BetterConduct

The NPI, or Neuropsychiatric Inventory, is one of the most used tests in dementia assessment and evaluation to determine symptoms of psychiatric issues.  The test result patterns have been analyzed for decades and even reanalyzed for the syndromes and subsyndromes the test purports to measure. 

 

In 1994, an interpretation of the results of the NPI in reference to Alzheimer’s behaviors grouped the syndromes into 4 categories with occurring symptoms (now called subsyndromes) in each. The symptoms were referred to as Behavioral and Psychological Symptoms of Dementia or BPSD.   Here is a breakdown of those results based on factor analysis. 

The first category was labeled Behavioral Dyscontrol.  It included the symptoms of euphoria, disinhibition, ambulation, sleep disturbances, and eating disorders. 

The second category was Psychosis and included delusions and hallucinations.

The third was Mood.  The symptoms included were depression, anxiety, and apathy.

The fourth was Agitation, and included aggression and irritability (Cummings and McPherson, 2001).

The belief that identification of a pattern of syndromes could help decide if there were different ways to address symptoms or even help determine subcategories of AD continues today.  The data obtained from AD patients has increased exponentially and been reanalyzed.  The current presentation of symptoms from the NPI in AD patients is a bit different.  Pharmacological studies show individual symptoms might not be affected through the use of specific medications, but syndromes may show improvement as a whole.

 

In 2007, the European Alzheimer’s Disease Consortium (EADC) pooled the NPI test data from 12 European countries and included a dataset of 2,354 Alzheimer’s disease patients for their analysis of symptoms and presenting patterns (Aalten et al, 2007). Using factor or cluster analysis, four symptom clusters were identified. 

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The most prevalent syndrome, called Apathetic, occurred in 65% of the AD cases included in this large study.  This syndrome included subsyndromes(behaviors) of apathy, appetite issues, and eating abnormalities.  In the 1994 NPI study, apathy was included in the mood category and was not indicated as a separate syndrome.  Whether depression and apathy are separate syndromes or are specific neuropsychiatric symptoms is still debated today.  Studies differ considerably on this, which might be explained by the similarity in overt behavioral manifestations of each. Both are exhibited by lack of energy and diminished interest (Aalten et al, 2007 p.458).

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The second most prevalent syndrome, labeled Hyperactivity, included euphoria, disinhibition and aberrant motor behavior (as did the 1994 grouping).  However, the symptoms of irritability and agitation were also included in the Hyperactivity syndrome, which accounted for 64% of the cases—a close second to the Apathetic syndrome.  As mentioned previously, eating abnormalities used to be grouped under Behavioral Dyscontrol in the 1994 data interpretation, and apathy was previously in the Mood category.  Agitation was a separate syndrome of its own and included irritability as a subsyndrome. 

It should be noted that AD clients can present a combination of syndromes in their disease profile. The Hyperactivity syndrome occurred most frequently in conjunction with the Apathetic syndrome in 42% of the patients.  

 

Next is the Affective syndrome in 59% of cases.  The Affective syndrome includes depression and anxiety.  More than 38% of the clients exhibited both the Hyperactivity and Affective syndromes. 

 

The Psychosis syndrome under the EADC model was less prevalent (38%) but resulted in the highest level of total neurological problems (Aalten p. 461).  It included the symptoms of delusions, hallucinations, and sleep disorders, which are now termed nighttime behavioral disturbances.  The inclusion of nighttime disturbances in this category is interesting as all these symptoms require specific treatment strategies (Aalten et al 2007 p. 461), and there is some evidence that sleep issues may be related to hallucinations (Schreinzer et al, 2005). The psychosis syndrome was more likely to appear in isolation than in association with any other syndrome (hyperactivity and psychosis -28%, apathy and psychosis -25%, and affective and psychosis -24%). 

 

There were several points made about these results, many of which are mentioned in the discussion segment of the study itself.  The study included only AD clients worldwide and results cannot necessarily be generalized to other dementias.  It was not a naturalistic study as many of the participants were medicated with anticholinesterase inhibitors (76%) and or antipsychotics (8%).  The study did not account for severity of the AD, age, or gender.  However, it is a study that is used for the framework of BPSD in AD and the behavioral patterns that are expressed in the disease.  If behavioral patterns can be addressed with effective strategies—both pharmacological and nonpharmacological—we would be another step closer to treating not just the symptoms but the source of the disease.  This is important as the behavioral issues associated with AD—and all of the dementias—are more distressing, impairing, and costly than the cognitive symptoms for both the patient and the caregivers (D’Onofrio et al, 2015). 

 

Sources:

Aalten P, Verhey F, R, J, Boziki M, Bullock R, Byrne E, J, Camus V, Caputo M, Collins D, De Deyn P, P, Elina K, Frisoni G, Girtler N, Holmes C, Hurt C, Marriott A, Mecocci P, Nobiii F, Ousset P, J, Reynish E, Salmon E, Tsolaki M, Vellas B, Robert P, H: Neuropsychiatric  syndromes in dementia.  Dementia Geriatr Cogn Disord 2007;24:457-463.

 

Cummings JL, McPherson S.  Neuropsychiatric assessment of Alzheimer’s disease and related dementias.  Aging (Milano) 2001; 13:240-246

 

D'Onofrio, G., Sancarlo, D., Addante, F., Ciccone, F., Cascavilla, L., Paris, F., Picoco, M., Nuzzaci, C., Elia, A. C., Greco, A., Chiarini, R., Panza, F., & Pilotto, A. (2015). Caregiver burden characterization in patients with Alzheimer's disease or vascular dementia. International Journal of Geriatric Psychiatry, 30(9), 891-899. 

 

Schreinzer D, Ballaban T, Brannath W, Lang T, Hilger E, Fasching P, Fischer P: Components of behavioral pathology in dementia.  Int J Geriatr Psychiatry, 2005;20:137-145.