Assessment of neuropsychiatric symptoms in dementia: Toward improving accuracy

Stella, Florindo

doi:10.1590/S1980-57642013DN70300003

ABSTRACT

The issue of this article concerned the discussion about tools frequently used tools for assessing neuropsychiatric symptoms of patients with dementia, particularly Alzheimer's disease. The aims were to discuss the main tools for evaluating behavioral disturbances, and particularly the accuracy of the Neuropsychiatric Inventory - Clinician Rating Scale (NPI-C). The clinical approach to and diagnosis of neuropsychiatric syndromes in dementia require suitable accuracy. Advances in the recognition and early accurate diagnosis of psychopathological symptoms help guide appropriate pharmacological and non-pharmacological interventions. In addition, recommended standardized and validated measurements contribute to both scientific research and clinical practice. Emotional distress, caregiver burden, and cognitive impairment often experienced by elderly caregivers, may affect the quality of caregiver reports. The clinician rating approach helps attenuate these misinterpretations. In this scenario, the NPI-C is a promising and versatile tool for assessing neuropsychiatric syndromes in dementia, offering good accuracy and high reliability, mainly based on the diagnostic impression of the clinician. This tool can provide both strategies: a comprehensive assessment of neuropsychiatric symptoms in dementia or the investigation of specific psychopathological syndromes such as agitation, depression, anxiety, apathy, sleep disorders, and aberrant motor disorders, among others.

Key words:
neuropsychiatric symptoms; assessment; scales; Alzheimer's disease; dementia

RESUMO

Neste artigo, comentamos sobre as escalas frequentemente utilizadas para avaliação de sintomas neuropsiquiátricos presentes em pacientes com demência, especialmente, na doença de Alzheimer. Os objetivos consistiram na discussão sobre as principais estratégias de avaliação dos distúrbios de comportamento e, particularmente, no exame da acurácia do Inventário Neuropsiquiátrico - Avaliação do Clínico (NPI-C) A investigação clínica e o diagnóstico das síndromes neuropsiquiátricas requerem uma acurácia apropriada. Avanços no reconhecimento dos sintomas e na acurácia do diagnóstico precoce das manifestações psicopatológicas contribuem para a instituição do tratamento adequado, tanto farmacológico como não-farmacológico. Além disso, instrumentos padronizados e validados são recomendados tanto para a investigação científica, quanto para a prática clínica. Estresse emocional, sobrecarga de trabalho e declínio cognitivo, não raro presente no cuidador idoso, podem afetar a qualidade da descrição dos sintomas vivenciados pelo paciente. Neste contexto, o NPI-C é uma abordagem promissora e versátil para a avaliação das síndromes neuropsiquiátricas na demência, com boa acurácia e confiabilidade, principalmente, com base na impressão diagnóstica do clínico. Esta escala permite uma avaliação global dos sintomas neuropsiquiátricos na demência ou pode ser utilizada como uma estratégia para a investigação de síndromes psicopatológicas específicas na demência, como agitação, depressão, ansiedade, apatia, distúrbios do sono ou distúrbio motor aberrante, dentre outros.

Palavras-chave:
sintomas neuropsiquiátricos; avaliação; escalas; doença de Alzheimer; demência

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REFERENCES

Lyketsos CG, Steinberg M, Tschanz JT, Norton MC, Steffens DC, Breinter JCS. Mental and behavioral disturbances in dementia: Findings from Cache County Study on memory and aging. Am J Psychiatry 2000;157:708-714.
Zuidema S, Koopmans R, Verhey F. Prevalence and predictors of neuropsychiatric symptoms in cognitively impaired nursing home patients. J Geriatric Psychiatr Neurol 2007;20:41-49.
Tatsch MF, Bottino CMC, Azevedo D, et al. Neuropsychiatric symptoms in Alzheimer's disease and cognitively impaired non demented elderly from a community-based sample in Brazil: prevalence and relationship with dementia severity. Am J Geriatr Psychiatry 2006;4:438-445.
Vega UM, Marinho V, Engelhardt E, Laks J. Sintomas neuropsiquiátricos nas demências: Relato preliminar de uma avaliação prospectiva em um ambulatório do Brasil. Arq Neuropsiquiatr 2007;65:498-502.
Stella F, Forlenza OV, Laks J, et al. The Brazilian version of the Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of assessment of neuropsychiatric symptoms in dementia. Int Psychogeriatr 2013; 25:1503-1511.
Gauthier S, Cummings J, Ballard C, et al. Management of behavioral problems in Alzheimer's disease. Int Psychogeriatr2010;22:346-372.
Dubois B, Feldman HH, Jacova C, et al. Revising the definition of Alzheimer's disease: a new lexicon. Lancet Neurol 2010;9:1118- 1127.
Robert PH, Verhey FRJ, Byrne EJ, et al. Grouping for behavioral and psychological symptoms in dementia: clinical and biological aspects. Consensus paper of the European Alzheimer disease consortium. Eur Psychiatry 2005;20:490-496.
Lyketsos CG. Neuropsychiatric symptoms (behavioral and psychological symptoms of dementia) and the development of dementia treatments. Int Psychogeriatr2007;19:409-420.
Aalten P, Verhey FRJ, Boziki M, et al. Neuropsychiatric Syndromes in dementia. Dement Geriatr Cogn Disord 2007;24:457-463.
Lyketsos CG, Miller SS. Addressing the Alzheimer's disease crisis through better understanding, treatment, and eventual prevention of associated neuropsychiatric syndromes. Alzheimers Dement 2012;8: 60-64.
Benoit M, Berrut G, Doussaint J, et al. Apathy and Depression in Mild Alzheimer's Disease: A Cross-Sectional Study Using Diagnostic Criteria. J Alzheimers Dis 2012;31:325-334.
Feldman H, Scheltens P, Scarpini E, et al. Behavioral symptoms in mild cognitive impairment. Neurology 2004;62:1199-1201.
Gauthier S, Vellas B, Farlow M, Burn D. Aggressive course of disease in dementia. Alzheimers Dement2006:210-217.
Onyike C, Sheppard JM, Tschanz J, et al. Epidemiology of apathy in older adults; The Cache County Study. Am J Geriatr Psychiatry2007; 15:365-375.
Caputo M, Monastero R, Mariani E, et al. Neuropsychiatric symptoms in 921 elderly subjects with dementia: a comparison between vascular and neurodegenerative types. Acta Psyhchiatr Scand 2008;117:455-464.
Reisberg B, Auer SR, Monteiro IM. Behavioral pathology in Alzheimer´s disease (BEHAVE-AD) rating scale. Int Psychogeriatr1996;8:301-308.
Taragano FE, Allegri RF, Krupitzki H, et al. Mild behavioral impairment and risk of dementia. J Clin Psychiatry 2009;70:584-592.
Di Iulio F, Palmer K, Blundo C, Casini AR, Gianni W, Caltagirone C, Spalletta G. Occurrence of neuropsychiatric symptoms and psychiatric disorders in mild Alzheimer's disease and mild cognitive impairment subtypes. Int Psychogeriatr2010;22(4):629-640.
Cummings JL, Mackell J, Kaufer D. Behavioral effects of current Alzheimer's disease treatment: a descriptive review. Alzheimers Dement2008;4:49-60.
Wadsworth LP, Lorius N, Donovan NJ, et al. Neuropsychiatric Symptoms and Global Functional Impairment along the Alzheimer's Continuum. Dement Geriatr Cogn Disord2012;34:96-111.
Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages of Alzheimer's disease: recommendations from the National Institute on Aging Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement2011;7: 280-292.
de Medeiros K, Robert P, Gauthier S et al. and the NPI-C Research Group. The Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia. Int Psychogeriatr2010;22:984-994.
Lyketsos GC, Carrillo MC, Ryan JM, et al. Neuropsychiatric symptoms in Alzheimer's disease. Alzheimers Dement2011;7:532-539.
Cummings JL, Mega M, Gray K. Rosenberg-Thomson S, Carusi DA, Gornbein J.The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology1994;44:2308-2314.
Brodaty H, Draper B, Saab D, et al. Psychosis, depression and behavioral disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry 2001;16:504-512.
Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of agitation in a nursing home. J Gerontol 1989;44,M77-M84.
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284
Ventura J, Green MF, Shaner A, Liberman RP. Training and quality assurance with the brief psychiatric rating scale: "the drift buster." Int J Meth Psychiatr Res 1993;3:221-224.
Robert P H, Clairet S, Benoit M,et al. The Apathy Inventory: assessment of apathy and awareness in Alzheimer's disease, Parkinson's disease and mild cognitive impairment. Int J Geriatr Psychiatry2002;17: 1099-1105.
Robert P H, Mulin E, Malléa P, David R. Apathy diagnosis, assessment, and treatment in Alzheimer's disease. CNS Neurosci Ther 2010;16: 263-271.
Auer SR, Monteiro IM, Reisberg B. The Empirical Behavioral Pathology in Alzheimer's Disease (E-BEHAVE-AD) Rating Scale. Int Psychogeriatr1996;8:247-266.
Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, et al. Brazilian version of the Cornell depression scale in dementia. Arq Neuropsiquiatr2007;3:912-915.
Stella F, Radanovic M, Aprahamian I, Canineu PR, Andrade LP, Forlenza OV. Neurobiological bases of apathy in Alzheimer's disease and mild cognitive impairment: a systematic review. 2013b;(submitted).
Mulin E, Leone E, Dujardin K, et al. Diagnostic criteria for apathy in clinical practice. Int J Geriatr Psychiatry2011;26:158-165.
Stella F, Andrade LP, Garuffi M, et al. Validation of the Brazilian version of the Apathy Inventory. Int J Geriatr Psychiatry2013;28:979-86.
Starkstein SE, Mayberg HS, Preziosi TJ, Andrezejewski P, Leiguarda R, Robinson RG. Reliability, validity, and clinical correlates of apathy in Parkinson's disease. J Neuropsychiatry Clin Neurosci 1992;4:134-139.
Marin RS, Biedrzycki RC, Firinciogullari S. Reliability and validity of the Apathy Evaluation Scale. Psychiatry Res 1991;38:143-162.
Reisberg B, Ferris SH, De Leon MJ. The Global Deterioration Scale for assessment of primary degenerate dementia. Am J Psychiatry1982; 139:1136-1139.
Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep 1962;10:799-812.
Romano F, Elkis H. Tradução e adaptação de um instrumento de avaliação psicopatológica das psicoses: a escala breve de avaliação psiquiátrica - versão ancorada (BPRS-A). J Bras Psiquiatr 1996;45:43-49.
Shader RI, Harmatz JS, Salzman C. A new scale for clinical assessment in geriatric populations: Sandoz Clinical Assessment-Geriatric (SCAG). J Am Geriatr Soc 1974;3:107-113.
Frota NAF, Nitrini RDamasceno BP, et al. Criteria for the diagnosis of Alzheimer's disease: Recommendations of the Scientific Department of Cognitive Neurologyand Aging of the Brazilian Academy of. Neurology Dement Neuropsychol 2011;5:146-152.
Rosenberg PB, Mielke M, Lyketsos CG. Caregiver assessment of patients' depression in Alzheimer disease: longitudinal analysis in a drug treatment study. Am J Geriatr Psychiatry2005;13:822-826.

Publication Dates

Publication in this collection
Jul-Sep 2013

History

Received
19 June 2013
Accepted
19 Aug 2013

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] Lyketsos CG, Steinberg M, Tschanz JT, Norton MC, Steffens DC, Breinter JCS. Mental and behavioral disturbances in dementia: Findings from Cache County Study on memory and aging. Am J Psychiatry 2000;157:708-714.

[2] Zuidema S, Koopmans R, Verhey F. Prevalence and predictors of neuropsychiatric symptoms in cognitively impaired nursing home patients. J Geriatric Psychiatr Neurol 2007;20:41-49.

[3] Tatsch MF, Bottino CMC, Azevedo D, et al. Neuropsychiatric symptoms in Alzheimer's disease and cognitively impaired non demented elderly from a community-based sample in Brazil: prevalence and relationship with dementia severity. Am J Geriatr Psychiatry 2006;4:438-445.

[4] Vega UM, Marinho V, Engelhardt E, Laks J. Sintomas neuropsiquiátricos nas demências: Relato preliminar de uma avaliação prospectiva em um ambulatório do Brasil. Arq Neuropsiquiatr 2007;65:498-502.

[5] Stella F, Forlenza OV, Laks J, et al. The Brazilian version of the Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of assessment of neuropsychiatric symptoms in dementia. Int Psychogeriatr 2013; 25:1503-1511.

[6] Gauthier S, Cummings J, Ballard C, et al. Management of behavioral problems in Alzheimer's disease. Int Psychogeriatr2010;22:346-372.

[7] Dubois B, Feldman HH, Jacova C, et al. Revising the definition of Alzheimer's disease: a new lexicon. Lancet Neurol 2010;9:1118- 1127.

[8] Robert PH, Verhey FRJ, Byrne EJ, et al. Grouping for behavioral and psychological symptoms in dementia: clinical and biological aspects. Consensus paper of the European Alzheimer disease consortium. Eur Psychiatry 2005;20:490-496.

[9] Lyketsos CG. Neuropsychiatric symptoms (behavioral and psychological symptoms of dementia) and the development of dementia treatments. Int Psychogeriatr2007;19:409-420.

[10] Aalten P, Verhey FRJ, Boziki M, et al. Neuropsychiatric Syndromes in dementia. Dement Geriatr Cogn Disord 2007;24:457-463.

[11] Lyketsos CG, Miller SS. Addressing the Alzheimer's disease crisis through better understanding, treatment, and eventual prevention of associated neuropsychiatric syndromes. Alzheimers Dement 2012;8: 60-64.

[12] Benoit M, Berrut G, Doussaint J, et al. Apathy and Depression in Mild Alzheimer's Disease: A Cross-Sectional Study Using Diagnostic Criteria. J Alzheimers Dis 2012;31:325-334.

[13] Feldman H, Scheltens P, Scarpini E, et al. Behavioral symptoms in mild cognitive impairment. Neurology 2004;62:1199-1201.

[14] Gauthier S, Vellas B, Farlow M, Burn D. Aggressive course of disease in dementia. Alzheimers Dement2006:210-217.

[15] Onyike C, Sheppard JM, Tschanz J, et al. Epidemiology of apathy in older adults; The Cache County Study. Am J Geriatr Psychiatry2007; 15:365-375.

[16] Caputo M, Monastero R, Mariani E, et al. Neuropsychiatric symptoms in 921 elderly subjects with dementia: a comparison between vascular and neurodegenerative types. Acta Psyhchiatr Scand 2008;117:455-464.

[17] Reisberg B, Auer SR, Monteiro IM. Behavioral pathology in Alzheimer´s disease (BEHAVE-AD) rating scale. Int Psychogeriatr1996;8:301-308.

[18] Taragano FE, Allegri RF, Krupitzki H, et al. Mild behavioral impairment and risk of dementia. J Clin Psychiatry 2009;70:584-592.

[19] Di Iulio F, Palmer K, Blundo C, Casini AR, Gianni W, Caltagirone C, Spalletta G. Occurrence of neuropsychiatric symptoms and psychiatric disorders in mild Alzheimer's disease and mild cognitive impairment subtypes. Int Psychogeriatr2010;22(4):629-640.

[20] Cummings JL, Mackell J, Kaufer D. Behavioral effects of current Alzheimer's disease treatment: a descriptive review. Alzheimers Dement2008;4:49-60.

[21] Wadsworth LP, Lorius N, Donovan NJ, et al. Neuropsychiatric Symptoms and Global Functional Impairment along the Alzheimer's Continuum. Dement Geriatr Cogn Disord2012;34:96-111.

[22] Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages of Alzheimer's disease: recommendations from the National Institute on Aging Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement2011;7: 280-292.

[23] de Medeiros K, Robert P, Gauthier S et al. and the NPI-C Research Group. The Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia. Int Psychogeriatr2010;22:984-994.

[24] Lyketsos GC, Carrillo MC, Ryan JM, et al. Neuropsychiatric symptoms in Alzheimer's disease. Alzheimers Dement2011;7:532-539.

[25] Cummings JL, Mega M, Gray K. Rosenberg-Thomson S, Carusi DA, Gornbein J.The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology1994;44:2308-2314.

[26] Brodaty H, Draper B, Saab D, et al. Psychosis, depression and behavioral disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry 2001;16:504-512.

[27] Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of agitation in a nursing home. J Gerontol 1989;44,M77-M84.

[28] Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284

[29] Ventura J, Green MF, Shaner A, Liberman RP. Training and quality assurance with the brief psychiatric rating scale: "the drift buster." Int J Meth Psychiatr Res 1993;3:221-224.

[30] Robert P H, Clairet S, Benoit M,et al. The Apathy Inventory: assessment of apathy and awareness in Alzheimer's disease, Parkinson's disease and mild cognitive impairment. Int J Geriatr Psychiatry2002;17: 1099-1105.

[31] Robert P H, Mulin E, Malléa P, David R. Apathy diagnosis, assessment, and treatment in Alzheimer's disease. CNS Neurosci Ther 2010;16: 263-271.

[32] Auer SR, Monteiro IM, Reisberg B. The Empirical Behavioral Pathology in Alzheimer's Disease (E-BEHAVE-AD) Rating Scale. Int Psychogeriatr1996;8:247-266.

[33] Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, et al. Brazilian version of the Cornell depression scale in dementia. Arq Neuropsiquiatr2007;3:912-915.

[34] Stella F, Radanovic M, Aprahamian I, Canineu PR, Andrade LP, Forlenza OV. Neurobiological bases of apathy in Alzheimer's disease and mild cognitive impairment: a systematic review. 2013b;(submitted).

[35] Mulin E, Leone E, Dujardin K, et al. Diagnostic criteria for apathy in clinical practice. Int J Geriatr Psychiatry2011;26:158-165.

[36] Stella F, Andrade LP, Garuffi M, et al. Validation of the Brazilian version of the Apathy Inventory. Int J Geriatr Psychiatry2013;28:979-86.

[37] Starkstein SE, Mayberg HS, Preziosi TJ, Andrezejewski P, Leiguarda R, Robinson RG. Reliability, validity, and clinical correlates of apathy in Parkinson's disease. J Neuropsychiatry Clin Neurosci 1992;4:134-139.

[38] Marin RS, Biedrzycki RC, Firinciogullari S. Reliability and validity of the Apathy Evaluation Scale. Psychiatry Res 1991;38:143-162.

[39] Reisberg B, Ferris SH, De Leon MJ. The Global Deterioration Scale for assessment of primary degenerate dementia. Am J Psychiatry1982; 139:1136-1139.

[40] Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep 1962;10:799-812.

[41] Romano F, Elkis H. Tradução e adaptação de um instrumento de avaliação psicopatológica das psicoses: a escala breve de avaliação psiquiátrica - versão ancorada (BPRS-A). J Bras Psiquiatr 1996;45:43-49.

[42] Shader RI, Harmatz JS, Salzman C. A new scale for clinical assessment in geriatric populations: Sandoz Clinical Assessment-Geriatric (SCAG). J Am Geriatr Soc 1974;3:107-113.

[43] Frota NAF, Nitrini RDamasceno BP, et al. Criteria for the diagnosis of Alzheimer's disease: Recommendations of the Scientific Department of Cognitive Neurologyand Aging of the Brazilian Academy of. Neurology Dement Neuropsychol 2011;5:146-152.

[44] Rosenberg PB, Mielke M, Lyketsos CG. Caregiver assessment of patients' depression in Alzheimer disease: longitudinal analysis in a drug treatment study. Am J Geriatr Psychiatry2005;13:822-826.

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