Behavioural and Psychological Symptoms in Vascular ...

Behavioural and Psychological Symptoms in Vascular Dementia in Hong Kong Chinese
Dr Cho Yiu YUNGFRCP (London, Edinburgh, Glasgow, Ireland)Head, Division of Geriatric MedicineDept. of Medicine & GeriatricsUnited Christian HospitalHong Kong
Objective
To study the pattern of behavioural and psychological symptoms (BPSD) invascular dementiaamongstHong Kong Chinese
Subjects
100 consecutive subjects attending aMemory Clinic, located in a district hospital in Hong KongDiagnosed to have vascular dementia (in accordance withNINDS-AIREN criteria):ProbablePossible
NINDS-AIREN Criteria
Thecriteria for the clinical diagnosis ofprobablevascular dementia includeallof the following:Dementiadefined bycognitive declinefrom a previously higher level of functioning and manifested by impairment of memory and oftwo or more cognitive domains(orientation, attention, language, visuospatial functions, executive functions, motor control, and praxis), preferable established by clinical examination and documented by neuropsychological testing; deficits should be severe enough tointerfere with activities of daily livingnot due to physical effects of stroke alone.Exclusion criteria: cases with disturbance of consciousness, delirium, psychosis, severe aphasia, or major sensorimotor impairment precluding neuropsychological testing. Also excluded are systemic disorders or other brain diseases (such as AD) that in and of themselves could account for deficits in memory and cognition.Cerebrovascular disease, defined by the presence offocal signson neurologic examination, such as hemiparesis, lower facial weakness, Babinski sign, sensory deficit, hemianopia, and dysarthria consistent with stroke (with or without history of stroke), and evidence ofofrelevant CVD bybrain imaging(CT or MRI) includingmultiple large vessel infarctsor asingle strategically placed infarct(angular gyrus, thalamus, basal forebrain, or PCA or ACA territories), as well asmultiple basal gangliaandwhite matterlacunes, orextensive periventricular white matter lesions, or combinations thereof.A relationship between the above two disorders, manifested or inferred by the presence of one or more of the following: (a)onset of dementia within 3 months following a recognized stroke; (b)abrupt deterioration in cognitive functions; or fluctuating, stepwise progression of cognitivedeficits
NINDS-AIREN Criteria
Clinicaldiagnosis ofpossiblevascular dementia may bemade:inthe presence ofdementiawithfocal neurologic signsin patients in whombrain imaging studies to confirm definite CVD are missing;orin theabsence of clear temporal relationshipbetween dementia and stroke; or in patients with subtle onset and variable course (plateau or improvement) of cognitive deficits and evidence of relevant CVD.
Assessment
Patientsubjective experiencesCollateralclinical history: objective behaviourNeuropsychiatric Inventory (NPI)Global Deterioration Scale (GDS)
NPI
Tool for assessing changes in behavioral andpsychologicaldisturbancesAlso evaluates impact of behavior on caregiversNumericscale:1– 144<20: Mild20– 50: Moderate>50 : SevereCan be used to monitor treatment efficacy
NPI: 12 domains
Delusions (paranoia)HallucinationsAgitation / aggressionDysphoriaAnxietyApathy
IrritabilityEuphoriaDisinhibitionAberrant motor behaviorNighttime behavior disturbanceAppetite/ eatingabnormalities
Assessment
Patientsubjective experiencesCollateralclinical history: objective behaviourNeuropsychiatric Inventory (NPI)Global Deterioration Scale (GDS)
GLOBAL DETERIORATION SCALE (GDS)
Stage 1: Nosubjective complaints of memory deficit. No memory deficit evident on clinical interview.Stage 2: Subjectivecomplaints of memory deficit, most frequently in following areas:(a) forgetting where one has placed familiar objects;(b) forgetting names one formerly knew well.No objective evidence of memory deficit on clinical interview.No objective deficit in employment or social situations.Appropriate concern with respect to symptomatology.Stage 3: Earliestclear-cut deficits.Manifestations in more than one of the following areas:(a) patient may have gotten lost when traveling to an unfamiliar location.(b) co-workers become aware of patient's relatively poor performance.(c) word and/or name finding deficit become evident to intimates.(d) patient may read a passage or book and retain relatively little material.(e) patient may demonstrate decreased facility remembering names upon introductionto newpeople.(f) patient may have lost or misplaced an object of value.(g) concentration deficit may be evident on clinical testing.Objective evidence of memory deficit obtained only with an intensive interview.Decreased performance in demanding employment and social settings.Denial begins to become manifest in patient.Mild to moderate anxiety frequently accompanies symptoms.
GLOBAL DETERIORATION SCALE (GDS)
Stage 4.Clear-cut deficit on careful clinical interview.Deficit manifest in following areas:(a) decreased knowledge of current and recent events.(b) may exhibit some deficit in memory of one's personal history.(c) concentration deficit elicited on serial subtractions.(d) decreased ability to travel, handle finances, etc.Frequently no deficit in following areas:(a) orientation to time and place.(b) recognition of familiar persons and faces.(c) ability to travel to familiar locations.Inability to perform complex tasks.Denial is dominant defense mechanism.Flattening of affect and withdrawal from challenging situations.Stage 5.Patient can no longer survive without some assistance.Patient is unable during interview to recall a majorrelevant aspectof their current life, e.g.:(a) their address or telephone number of many years.(b) the names of close members of their family (suchas grandchildren).(c) the name of the high school or college from whichthey graduated.Frequently some disorientation to time (date, day of the week, season, etc.) or to place.An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s.Persons at this stage retain knowledge of many major facts regarding themselves and others.They invariably know their own names and generally know their spouse's andchildren's names.They require no assistance with toileting or eating, but may have difficulty choosingthe proper clothingto wear.
GLOBAL DETERIORATION SCALE (GDS)
Stage 6.Mayoccasionally forget the name of the spouse upon whom they are entirelydependent forsurvival.Will be largely unaware of all recent events and experiences in their lives.Retain some knowledge of their surroundings; the year, the season, etc.May have difficulty counting by 1s from 10, both backward and sometimes forward.Will require some assistance with activities of daily living:(a) may become incontinent.(b) will require travel assistance but occasionally will be able totravel tofamiliar locations.Diurnal rhythm frequently disturbed.Almost always recall their own name.Frequently continue to be able to distinguish familiar from unfamiliar persons intheir environment.Personality and emotional changes occur. These are quite variable and include:(a) delusional behavior, e.g., patients may accuse their spouseof beingan imposter; may talk to imaginary figures in theenvironment, or to their own reflection in the mirror.(b) obsessive symptoms, e.g., person may continually repeat simple cleaning activities.(c) anxiety symptoms, agitation, and even previouslynon-existent violentbehavior may occur.(d) cognitiveabulia, e.g., loss of willpower because anindividual cannotcarry a thought long enough to determine apurposeful courseof action.Stage 7.Allverbal abilities are lost over the course of this stage.Early in this stage words and phrases are spoken but speech is very circumscribed.Later there is no serviceable speech at all - only unintelligible utterances withrare emergenceof seemingly forgotten words and phrases.Incontinent; requires assistance toileting and feeding.Basic psychomotor skills (e.g. ability to walk) are lost with the progression of this stage.The brain appears to no longer be able to tell the body what to do.Generalized rigidity and developmental neurologic reflexes are frequently present
Results: Severity of Disease
Results: Incidence of BPSD
Results: Pattern of BPSD
Conclusion
BPSDs arefrequentin vascular dementia of mild-to-moderate severityLike other types of dementia, correct identification and evaluation of BPSDs is acrucial component of clinical approachto vascular dementia
NINDS-AIREN Criteria
Clinicalfeatures consistent with the diagnosis ofprobablevascular dementia include the following:Earlypresence of gait disturbance (small-step gait ormarcheapetitspas, or magnetic,apraxic-ataxic or parkinsonian gait)Historyof unsteadiness and frequent, unprovokedfallsEarlyurinary frequency, urgency, and other urinary symptoms not explained by urologicdiseasePseudobulbarpalsyPersonalityand mood changes,abulia, depression, emotional incontinence, or other subcortical deficits including psychomotor retardation and abnormal executive function.
NINDS-AIREN Criteria
Featuresthat make the diagnosis of vascular dementia uncertain or unlikelyinclude:Earlyonset ofmemorydeficit and progressive worsening of memory deficit and progressive worsening of memory and other cognitive functions such as language (transcortical sensory aphasia), motor skills (apraxia), and perception (agnosia), in the absence of corresponding focal lesions on brainimagingAbsenceof focal neurological signs, other than cognitivedisturbanceAbsenceof cerebrovascular lesions on brain CT orMRI
NINDS-AIREN Criteria
Criteriafor diagnosis ofdefinitevascular dementiaare:clinicalcriteria forprobablevasculardementiahistopathologicevidence of CVD obtained from biopsy orautopsyabsenceof neurofibrillary tangles andneuriticplaques exceeding those expected forageabsenceof other clinical or pathological disorder capable of producingdementiaClassificationof vascular dementia for research purposes may be made on the basis of clinical, radiologic, andneuropathologicfeatures, for subcategories or defined conditions such as cortical vascular dementia, subcortical vascular dementia, BD, and thalamic dementia.
NPI: Scoring
Frequency X SeverityFrequency1:Occasionally(lessthan1/week)2:Often(about 1/week)3:Frequently(several times/week, but< every day)4:Very frequently(onceormore/day)
NPI: Scoring
Frequency X SeveritySeverity1:Mild(noticeable, but not asignificantchange)2:Moderate(significant, butnota dramatic change)3:Severe(very marked, adramatic change)