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.

[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.

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.

Mental impairment (dementia) and cerebral atrophy in geriatric patients.

In predicting the degree of brain atrophy as measured by CT, the AGP score and a few clinical variables were of some remarkable value. Especially the variables related to memory disorders and lack of insight are easily and reliably assessed during the course of the examination. In comparison to other more widely used neurological methods, the FHT proved to be an effective device for detecting brain atrophy, whereas the PMR and the glabellar blink were less effective. The close correlations between cerebral atrophy as measured by CT and a considerable number of clinical variables support the opinion that the organic substratum is not inconsistent with the clinically assessed function. Further research using strictly defined and standardized quantitative methods of psychopathological as well as neuroradiological assessment would seem to be a most promising attempt to answer the questions here only touched upon.

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.

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.

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.

Emotion control and cerebellar atrophy in senile dementia.

New research increasingly indicates that the cerebellum coordinates and integrates a wide range of processes not confined to the motor sphere. Since satisfying correlations between affective disturbances and signs of cerebral atrophy have not been found, the relationship of CT-indicated cerebellar atrophy to certain psychopathologic indicators, in patients suffering from senile dementia, has been studied. The patients participating in the study were 21 women and 18 men with a mean age of 69.4 years. Each patient showed a definite pathologic score in at least one cerebral CT-measurement. The Spearman rank correlations between affective incontinency, lability of affect, and cerebellar atrophy suggest substantial relationships between affective symptoms and cerebellar pathology. This seems all the more remarkable since all of the various indicators of cerebral cortical and subcortical atrophy lacked to show any strong relationship to affective symptoms at all. The implications of the findings for research and clinical purposes are discussed.

Correlations between psychopathology, psychological test results and computerized tomography changes in senile dementia.

This study is an investigation of the relationship between morphological, neuropsychological, and clinical measurements, all presumably contributing to an expert's diagnosis of senile dementia. Morphological assessment was carried out by linear measurements taken from the photographs of the CT scanners display. The battery of tests comprised instruments able to evaluate performance (WAIS, Benton test, d2 test, Trail Making test) as well as personality (FPI) from a quantitative point of view. For clinical assessment the Assessment Scale for Gerontopsychiatry (AGP) was used. A group of 39 patients suffering from mild to severe dementia was studied. The results show strong correlations between some sub-tests of the WAIS and certain CT measurements but fail to show comparable features in using the full scale IQ. The other cognitive tests did not work as well in detecting brain atrophy. Surprisingly, the personality inventory (FPI) showed some correlations with brain atrophy. A number of correlations between morphological and clinical variables were found as well, consistent with well-known clinical experience. Topographical features will be discussed supporting the view that cerebral lesions in the progress of senile dementia take the form of distinct patterns.

[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.

[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.

[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.

[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.

[Frontal lobe syndromes in (pre-)senile dementias of the Alzheimer type: a correlative statistical study]. / Frontallappensyndrome bei (prä-)senilen Demenzen vom Alzheimer-Typ: Eine korrelationsstatistische Untersuchung.

A group of gerontopsychiatric patients suffering from mild to severe dementia was studied. Clinical instruments were a psychological assessment system and a battery of tests. Structural changes of the brain were detected by computerized tomography. A number of correlations between clinical and morphological variables was found. The statistical analysis of most of the variables correlating with the CT determinants of the frontal lobe (Huckman-number, width of the frontal interhemispheric fissure) revealed plausibility consistent with the classical frontal lobe syndrome. The relations of the remaining items with the symptomatology of normal pressure hydrocephalus are critically discussed.

[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.

[Therapeutic travel with patients in a gerontopsychiatric polyclinic]. / Therapeutische Reise mit Patienten einer gerontopsychiatrischen Poliklinik.

In order to look into the problem of social isolation of mentally ill old people, we organized a 3-week trip for 19 patients, most of them depressive, of a psychogeriatric outpatient clinic. The group was professionally supervised by a team of four therapists. Patients were selected in accordance with the following main therapeutic goals: -Physical and mental stimulation through exposure to new impressions, -Promotion of social behaviour, -Opportunities for new interpersonal contacts, -Motivation for further individual travel activities, -Relaxation. Preparations comprised an interview and six group contacts. Four additional group meetings were held afterwards. The results of the trip were assessed by means of ratings made by the patients themselves and by the staff.

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.

Reliability and clinical concepts underlying global judgments in dementia: implications for clinical research.

The Clinical Global Impression Scale (CGI) is a recognized rating scale for global clinical judgments comprising scores for disease severity, change of disease conditions, and a so-called "efficacy index." In this report, the authors subject the CGI to a methodological analysis. Thirty-seven physicians working in psychogeriatric wards were interviewed on 12 patients each with a DSM-III diagnosis of a dementia syndrome. After the physicians made global judgments on the patients with the CGI, "personal" assessment criteria were elicited. The CGI data were correlated in the statistical analysis with the physicians' assessments of the patients on their personal criteria and on "recognized" assessment criteria obtained from DSM-III-R diagnostic criteria for dementia syndrome. Interrater reliabilities between physicians and nursing staff as well as retest reliabilities for the CGI criteria were also measured. While the CGI-severity reflects primarily the cognitive aspects of dementia, the CGI global assessment of change of the disease condition was poorly correlated with the assessments based on "personal" or the recognized DSM-III-R criteria. This was also indicated by the result that the reliability scores for CGI-severity were high and did not vary greatly, whereas the reliability scores for CGI change showed wide confidence intervals.