Mood and Behavioral Disturbances

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Overall, the behavioral and psychological symptoms of dementia are such a salient feature of the disease that there is now a push to include this as a diagnosis or syndrome in the International Classification of Diseases (ICD; Zaudig, 2000). Depression and anxiety are common in dementia, and these can be the first symptoms of a dementia in the absence of initial cognitive deficits (Reding, Haycox, & Blass, 1985). The clinician should suspect a mood or anxiety disorder in individuals presenting with possible dementia, most particularly in persons who are aware of their memory and cognitive failings, compared to patients whose relative or caregiver is noticing the cognitive difficulties (U.S. Department of Health and Human Services, 1996). An individual in the early stages of dementia is more likely to experience a mood or anxiety disorder than one in the moderate or later stage (Merriam, Aronson, Gaston, Wey, & Katz, 1988). The clinical interview is a necessity in ruling out a mood disturbance and, because of the cognitive deficits that are present in dementia, collateral information as to the patient's mood is necessary.

The clinical presentations of depression and anxiety are not often distinguishable between dementias, further clouding the picture among AD, VaD, and MD. In addition, mood disturbances can range from major depressive disorder to mild depression symptoms. However, studies suggest that the presence of ischemic disease seems to be positively correlated with the presence of depressed mood and psychomotor slowing (e.g., Corey-Bloom et al., 1993; Hargrave, Geck, Reed, & Mungas, 2000). In a study of 256 individuals with AD and 36 with ischemic vascular disease or MD, not only was depression more frequent in the latter group, but also it was more severe (Hargrave, Geck, et al., 2000). In another study of three large groups of patients (possible AD, probable AD, and MD), a trend toward a greater frequency of depressed mood was found in the MD group (Corey-Bloom et al., 1993). Therefore, it appears to be critical for the clinician to assess for mood disturbance in individuals presenting with MD.

Apathy also seems to afflict a significant proportion of demented individuals (Corey-Bloom et al., 1993). It can present by itself or, less commonly, as a combination of periods of agitation and periods of passivity (U.S. Department of Health and Human Services, 1996). Much of the initiation and motivation to complete even simple tasks dwindles as the disease progresses. In contrast to the slightly higher rate of depression in MD patients cited previously, apathy was observed less frequently in MD than in AD patients (Kunik et al., 2000). In addition to interdementia differences, there may be ethnic differences. For example, the risk of anxiety and depression concomitant with dementia (not specific to MD) was lower for African Americans and Hispanics than for White individuals (Hargrave, Geck, et al., 2000), whereas the risk of apathy was lower for Hispanic individuals with MD (Hargrave, Stoeklin, Haan, & Reed, 2000).

Apathy can be a burden to caregivers because they must work all that much harder to get the individual to initiate behavior. In addition, indifference to a person's own deficits can be a significant safety risk. Anosagnosia, or an unawareness of deficits, is a common sequela of right hemisphere lesions and may lead to patients' engaging in activities that they cannot safely perform (Hoffman & Platt, 2000). Because of their apathetic behavior, demented individuals also tend to interact less frequently and withdraw from social situations. In a study that compared individuals with AD to those who had either ischemic vascular disease or MD (the authors combined these two groups), decreased affect and withdrawal were more prevalent and more severe in the vascular disease/MD group (Hargrave, Geck, et al., 2000).

In contrast to apathy and withdrawal, some individuals exhibit agitation, aggression, or sexually inappropriate behavior (Hermann & Black, 2000). Psychotic symptoms may include a wide variety of delusions, hallucinations (usually visual), and nocturnal agitation (Eker & Ertan, 2000). Studies report contradictory findings on the comparative rates of behavioral disturbances across dementia groups. For example, the frequency and severity of behavioral disturbances did not differ across patients with MD, VaD, and AD (Swearer, Drachman, O'Donnell, & Mitchell, 1988). Yet, others have reported that behavioral disturbances were more common in MD than AD or MID patients, which the authors interpret as the synergis-tic effect of two brain diseases on behavior (D. Cohen et al., 1993). Another study compared the differences in cognitive and behavioral problems exhibited by AD, VaD, dementia due to alcohol, and MD (Kunik et al., 2000). On the Cohen-Mansfield Agitation Inventory, the MD individuals had significantly more frequent episodes of agitation and verbal aggression than did the individuals with dementia due to alcohol abuse; however, there was no significant difference in the character or severity of agitation among the four groups. In a longitudinal study, the rate of deteriorating behavior was similar in AD, VaD, and MD patients (Barclay, Zemcov, Blass, & Sansone, 1985). Importantly, at 30 months after the initial evaluation, all groups had higher scores on the Haycox, a behavioral rating scale, and equivalent proportions of patients from all groups required institutional care.

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