The treatment of behavioural and psychological symptoms in dementia: pragmatic recommendations.

Behavioural and psychological symptoms of dementia (BPSD) are a clinical challenge for the lack of a sound taxonomy, frequent presentation with comorbid BPSD, lack of specific pharmacologic interventions, poor base of methodologically sound evidence with randomized clinical trials, contamination from the treatment of behavioural disturbances of young and adult psychiatric conditions, and small efficacy window of psychotropic drugs. We present here a treatment workflow based on a concept-driven literature review based on the notions that (i) the aetiology of BPSD can be mainly neurobiological (so-called 'primary' symptoms) or mainly environmental and functional ('secondary' symptoms) and that this drives treatment; (ii) the clinical efficacy of psychotropic drugs is driven by their specific profile of receptor affinity; (iii) drug treatment should follow the rules of 'start low-go slow, prescribe and revise'. This article argues in support of the distinction between primary and secondary BPSD, as well as their characteristics, which until now have been just sketchily described in the literature. It also offers comprehensive and pragmatic clinician-oriented recommendations for the treatment of BPSD.

[Sundowning of the elderly person]. / Syndrome vespéral chez la personne âgée.

Sundowning is an aggravation of the elderly's neuropsychiatric symptoms that happen when daylight disappears. Behavioral disorders occur during these hours and are a source of disturbance within the care teams. Caregivers may find themselves unable to do their jobs. The etiology remains unclear despite the pathophysiological hypotheses implying an alteration of the circadian rhythm by the reach of the suprachiasmatic nucleus and the decrease in the production rate of melatonin. There are some therapeutic solutions with pharmacological and non-pharmacological approaches, but the effectiveness has not yet been proved. The main differential diagnosis of this syndrome is the delirium. This article represent this pathology and the existent treatments.

Le syndrome vespéral est une aggravation des symptômes neuropsychiatriques chez la personne âgée en fin de journée, lorsque la lumière du jour disparaît. Des troubles du comportement surviennent et créent un déséquilibre au sein des équipes soignantes dans les services en charge de personnes âgées. Les soignants peuvent se retrouver incapables d'assumer leurs tâches. L'étiologie reste peu claire malgré les hypothèses physiopathologiques impliquant une altération du rythme circadien par l'atteinte du noyau suprachiasmatique et la diminution du taux de production de mélatonine. Il existe quelques pistes thérapeutiques pharmacologiques et non pharmacologiques dont l'efficacité n'est pas encore démontrée. Le diagnostic différentiel principal est l'état confusionnel aigu. Cet article présente cette pathologie et la prise en charge existante.

[Dementia : current guidelines for clinical management]. / Démences : recommandations actuelles de prise en charge.

Dementia is an umbrella term used to describe a group of symptoms associated with a decline in cognitive abilities that are severe enough to interfere with daily functioning and independence. While Alzheimer's disease (AD) is the most frequent cause, dementia in old aged persons represents rather a syndrome caused by various underlying conditions and diseases. Successful treatment allows for the individual clinical picture, and should be aimed at helping the patient regarding his cognitive deficits, behavioral and psychiatric complaints, sleep disorders, as well as management of daily life. Recently published promising study results on the use of monoclonal antibody therapies in AD give reason to believe that treatments will be available soon that can modulate disease progression at the neurobiological level.

La démence est un terme générique utilisé pour décrire un groupe de symptômes associés à un déclin des capacités cognitives suffisamment grave pour interférer avec le fonctionnement quotidien. Bien que la maladie d'Alzheimer (MA) soit la cause la plus fréquente, la démence chez les personnes âgées représente plutôt un syndrome causé par diverses conditions et maladies sous-jacentes. Un traitement efficace tient compte du tableau clinique individuel et doit viser à surmonter les déficits cognitifs, comportementaux et psychiatriques, les troubles du sommeil, ainsi qu'à gérer la vie quotidienne. Les résultats prometteurs d'études récemment publiées sur l'utilisation de thérapies à base d'anticorps monoclonaux dans la MA laissent envisager la mise à disposition de traitements capables de moduler la progression au niveau neurobiologique.

[Hypoactive delirium]. / État confusionnel aigu hypoactif. Un diagnostic différentiel dans le traitement de la démence et de la dépression.

Delirium (or Acute Confusional State) refers to an acute alteration of attention, consciousness, and cognitive performance. Particularly the hypoactive subtype of delirium represents a diagnostic and clinical challenge. As symptoms of hypoactive delirium may overlap with the clinical picture present in dementia and depression, correct diagnostic differentiation can be challenging. In the absence of timely diagnosis and treatment, hypoactive delirium can last for several weeks. Apart from the health consequences for the patient, such a long course can stress caregivers and the family to their very limit. In this article, we will address the particularities of hypoactive delirium in hospital practice, the neurobiological bases of this disorder, the challenges it represents at the diagnostic level as well as its recommended management according to current literature.

L'état confusionnel aigu (ECA) correspond à une altération aiguë de l'attention et de la conscience ainsi que de la cognition. L'ECA hypoactif représente un défi pour l'équipe médico-soignante en ce qui concerne le diagnostic et la prise en charge. Par ailleurs, les symptômes de l'ECA hypoactif se recoupent le plus souvent avec ceux de la démence et la dépression, ce qui peut mener à une erreur diagnostique. Lorsqu'il se prolonge (plusieurs semaines), l'ECA hypoactif met les soignants et la famille du patient en grande difficulté. Dans cet article vont être abordés les particularités de l'ECA hypoactif dans la pratique en milieu hospitalier, ses bases neurobiologiques, les défis qu'il représente au niveau diagnostique ainsi que sa prise en charge selon les dernières données de la littérature.

Sexuality and Neurodegenerative Disease: An Unmet Challenge for Patients, Caregivers, and Treatment.

BACKGROUND: Many factors affect sexuality in the elderly such as dementia which is a common cause of inappropriate sexual behaviors. These behavioral disturbances are distressing, disruptive, and impair the care of the patient. SUMMARY: The onset of dementia does not erase sexuality. Sexual expression can be an important aspect of well-being for older adults with dementia. This study gives a general overview about the relationship between sexuality and cognitive impairment. It starts with a general discussion of sexual aspects in the elderly. This is followed by research studies in this field including effects of dementia on sexual life, sexuality issues related to cognitive decline, inappropriate sexual behaviors in dementia patients, and sexuality in healthcare institutions. We discuss also ethical aspects in relation with sexuality and dementia. Finally, we show different approaches to treat inappropriate sexual behaviors. KEY MESSAGES: The discussion of sexuality in dementia raises many medical and ethical concerns. Inappropriate sexual behaviors are estimated to occur in about 7%-25% of demented patients. The question is how to address such a delicate subject and discuss it in an easy way without making the patient feel humiliated or mistreated. This narrative review reveals sexual problems and difficult questions encountered in daily practice with patients suffering from cognitive impairment.

[Advanced age, cognitive decline and sexuality in healthcare institutions]. / Âge avancé, déclin cognitif et sexualité dans les institutions de santé.

Sexuality in an important aspect of human life at all ages and expressing it is an essential human need regardless of age. Society is ageing and people are living longer life. As the sexuality continues during the entire life many factors affect the sexuality in older population. The aging process and remodeling of the life style play an important role in the alteration of sexual needs and sexual behavior in advanced age. Sexuality expression is considered as a fundamental mental health need of all individuals, regardless of gender and age. The majority of healthcare professionals do not proactively discuss sexuality issues with old age patients, and this requires further attention.

La sexualité est un aspect important de la vie humaine à tous les âges et son expression est un besoin humain essentiel, quel que soit l'âge. La société vieillit et les gens vivent plus longtemps. Alors qu'elle se poursuit tout au long de la vie, de nombreux facteurs influent sur la sexualité des personnes âgées. Le processus de vieillissement et le remodelage du mode de vie jouent un rôle important dans la modification des besoins sexuels et du comportement sexuel à un âge avancé. L'expression de la sexualité est considérée comme un besoin fondamental de la santé mentale de tous les individus, sans distinction de sexe et d'âge. La majorité des professionnels de la santé ne discutent pas de manière proactive des problèmes de sexualité avec les personnes âgées, ce qui nécessite une plus grande attention.

Preoperative Depression and Plasma Cortisol Levels as Predictors of Delirium after Cardiac Surgery.

BACKGROUND: Delirium is common in old patients who undergo cardiac surgery, and it is associated with adverse outcomes. The genesis of delirium is thought to be multi-factorial, but it is still not well understood. Symptoms of depression and elevated cortisol level have been described in some previous studies as factors associated with delirium, suggesting a shared pathophysiology. AIMS: The objective of the present study was to determine whether preoperative depression symptoms and increased cortisol level represent risk factors for delirium after cardiac surgery. METHODS: We performed a prospective cohort study in 183 patients aged >50 years undergoing elective cardiac surgery. The Geriatric Depression Scale (GDS) was used to assess patients for depressive symptoms before surgery. Preoperative plasma cortisol levels were available in 145 participants. Delirium was diagnosed using the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) during the first 7 days after surgery. Spearman correlation was used for correlations between GDS, Mini-Mental State Examination (MMSE), Charlson comorbidity index, and age. Binary logistic regression was used to determine whether GDS and cortisol levels predict postoperative delirium. RESULTS: Delirium occurred in 60 patients out of 183 (32.8%) included and lasted 2.3 days (SD 1.36). GDS was correlated with age (p = 0.001) and comorbidity index (p = 0.003) and inversely correlated with MMSE score (p < 0.001). Higher preoperative GDS scores were associated with incidence of delirium in the postoperative period (p = 0.002). The association was significant after controlling for age, MMSE score, history of stroke, and Charlson comorbidity index (p = 0.045). Preoperative cortisol level was not associated with the development of postoperative delirium. CONCLUSION: Our results suggest that a higher preoperative depression score is associated with an increased risk of postoperative delirium. On the other hand, preoperative plasma cortisol level does not seem to be a predictor of delirium after surgery. Further studies are needed to determine the potential of preoperative depression treatment to prevent postoperative delirium.

[Relationship difficulties with borderline patients in five questions]. / Les difficultés relationnelles avec les patients borderline en cinq questions.

Borderline personality disorder is a common and severe disorder that confronts health professionals with some of their limitations. Relational difficulties with these patients lead to discontinuation of follow-up or unnecessary or even deleterious care. We present here simple answers to the questions that will inevitably arise in the management of your borderline patients. They are applicable by both general practitioners and specialists, to better meet the challenge that these patients ask us. We insist on properly recognizing and detecting the disorder. We propose to disclose the diagnosis to the patient and provide the necessary explanations. This is the better way to anticipate the repeating crises. Finally, interacting with other caregivers is important to ensure an effective and sustainable care system for these patients.

Le trouble de la personnalité borderline est un trouble fréquent, sévère et qui confronte les professionnels de la santé à certaines de leurs limites. Les difficultés relationnelles avec ces patients entraînent des ruptures de suivi, des soins inutiles ou délétères. Nous proposons des réponses simples aux questions qui surgiront immanquablement dans la prise en charge des patients borderline. Elles sont applicables par les généralistes et les spécialistes, afin de relever au mieux le défi que ces patients nous posent. Nous insistons sur l'importance de reconnaître et dépister le trouble. Nous proposons d'en parler avec le patient et de fournir les explications nécessaires. Cela permet de se préparer aux crises. Enfin, interagir avec les autres soignants est important pour garantir un dispositif de soins efficace et durable pour ces patients.

Functional network centrality indicates interactions between APOE4 and age across the clinical spectrum of AD.

Advanced age is the most important risk factor for Alzheimer's disease (AD), and carrier-status of the Apolipoprotein E4 (APOE4) allele is the strongest known genetic risk factor. Many studies have consistently shown a link between APOE4 and synaptic dysfunction, possibly reflecting pathologically accelerated biological aging in persons at risk for AD. To test the hypothesis that distinct functional connectivity patterns characterize APOE4 carriers across the clinical spectrum of AD, we investigated 128 resting state functional Magnetic Resonance Imaging (fMRI) datasets from the Alzheimer's Disease Neuroimaging Initiative database (ADNI), representing all disease stages from cognitive normal to clinical dementia. Brain region centralities within functional networks, computed as eigenvector centrality, were tested for multivariate associations with chronological age, APOE4 carrier status and clinical stage (as well as their interactions) by partial least square analysis (PLSC). By PLSC analysis two distinct brain activity patterns could be identified, which reflected interactive effects of age, APOE4 and clinical disease stage. A first component including sensorimotor regions and parietal regions correlated with age and AD clinical stage (p < 0.001). A second component focused on medial-frontal regions and was specifically related to the interaction between age and APOE4 (p = 0.032). Our findings are consistent with earlier reports on altered network connectivity in APOE4 carriers. Results of our study highlight promise of graph-theory based network centrality to identify brain connectivity linked to genetic risk, clinical stage and age. Our data suggest the existence of brain network activity patterns that characterize APOE4 carriers across clinical stages of AD.