Patterns and persistence of behavioural and psychological symptoms in those with cognitive impairment: the importance of apathy.

OBJECTIVE: To study the stability and emergence of a range of behavioural and psychological symptoms (BPS), their association with mortality and the effect of covariates on these transitions in a population-based study of cognitively impaired older people with a long follow-up period and large sample size, with a particular focus on apathy. METHODS: Data were from a population-based, longitudinal cohort study of ageing. Interviews were conducted at 0, 2, 6, 8 and 10 years with 3626 participants aged 65+. The persistence of 11 BPS and their association with mortality in those with cognitive impairment (MMSE 25 or below) was investigated using multi-state models, allowing us to take into account estimations of the probability of transitions that occurred in the time between interviews. RESULTS: Most BPS were persistent. Apathy was one of the most stable symptoms; in those with apathy, the probability of still having apathy after 1 year is 62%. Apathy, sleep problems, depression, irritability and wandering were most likely to develop. BPS are associated with mortality; in those with apathy, mortality is 3.1 times more likely than in those without apathy. Low cognitive function and dementia were associated with emergence of new symptoms. CONCLUSIONS: This population-based, multi-centre study with a follow-up period of 10 years showed that BPS are associated with mortality and most symptoms are persistent. Apathy was characterised by a high prevalence, a high persistence and a strong association with mortality, and has a negative impact on disability, management of other disease and caregiver burden.

Longitudinal course of behavioural and psychological symptoms of dementia: systematic review.

BACKGROUND: More information about the pattern of behavioural and psychological symptoms of dementia (BPSD) in the course of dementia is needed to inform patients and clinicians and to design future interventions. AIMS: To determine the persistence and incidence of BPSD and their relation to cognitive function, in individuals with dementia or in cohorts investigated for dementia onset. METHOD: A systematic literature review analysed the baseline prevalence, persistence and incidence of 11 symptoms. The review was conducted according to established guidelines with the exception that we could not exclude the possibilities of bias in the studies examined. RESULTS: The 59 included studies showed considerable heterogeneity in their objectives and methods. The symptoms hyperactivity and apathy showed high persistence and incidence; depression and anxiety low or moderate persistence and moderate incidence; and psychotic symptoms low persistence with moderate or low incidence. CONCLUSIONS: Despite heterogeneity across studies in terms of setting, focus and length of follow-up, there were clinically relevant differences in the longitudinal courses of different BPSD. Apathy was the only symptom with high baseline prevalence, persistence and incidence during the course of dementia.

Grouping of behavioural and psychological symptoms of dementia.

OBJECTIVE: A wide range of behavioural and psychological symptoms (BPSD) are common in dementia, and it has been suggested that groups of correlated symptoms should be studied together. Here, we describe the groups of BPSD that have been identified in the literature and how they have been used to study associations, burden, treatment and underlying biology. METHODS: The literature database PubMed was searched for articles that identified clusters or factors of BPSD or used previously defined symptom groups. RESULTS: Sixty-two studies were included. Generally, the following symptom groups were suggested: affective symptoms, including depression and anxiety; psychosis, including delusions and hallucinations; hyperactivity, including irritability and aggression; and euphoria. Symptoms that did not show consistent results include apathy, eating disturbances, night-time behaviour disturbances, disinhibition and aberrant motor behaviour. Symptom groups differed in their associations, treatment and biology. CONCLUSIONS: Studies investigating symptom groups show relatively consistent results. Studying symptom groups allows similar symptoms to be studied together, which might strengthen results and may point to differences in their aetiology and treatment. However, a large amount of the individual variability of the symptoms could not be explained by the factors, and authors should carefully address their research question and hypotheses to decide if symptoms should be studied in groups or individually. Clinicians need to consider each symptom in its own right and also to be aware of the interrelations between them when assessing patients and developing strategies for treatment.

Instruments to measure behavioural and psychological symptoms of dementia.

Reliable and valid measurement of behavioural and psychological symptoms of dementia (BPSD) is important for research and clinical practice. Here we provide an overview of the different instruments and discuss issues involved in the choice of the most appropriate instrument to measure BPSD in research. A list of BPSD instruments was generated. For each instrument Pubmed and SCOPUS were searched for articles that reported on their use or quality. Eighty-three instruments that are used to measure BPSD were identified. Instruments differ in length and detail, whether the interview is with participants, informants or by observation, the target sample and the time frames for use. Reliability and validity is generally good, but reported in few independent samples. When choosing a BPSD instrument for research the research question should be carefully scrutinised and the symptoms of interest, population, quality, detail, time frame and practical issues should be considered.

Self-rated health and cardiovascular disease incidence: results from a longitudinal population-based cohort in Norfolk, UK.

INTRODUCTION: Self-rated health (SRH) predicts chronic disease morbidity including cardiovascular disease (CVD). In a population-based cohort, we examined the association between SRH and incident CVD and whether this association was independent of socio-demographic, clinical and behavioural participant characteristics. METHODS: Population-based prospective cohort study (European Prospective Investigation of Cancer-Norfolk). 20,941 men and women aged 39-74 years without prevalent CVD attended a baseline health examination (1993-1998) and were followed for CVD events/death until March 2007 (mean 11 years). We used a Cox proportional hazards model to quantify the association between baseline SRH (reported on a four point scale--excellent, good, fair, poor) and risk of developing CVD at follow-up after adjusting for socio-demographic, clinical and behavioural risk factors. RESULTS: Baseline SRH was reported as excellent by 17.8% participants, good by 65.1%, fair by 16.0% and poor by 1.2%. During 225,508 person-years of follow-up, there were 55 (21.2%) CVD events in the poor SRH group and 259 (7.0%) in the excellent SRH group (HR 3.7, 95% CI 2.8-4.9). The HR remained significant after adjustment for behavioural risk factors (HR 2.6, 95% CI 1.9-3.5) and after adjustment for all socio-demographic, clinical and behavioural risk factors (HR 3.3, 95% CI 2.4-4.4). Associations were strong for both fatal and non-fatal events and remained strong over time. CONCLUSIONS: SRH is a strong predictor of incident fatal and non-fatal CVD events in this healthy, middle-aged population. Some of the association is explained by lifestyle behaviours, but SRH remains a strong predictor after adjustment for socio-demographic, clinical and behavioural risk factors and after a decade of follow-up. This easily accessible patient-centred measure of health status may be a useful indicator of individual and population health for those working in primary care and public health.

The presence of behavioural and psychological symptoms and progression to dementia in the cognitively impaired older population.

OBJECTIVE: Behavioural and psychological symptoms (BPS) are common in the older population and may be an indication of early dementia. We explored the predictive effect of the presence of BPS on the 2-year progression to dementia in a cognitively impaired population aged 65 years and over without dementia at baseline. METHODS: Twelve symptoms were measured in 2024 participants without dementia at baseline as part of a population-based longitudinal study of ageing. The risk of progression to dementia was predicted in those with cognitive impairment for each individual BPS and using a BPS composite score. RESULTS: Wandering and persecution were independently associated with progression to dementia after adjustment for socio-demographic factors, cognitive domains and other BPS. When stratifying by cognitive function, those with low cognition (MMSE 0-18) and 4 or more BPS were more likely to progress to dementia than those without BPS. CONCLUSIONS: We have shown that some psychiatric symptoms are associated with increased short-term progression to dementia in those with low cognition. The predictive effect of BPS in dementia progression has implications for risk stratification of those at high risk of progression to dementia, along with memory impairment, other cognitive impairment and health variables.

Systematic reviews on behavioural and psychological symptoms in the older or demented population.

INTRODUCTION: Behavioural and psychological symptoms of dementia (BPS) include depressive symptoms, anxiety, apathy, sleep problems, irritability, psychosis, wandering, elation and agitation, and are common in the non-demented and demented population. METHODS: We have undertaken a systematic review of reviews to give a broad overview of the prevalence, course, biological and psychosocial associations, care and outcomes of BPS in the older or demented population, and highlight limitations and gaps in existing research. Embase and Medline were searched for systematic reviews using search terms for BPS, dementia and ageing. RESULTS: Thirty-six reviews were identified. Most investigated the prevalence or course of symptoms, while few reviewed the effects of BPS on outcomes and care. BPS were found to occur in non-demented, cognitively impaired and demented people, but reported estimates vary widely. Biological factors associated with BPS in dementia include genetic factors, homocysteine levels and vascular changes. Psychosocial factors increase risk of BPS; however, across studies and between symptoms findings are inconsistent. BPS have been associated with burden of care, caregiver's general health and caregiver depression scores, but findings are limited regarding institutionalisation, quality of life and disease outcome. CONCLUSIONS: Limitations of reviews include a lack of high quality reviews, particularly of BPS other than depression. Limitations of original studies include heterogeneity in study design particularly related to measurement of BPS, level of cognitive impairment, population characteristics and participant recruitment. It is our recommendation that more high quality reviews, including all BPS, and longitudinal studies with larger sample sizes that use frequently cited instruments to measure BPS are undertaken. A better understanding of the risk factors and course of BPS will inform prevention, treatment and management and possibly improve quality of life for the patients and their carers.