and the profile of young patients they took in care, and to assess their aptitude for accepting or not such patients. RESULTS: Forty-four day care centers had fulfilled the questionnaire (45%). The young patients displayed heterogeneous clinical presentations and types of coping. Only 29.5% of the day care centers received young ADAD patients. However most of them (78.6%) claimed to be ready to accept these patients even if they reported limitations for their activity. CONCLUSION: This study gives a fair idea of the present taking in care for young ADAD patients by day units in Rhone-Alpes region and provides some indications to improve their management.

Influence of emotional content and context on memory in mild Alzheimer's disease.

Healthy subjects remember emotional stimuli better than neutral, as well as stimuli embedded in an emotional context. This better memory of emotional messages is linked to an amygdalo-hippocampal cooperation taking place in a larger fronto-temporal network particularly sensitive to pathological aging. Amygdala is mainly involved in gist memory of emotional messages. Whether emotional content or context enhances memory in mild Alzheimer's disease (AD) patients is still debated. The aim of the present study is to examine the influence of emotional content and emotional context on the memory in mild AD, and whether this influence is linked to amygdala volume. Fifteen patients affected by mild AD and 15 age-matched controls were submitted to series of negative, positive, and neutral pictures. Each series was embedded in an emotional or neutral sound context. At the end of each series, participants had to freely recall pictures, and answer questions about each picture. Amygdala volumes were measured on patient 3D-MRI scans. In the present study, emotional content significantly favored memory of gist but not of details in healthy elderly and in AD patients. Patients' amygdala volume was positively correlated to emotional content memory effect, implying a reduced memory benefit from emotional content when amygdala was atrophied. A positive context enhanced memory of pictures in healthy elderly, but not in AD, corroborating early fronto-temporal dysfunction and early working memory limitation in this disease.

Evidence for a selective deficit in automatic activation of positive information in patients with Alzheimer's disease in an affective priming paradigm.

Using an affective priming paradigm, we studied the automatic and unconscious activation of emotional information in long-term memory. Participants had to judge target words preceded by various primes as positive or negative. The primes were masked and the SOA between the onset of primes and the onset of targets was 50 ms. Our results showed that in patients with dementia of the Alzheimer type (DAT), the negativity bias was preserved and the emotional priming effect was perturbed with positive targets. In control participants, this priming effect was restricted to negative targets. These findings are discussed in terms of preserved automatic activation of emotional information in Alzheimer's disease (AD) and in terms of an early deficit of the left hemisphere in AD making positive information more vulnerable to disease.