Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, represent a heterogeneous group of non-cognitive symptoms and behaviors occurring in subjects with dementia. BPSD constitute a major component of the dementia syndrome irrespective of its subtype. They are as clinically relevant as cognitive symptoms as they strongly correlate with the degree of functional and cognitive impairment. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. It is estimated that BPSD affect up to 90% of all dementia subjects over the course of their illness, and is independently associated with poor outcomes, including distress among patients and caregivers, long-term hospitalization, misuse of medication, and increased health care costs. Although these symptoms can be present individually it is more common that various psychopathological features co-occur simultaneously in the same patient. Thus, categorization of BPSD in clusters taking into account their natural course, prognosis, and treatment response may be useful in the clinical practice. The pathogenesis of BPSD has not been clearly delineated but it is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD. A high degree of clinical expertise is crucial to appropriately recognize and manage the neuropsychiatric symptoms in a patient with dementia. Combination of non-pharmacological and careful use of pharmacological interventions is the recommended therapeutic for managing BPSD. Given the modest efficacy of current strategies, there is an urgent need to identify novel pharmacological targets and develop new non-pharmacological approaches to improve the adverse outcomes associated with BPSD.
Delirium is an acute neuropsychiatric syndrome characterized by acute-onset global cognitive deficits, perceptual and behavioural disturbances affecting mainly elderly subjects with underlying medical or surgical conditions. The pathophysiology of delirium is complex and inflammation is a relevant precipitant factor of this syndrome, although it remains unclear how acute systemic inflammation induces the clinical picture of delirium. The central nervous system is able to detect peripheral infection or tissue destruction through circulating immune mediators and neural ascending signs. Activated microglia is responsible for an acute neuroinflammatory reaction underlying the symptoms of sickness. In healthy conditions descending pathways from the paraventricular nucleus, locus coeruleus and dorsal motor nucleus organize a centralized response to influence the immune response at the periphery and restore homeostasis. In the context of ageing and chronic neurodegeneration, adaptive changes to acute insults are characterized by exaggerated production of pro-inflammatory cytokines by primed microglia coupled with dysfunction of brain-to-immune pathways. In animal models, these changes underlie a more severe manifestation of sickness behaviour with working memory deficits suggesting that inattention, a core feature of delirium, can be a clinical correlate of an increased neuroinflammatory reaction. In patients with delirium, higher levels of pro-inflammatory cytokines and cortisol were identified in plasma and cerebrospinal fluid. However, to date it has not been clarified how peripheral inflammatory or endocrine biomarkers can reflect the likelihood or severity of delirium symptoms. In the future, a better understanding of the interaction between the brain and peripheral organs and the exact mechanism by which systemic inflammation can lead to delirium, will allow the development of new therapeutic agents.
The results reveal different patterns of clinical characteristics in elderly patients with delirium. This is relevant to clinical care of acute medically ill patients and suggests that different pathways are implicated in delirium pathophysiology.
IntroductionDementia is one of the leading causes of disability and burden in Western countries. In Portugal, there is a lack of data regarding dementia prevalence in hospitalized elderly patients and factors associated with in-hospital adverse outcomes of these patients.ObjectivesDetermine dementia prevalence in acutely-ill medical hospitalized elderly patients and its impact in health outcomes.MethodsAll male patients (> 65 years) admitted to a medical ward (> 48 h) between 1.03.2015 to 31.08.2015 were included in the study. Patients were excluded if unable to be assessed due to sensorial deficits, communication problems or severity of the acute medical condition. Baseline evaluation included socio-demographic variables, RASS, NPI, Barthel Index and Confusion Assessment Method.ResultsThe final sample consisted of 270 male subjects with a mean age of 80.9 years, 116 (43%) having prior dementia. Dementia patients were significantly older (83.5 vs 78.9; P < 0.001) and had lower values of Barthel Index (dementia: 34.8 vs non-dementia: 85.8; P < 0.001). Mortality rate (9,3%) and length of hospitalization (11.2 days) were similar between groups (12.1 vs 7.1; P = 0.204 and 11.9 vs 10.6; P = 0.218, respectively). Patients with dementia had higher rates of all neuropsychiatric symptoms except depression, anxiety and mood elation. The level of consciousness (measured by RASS) was impaired in 50% of patients with dementia, which was significantly higher than in non-demented subjects (12.3%; P < 0.001). Delirium rates were 29.5% in dementia compared with 7.1% in controls (P < 0.001).ConclusionsThere is a high prevalence of dementia and an appreciable rate of delirium among these patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.
are an academic affiliated institution providing high standard health care to the central region of Portugal. A significant proportion of admitted patients to the medical or surgical wards have 65 or more years, with psychiatric co morbidities such as dementia, depression and delirium being highly prevalent. So far, mental health care to inpatients has been provided by the emergency psychiatric team. However this type of service has several important limitations, including the lack of continuity of care, difficulties regarding interaction with the ward staff and poor quality of clinical notes. Thus, the Psychogeriatric Unit from Coimbra University Hospital created a new LOAP service in order to initiate a consistent project that focus on psychiatric disturbances occurring in elderly inpatients at medical wards, based on the following premises: 1. providing a high quality standard of services; 2. performing standardized clinical assessment and data gathering (with essential neurocognitive tools); 3. ensuring continuity of care during hospitalization and after discharge (outpatient setting, day hospital). Additionally, our Unit is currently developing clinical investigation on Delirium and organizing educational meetings covering psychiatric areas such as Depression in the elderly, Dementia and Delirium. With this work the authors aim to present the project as well as some preliminary results.
Introduction: Brief Psychiatric Rating Scale (BPRS) is a widely used outcome measure to assess 24 different psychiatric symptoms. For several reasons it is important to study psychiatric subsyndromes instead of investigating separate symptoms because these subsyndromes may point to a common neurobiological pathogenesis or may have similar treatment. Objectives: The focus of the present study was to determine the factor structure of the BPRS for psychiatric inpatients with different diagnostics. The aim of this study was to detect subscales of the 24-item BPRS that could bring some relevant information to sustain the daily practice. Methods: Factor analysis of symptom ratings recorded on the BPRS for a sample of 139 inpatients, during the first week of hospitalization at the department of Psychiatry of HUC between April 2010 and September 2011. Principal component analysis (with Varimax rotation) was used for factor analysis. Results: The results of the exploratory factor analyses obtained eight factors, which explained 73,225% of the variance in the data. The first factor represents 19.511% of the total variance, and the other seven factors represents, respectively, 13.069%,
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