Indian Journal of Social Psychiatry

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 38  |  Issue : 4  |  Page : 362--368

Magnitude and determinants of behavioral and psychological symptoms in dementia patients visiting a geriatric psychiatry clinic in a rural medical college


Kshirod Kumar Mishra, Ahmed Mushtaq Reshamvala, Harshal Shriram Sathe 
 Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India

Correspondence Address:
Dr. Kshirod Kumar Mishra
Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
India

Abstract

Background: The proportion of elderly people in the Indian population is increasing, thereby making dementia a major public health concern. The behavioral and psychological symptoms of dementia (BPSD) are deleterious to the illness course in dementia. The characteristics and sociodemographic and clinical correlates of BPSD is an understudied area. Materials and Methods: This was a retrospective cross-sectional observational descriptive study conducted in a public hospital. Hospital records of 97 dementia patients who visited the geriatric clinic in the time span of 20 months were analyzed using appropriate descriptive and inferential statistics. Results: The mean age of the patients was 69.9 ± 8.50 years, majority being males (72%). Sleep disturbance (75.3%), changes in psychomotor activity (55.7%), and irritability (45.3%) were the most common behavioral and psychological symptoms associated with dementia. Apathy was seen in 39% of patients, whereas the proportion of patients with depression and anxiety was 26% and 35%, respectively. Psychotic symptoms such as delusions and hallucinations were seen in approximately 24% and 15.5% of patients, respectively. The psychotic symptoms showed a significant association with lower levels of education, whereas apathy was negatively associated with age. Females had a higher likelihood of having psychotic symptoms as compared to males. Conclusion: In the present study, the frequency and association of neuropsychiatric symptoms with demographic variables have been described in dementia patients visiting a public hospital in rural India. Among BPSD, sleep and motor disturbances were most frequent whereas agitation/aggression was least frequent. The age, education level, and gender differences noted in the individual symptoms need to be confirmed in further studies with better design.



How to cite this article:
Mishra KK, Reshamvala AM, Sathe HS. Magnitude and determinants of behavioral and psychological symptoms in dementia patients visiting a geriatric psychiatry clinic in a rural medical college.Indian J Soc Psychiatry 2022;38:362-368


How to cite this URL:
Mishra KK, Reshamvala AM, Sathe HS. Magnitude and determinants of behavioral and psychological symptoms in dementia patients visiting a geriatric psychiatry clinic in a rural medical college. Indian J Soc Psychiatry [serial online] 2022 [cited 2023 Feb 6 ];38:362-368
Available from: https://www.indjsp.org/text.asp?2022/38/4/362/360988


Full Text



 Introduction



India is facing a demographic shift with an increase in the proportion of elderly people in the population.[1] Hence, dementia, which mainly affects old-age people, is becoming a major public health concern in India.[2] In dementia, there is a global cognitive decline that significantly impairs the day-to-day functioning of an individual.[3] However, apart from cognitive decline and its functional consequences, at least 80% of dementia patients suffer from behavioral and psychological symptoms (BPSs).[4] BPSs of dementia (BPSD) include a heterogeneous range of psychological reactions and behavioral alterations such as agitation, aggression, depression, psychotic symptoms, and sleep disturbances.[5] The term behavioral and psychological disorder was first used by the International Psychogeriatric Society in 1996.[6] The International Classification of Diseases, Tenth Edition (ICD-10),[7] and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,[8] use the specifier for additional symptoms in dementia patients, whereas the latest version of ICD (ICD-11)[9] has a separate diagnostic coding subcategory 6D86 for BPSD.

The presence of BPSD is associated with increased morbidity and mortality in patients with dementia.[10] It has also been found to increase the treatment cost, need for hospitalization, and the caregiver burden in dementia.[11] Additionally, unlike the symptom of cognitive decline, BPSD is treatable by pharmacological methods.[12]

About four out of five patients with dementia and half of the patients with mild cognitive impairment may suffer from BPSD.[4] The diagnosis of BPSD in dementia patients is made by combining interviews, direct observation, and informant reports.[13] The psychometric scales used for assessing the severity of these neuropsychiatric symptoms such as BEHAVE-AD are completed by interviewing a reliable informant accompanying the patient.[14] In the present study, the information in the patient records of dementia patients visiting a hospital, which is a combination of clinical interviews, informant reports, and mental status examination of dementia patients, was used to assess the presence of BPSD in the cases of dementia.

Previous Indian work in the area of BPSD has focused on the frequency of these symptoms and their association with the severity of dementia.[15] The European Alzheimer's Disease Consortium study on BPSD using neuropsychiatric inventory (NPI) assessed associations with demographic and clinical variables with BPSD.[16] Given that BPSD affect a large proportion of dementia patients and is amenable to treatment, a careful analysis of its symptoms may be worthwhile in the pursuit of effective management of dementia. Additionally, most of the current researches on the topic focus on patients residing in urban areas.[17] Hence, the present study was conducted in a rural tertiary health-care center with the objectives of finding the magnitude of various BPSD and their association with demographic variables such as age, sex, education level, and presence of physical comorbidities in dementia patients.

 Materials and Methods



Study procedure

The study was conducted in the geriatric psychiatry clinic of a rural medical college and teaching hospital in Central India after approval from the institutional ethics committee. It was a retrospective, cross-sectional observational descriptive study done using the clinical records of patients visiting the geriatric psychiatry clinic and diagnosed with dementia as per the ICD-10. The data of all the dementia patients, who visited the hospital during the 20 months from April 2019 to December 2020, were collected.

Data collection

Sociodemographic data were collected from the outpatient department (OPD) records using semi-structured pro forma which noted the age, gender, and education level of the patients. The presence of physical comorbidities such as diabetes mellitus, hypertension, and stroke was noted as mentioned in records. We reviewed clinical histories taken at the first visit of dementia patients to the geriatric clinic. The NPI which is a commonly used scale for assessment of BPSs was used as a reference for NPI was used as a reference tool to mark the presence or absence of BPSs. The description of clinical symptoms in history section was studied for the presence of BPS enumerated in the neuropsychological inventory (NPI) as per the definitions mentioned in the NPI manual.[18] The items of NPI not mentioned in the history were considered absent.

Data analysis

The data were first entered in Microsoft Excel, and data cleaning was done. The JASP software version 0.14, JASP team, University of Amsterdam, Amsterdam, The Netherlands. was used for applying descriptive and inferential statistics to the data. The qualitative data such as gender and presence or absence of various neuropsychiatric symptoms were expressed in total number and percentage, whereas median and interquartile range have been given for continuous variables such as age and educational level. Normality test (Shapiro–Wilk test) of quantitative variables, such as age and educational level, revealed nonnormal distribution (P < 0.05). Hence, association between the presence of neuropsychiatric symptoms and quantitative variables such as age and education level was done by Mann–Whitney U-test. Chi-square test was used to find the association of neuropsychiatric symptoms with dichotomous categorical variables, such as sex and presence/absence of physical comorbidities.

 Results



Demographic characteristics, physical comorbidities, and frequency of neuropsychiatric symptoms in study population (descriptive statistics)

Ninety-seven dementia patients had visited the OPD during the specified period. The mean age of the study subjects (n = 97) was 69.90 ± 8.50 years, and the majority of them were males (n = 70, 72%). 20.6% (n = 20) of the patients were illiterate, whereas nearly 59% (n = 58) of dementia patients had education levels lower than secondary school or 10th standard. Very few cases (n = 2) were educated above graduate level. Physical comorbidities were present in 53.6% (n = 53). Hypertension (n=36, 37.11%) followed by diabetes (n=14, 14.4%) and cerebrovascular event or stroke (n=15, 15.4%) were the most common physical co morbidities, about 23% (n = 22) of cases had more than one physical comorbidity. Comorbid substance use was seen in only about 24% (n = 23) of the population, the majority of which were males as shown in [Table 1]. Sleep disturbance was the most common behavioral symptom (n = 73, 75.3%) noted which was followed by a change in the level of motor activity (n = 54, 55.7%) and irritability (n = 44, 45.7%). Apathy was present in 38 patients (39.2%), whereas depressive and anxiety symptoms were noted in 26 (26.8%) and 34 (35.1%) patients, respectively. Psychotic symptoms such as delusions (n = 24, 24.7%) and hallucinations (n = 15, 15.5%) were observed in a comparatively lesser frequency. The manic symptoms of elation (n = 8, 8.2%), disinhibition (n = 7, 7.2%), and agitation (n = 4, 4.05%) were observed only in a minority of patients as shown in [Table 2].{Table 1}{Table 2}

Association of behavioral and psychological symptoms of dementia symptom clusters with demographic variables (age, education level, sex) and presence/absence of physical comorbidities

Age is a quantitative variable, and education level (number of grades passed by the patient) was treated as an ordinal variable. The neurovegetative symptoms such as sleep and appetite changes did not significantly vary with change in age (U = 854, P = 0.854; U = 525.5, P = 0.371, respectively) or educational levels (U = 826.5, P = 0.676; U = 597, P = 0.856, respectively). The lower education level had a significant association with the presence of delusions (U = 559.5, P = 0.007) and near significant association with hallucinations (U = 401, P = 0.078). The psychotic symptoms did not vary significantly with the age (delusions: U = 794.5, P = 0.495; hallucinations: U = 494.5, P = 0.406). In contrast, the higher levels of education were associated with the presence of aggression, but levels were not significant (U = 92.5, P = 0.09). The mood changes such as depressive symptoms and hypomanic symptoms such as elation and disinhibition did not vary significantly with age as well as educational status. Apathy was negatively associated with age (U = 861.5, P = 0.055), but it had no association with education level (U = 1069.5, P = 0.7). The commonly found symptoms of irritability and change in psychomotor activity did not show a significant association with age as well as education level [Table 3].{Table 3}

Association of categorical variables such as sex and presence/absence of physical comorbidities with the neuropsychiatric symptoms was done with Chi-square test. Females had a higher presence of delusions (Χ2 = 3.037, P = 0.081) and hallucinations (Χ2 = 3.133, P = 0.077) as compared to males, and the difference approximated the significance levels. The psychotic symptoms did not show any association with the presence of physical comorbidities. Except for the hypomanic symptom of disinhibition which was significantly associated with an absence of physical comorbidity (Χ2 = 4.69, P = 0.03), the mood symptoms such as depression and elation showed no association with the sex of patient or physical comorbidities. The neurovegetative symptoms of sleep and appetite disturbances also did not vary with sex or physical illnesses. The distribution of symptoms of apathy, irritability, and changes in psychomotor activity was also similar in both the sexes and in the patients with or without physical comorbidity [Table 4].{Table 4}

 Discussion



In the present study, the determinants of BPSs in the cases of dementia were explored. The majority of the dementia cases presenting with behavioral problems in our study were males. These findings were similar to another study done in the South Indian state of Kerala[13] but differed from the European Alzheimer's Disease Consortium study which recorded a female-to-male patient ratio of 3:2.[16] As the current study is done in an Indian rural medical college, these findings may indicate lower accessibility of health services for females in rural areas of India.

Sleep disturbance was the most common neuropsychiatric symptom in dementia found in more than three-fourth of the cases in the present study. These findings match with those of Lyketsos et al. where sleep disturbance was only second to apathy as the most common neuropsychiatric symptom.[4] Lack of sleep leads to a significant caregiver burden as well as is one of the prime reasons underlying the decline in health-related quality of life.[19] Over half of the study subjects of the present study showed disturbances in psychomotor activity. This figure was much higher than the findings of Petrovic et al. who found aberrant motor behavior in approximately 30% of dementia patients.[16] However, our findings approximated with a previous Indian study which reported wandering, purposeless, and inappropriate activity in over 40% of dementia patients.[15] In a South Indian study, motor behavior changes were seen in about 65% of patients which led to the maximum caregiver burden in dementia cases.[17] Another Indian study reported sleep problems in 58.9% participants whereas abnormal motor behaviour was present in 31.8% of the patients.[20]

There is a wide variation in reporting of the rates of depression in dementia patients across various cross-sectional studies. This could be because of different study procedures and cultural variations in reporting the symptoms. Twenty-six percent of patients in the present study had a depressed mood at the presentation. These findings matched with Khandelwal et al.[15] who found a depressed mood in 33% of dementia patients but differed from a study done by Mukherjee et al.,[20] where depressive symptoms were reported in 56% of patients. It is important to carefully evaluate the depressive symptoms in dementia as it they are often underdiagnosed and hence undertreated in elderly people.[21] Anxiety symptoms were found in 35% of patients in the present study which was similar to the findings of Shaji et al.[17] Anxiety in dementia patients implies the stress caused by awareness of cognitive decline and consequent difficulties in activities of daily living.[22] Apathy is one of the most common presentations among all the neuropsychiatric symptoms of dementia and is associated with aberrant motor behavior and irritability. The presence of apathy is associated with significant functional impairment and caregiver burden.[23] Although apathy was not the most common symptom, a substantial proportion (36%) of dementia patients suffered from apathy in the present study, which vastly differed from apathy/indifference found in 72.9% of patients in another Indian study.[20] In the present study, nearly 25% of patients demonstrated delusions whereas hallucinations were present in about 14% of cases. These findings matched with the European Consortium of Alzheimer's Disease study who found the same proportion of the patients having these psychotic symptoms.[16] Khandelwal et al. also reported a similar rate of delusion in dementia patients (27%).[15] However, the number was far lower than Shaji et al. who found delusions in 53% and hallucinations in 33% of study participants.[17]

According to a study conducted on 399 older adults in Singapore, the psychotic symptoms, as well as mood disturbances found in the patients of dementia, increased with the age of the patient.[24] An Indian study comparing early- and late-onset Alzheimer's disease found that behavioral problems had higher severity in late-onset as compared to early-onset dementia.[25] However, our study found no significant association of age with the presence of any of the neuropsychiatric symptoms except for apathy. It is well known that the presence of apathy precedes cognitive impairment in cases of dementia. Apathy is also considered a risk factor for the development of dementia.[26] The near-significant association of lower age with the presence of apathy (P = 0.055) matches these literature findings.

Females have been found to have a higher mean total NPI score as well as higher levels of depression.[27] In contrast, men with Alzheimer's dementia are more likely to have agitation compared to women.[28] In our study, it was noted that a higher proportion of females showed depressive, psychotic as well as instinctual symptoms such as sleep disturbances. Among these, the probability of female dementia patients developing psychotic symptoms approximated the significant level (P = 0.077). Men are more likely than women to present with aggressiveness and diurnal rhythm disturbances and less likely to present with paranoid, delusional ideation; hallucination; and affective disturbances and anxieties and phobias.[29] Similar findings were noted in the present study where aggression and disinhibition were mostly seen in men. Only one female patient was recorded to have disinhibition, and no female patient had aggressive behavior. Kitamura et al. reported similar findings where males were less likely to suffer from delusions, hallucinations, anxiety, and emotional impairment.[29] Patients with chronic physical illnesses such as diabetes have been found to have earlier onset and increased severity of neuropsychiatric symptoms.[30] However, contrary to these findings, the present study found no association of the presence of NPI with the presence of physical comorbidity. The methodological differences between these studies could account for these variations.

The educational attainment of an individual is directly associated with resilience. Higher resilience is known to reduce the risk of dementia.[31] Thus, we expect highly educated people to develop dementia at a later age. However, not much is known about the impact of education on BPSs. In the present study, it was found that lower levels of education were associated with the presence of psychotic symptoms such as delusions and hallucinations in dementia patients. Lower education has been previously associated with psychotic symptoms in mental illnesses other than dementia.[32]

Mukherjee et al. found in their study that rural population had a relatively higher score on NPI scale compared to urban. Although not significant, urban population showed higher levels of aggression, irritability, and disinhibition. Significantly higher levels of apathy and appetite disorders were seen in rural population.[20] Another French study revealed higher odds of those being treated in urban population having aggressiveness and screaming behavior.[33] The study population in the present study was rural. We found lower levels of aggression and disinhibition and higher levels of apathy which is similar to previous studies.

Limitations

As the present study was conducted based on records of the patients visiting the hospital, the findings cannot be generalized to the population. The lack of psychometric data of cognitive and behavioral assessment also limited the quantification of the severity of BPSs.

 Conclusion



Most patients with dementia presenting to tertiary health-care setups show different neuropsychiatric symptoms which are amenable to medical management. In the present study, BPSD most frequently presented with sleep and motor disturbances whereas agitation/aggression was the least frequent symptom. The age, education, and gender differences noted among BPS may need confirmation from further research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ingle GK, Nath A. Geriatric health in India: Concerns and solutions. Indian J Community Med 2008;33:214.
2Das SK, Pal S, Ghosal MK. Dementia: Indian scenario. Neurol India 2012;60:618.
3Rabins PV, Lyketsos CG, Steele CD. Practical Dementia Care. oUP USa; 2006.
4Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: Results from the cardiovascular health study. JAMA 2002;288:1475-83.
5Lyketsos CG, Carrillo MC, Ryan JM, Khachaturian AS, Trzepacz P, Amatniek J, et al. Neuropsychiatric symptoms in Alzheimer's disease. Alzheimers Dement 2011;7:532-9.
6Finkel SI, Costa e Silva J, Cohen G, Miller S, Sartorius N. Behavioral and psychological signs and symptoms of dementia: A consensus statement on current knowledge and implications for research and treatment. Int Psychogeriatr 1996;8 Suppl 3:497-500.
7World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
8American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.
9World Health Organization. ICD-11 Reference Guide. Geneva: World Health Organization 2019.
10Bränsvik V, Granvik E, Minthon L, Nordström P, Nägga K. Mortality in patients with behavioural and psychological symptoms of dementia: A registry-based study. Aging Ment Health 2021;25:1101-9.
11Zhu CW, Scarmeas N, Ornstein K, Albert M, Brandt J, Blacker D, et al. Health-care use and cost in dementia caregivers: Longitudinal results from the predictors caregiver study. Alzheimers Dement 2015;11:444-54.
12Pinto C, Seethalakshmi R. Longitudinal progression of behavioral and psychological symptoms of dementia: A pilot study from India. Psychogeriatrics 2006;6:154-8.
13Shaji S, Bose S, Kuriakose S. Behavioral and psychological symptoms of dementia: A study of symptomatology. Indian J Psychiatry 2009;51:38.
14Reisberg B, Monteiro I, Torossian C, Auer S, Shulman MB, Ghimire S, et al. The BEHAVE-AD assessment system: A perspective, a commentary on new findings, and a historical review. Dement Geriatr Cogn Disord 2014;38:89-146.
15Khandelwal SK, Ahuja GK, Gupta S. Behavioural symptoms in dementia: Nature and treatment. Indian J Psychiatry 1992;34:36-40.
16Petrovic M, Hurt C, Collins D, Burns A, Camus V, Liperoti R, et al. Clustering of behavioural and psychological symptoms in dementia (BPSD): A European Alzheimer's disease consortium (EADC) study. Acta Clin Belg 2007;62:426-32.
17Shaji S, Bose S, Verghese A. Prevalence of dementia in an urban population in Kerala, India. Br J Psychiatry 2005;186:136-40.
18Kaufer DI, Cummings JL, Ketchel P, Smith V, MacMillan A, Shelley T, et al. Validation of the NPI-Q, a brief clinical form of the neuropsychiatric inventory. J Neuropsychiatry Clin Neurosci 2000;12:233-9.
19Bartolomei L, Pastore A, Meligrana L, Sanson E, Bonetto N, Minicuci GM, et al. Relevance of sleep quality on caregiver burden in Parkinson's disease. Neurol Sci 2018;39:835-9.
20Mukherjee A, Biswas A, Roy A, Biswas S, Gangopadhyay G, Das SK. Behavioural and psychological symptoms of dementia: Correlates and impact on caregiver distress. Dement Geriatr Cogn Dis Extra 2017;7:354-65.
21Allan CE, Valkanova V, Ebmeier KP. Depression in older people is underdiagnosed. Practitioner 2014;258:19-22, 2-3.
22Beaudreau SA, O'Hara R. Late-life anxiety and cognitive impairment: A review. Am J Geriatr Psychiatry 2008;16:790-803.
23Clarke DE, van Reekum R, Simard M, Streiner DL, Conn D, Cohen T, et al. Apathy in dementia: Clinical and sociodemographic correlates. J Neuropsychiatry Clin Neurosci 2008;20:337-47.
24Vaingankar JA, Chong SA, Abdin E, Picco L, Jeyagurunathan A, Seow E, et al. Behavioral and psychological symptoms of dementia: Prevalence, symptom groups and their correlates in community-based older adults with dementia in Singapore. Int Psychogeriatr 2017;29:1363-76.
25Mushtaq R, Pinto C, Tarfarosh SF, Hussain A, Shoib S, Shah T, et al. A comparison of the behavioral and psychological symptoms of dementia (BPSD) in early-onset and late-onset Alzheimer's disease-a study from South East Asia (Kashmir, India). Cureus 2016;8:e625.
26van Dalen JW, Van Wanrooij LL, van Charante EP, Richard E, van Gool WA. Apathy is associated with incident dementia in community-dwelling older people. Neurology 2018;90:e82-9.
27Spalletta G, Musicco M, Padovani A, Rozzini L, Perri R, Fadda L, et al. Neuropsychiatric symptoms and syndromes in a large cohort of newly diagnosed, untreated patients with Alzheimer disease. Am J Geriatr Psychiatry 2010;18:1026-35.
28Lee J, Lee KJ, Kim H. Gender differences in behavioral and psychological symptoms of patients with Alzheimer's disease. Asian J Psychiatr 2017;26:124-8.
29Kitamura T, Kitamura M, Hino S, Tanaka N, Kurata K. Gender differences in clinical manifestations and outcomes among hospitalized patients with behavioral and psychological symptoms of dementia. J Clin Psychiatry 2012;73:1548-54.
30Shi Q, Zhou F, Mei J, Yang H, Li H. The effect of type 2 diabetes mellitus on neuropsychological symptoms in Chinese early Alzheimer's disease population. Neuropsychiatr Dis Treat 2020;16:829-36.
31Livingston G, Selbaek G, Rockwood K, Huntley JD, Sommerlad A, Mukadam N. Cognitive reserve and resilience: Possible mechanisms of dementia prevention: Reserve and resilience: Opportunities and mechanisms for dementia prevention. Alzheimers Dement 2020;16:e037931.
32Hakulinen C, McGrath JJ, Timmerman A, Skipper N, Mortensen PB, Pedersen CB, et al. The association between early-onset schizophrenia with employment, income, education, and cohabitation status: Nationwide study with 35 years of follow-up. Soc Psychiatry Psychiatr Epidemiol 2019;54:1343-51.
33de Souto Barreto P, Lapeyre-Mestre M, Vellas B, Rolland Y. From rural to urban areas: Differences in behavioural and psychological symptoms of dementia in nursing home residents according to geographical location. Psychogeriatrics 2014;14:229-34.