Dr. Robert van Reekum, MD, FRCPC
Department of Psychiatry and KLARU,
Baycrest Centre for Geriatric Care,
Assistant Professor,
Department of Psychiatry,
University of Toronto, Toronto, ON.
Neuropsychiatric assessment in dementia is important as changes in mood and behaviour are common, cause suffering, impact on disability and handicap, influence diagnosis, have prognostic implications and are often treatable. Behaviour may be conceptualized as affecting 'the ABCs': affect, behaviour, cognition, disability, economics, family and goals. Important premorbid factors to assess include a past history of medical, psychiatric, personal, neurodevelopmental, social support/stressors and response to previous treatments. Important current factors to assess include medical status (e.g. metabolic, infections, nutrition, pain, medications), arousal (e.g. delirium), antecedents/precipitants/patterns, cognitive status (e.g. insight), neurologic status (e.g. localizing signs, Parkinsonism). Common behaviours in dementia include agitation, wandering, panic attacks/catastrophic reactions, mood disorders, affective lability, hallucinations, delusions, disinhibition, sexual behaviours, compulsions/perseveration and incontinence. CNS disease may mimic or mask psychiatric disorders (e.g. Parkinson's disease causing the slowing seen in depression, expressive aprosodia masking expression of dysphoria) so that the evaluation of psychiatric illness in this population needs to take into account direct effects of CNS disease. Major Depression is not simply sadness, but is a syndrome of behaviours, which are persistent, severe and have an impact. "Mild depression" does not imply the use of low-dose antidepressants. Given the potential for masking and potential for improvement with the treatment, many clinicians "over-diagnosis" this condition (beware of risks due to antidepressants). Psychotic symptoms include hallucinations and delusions (e.g. of stealing) and are often associated with distress and changes in behaviour (e.g. agitation) which warrant pharmacological intervention. There are many anxiety disorders (e.g. panic, social phobia etc.) which are common in dementia and often warrant treatment. Anxiety may affect cognitive performance, as may depression and psychoses. Apathy (decreased interest, initiation and motivation plus flat affect) is also common in the dementias; rule out sleep disorders, metabolic disturbance (e.g. thyroid), decreased arousal (e.g. side effects of medication) and effects of role loss (e.g. institutionalization). Disinhibition (i.e. behavioural impulsivity, affective lability) is also common and contributes to other problems (e.g. aggression). Finally, this presentation stressed the need for the use of structured, reliable and valid Behavioural inventories to improve consistency of communication and quantification of behaviours (e.g. to allow for improved monitoring of the treatment response) and often to save time (e.g. it can be quicker to complete a structured inventory than it is to write a detailed progress note). The Neuropsychiatric Inventory (NPI) was reviewed, and its use encouraged for clinicians working with dementia populations.
