Factors Associated With Behavioral and Psychological Symptoms of Dementia: Prospective Observational Study Using Actigraphy

Abstract

Background Although disclosing the predictors of different behavioral and psychological symptoms of dementia (BPSD) is the first step in developing person-centered interventions, current understanding is limited, as it considers BPSD as a homogenous construct. This fails to account for their heterogeneity and hinders development of interventions that address the underlying causes of the target BPSD subsyndromes. Moreover, understanding the influence of proximal factors—circadian rhythm–related factors (ie, sleep and activity levels) and physical and psychosocial unmet needs states—on BPSD subsyndromes is limited, due to the challenges of obtaining objective and/or continuous time-varying measures. Objective The aim of this study was to explore factors associated with BPSD subsyndromes among community-dwelling older adults with dementia, considering sets of background and proximal factors (ie, actigraphy-measured sleep and physical activity levels and diary-based caregiver-perceived symptom triggers), guided by the need-driven dementia-compromised behavior model. Methods A prospective observational study design was employed. Study participants included 145 older adults with dementia living at home. The mean age at baseline was 81.2 (SD 6.01) years and the sample consisted of 86 (59.3%) women. BPSD were measured with a BPSD diary kept by caregivers and were categorized into seven subsyndromes. Independent variables consisted of background characteristics and proximal factors (ie, sleep and physical activity levels measured using actigraphy and caregiver-reported contributing factors assessed using a BPSD diary). Generalized linear mixed models (GLMMs) were used to examine the factors that predicted the occurrence of BPSD subsyndromes. We compared the models based on the Akaike information criterion, the Bayesian information criterion, and likelihood ratio testing. Results Compared to the GLMMs with only background factors, the addition of actigraphy and diary-based data improved model fit for every BPSD subsyndrome. The number of hours of nighttime sleep was a predictor of the next day’s sleep and nighttime behaviors (odds ratio [OR] 0.9, 95% CI 0.8-1.0; P=.005), and the amount of energy expenditure was a predictor for euphoria or elation (OR 0.02, 95% CI 0.0-0.5; P=.02). All subsyndromes, except for euphoria or elation, were significantly associated with hunger or thirst and urination or bowel movements, and all BPSD subsyndromes showed an association with environmental change. Age, marital status, premorbid personality, and taking sedatives were predictors of specific BPSD subsyndromes. Conclusions BPSD are clinically heterogeneous, and their occurrence can be predicted by different contributing factors. Our results for various BPSD suggest a critical window for timely intervention and care planning. Findings from this study will help devise symptom-targeted and individualized interventions to prevent and manage BPSD and facilitate personalized dementia care.

Biweekly fluctuations of neuropsychiatric symptoms according to the Neuropsychiatric Inventory: Erratic symptoms or scores?

“…Previous studies that have used diaries to daily assess NPS in dementia suggested a rather erratic nature of NPS. [16][17][18] This is in line with the growing body of evidence emphasizing the role of proximal causes of NPS including psychosocial factors (e.g., caregiver burden, caregiver communication style), environmental factors (e.g., light, temperature), and somatic conditions (e.g., pain, thirst). 17,19 Alternatively, the irregular course of NPI scores could also arise from methodologic issues related to the NPI.…”

“…[16][17][18] This is in line with the growing body of evidence emphasizing the role of proximal causes of NPS including psychosocial factors (e.g., caregiver burden, caregiver communication style), environmental factors (e.g., light, temperature), and somatic conditions (e.g., pain, thirst). 17,19 Alternatively, the irregular course of NPI scores could also arise from methodologic issues related to the NPI. Our finding that changes in NPI scores were unrelated to changes in caregiver burden could support this.…”

“…The large within‐person variation in NPI scores could reflect substantial fluctuations in the manifestation of NPS in patients visiting the memory clinic. Previous studies that have used diaries to daily assess NPS in dementia suggested a rather erratic nature of NPS 16–18 . This is in line with the growing body of evidence emphasizing the role of proximal causes of NPS including psychosocial factors (e.g., caregiver burden, caregiver communication style), environmental factors (e.g., light, temperature), and somatic conditions (e.g., pain, thirst) 17,19 …”

The association of physical activity and behavioral and psychological symptoms among a sample of hospitalized older adults living with dementia

“…4,5 Previous research indicates that gender, age, dementia severity, functional ability, comorbidities, pain, delirium, and the quality of staff-patient interactions can be associated with behavioral and psychological symptoms among individuals with dementia. [6][7][8][9] Additionally, when hospitalized, older adults with dementia may experience physical symptoms due to their acute illness or confusion related to their new hospital environment. This experience can increase behavioral and psychological symptoms of dementia, especially symptoms of aggression, motor disturbance, and sleep disturbance.…”

“…BPSD can be divided into four clusters: the hyperactivity cluster (agitation/aggression, euphoria, disinhibition, irritability, motor disturbance), the psychosis cluster (delusions, hallucinations), the mood lability cluster (depression/dysphoria, anxiety), and the instinctual cluster (appetite disturbance, sleep disturbance, apathy) 4,5 . Previous research indicates that gender, age, dementia severity, functional ability, comorbidities, pain, delirium, and the quality of staff‐patient interactions can be associated with behavioral and psychological symptoms among individuals with dementia 6–9 . Additionally, when hospitalized, older adults with dementia may experience physical symptoms due to their acute illness or confusion related to their new hospital environment.…”