A smartphone test for delirium assessment in hospital

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The August International Psychogeriatrics Article of the Month is entitled “Development of a smartphone application for the objective detection of attentional deficits in delirium” by Zoë Tieges, Antaine Stíobhairt, Katie Scott, Klaudia Suchorab, Alexander Weir, Stuart Parks, Susan Shenkin and Alasdair MacLullich.

Delirium is a sudden disruption in consciousness and cognition marked by an inability to focus and sustain attention. People with delirium can also experience psychotic symptoms such as terrifying hallucinations and delusions. Delirium is extremely common, affecting around one in eight hospital patients. It can occur at any age but is particularly common in older patients in hospital, where it is often mistaken for dementia. Delirium tends to develop after infection or surgery, or as a result of drug side-effects, and has serious consequences: it affects how long patients stay in hospital and future mental and physical well-being, and increases the risk for future dementia and death.

The first step towards improving treatment and subsequent health outcomes of patients with delirium is accurate detection of the syndrome. Yet up to three-quarters of delirium is undetected. Part of the problem is that delirium is difficult to recognise, with some features similar to those in other conditions such as dementia and depression. Most available delirium tests discriminate inadequately between delirium and dementia, rely on subjective judgements, and require trained personnel. It is evident that new ways of easily and accurately detecting delirium are needed.

Researchers at the Edinburgh Delirium Research Group and LLHW Centre for Cognitive Ageing and Epidemiology (CCACE), at the University of Edinburgh, have previously developed an electronic method for measuring delirium using simple visual attention tests, which were implemented on a purpose-built device known as ‘Delbox’. The rationale for this method is that patients with dementia will perform better because they are able to focus their attention for longer periods than patients with delirium. This is exactly what the researchers found.

The team have taken this approach one step further by developing a software application (‘DelApp’) for smartphones based on the Delbox, in collaboration with the Medical Devices Unit in Glasgow (NHS Greater Glasgow & Clyde). The DelApp incorporates a brief arousal assessment, a visual test and a graded counting task to measure inattention. The patient is asked to count a short sequence of circles shown on the smartphone screen. The DelApp takes a few minutes.

The researchers studied the feasibility and validity of the DelApp. First, 20 older hospital patients were tested with both Delbox and Delapp, showing comparable performance on both tests. Patient feedback was overall positive and suggested that the DelApp was acceptable to them. Secondly, the DelApp was pilot tested in 156 selected older patients split in three groups (delirium, dementia, and no delirium/no dementia). The delirium group performed more poorly compared to dementia and no delirium/no dementia groups. The DelApp not only showed good diagnostic performance, but also appeared to capture the severity of delirium as measured with a validated delirium severity scale.

In conclusion, this study showed the initial feasibility and validity of using a smartphone test for delirium assessment in hospital. The DelApp test appears to be objective and easy to use at the patient’s bedside. It requires little training, which may be particularly useful for non-experts.

The research team is developing the DelApp further and will confirm the clinical effectiveness of the test in larger trials with blinded raters.

The full paper “Development of a smartphone application for the objective detection of attentional deficits in delirium” is available free of charge for a limited time here.

The commentary paper “Bringing delirium into the 21st century: will physicians get the app out?” by Kenneth Rockwood is also available free of charge here.

Psychotic symptoms in frontotemporal dementia: a diagnostic dilemma?

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The April International Psychogeriatrics Article of the Month is entitled “Psychotic symptoms in frontotemporal dementia: a diagnostic dilemma?” by Maria Landqvist Waldö, Lars Gustafson, Ulla Passant and Elisabet Englund.

Despite all attempts to develop clinical diagnostic criteria with high specificity and sensitivity early diagnosis in FTD remains a challenge, even for the experienced clinician. The patients may present with a wide range of symptoms that often mimic other psychiatric disorders and initial psychiatric diagnoses are common. Psychotic symptoms are known to be prominent symptoms in several neurodegenerative diseases including AD and DLB, and have previously been thought to be quite rare in FTD. There are indications that a high prevalence of psychotic symptoms seems to be associated with specific molecular and genetic subgroups of FTD, but as this has not been adequately studied we examined prevalence of psychotic symptoms and possible correlations to brain pathology in FTD. Furthermore we evaluated clinical diagnostic accuracy as well as family history in our cohort of 97 neuropathologically diagnosed FTD cases.

We found that psychotic symptoms were present at some time during the course of dementia in 32% of our cases. There were no significant differences in gender, age at onset or disease duration between patients with and without psychotic symptoms. The most common type of psychotic symptoms was paranoid ideas (20.6%) followed by hallucinations and delusions (17.5%) in equal measure. There was a strong significant correlation between psychotic symptoms and predominantly right-sided brain degeneration.

We could see a trend with more frequent psychotic symptoms in tau-negative cases, however not statistically significant. Psychotic symptoms were particularly common in the cases with FUS pathology and in those without identified brain protein pathology.

The majority of patients received other first diagnoses than FTD, often psychiatric diagnoses. The patients with an initial psychiatric diagnosis were significantly younger than patients with other first diagnoses. About 80% patients where subsequently diagnosed with FTD and among these the median time from symptom onset until diagnosis was 4 years with median disease duration of 7.5 years, however with large variations. A clinical diagnosis of psychosis was almost exclusively given to tau-negative cases.

This is one of the largest studies aimed at assessing the prevalence of psychotic symptoms in FTD and relating them to neuropathology. Compared to many other studies we found a higher prevalence of psychotic symptoms. A correlation between psychotic symptoms and right-sided predominant pathology has been suggested earlier, but to our knowledge never shown in such a large neuropathological study. Although previous studies have found differences in the prevalence of psychotic symptoms between tau-positive and tau-negative cases, we did not find any significant differences between the groups. We identified two groups with particular high prevalence of psychotic symptoms: the FUS pathology cases and those with no identified protein pathology. Our FUS cases share many features with previous reports of this specific group such as young age at onset, no heredity for dementia and prominent neuropsychiatric symptoms. Interestingly, the cases from the group without specific protein pathology also display prominent psychiatric symptoms.

Read the full paper “Psychotic symptoms in frontotemporal dementia: a diagnostic dilemma” by Maria Landqvist Waldö, Lars Gustafson, Ulla Passant and Elisabet Englund

Read the commentary paper “Commentary on:  in frontotemporal dementia: a diagnostic dilemma?” by John T. O’Brien

Variability in estimating the self-awareness of memory deficits

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The March International Psychogeriatrics Article of the Month is entitled ‘Awareness of memory deficits in subjective cognitive decline, mild cognitive impairment, Alzheimer’s disease and Parkinson’s disease’ by Johann Lehrner, Sandra Kogler, Claus Lamm, Doris Moser, Stefanie Klug, Gisela Pusswald, Peter Dal-Bianco, Walter Pirker and Eduard Auff

As the world population ages, we face sharp rises in prevalence rates for neurodegenerative diseases. In order to minimize entailing individual and societal burdens, early diagnosis is becoming increasingly important. Efforts to enable early recognition of impending cognitive decline led to the development of the concept of Mild Cognitive Impairment (MCI), which describes a transitional stage between normal age-related memory decline and dementia. Yet, not all individuals diagnosed with MCI can be considered as being in a prodromal phase of dementia. Accordingly, ongoing research is now focusing on the identification of (a) those individuals with MCI who are most likely to convert to dementia and (b) asymptomatic individuals in a pre-MCI stage. Yet, which early markers are available for their identification?

With some evidence pointing towards a connection between low memory awareness – an inability to (fully) recognize memory deficits – and subsequent memory decline, awareness measures bear potential as an important marker of underlying dementia pathologies. However, as research in this field is defined by inconsistencies, this hypothesis needs further investigation.

We therefore used data concerning our patients’ subjective memory appraisals and objective memory performance to create an awareness index, which allowed us to compare levels of awareness (and frequencies of memory overestimation) across healthy elderly people and patients with varying degrees of memory impairment. Our question was whether our approach would reveal characteristic awareness differences similar to prior research.

As expected, our findings suggest that self-awareness of memory deficits decreases as cognitive deficits – especially memory deficits – increase. Accordingly, the highest rate of overestimation of memory function was found among patients suffering from Alzheimer’s disease (63%), followed by amnestic MCI patients without and with Parkinson’s disease (46%, 38%), while patients with cognitive deficits other than memory (non-amnestic MCI) showed a tendency towards underestimation of memory function. Our analyses further revealed considerable between-group overlaps in awareness scores and strong influences of non-cognitive factors such as depression.

The main implication of our study is that memory awareness reflects objective deterioration to some extent, but that there is considerable inter-individual variability in awareness. It is this variability which gives rise to the question whether differences in awareness are predictive of future conversion to dementia.

We hold the view that research in this field is important insofar as awareness measures are of high practical relevance: As opposed to biomarkers and neuroimaging technologies, which are of restricted availability in primary care settings, both measures of subjective memory complaint and objective memory performance provide easily, time- and cost efficiently accessible sources of information. Moreover, they count among the standard repertoire of diagnosis in MCI and other dementia-related diseases. Researchers could use these data to further explore the diagnostic and predictive validity of awareness measures. We hope that our work inspires further research concerning memory awareness and strongly welcome any comments and remarks.

The full paper “Awareness of memory deficits in subjective cognitive decline, mild cognitive impairment, Alzheimer’s disease and Parkinson’s disease” is available free of charge for a limited time here.

The commentary on the paper, “Awareness of memory deficits in subjective cognitive decline, mild cognitive impairment, Alzheimer’s disease and Parkinson’s disease” is also available free of charge here.

A provisional consensus clinical and research definition for Agitation in cognitive disorders

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The January International Psychogeriatrics Article of the Month is entitled ‘Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition’ by Jeffrey Cummings, Jacobo Mintzer, Henry Brodaty, Mary Sano et al.

Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome.

Agitation is a common clinical manifestation of many neuropsychiatric disorders. It is a frequent manifestation of Alzheimer’s disease (AD), frontotemporal dementia (FTD), dementia with Lewy bodies (DLB), and other dementia but also occurs in schizophrenia, bipolar illness, and depression. While agitation may include aggressive behaviors, it is not identical to aggression, and agitation can occur without aggression (e.g. pacing, rocking, repetitious mannerisms).

The International Psychogeriatric Association (IPA) formed an Agitation Definition Work Group (ADWG) to develop a provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies. A consensus definition will facilitate communication and cross-study comparison and may have regulatory applications in drug development programs.

The ADWG implemented a transparent process that included nearly 1,000 survey respondents and engaged the memberships of the IPA, IPA affiliates, and other organizations involved in the care and research of neuropsychiatric disorders in patients with cognitive impairment. The group used a combination of electronic, face-to-face, and survey-based strategies to develop a consensus based on agreement of a majority of participants. Nine-hundred twenty-eight respondents participated in the different phases of the process.

An initial survey provided valuable insights from those involved in the care of agitated patients, and key elements of the definition were identified. Of the items listed as possible behaviors to be included in a definition of agitation, the following were endorsed by at least 50% of the respondents: pacing, aimless wandering, verbal aggression, constant unwarranted requests for attention or help, hitting others, hitting self, pushing people, throwing things, general restlessness, screaming, resistiveness, hurting self, hurting others, tearing things or destroying property, shouting, and kicking furniture. This information guided the elements included in the definition by the ADWG.

Agitation was defined broadly as: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related). A majority of the respondents rated all surveyed elements of the definition as “strongly agree” or “somewhat agree” (68–88% across elements). A majority of the respondents also agreed that the definition is appropriate for clinical and research applications.

The development of a provisional definition of agitation is the first step in advancing a research agenda for the definition. Not all elements were unanimously endorsed; a consensus was achieved on all aspects of the definition. Validity studies using other agitation assessments, reliability of the application of the definition, usefulness in clinical trials, usefulness in non-pharmacologic research, and real-world application in clinical and healthcare settings will lead to refinements and adjustments that will enhance the definition and advance the study of neuropsychiatric syndromes in cognitive impairment disorders.

 

The full paper “Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition” has been published Open Access and is available here.

The commentary on the paper, “Defining agitation in the cognitively impaired–a work in progress” is also available free of charge here.

International Psychogeriatrics – Special issue on Young Onset Dementia

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International Psychogeriatrics
has published a special issue on Young Onset Dementia, guest edited by Raymond Koopmans and Tor Rosness.

The rising prevalence of dementia includes an increase of people with Young Onset Dementia (YOD). Studies have scrutinized the literature and documented distinct differences in traits between younger and older persons with dementia in several areas such as medical treatment, physical activity, functional level, activities of daily living, comorbidity, risk profiles, and caregiver distress. However, the cut-off of 65 years is arbitrary and there is still no consensus on if a diagnosis of dementia has to be made before the age of 65 years or if it is sufficient that the first symptoms are detected before the age of 65 years?

YOD is being steadily recognized as an important psychosocial and medical health problem with specific-age-related adverse consequences for both these younger persons and their families, however, many countries lack specific plans in their dementia strategies and do not offer any specific form of services or support for this group of individuals. Therefore the International Psychogeriatric Association (IPA) established a taskforce on YOD. The idea of composing a special issue on YOD was raised during The Hague meeting in 2011, and the issue consists partially of papers that have been presented during the symposia and workshop-meetings of the taskforce.

The YOD special issue provides an overview of important topics including unmet needs of carers, different clinical approaches to YOD diagnoses, needs of children with YOD parents, and medical treatment of behavioral symptoms of YOD patients.

We are offering limited time free access to the articles from this issue – simply register using our short form, using the code IPGYOD2

Traumatic Brain Injury and the speed of decline of Alzheimer’s Disease

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The October International Psychogeriatrics Article of the Month is entitled ‘The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County Dementia Progression Study’ by Mac Gilbert, Christine Snyder, Chris Corcoran, Maria C. Norton, Constantine G. Lyketsos and JoAnn T. Tschanz

With a diagnosis of Alzheimer’s dementia comes an understanding that the affected individual will suffer an inevitable and progressive decline in their cognitive and functional abilities. However, what is not known is how fast the decline will occur. Will the person need 24 hour supervision and care shortly after diagnosis or five to ten years in the future?

We have studied this question in our population-based sample of persons with Alzheimer’s dementia and found tremendous variability in the course of decline. It seems that about half of those in our sample declined slowly and a small but significant percentage declined quite rapidly. Is there anything in person’s background that will predict whether they will become a slow or a fast decliner?

We set out to study this issue by examining a person’s medical history, specifically, whether they had a history of concussion or traumatic brain injury (TBI). Several studies have found that those who have had a history of TBI in their lifetimes show an increased risk for Alzheimer’s dementia later in life. However, it was not known whether TBI also predicts the rate of decline after the onset of dementia.

As published in this month’s issue of the journal, we obtained the medical history of persons with Alzheimer’s dementia before onset, and characterized them as either positive or negative for a history of TBI and its severity. We also examined number of TBI (0, 1, 2 or more) and timing of TBI relative to the onset of dementia (none, within 10 years of onset, or greater than 10 years of onset). We repeatedly tested those with Alzheimer’s dementia about every 6 to 18 months, checking their memory, attention, concentration, language and visuospatial abilities. We also rated their functional decline from their caregiver’s report.

We found that a history of TBI predicted more rapid functional decline, but only among those who had experienced a TBI within 10 years of dementia onset. This finding adds to our previous work where a history of TBI was associated with disinhibited behavior after the onset of Alzheimer’s dementia, and persons in better overall health tended to function at higher levels after the onset of dementia.

What is the take home message of this research? While we can’t change the past, we can be proactive by taking steps to prevent TBI and other health problems from occurring. Preventing falls (a major cause of TBI in late life) by ensuring proper foot ware, installing safety bars, and ensuring safe walkways may help prevent new instances of TBI in older adults. Following up with one’s health care provider for any health problems is also suggested. Although there is currently no cure for Alzheimer’s dementia, adopting preventive measures may be one way to slow the progression of decline and optimize one’s level of functioning over the course of the illness.

 

The full paper “The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County Dementia Progression Study” is available free of charge for a limited time here.

The commentary on the paper, “The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County dementia progression study by Gilbert et al. Late effects of traumatic brain injury on dementia progression” is also available free of charge for a limited time here.

 

Good days and bad days in dementia

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The August International Psychogeriatrics Article of the Month is entitled ‘Good days and bad days in dementia: a qualitative chart review of variable symptom expression’ by Kenneth Rockwood, Sherri Fay, Laura Hamilton, Elyse Ross and Paige Moorhouse.

Anyone who works with people with dementia is bound to experience poignant moments. Especially striking is hearing that a person seemingly lost to permanent unknowing – even near muteness – suddenly spoke a full sentence, or sometimes more. Much more common, but still compelling, are reports of people with dementia having remarkably good or bad days.

In what does daily variability consist? For some years, that question has motivated our group. In a paper in this month’s issue, we report the findings of a clinical chart review spanning 30 months, to understand how patients and families experienced variability living with dementia from day to day. This line of inquiry was born from the realization that, for many patients and families, variability was a source of expectations – and often disappointments. Families asked questions that I couldn’t answer: “why can he be so helpful some days, and other days can’t even do for himself?” Often, they had answers as good as anything I could muster: “it’s best if he has a good night’s sleep”, or “I can tell if he’s missed his medications”.

The challenge is to understand the mechanisms of variability. To get there, we need to know just what is happening, and for that we need careful qualitative studies. The area is tricky, because variability threatens reliability, and that undermines measurement, which undermines understanding. Or so the argument goes. Progress however, obliges investigating the variability itself – as is being done in Lewy body dementia – and not just seeking ways to reduce it for testing purposes.

Our study offers some clues. For an important proportion of patients, variability occurs within the same symptom set: a good day is when the symptom is seen less, and a bad day when it occurs more. This makes fluctuation in specific neurochemical transmission seem likely. That some are implicated more than others is suggested by the patterns: most of these symptoms involve social conduct and engagement; other descriptions sound like attentional problems. For a second group of dementia symptoms, a bad day is marked by even a single occurrence of a bad problem: not being struck does not constitute a good day, even if being struck means a bad one.

Our group also gives thought to the mathematics of variable disease expression in dementia. On scales of months and years, a comprehensible, stochastic process can be modeled with high precision. Is what we see clinically another face of that, or does it signal instability that so often heralds more rapid decline, or is it a variation of the fluctuating attention seen in delirium and in Lewy Body dementia?

However it works, we should aim for treatment. Many families believe that some part is modifiable. Are they correct? Aiming for therapies might seem obvious, but against the thankfully fading fashion of rubbishing symptomatic treatments, it’s good to be reminded of how big is the gap between what we offer and what people need. And that is poignant.

Kenneth Rockwood, Dalhousie University, Halifax, Canada

 

The full paper “Good days and bad days in dementia: a qualitative chart review of variable symptom expression” is available free of charge for a limited time here.

The commentary on the paper, “Symptom variability in dementia” is also available free of charge for one month here.

 

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