An Update On Current Treatment Strategies for Behavioural and Psychological Symptoms of Dementia
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Behavioural and psychological symptoms of dementia (BPSD) such as agitation, aggressive behaviour, repetitive vocalizations, apathy, etc. are a frequent challenge in the care for patients with dementia. BPSD are furthermore associated with individual suffering, reduced quality of life and caregiver burden. This talk will provide an update on current pharmacological and non-pharmacological treatment strategies for BPSD on the basis of the relevant guidelines and a review of the current literature. For pharmacological treatment, the focus has recently shifted from antipsychotics to antidepressants due to their more favourable risk/benefit profile. Treatment algorithms that include behavioural diagnostics and both pharmacological and non-pharmacological interventions will be presented as a tool to guide clinical practice.Keywords:
Apathy
Background:Apathy is a complex multidimensional syndrome frequently reported in Alzheimer's disease (AD) and is associated with impaired awareness. Here we present a psychometrically robust method to profile apathy in AD. Objectives:To determine the validity and reliability of a multidimensional ap athy measure, the Dimensional Apathy Scale (DAS), and explore the apathy subtype profile and its associations in AD. Methods:102 people with AD and 55 healthy controls were recruited. Participants completed the DAS, the Apathy Evaluation Scale (AES), Geriatric Depression Short form (GDS-15), and Lawton Instrumental Activities of Daily Living (LIADL). Psychometric properties of the DAS were determined. AD-Control comparison was performed to explore group differences on the DAS. Latent Class Analysis (LCA) was used to explore the profile of apathy in AD. Results:The DAS had a good to excellent Cronbach's standardized alpha (self-rated = 0.85, informant/carer-rated = 0.93) and good convergent and divergent validity against standard apathy (AES) and depression (GDS-15) measures. Group comparison showed people with AD were significantly higher for all apathy subtypes than controls (p < 0.001), and lacking in awareness over all apathy subtype deficits. LCA showed three distinct AD subgroups, with 42.2% in the Executive-Initiation apathy, 28.4% in the Global apathy, and 29.4% in the Minimal apathy group. Conclusions:The DAS is a psychometrically robust method of assessing multidimensional apathy in AD. The apathy profiles in AD are heterogeneous, with additional specific impairments relating to awareness dependent on apathy subtype.
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An aim of the study was to evaluate clinical features and risk factors of post stroke apathy. The study included 209 patients with first-time stroke. Assessments of neurological and mental status were carried out on the 1st, 7th day, after 2 weeks, 1 month, 3, 6 and 12 months after stroke. The frequency of apathy was 28.2%. Three types of apathy were singled out: classical, depressive, and combined. Apathy was significantly associated with the older age of patients, right-sided brain lesion and worst recovery of neurological deficit. Patients with depressive apathy were significantly older than patients without apathy, classic apathy was more common in men, and depressive apathy - in women. Depressive apathy was significantly associated with small lesions, while classic or combined apathy was significantly associated with the average volume of lesions.
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Apathy is one of the most common Neuropsychiatric Symptom (NPS) and is associated with worse clinical outcomes. Despite this apathy remains under-researched and the medical classification of apathy remains unclear, possibly due to the fact that apathy is commonly a comorbidity with depression making differentiation difficult. An analysis was conducted to examine the prevalence of apathy and the relationship between apathy, depression, dementia severity levels and other NPS. Meta-analysis of 4320 AD cases from 20 cohort studies was conducted to analyse the prevalence and course of apathy over time. Depression and apathy were defined based on item D (Depression/dysphoria) and G (Apathy/Indifference) respectively of the NPI scale. Of the 4320 subjects, 62% were female and 38% were male with a mean age 60 years and mean MMSE 19. Forty-nine percent presented with apathy. Cases of apathy without depressive symptoms accounted for 19%. In a subset of participants who were assessed longitudinally and had apathy at baseline, 42% had apathy at follow up with 58% having no apathy at follow up. Of cases without apathy at baseline 13% developed apathy at follow up. Apathy was common in this cohort, and persistent in nearly half of cases. Only a small proportion of people who had no apathy at baseline progressed to develop it. Apathy was commonly present alongside depression but there was also evidence of a distinct subset of patients who presented with apathy without depression. These findings support future analysis to examine the possible existence of distinct apathy subsyndromes and provide a basis for determining phenotypes in genetic and biomarker studies.
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Apathy is a prominent and disabling symptom in Parkinson's disease (PD) and is a multidimensional behaviour, but which dimensions are specifically affected is unclear. Therefore, the aim of this preliminary study was to determine the psychometric properties of the Dimensional Apathy Scale (DAS) and explore the multidimensional profile of apathy in PD patients.Thirty-four PD patients, with 30 of their informants/carers, and 34 healthy controls, with 30 of their informants, completed the DAS, Apathy Evaluation Scale and the Geriatric Depression Scale Short Form. Motor staging and independent living status were recorded.Comparative group analyses revealed that PD patients were significantly more apathetic on self-rated executive (p = 0.01) and initiation (p = 0.03) dimensions than controls, where only executive apathy was significantly higher in ratings of patients' informants/carers compared with controls' informants (p = 0.02). A third of patients were impaired on at least one apathy dimension. Additionally, patients with apathy tended to have more impaired activities of daily living, while none of the apathy dimensions related to motor disability.Our findings show the DAS is a valid and reliable multidimensional apathy tool for use in PD. PD is characterised by an executive apathy profile as determined by informants/carers, although patients described both executive and initiation apathy. This indicates a lack of motivation for planning, organisation and attention and lack of initiation of thoughts or behaviours. Further research is needed to determine the cognitive underpinnings of this emerging apathy profile and the clinical impact in PD. Copyright © 2017 John Wiley & Sons, Ltd.
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Apathy is a common feature of Huntington’s disease (HD), even from early disease. However, patients are believed to lack insight into their own apathy and therefore clinicians and/or companions are relied upon to estimate the extent of a patient’s apathy. In addition, the evolution of apathy over time in HD has not been unequivocally established. OBJECTIVEs: The purpose of this study was to determine whether HD patient’s self-rated apathy scores were consistent with the scores given by companions who were also asked to rate the patients apathy. Furthermore, the clinical correlates of apathy and its stability over time were examined for both self-rated and companion-rated scores. METHODs: Apathy was measured in a large cross-sectional population of HD patients ranging from early to late stage disease (n = 106) using the Apathy Evaluation Scale; a subgroup of whom were followed longitudinally (n = 62) on average 18.7 (1.2 SD) months later. Comparisons were made between self-rated and companion-rated apathy and the relationship between apathy and motor, cognitive and functional performance was explored.Analysis of the cross-sectional data revealed that self-rated and companion-rated apathy were highly correlated, establishing the validity of using self-rated instead of, or in combination with, companion-rated assessments of apathy in future studies. Both self-rated and companion-rated scores had a relationship with motor and functional impairment, but had a complex relationship with cognition. The results of the longitudinal comparison revealed that apathy did not change over time in this cohort.CONCLUSIONs: Apathy can be equally well assessed by either patients or companions and does not change significantly over an18 month period. These findings have implications in the design of studies looking at treating this important aspect of HD.
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Apathy has traditionally been conceptualised as part of depression. The appropriateness of this conceptualisation has now been questioned, with the realization that apathy constitutes a distinct neuropsychiatric condition, with separate rehabilitation and patient-care implications to depression. Research on the relationship between apathy and depression has, however, produced mixed results. One reason for this inconsistency may lie behind who does the apathy evaluation. In this study we investigated whether the relationship between apathy and depression would differ when apathy was evaluated by the patients or an informant. A total of 49 brain damaged patients were assessed on self- and informant-rated Apathy Evaluation Scales. The relationship between the apathy scores and depressive symptoms was then investigated. Patient-rated, and not informant-rated apathy significantly correlated with depression. We discuss the implication of these results on the relationship between the two neuropsychiatric conditions and also in relation to the utility of patient self-evaluations in apathy.
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Apathy, a syndrome of decreased initiation and motivation, affects over 70% of individuals with Alzheimer's disease (AD) and is the most common neuropsychiatric symptom reported in AD patients. The syndrome of apathy is associated with functional impairment among patients and elevated stress among their caregivers. Apathy is one of the primary neuropsychiatric manifestations of frontal system dysfunction, and AD-related apathy is thought to reflect the interaction between cholinergic deficiency and neuropathological changes in frontal brain regions. This article reviews the assessment and treatment of apathy in AD, with emphasis on the utility of acetylcholinesterase inhibitors for reducing apathy in AD. The potential benefits of other pharmacologic agents and combined pharmacologic-behavioral interventions are also discussed, and recommendations for future research are provided.
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Abstract Apathy is a common neurobehavioral feature in a variety of neuropsychiatric disorders. Apathy is often interpreted as a sign of depression or as a nonspecific symptom of other medical conditions. However, recent research indicates that the essential meaning of apathy is lack of motivation. This article presents a framework for the classification and differential diagnosis of apathy and addresses issues related to the assessment and treatment of apathy in neuropsychiatric patients.
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Apathy, or loss of motivation, is arguably the most common change in behavior in Alzheimer's disease (AD) but is underrecognized. Apathy represents a form of executive cognitive dysfunction. Patients with apathy suffer from decreased daily function and specific cognitive deficits and rely on families to provide more care, which results in increased stress for families. Apathy is one of the primary syndromes associated with frontal and subcortical pathology, and apathy in AD appears to have multiple neuroanatomical correlates that implicate components of frontal subcortical networks. Despite the profound effects of this common syndrome, only a few instruments have been designed to specifically assess apathy, and these instruments have not been directly compared. Assessment of apathy in AD requires clinicians to distinguish loss of motivation from loss of ability due to cognitive decline. Although apathy may be misdiagnosed as depression because of an overlap in symptoms, current research has shown apathy to be a discrete syndrome. Distinguishing apathy from depression has important treatment implications, because these disorders respond to different interventions. Further research is required to clarify the specific neuroanatomical and neuropsychological correlates of apathy and to determine how correct diagnosis and treatment of apathy may improve patient functioning and ease caregiver burden.
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