Very frequent physical aggression and vocalizations in nursing home residents with dementia.

OBJECTIVES: We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia. METHOD/DESIGN: This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items 'hitting', pushing', 'biting' and 'kicking' of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on 'screaming' and 'making strange noises'. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses. RESULTS: We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63-2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23-12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04-3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951-0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08-2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34-5.68) and euphoria (OR = 2.01, 95% CI: 1.22-3.31). CONCLUSION: Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life.

Course of Cognitive Functioning in Institutionalized Persons With Moderate to Severe Dementia: Evidence From the Severe Impairment Battery Short Version.

OBJECTIVES: To adequately monitor the course of cognitive functioning in persons with moderate to severe dementia, relevant cognitive tests for the advanced dementia stages are needed. We examined the ability of a test developed for the advanced dementia stages, the Severe Impairment Battery Short version (SIB-S), to measure cognitive change over time. Second, we examined type of memory impairment measured with the SIB-S in different dementia stages. METHODS: Participants were institutionalized persons with moderate to severe dementia (N = 217). The SIB-S was administered at 6-month intervals during a 2-year period. Dementia severity at baseline was classified according to Global Deterioration Scale criteria. We used mixed models to evaluate the course of SIB-S total and domain scores, and whether dementia stage at baseline affected these courses. RESULTS: SIB-S total scores declined significantly over time, and the course of decline differed significantly between dementia stages at baseline. Persons with moderately severe dementia declined faster in mean SIB-S total scores than persons with moderate or severe dementia. Between persons with moderate and moderately severe dementia, there was only a difference in the rate of decline of semantic items, but not episodic and non-semantic items. CONCLUSIONS: Although modest floor and slight ceiling effects were noted in severe and milder cases, respectively, the SIB-S proved to be one of few available adequate measures of cognitive change in institutionalized persons with moderate to severe dementia. (JINS, 2019, 25, 204-214).

The course of neuropsychiatric symptoms in patients with dementia in primary care.

BACKGROUND: During the course of dementia, most people develop some type of neuropsychiatric symptoms (NPS), which result in lower quality of life, high caregiver burden, psychotropic drug use and a major risk of institutionalization. Studies on NPS in people with dementia have been mainly conducted in clinical centres or psychiatric services. OBJECTIVES: To investigate the course of NPS in people with dementia in primary care. METHODS: Analysis of (cumulative) prevalence and incidence, persistence and resolution based on data collected during an assessment at home of a prospective naturalistic cohort study in primary care in a sample of 117 people with dementia and their informal caregivers. Subsyndromes of NPS were assessed with the Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory. Multivariate analyses were used to detect determinants for the course of NPS. RESULTS: The mean age of the people with dementia was 78.6 years, and 52% were female. Mean Mini-Mental State Examination total score was 19.5, mean NPI total score 15.7. The most prevalent clinically relevant subsyndromes of the NPI were hyperactivity and mood/apathy, and the most prevalent individual NPS were aberrant motor behaviour (28%), agitation/aggression (24%) and apathy/indifference (22%). Of the people with dementia, 72.3% had one or more symptoms of the mood/apathy and 75.3% of the hyperactivity subsyndrome. CONCLUSIONS: GPs should be aware of NPS in people with dementia and should actively identify them when they visit these patients or when informal caregivers consult them. Timely diagnosing facilitates adequate professional care.

[Is the approach of delirium in Dutch nursing-homes in accordance with the national guideline?] / Is de aanpak van delier in Nederlandse verpleeghuizen conform de richtlijn?

INTRODUCTION: Delirium is a common disorder, affecting many patients in nursing-homes, with large impact on patients. Implementation of good care and treatment can potentially prevent development of a delirium or may reduce the severity or duration. This research was conducted to get an impression of delirium care in Dutch nursing homes, and of the implementation of the recommendations of the national guideline. OBJECTIVES: 1. How many Dutch nursing homes have a local protocol for delirium?2. To what extend do doctors, specialised in care for older people in nursing homes, screen, diagnose and treat delirium according to the Dutch guideline for delirium? METHODS: Between June and December 2016, Dutch nursing homes were approached with an online questionnaire. Data were collected in Survey Monkey and descriptive analyses were performed. RESULTS: 68 nursing homes were included. 32% of the nursing homes had a local delirium protocol. 48% of the doctors knew about the national guideline delirium, 60% used preventive measures, and screening instruments were used in 98%. 29% used diagnostic criteria. Non-medical interventions were applied by 96%. In 98%, haloperidol was the drug of first choice. Preventive antipsychotics were prescribed by 21%. CONCLUSIONS: Only a third of the organisations developed a local delirium protocol. Standardising delirium care by a local delirium protocol, with special attention for prevention, diagnostics and aftercare of delirium, can be an important step in improving the quality of care in nursing homes.

Two-Year Course of Quality of Life in Nursing Home Residents with Dementia.

OBJECTIVE: To assess the course of quality of life (QoL) in nursing home residents with dementia and to study its predictors. METHODS: This longitudinal, multicenter, observational cohort study with a 2-year follow-up looked at 290 residents with dementia, who lived in 14 dementia special care units in nine nursing homes in the Netherlands. QoL was assessed with the Qualidem, providing a total score and QoL profile with nine subscales. Residents were assessed at five assessments: every 6 months during 2 years. A linear mixed model was used for data analysis. RESULTS: No change was found in the Qualidem total score (range: 0-111) over 2 years. However, a significant increase of QoL over time was seen in the subscales "Care relationship," "Negative affect," "Restless tense behavior," "Positive self-image," "Social isolation," and "Feeling at home." A significant decrease of QoL was seen in the subscales "Positive affect," "Social relations," and "Having something to do." Most predictors of the course of Qol were found for the subscales "Positive self-image" (sex, Global Deterioration Scale, Severe Impairment Battery, Activities of Daily Living, and Neuropsychiatric Inventory) and "Having something to do" (Global Deterioration Scale, Severe Impairment Battery, and Activities of Daily Living). Sex and Neuropsychiatric Inventory at baseline were the predictors found most frequently. CONCLUSION: The total QoL score was stable over a 2-year period. However, QoL subscales showed multidirectional changes. The largest QoL decline in the subscale "Having something to do" suggests that more attention should be given to useful activities in nursing home care.

The effect of biannual medication reviews on the appropriateness of psychotropic drug use for neuropsychiatric symptoms in patients with dementia: a randomised controlled trial.

Objective: We studied the efficacy of biannual structured medication reviews to improve the appropriateness of psychotropic drug (PD) prescriptions for neuropsychiatric symptoms (NPS) in nursing home patients with dementia. Study Design and Setting: In this randomised controlled trial, the intervention encompassed a structured multidisciplinary medication review by physician, pharmacist and nurse. During this 18-month study, the patient's medical files were assessed every 6 months. The primary outcome was the appropriateness of PD prescriptions defined by the Appropriate Psychotropic drug use In Dementia (APID) index sum score, lower scores indicating more appropriate use. Results: At baseline, 380 patients were included, of which 222 were randomised to the intervention group. Compared to the control group, the APID index sum score in the intervention group improved significantly for all PD prescriptions (-5.28, P = 0.005). Conclusion: We advise the implementation of a structured, repeated medication review with the essential roles of pharmacist, physician and nurse, into daily practice. This work was supported and funded by the Netherlands Organisation for Health Research and Development (ZonMw). Netherlands Trial Register (NTR3569).

Neuropsychiatric symptoms and psychotropic drug use in patients with dementia in general practices.

Background: Neuropsychiatric symptoms (NPS) frequently occur in community-dwelling patients with dementia and they are also frequently prescribed psychotropic drugs. The prescription of psychotropic drugs has been found to be associated with the level of NPS. Data on NPS in patients with dementia in general practices are scarce. Objectives: The aim of this study was to assess the prevalence rates of NPS and psychotropic drug use (PDU) in patients with dementia in general practices. Methods: We analyzed data from the baseline measurement of a prospective cohort study in a sample of (Dutch) patients in general practices. Prevalence rates of NPS and subsyndromes assessed with the Neuropsychiatric Inventory (NPI) and of PDU were calculated. Prevalence rates of individual NPS are presented both as clinically relevant symptoms (NPI symptom score ≥ 4) and as prevalence rates of symptoms with symptom score > 0. Results: Of the 117 patients, more than 90% had at least one symptom and more than 65% had at least one clinically relevant symptom. The most common NPS were agitation/aggression, dysphoria/depression and irritability/lability. The most common clinically relevant NPS were aberrant motor behaviour, agitation/aggression and apathy/indifference. Only 28.7% of the patients used at least one, 7.0% used at least two different and 1.7% used at least three different types of psychotropic drugs (excluding anti-dementia medication). Conclusions: NPS are highly prevalent in patients with dementia in general practices, but PDU is rather low. The most common clinically relevant NPS were aberrant motor behaviour, agitation/aggression and apathy/indifference.

Factors associated with appropriate psychotropic drug prescription in nursing home patients with severe dementia.

ABSTRACTBackground:We studied the patient and non-patients factors of inappropriate psychotropic drug (PD) prescription for neuropsychiatric symptoms (NPS) in nursing home patients with severe dementia. METHODS: In a cross-sectional study, the appropriateness of prescriptions was explored using the Appropriate Psychotropic drug use In Dementia (APID) index sum score. This index assesses information from medical records on indication, evaluation, dosage, drug-drug interactions, drug-disease interactions, duplications, and therapy duration. Various measurements were carried out to identify the possible patient and non-patient factors. Linear multilevel regression analysis was used to identify factors that are associated with APID index sum scores. Analyses were performed for groups of PDs separately, i.e. antipsychotics, antidepressants, anxiolytics, and hypnotics. RESULTS: The sample consisted of 338 patients with a PD prescription that used 147 antipsychotics, 167 antidepressants, 85 anxiolytics, and 76 hypnotics. It was found that older patients and more severe aggression, agitation, apathy, and depression were associated with more appropriate prescriptions. Additionally, less appropriate prescriptions were found to be associated with more severe anxiety, dementia diagnoses other than Alzheimer dementia, more physician time available per patient, more patients per physician, more years of experience of the physician, and higher nurse's workload. CONCLUSIONS: The association of more pronounced NPS with more appropriate PD prescriptions implies that physicians should pay more attention to the appropriateness of PD prescriptions when NPS are less manifest. Non-patient-related factors are also associated with the appropriateness of PD prescriptions. However, especially considering that some of these findings are counter-intuitive, more research on the topic is recommended.

Nursing Home Residents with Dementia and Very Frequent Agitation: A Particular Group.

OBJECTIVE: Although many nursing home residents with dementia show agitation, hardly any literature is published about very frequent agitation. The WAALBED-III study focuses on the 2-week prevalence and correlates of very frequent agitation in these residents. DESIGN: Cross-sectional study using combined data of four studies. SETTING: One hundred nineteen dementia special care units in twenty-six nursing homes in The Netherlands. PARTICIPANTS: Two thousand seventy-four residents with dementia. MEASUREMENTS: We operationally defined very frequent agitation as having a score of 6 (several times a day) or 7 (several times an hour) on at least five items of the Cohen Mansfield Agitation Inventory (CMAI) combined with a CMAI total score above the 90th percentile. To assess the association of demographic and behavioral characteristics with very frequent agitation, we performed a multivariate multilevel logistic regression analysis. RESULTS: The 2-week prevalence of very frequent agitation was 7.4% (95% CI: 6.374-8.634). Correlates for very frequent agitation were age (OR: 0.967, 95% CI: 0.942-0.992), dementia severity (GDS 6 = OR: 3.636, 95% CI: 1.929-6.875; GDS 7 = OR: 2.951, 95% CI: 1.321-6.588), delusions (OR: 2.480, 95% CI: 1.555-3.956), anxiety (OR: 1.904, 95% CI: 1.259-2.881), euphoria (OR: 3.712, 95% CI: 2.171-6.337) and irritability (OR: 4.411, 95% CI: 2.854-6.816). CONCLUSIONS: To our knowledge, this study is the first to report prevalence data and correlates about nursing home residents with very frequent agitation. We found several correlated factors for very frequent agitation. Still, further research is needed for a better understanding of the behavior of this group, and to identify good treatment options.

Structural validity and internal consistency of the Qualidem in people with severe dementia.

BACKGROUND: Since its development, the Qualidem has had items that were considered unsuited for people with very severe dementia. This study attempted to investigate the applicability of all Qualidem items in people with all stages of dementia severity. METHODS: Four data sets that contained Qualidem observations on people with dementia were combined. Dementia severity was categorized based on the Global Deterioration Scale (GDS), with a dichotomization of very severe dementia (GDS 7) and others (GDS 1-6). Unidimensional latent-trait models (Mokken scaling) were estimated to fit the Qualidem responses in the overall sample and the dichotomized groups. Scalability was assessed using coefficients of homogeneity (Loevinger's H), while reliability was assessed with Cronbach's α and ρ. RESULTS: Combining the four databases resulted in 4,354 Qualidem measurements. The scalability of all scales was considered acceptable in the overall sample, as well is in the subgroups (all H > 0.3). Additionally, the reliability was good-excellent in the scales: "positive affect," "positive self-image," "care relationship," and "negative affect." Reliability was questionable-acceptable for "feeling at home," "social relations," "social isolation," and "restless tense behavior." Reliability was poor for "having something to do." CONCLUSIONS: Statistical considerations allow using all Qualidem items in all dementia stages. Future research should determine balance of statistical- versus conceptual-based reasoning in this academic debate.

Gender differences in clusters of NPS in Dutch nursing homes - a factor analysis.

BACKGROUND: Neuropsychiatric symptoms (NPS) have a high prevalence among patients with dementia, up to 80%. NPS can be grouped by type and stage of dementia. However, NPS have not previously been grouped by gender. Our objective was to investigate whether NPS cluster differently in men or women in the nursing home patients. METHODS: Factor analysis to assess the clustering of items in the Cohen-Mansfield Agitation Inventory (CMAI) and Neuropsychiatric Inventory-Nursing home version (NPI-NH) into components, for both scales and for gender. Differences in symptom clustering between male and female patients were assessed using a three-step procedure: (1) identifying a gender specific distinctive item, (2) describe the correlation between the distinctive item with any other item in this cluster, (3) testing whether the correlation between a distinctive item and any other item in the cluster (which is present in both sexes) is different for males and females using a general linear model. RESULTS: Our database consisted of 1,609 patients. There were five male and three female clusters for NPI-NH and eight male and seven female clusters for CMAI. There were three distinctive items in the NPI-NH and ten in the CMAI. CONCLUSIONS: There are other clusters of NPS in males and females. Our analysis revealed more significant relations in female than male patients. This might have an implication on the clinical course.

Only 10% of the psychotropic drug use for neuropsychiatric symptoms in patients with dementia is fully appropriate. The PROPER I-study.

BACKGROUND: This study explores the appropriateness of psychotropic drug (PD) use for neuropsychiatric symptoms (NPS) in nursing home patients with dementia. METHODS: A cross-sectional study on 559 patients with dementia residing on dementia special care units in Dutch nursing homes was conducted. Appropriateness of PD use was assessed using the Appropriate Psychotropic drug use In Dementia (APID) index. The APID index score is calculated using information about individual PDs from patients' medical records. The index encompasses seven (different) domains of appropriateness, i.e. indication, evaluation, dosage, drug-drug interactions, drug-disease interactions, duplications, and therapy duration. RESULTS: A total of 578 PDs were used for NPS by 60% of the nursing home patients. Indication, evaluation, and therapy duration contributed the most to inappropriate use. Ten per cent of the PDs scored fully appropriate according to the APID index sum score, 36% scored fully appropriate for indication, 46% scored fully appropriate for evaluation, and 58% scored fully appropriate for therapy duration. Antidepressants were used the most appropriately, and antiepileptics the most inappropriately. CONCLUSIONS: The minority of the PD use was fully appropriate. The results imply that PD use for NPS in dementia can be improved; the appropriateness should be optimized with a clinical focus on the appropriate indications, evaluations, and therapy duration.

The course of neuropsychiatric symptoms in community-dwelling patients with dementia: a systematic review.

BACKGROUND: Neuropsychiatric symptoms (NPS) often occur in patients with dementia. Understanding the course of NPS in dementia is important for healthcare professionals for psycho-educational purposes and adequate and timely interventions to prevent or diminish NPS as much as possible. METHODS: We conducted a systematic literature search in several electronic databases. We combined search strings for the terms dementia, community-dwelling, cohort studies and NPS. Screening titles and abstracts, assessing the methodological quality and data-extraction were independently conducted by at least two authors. RESULTS: This literature search revealed 6605 unique records of which 23 studies were included in data synthesis. In total 7184 patients participated in the included studies with a mean number of 312. Sixty percent of the participants were female and the mean age of all participants was 74.8 years. Follow-up varied between 1 and 6 years; in 17 studies loss to follow-up was less than 20% per year. NPS are highly prevalent, incident and persistent although frequency parameters vary considerably across studies. Delusions/delusional misidentification, wandering/agitation, aberrant motor behavior/motor hyperactivity and apathy are the most common NPS. For hallucinations, delusions/delusional misidentification, paranoia, aggression, wandering/agitation, aberrant motor behavior/motor hyperactivity, disinhibition, apathy, and sleep disturbance increasing trends in point prevalence rates have been found. CONCLUSIONS: NPS in community-dwelling patients are frequent and persistent. The increasing trends of several NPS in the course of dementia require a preventive approach of professional caretakers. For such an approach, a timely diagnosis and adequate professional support to prevent or diminish these problems is necessary.

Neuropsychiatric symptoms in patients with dementia in primary care: a study protocol.

BACKGROUND: Neuropsychiatric symptoms (NPS) frequently occur in patients with dementia. To date, prospective studies on the course of NPS have been conducted in patients with dementia in clinical centers or psychiatric services. The primary goal of this study is to investigate the course of NPS in patients with dementia and caregiver distress in primary care. We also aim to detect determinants of both the course of NPS in patients with dementia and informal caregiver distress in primary care. METHODS/DESIGN: This is a prospective observational study on the course of NPS in patients with dementia in primary care. Thirty-seven general practitioners (GPs) in 18 general practices were selected based on their interest in participating in this study. We will retrieve electronic medical files of patients with dementia from these general practices. Patients and caregivers will be followed for 18 months during the period January 2012 to December 2013. Patient characteristics will be collected at baseline. Time to death or institutionalization will be measured. Co-morbidity will be assessed using the Charlson index. Psychotropic drug use and primary and secondary outcome measures will be measured at 3 assessments, baseline, 9 and 18 months. The primary outcome measures are the Neuropsychiatric Inventory score for patients with dementia and the Sense of Competence score for informal caregivers. In addition to descriptive analyses frequency parameters will be computed. Univariate analysis will be performed to identify determinants of the course of NPS and informal caregiver distress. All determinants will then be tested in a multivariate regression analysis to determine their unique contribution to the course of NPS and caregiver distress. DISCUSSION: The results of this study will provide data on the course of NPS, which is clinically important for prognosis. The data will help GPs and other professionals in planning follow-up visits and in the timing for offering psycho-education, psychosocial interventions and the provision of care. In addition, these data will enlarge health professionals' awareness of NPS in their patients with dementia.

The impact of antipsychotics and neuropsychiatric symptoms on the quality of life of people with dementia living in nursing homes.

OBJECTIVE: This study aimed to establish whether antipsychotic (AP) use in patients with dementia negatively affects quality of life (QoL) independent of neuropsychiatric symptoms (NPS). METHOD: We tested 290 patients with dementia living in nine nursing homes throughout the Netherlands in a longitudinal study. The measurements were repeated every 6 months over 2 years. We studied the change in NPS and AP use and their effect on QoL over time in two separate generalized estimating equations. We assessed QoL and NPS using the Qualidem questionnaire and the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), respectively. RESULTS: Antipsychotic prescriptions did not significantly change participant QoL, whereas NPI-NH total score changes consistently predicted changes in QoL. According to the Qualidem, the development of QoL in patients who chronically used APs did not differ from AP-free patients, except on the restless tense behavior subscale. AP-free patients' "restless tense behavior" improved compared with patients who chronically used APs, who showed a slight deterioration in these symptoms; however, this effect did not significantly influence total QoL. CONCLUSION: Antipsychotic use does not necessarily have detrimental effects on the QoL of patients with dementia; rather, NPS consistently and negatively affects QoL. The use of APs to treat NPS is justified when used carefully (i.e., their benefits and side effects should be monitored).

PROPER I: frequency and appropriateness of psychotropic drugs use in nursing home patients and its associations: a study protocol.

BACKGROUND: Nursing home patients with dementia use psychotropic drugs longer and more frequently than recommended by guidelines implying psychotropic drugs are not always prescribed appropriately. These drugs can have many side effects and effectiveness is limited. Psychotropic drug use between nursing home units varies and is not solely related to the severity of neuropsychiatric symptoms. There is growing evidence indicating that psychotropic drug use is associated with environmental factors, suggesting that the prescription of psychotropic drugs is not only related to (objective) patient factors. However, other factors related to the patient, elderly care physician, nurse and the physical environment are only partially identified. Using a mixed method of qualitative and quantitative research, this study aims to understand the nature of psychotropic drug use and its underlying factors by identifying: 1) frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms in nursing home patients with dementia, 2) factors associated with (appropriateness of) psychotropic drug use. METHODS: A cross-sectional mixed methods study. For the quantitative study, patients with dementia (n = 540), nursing staff and elderly care physicians of 36 Dementia Special Care Units of 12 nursing homes throughout the Netherlands will be recruited. Six nursing homes with high average rates and six with low average rates of psychotropic drug use, based on a national survey about frequency of psychotropic drug use on units, will be included. Psychotropic drugs include antipsychotics, anxiolytics, hypnotics, antidepressants, anticonvulsants and anti-dementia drugs. Appropriateness will be measured by an instrument based on the Medication Appropriateness Index and current guidelines for treatment of neuropsychiatric symptoms. Factors associated to psychotropic drug use, related to the patient, elderly care physician, nurse and physical environment, will be explored using multilevel regression analyses. For the qualitative study, in depth interviews with staff will be held and analyzed to identify and explore other unknown factors. DISCUSSION: This study will provide insight into factors that are associated with the frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms. Understanding psychotropic drug use and its associations may contribute to better dementia care.

Improving psychotropic drug prescription in nursing home patients with dementia: design of a cluster randomized controlled trial.

BACKGROUND: Neuropsychiatric symptoms are highly prevalent in nursing home patients with dementia. Despite modest effectiveness and considerable side effects, psychotropic drugs are frequently prescribed for these neuropsychiatric symptoms. This raises questions whether psychotropic drugs are appropriately prescribed. The aim of the PROPER (PRescription Optimization of Psychotropic drugs in Elderly nuRsing home patients with dementia) II study is to investigate the efficacy of an intervention for improving the appropriateness of psychotropic drug prescription in nursing home patients with dementia. METHODS/DESIGN: The PROPER II study is a multi-center cluster randomized controlled, pragmatic trial using parallel groups. It has a duration of eighteen months and four six-monthly assessments. Six nursing homes will participate in the intervention and six will continue care as usual. The nursing homes will be located throughout the Netherlands, each participating with two dementia special care units with an average of fifteen patients per unit, resulting in 360 patients. The intervention consists of a structured and repeated multidisciplinary medication review supported by education and continuous evaluation. It is conducted by pharmacists, physicians, and nurses and consists of three components: 1) preparation and education, 2) conduct, and 3) evaluation/guidance. The primary outcome is the proportion of patients with appropriate psychotropic drug use. Secondary outcomes are the overall frequency of psychotropic drug use, neuropsychiatric symptoms, quality of life, activities of daily living, psychotropic drug side effects and adverse events (including cognition, comorbidity, and mortality). Besides, a process analysis on the intervention will be carried out. DISCUSSION: This study is expected to improve the appropriateness of psychotropic drug prescription for neuropsychiatric symptoms in nursing home patients with dementia by introducing a structured and repeated multidisciplinary medication review supported by education and continuous evaluation. TRIAL REGISTRATION: Netherlands Trial Registry (NTR): NTR3569.

[Canopy-enclosed bed: the state of the art]. / Het tentbed: hoe staan de zaken?

Due to the persistence and complexity of problem behaviour in patients with dementia, doctors often prescribe psychotropic drugs for long periods of time. The need for psychosocial interventions in patients with dementia and psychological or psychiatric problems remains high and, according to the existing guidelines on problem behavior, they are the treatment of first choice. 5 years ago we described that the canopy-enclosed bed seemed to be able to meet this need. We observed that within a few weeks of patients getting a canopy-enclosed bed, psychotropic drugs could be reduced or even stopped. In this article, we would like to argue once again for more research into psychosocial interventions for problem behaviour.

Course of neuropsychiatric symptoms in residents with dementia in nursing homes over 2-year period.

OBJECTIVE: To determine the course of neuropsychiatric symptoms (NPSs) in nursing home residents with dementia and to determine their variability across diagnosis. DESIGN: Prospective cohort study over 2 years. SETTING: Fourteen dementia special care units in nine nursing homes in The Netherlands. PARTICIPANTS: One hundred seventeen residents with dementia. MEASUREMENTS: NPSs were measured using the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). RESULTS: The majority of residents had moderately severe to severe dementia. All but a few residents (97%) showed any NPS, and co-occurrence of NPSs was high. Agitation, irritability, and aberrant motor behavior were the most prevalent over the 2 years. Depression and anxiety as well as NPI total score decreased over time, whereas apathy tended to increase. Agitation and aberrant motor behavior were the most persistent symptoms. In asymptomatic residents, highest incidence rates were found for apathy, aggression/ agitation, irritability, and aberrant motor behavior. Anxiety and apathy were more prevalent in Alzheimer disease (AD) compared with vascular disease (VaD); vice versa, aggression and depression were more prevalent in VaD. Differences in change over time between AD and VaD were found for irritability and disinhibition. CONCLUSION: This is the first study examining the 2-year course of NPSs in a large group of nursing home residents with dementia. Virtually all residents demonstrated and/or developed NPSs. Although affective symptoms decreased, apathy tended to increase. Agitated behaviors were particularly persistent. Our data may contribute to improve mental healthcare for demented nursing home residents.

Course of neuropsychiatric symptoms in residents with dementia in long-term care institutions: a systematic review.

BACKGROUND: Neuropsychiatric symptoms (NPS) occur frequently in residents of long-term care institutions. The aim of this study was to review the literature systematically on the course of NPS in residents with dementia in long-term care institutions. METHODS: A systematic literature search was conducted using Medline, PsychInfo, Embase and Cinahl. Search terms included "dementia", "long-term care institutions", "NPS", "longitudinal", and additional related terms. All titles and abstracts were independently assessed for inclusion and for methodological quality by two researchers, and the full texts of relevant papers were retrieved. Inclusion criteria were: dementia diagnosis, long-term care institutions, NPS, and longitudinal design. RESULTS: The literature search revealed 1982 papers of which 18 met the inclusion criteria. The patients were predominately female and aged 75 years and over. The follow-up period ranged from three months to one year. The number of assessments ranged from two to five, and 12 different assessment instruments were used to study NPS. Aberrant motor behavior, depression, anxiety, and euphoria showed decline over time, and psychosis remained constant whereas apathy, agitation, irritability, and disinhibition increased over time. All symptoms showed specific intermittent courses. The methodological quality of the literature was limited by the small sample sizes, short follow-up periods, and lack of comprehensive neuropsychiatric assessment instruments. CONCLUSIONS: In the reviewed studies, NPS in institutionalized residents with dementia showed a heterogeneous course, although methodological limitations and the diversity of the studies call for caution in interpretation. Future research should focus on large prospective cohort studies with institutionalized residents with dementia, examining a wide range of NPS.