Assessing Behavioral And Psychiatric Symptoms

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While behavioral disturbances are not part of the diagnostic symptomatology, they are very common in AD, particularly as the disease progresses. Early in the disease, depression is noted, which may be minimally disturbing to patients and family. Later symptoms such as agitation, psychosis, and wandering can be disturbing and threaten patient safety. While clinicians often deal with these symptoms, there is less information on how to assess, prepare patient and family members, and treat in the earliest stages. Tools found useful for assessing behavioral and psychiatric disturbances in patients with AD are summarized in Table 2.3. While they may be burdensome

Assessing Behavioral and Psychiatric Symptoms 31

Table 2.2 Functional Assessments for Patients with Alzheimer's Disease

Score Range



Blessed Functional Assessment Scale8


Scores correlate with neuropathological findings.

Minimal sensitivity for mild disease.

Physical Self Maintenance Scale (PSMS)b



Widely used in demented and nonde-mented population.

Lengthy administration. Training required.

Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL)c



Tailored to specific level of disease. Captures changes in functional ability.

Long form requires the informant to be well acquainted with the patient.

a " The Association between Quantitative Measures of Dementia and of Senile Change in the Cerebral Gray Matter of Elderly Subjects," by G. Blessed, B. E. Tomlinson, and M. Roth, 1968, British Journal of Psychiatry, 114, pp. 797-811.

b "Assessment of Older People: Self-Maintaining and Instrumental Activities of Daily Living," by M. P. Lawton and E. M. Brody, 1969, Gerontologist, 9, pp. 179-186.

c "An Inventory to Assess Activities of Daily Living for Clinical Trials in Alzheimer's Disease," by D. Galasko et al., 1997, Alzheimer Disease and Associated Disorders, An International Journal, 11(Supp. 2), S33-S39.

to use in clinical practice, they can provide important guidelines for assessing behavioral symptoms via clinical interview. For example, it is important to ask about specific behavioral and psychiatric disturbances, encouraging reporting of even mild symptoms. In a cohort of longitudinally followed patients with AD, symptoms were likely to persist even with medication once they appear (Devanand et al., 1992). Given this finding, clinicians may choose to provide education to caregivers and to assess their ability and preparedness for coping with these problems. The Neuropsychiatric Inventory, a tool often used in research, has been adapted for use by clinicians (Kaufer et al., 2000). This instrument, which is administered to an informant (usually a family member or someone else providing care and supervision), consists of questions about a wide range of behavioral and psychiatric symptoms and assesses how disturbing each symptom is. This may provide an introduction into assessing the caregiver's ability to handle these behavioral disturbances.

In the earliest stages of disease, patients may experience depression. This can result from awareness of cognitive loss or of growing dependence. Alternately, cognitive loss can be the source of reduced initiative perhaps in response to difficulties planning and executing activities. This lack of

Table 2.3 Behavioral Assessments for Patients with Alzheimer's Disease

Score Range



Neuropsychiatric inven-tory-Q (NPI-Q)a


Clinician's brief version of NPI.b

Assesses psychiatric and behavioral disturbances and caregiver distress.

Requires minimal training.

Geriatric Depression Scale (GDS)c


Measures depression in the elderly.

Instrument is specific to depression.

Brief Psychiatric Rating Scale (BPRS)d


Used in a wide range of psychiatric illnesses, including dementia.

Requires experienced interviewer.

a "Validation of the NPI-Q: A Brief Clinical Form of the Neuropsychiatric Inventory, by D. I. Kaufer et al., 2000, Journal of Neuropsychiatry and Clinical Neurosciences, 12, pp. 233-239. b" The Neuropsychiatric Inventory: Comprehensive Assessment of Psychopathology in Dementia," by J. L. Cummings, M. Mega, K. Gray, S. Rosenberg-Thompson, D. A. Carusi, and J. Gornbein, 1994, Neurology, 44, pp. 2308-2314.

c "Screening Test for Geriatric Depression" by J. A. Yesavage, T. L. Brink, T. S. Rose, O. Lum, P. H. Heersema, and M. Adey, 1982, Clinical Gerontologist, 1, pp. 37-43; and "Development and Validation of a Geriatric Depression Rating Scale: A Preliminary Report," by J. A. Yesavage et al., 1982-1983, Journal of Psychiatric Research, 17, pp. 37-49.

d" The Brief Psychiatric Rating Scale," by J. E. Overall and D. R. Gorham, 1962, Psychological Reports, 10, pp. 799-812.

initiative may be interpreted as withdrawal or depression even in the absence of depressed mood on the part of the patient. Several studies have suggested that depressive symptoms may be responsive to pharmacologic intervention but that they have no effect on cognition (Lyketsos et al., 2000). As the disease progresses, agitation or psychotic features such as hallucinations or delusions may occur. These symptoms can also arise from cognitive compromise and can be disturbing, challenging the coping strategies of the patient and family (Raskind, 1999).

Wandering is likely to occur at some point during the course of the disease. While definitive studies as to the cause are difficult to conduct, several causal factors have been proposed, including medication side effects; stress; confusion related to time; inability to recognize familiar people, places, and objects; fear arising from the misinterpretation of sights and sounds; or desire to fulfill former obligations, such as going to work or looking after a child. The need to address this behavioral problem is great because it causes worry to family members, impedes providing care to the patient, and can be a source of significant danger to the patient.

The Caregiver Role in Managing AD 33

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