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Table of Contents
Vol. 26, No. 2, 2008
Issue release date: September 2008
Section title: Review Article
Dement Geriatr Cogn Disord 2008;26:138–146
(DOI:10.1159/000149584)

Patient and Caregiver Perspectives of Quality of Life in Dementia

An Investigation of the Relationship to Behavioural and Psychological Symptoms in Dementia

Hurt C.a · Bhattacharyya S.b · Burns A.b · Camus V.d · Liperoti R.g · Marriott A.c · Nobili F.h · Robert P.e · Tsolaki M.i · Vellas B.f · Verhey F.j · Byrne E.J.b
aKing’s College London, Institute of Psychiatry, London, bDivision of Psychiatry, University of Manchester, Manchester, and cKingshill Research Centre, Victoria Hospital, Swindon, UK; dClinique Psychiatrique Universitaire, Centre Hospitalier Régional Universitaire, Tours, eCentre Mémoire de Ressources et de Recherche au CHU, Université de Nice Sophia-Antipolis, Nice, and fCentre Mémoire de Ressources et de Recherche de Toulouse, Toulouse, France; gCentro Medicina dell’Invecchiamento, Università Cattolica del Sacro Cuore, Rome, and hClinical Neurophysiology Service, Department of Internal Medicine, University of Genoa, Genoa, Italy; iMemory and Dementia Centre, Aristotle University of Thessaloniki, Thessaloniki, Greece; jUniversity Hospital of Maastricht, Alzheimer Centre Limburg, Limburg, The Netherlands
email Corresponding Author

Abstract

Background/Aims: Behavioural and psychological symptoms have a high prevalence amongst patients with dementia and can be a significant source of distress to both patients and carers. The present study explored the relationships between quality of life and behavioural and psychological symptoms in dementia (BPSD) from both patient and carer perspectives. Contextual factors surrounding the occurrence of BPSD were explored. Methods: Forty-six patients and 116 carers completed questionnaire measures of BPSD and quality of life. Results: BPSD were negatively associated with both patient and carer ratings of patient quality of life. The symptoms related to lower quality of life differed between patient and carer ratings: depression and irritability were found to predict lower carer ratings of quality of life, whilst delusions and apathy indicated lower patient ratings. Carers were found to be poor at identifying antecedents and consequences of BPSD. Conclusions: The presence of BPSD is associated with lower quality of life in dementia. Interventions designed to improve the quality of life for patients should focus on the BPSD specifically associated with the patient’s rating of quality of life. Information regarding the role of contextual factors in behaviour management should be made available to carers.

© 2008 S. Karger AG, Basel


  

Key Words

  • Quality of life
  • Dementia, behavioural and psychological symptoms
  • Alzheimer’s disease
  • Antecedents, behaviour and consequences
  • Patient report
  • Carer report

References

  1. Finkel S, Burns A: Behavioral and Psychological Symptoms of Dementia (BPSD): a clinical and research update. IPA Bulletin 1999;16:2.
  2. Davis KL, Marin DB, Kane R, Patrick D, Peskind ER, Raskind MA, Puder KL: The Caregiver Activity Survey (CAS) development and validation of a new measure for caregivers of persons with Alzheimer’s disease. Int J Geriatr Psychiatry 1997;12:978–988.
  3. Marin DB, Green CR, Schmeidler J, Harvey PD, Lawlor BA, Ryan TM, Aryan M, Davis KL, Mohs RC: Noncognitive disturbances in Alzheimer’s disease: frequency, longitudinal course, and relationship to cognitive symptoms. J Am Geriatr Soc 1997;45:1331–1338.
  4. Lawlor B: Managing behavioural and psychological symptoms in dementia. Br J Psychiatry 2002;181:463–465.
  5. Finkel S: Behavioral and psychological signs and symptoms of dementia: implications for research and treatment. Int Psychogeriatr 1996;8(suppl 3):215–255.

    External Resources

  6. McShane R: What are the symptoms of behavioural and psychological symptoms of dementia? Int Psychogeriatr 2002;12(suppl 1):147–154.
  7. Mirakhur A, Craig D, Hart DJ, McLlroy SP, Passmore A: Behavioural and psychological syndromes in Alzheimer’s disease. Int J Geriatr Psychiatry 2004;19:1035–1039.
  8. Petrovic M, Hurt C, Collins D, Burns A, Camus V, Liperoti R, Marriott A, Nobili F, Robert P, Tsolaki M, Vellas B, Verhey F, Byrne EJ: Clustering of behavioural and psychological symptoms in dementia: a European Alzheimer’s Disease Consortium (EADC) study. Acta Clin Belg 2007;62:426–432.
  9. Robert P, Verhey FR, Byrne EJ, Hurt C, De Deyn PP, Nobili F, Riello R, Rodriguez G, Frisoni GB, Tsolaki M, Kyriazopoulou N, Bullock R, Burns A, Vellas B: Grouping for behavioural and psychological symptoms in dementia: clinical and biological aspects – consensus paper of the European Alzheimer Disease Consortium. Eur Psychiatry 2005;20:490–496.
  10. Aalten P, Verhey F, Boziki M, Bullock R, Byrne EJ, Camus V, Caputo M, Collins D, De Deyn PP, Elina K, Frisoni GB, Girtler N, Holmes C, Hurt C, Marriot A, Meccoci P, Nobili F, Ousset PJ, Reynish E Salmon E, Tsolaki M, Vellas B, Robert PH: Neuropsychiatric syndromes in dementia: results from the European Alzheimer’s Disease Consortium (EADC). I. Dement Geriatr Cogn Disord 2007;24:457–463.
  11. Frisoni GB, Rozzini L, Gozetti A, Binetti G, Zanetti O, Bianchetti A, Trabucchi M, Cummings JL: Behavioural syndromes in Alzheimer’s disease: description and correlates. Dement Geriatr Cogn Disord 1999;10:130–138.
  12. Donaldson C, Tarrier N, Burns A: The impact of the symptoms of dementia on caregivers. Br J Psychiatry 1997;170:62–68.
  13. Tariot PT: Agitation; in Qizilbash N, Schneider LS, Chui H, Tariot P, Brodaty H, Kaye J, Erkinjuntti T (eds): Evidence-Based Dementia Practice. Oxford, Blackwell Publishing, 2002, pp 705–707.
  14. Donaldson C, Tarrier N, Burns A: Determinants of carer stress in Alzheimer’s Disease. Int J Geriatr Psychiatry 1998;13:248–256.
  15. Ballard CG, Neill D, O’Brien J, McKeith I, Ince P, Perry R: Anxiety, depression and psychosis in vascular dementia: prevalence and associations. J Affect Disord 2000;59:97–106.
  16. Burns A: The burden of Alzheimer’s disease. Int J Neuropsychopharmacol 2000;3:31–38.
  17. Pruchno RA, Resch NL: Husbands and wives as caregivers: antecedents of depression and burden. Gerontologist 1989;29:159–165.
  18. Matsui T, Nakaaki S, Murata Y, Sato J, Shinagawa Y, Tatsumi H, Furukawa TA: Determinants of the quality of life in Alzheimer’s disease patients as assessed by the Japanese version of the Quality of Life – Alzheimer’s Disease Scale. Dement Geriatr Cogn Disord 2006;21:182–191.
  19. Banerjee S, Smith SC, Lamping DL, Harwood RH, Foley B, Smith P, Murray J, Prince M, Levin E, Mann A, Knapp M: Quality of life in dementia: more than just cognition – an analysis of associations with quality of life in dementia. J Neurol Neurosurg Psychiatry 2006;77:146–148.
  20. Karlawish JHT, Casarett D, Klocinski J, Clark CM: The relationship between caregivers’ global ratings of Alzheimer’s disease patients’ quality of life, disease severity, and the caregiving experience. J Am Geriatr Soc 2001;49:1066–1070.
  21. Selai CE, Trimble MR, Rossor M, Harvey RJ: Assessing quality of life in dementia: preliminary psychometric testing of the Quality of Life Assessment Schedule (QOLAS). Neuropsychol Rehabil 2001;11:219–243.
  22. Monteiro IM, Auer SR, Boksay I, Reisberg B: New and promising modalities for assessment of behavioural and psychological symptoms of dementia. Int Psychogeriatr 2000;12(suppl 1):175–178.

    External Resources

  23. Logsdon RG, Gibbons LE, McCurry SM, Teri L: Quality of life in Alzheimer’s disease: patient and caregiver reports. J Mental Health Ageing 1999;5:21–32.
  24. Godlove-Mozley C, Huxley P, Sutcliffe C, Bagley H, Burns A, Challis D, Cordingley L: ‘Not knowing where I am doesn’t mean I don’t know what I like’: cognitive impairment and quality of life responses in elderly people. Int J Geriatr Psychiatry 1999;14:776–783.
  25. Ready RE, Ott BR, Grace J: Patient versus informant perspectives of quality of life in mild cognitive impairment and Alzheimer’s disease. Int J Geriatr Psychiatry 2004;19:256–265.
  26. Jönsson L, Andreasen N, Kilander L, Soininen H, Waldemar G, Nygaard H, Winblad B, Jönhagen M, Hallikainen M, Wimo A: Patient- and proxy-reported utility in Alzheimer’s disease using the EuroQoL. Alzheimer Dis Assoc Disord 2006;20:49–55.
  27. Sprangers MAG, Aaronson NK: The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease: a review. J Clin Epidemiol 1992;45:743–760.
  28. Karlawish JH, Casarett DJ, James, BD, Tenhave T, Clark CM, Asch DA: Why would caregivers not want to treat their relative’s Alzheimer’s disease? J Am Geriatr Soc 2003;51:1391–1397.
  29. International Psychogeriatric Association: Behavioural and Psychological Symptoms of Dementia Educational Pack 2003. Illinois, IPA, 2003.
  30. McShane R, Gormley N: Assessment and management of behavioural and psychological symptoms of dementia (BPSD); in Copeland J, Abou-Saleh MT, Blazer DT (eds): Geriatric Psychiatry. Chichester, Wiley, 2002, pp 241–244.
  31. Cohen-Mansfield J, Werner P: Longitudinal changes in behavioural problems in old age: a study in an adult day care population. J Gerontol A Biol Sci Med Sci 1998;53:M65–M71.
  32. Awata S: A practical study on the early diagnosis and early care system for the elderly with dementia living in depopulated regions: a network system of public mental health services connected with local general hospital in north-western Miyagi. Jpn J Geriatr Psychiatry 1999;10:339–346.
  33. Mahoney E, Volicer L, Hurley A: Challenging Behaviors in Dementia. Baltimore, Health Professional Press, 2000.
  34. Omelan C: Approach to managing behavioural disturbances in dementia. Can Fam Physician 2006;52:191–199.
  35. Robert PH, Clairnet S, Benoit M: The apathy inventory: assessment of apathy and awareness in Alzheimer’s disease, Parkinson’s disease and mild cognitive impairment. Int J Geriatr Psychiatry 2002;17:1099–1105.
  36. Cummings J, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J: The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308–2314.
  37. Folstein ME, Folstein SE, McHugh PR: ‘Mini-Mental State’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.
  38. Sands L, Ferreira P, Stewart AL, Brod M, Yaffe K: What explains differences between dementia patients’ and their caregivers’ ratings of patients’ quality of life? Am J Geriatr Psychiatry 2004;12:272–280.
  39. Levy ML, Cummings JL, Fairbanks LA, Bravi D, Calvani M, Carta A: Longitudinal assessment of symptoms of depression, agitation, and psychosis in 181 patients with Alzheimer’s disease. Am J Psychiatry 1996;153:1438–1443.
  40. Thorgrimsen L, Selwood A, Spector A, Royan L, de Madariaga Lopez M, Woods RT, Orrell M: Whose quality of life is it anyway? The validity and reliability of the Quality of Life-Alzheimer’s Disease (QoL-AD) Scale. Alzheimer Disease Assoc Disord 2003;17:201–208.
  41. Cohen-Mansfield J: Non-pharmacological interventions for inappropriate behaviours in dementia. Am J Geriatr Psychiatry 2001;9:361–381.

  

Author Contacts

Dr. Catherine Hurt
King’s College London, Institute of Psychiatry
Department of Psychology PO77
De Crespigny Park, London SE5 8AF (UK)
Tel. +44 20 7848 0923, Fax +44 20 7848 5006, E-Mail Catherine.hurt@iop.kcl.ac.uk

  

Article Information

Accepted: May 12, 2008
Published online: August 4, 2008
Number of Print Pages : 9
Number of Figures : 3, Number of Tables : 4, Number of References : 41

  

Publication Details

Dementia and Geriatric Cognitive Disorders

Vol. 26, No. 2, Year 2008 (Cover Date: September 2008)

Journal Editor: Chan-Palay V. (New York, N.Y.)
ISSN: 1420–8008 (Print), eISSN: 1421–9824 (Online)

For additional information: http://www.karger.com/DEM


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Background/Aims: Behavioural and psychological symptoms have a high prevalence amongst patients with dementia and can be a significant source of distress to both patients and carers. The present study explored the relationships between quality of life and behavioural and psychological symptoms in dementia (BPSD) from both patient and carer perspectives. Contextual factors surrounding the occurrence of BPSD were explored. Methods: Forty-six patients and 116 carers completed questionnaire measures of BPSD and quality of life. Results: BPSD were negatively associated with both patient and carer ratings of patient quality of life. The symptoms related to lower quality of life differed between patient and carer ratings: depression and irritability were found to predict lower carer ratings of quality of life, whilst delusions and apathy indicated lower patient ratings. Carers were found to be poor at identifying antecedents and consequences of BPSD. Conclusions: The presence of BPSD is associated with lower quality of life in dementia. Interventions designed to improve the quality of life for patients should focus on the BPSD specifically associated with the patient’s rating of quality of life. Information regarding the role of contextual factors in behaviour management should be made available to carers.

© 2008 S. Karger AG, Basel


  

Author Contacts

Dr. Catherine Hurt
King’s College London, Institute of Psychiatry
Department of Psychology PO77
De Crespigny Park, London SE5 8AF (UK)
Tel. +44 20 7848 0923, Fax +44 20 7848 5006, E-Mail Catherine.hurt@iop.kcl.ac.uk

  

Article Information

Accepted: May 12, 2008
Published online: August 4, 2008
Number of Print Pages : 9
Number of Figures : 3, Number of Tables : 4, Number of References : 41

  

Publication Details

Dementia and Geriatric Cognitive Disorders

Vol. 26, No. 2, Year 2008 (Cover Date: September 2008)

Journal Editor: Chan-Palay V. (New York, N.Y.)
ISSN: 1420–8008 (Print), eISSN: 1421–9824 (Online)

For additional information: http://www.karger.com/DEM


Article / Publication Details

First-Page Preview
Abstract of Review Article

Accepted: 5/23/2008
Published online: 8/4/2008
Issue release date: September 2008

Number of Print Pages: 9
Number of Figures: 3
Number of Tables: 4

ISSN: 1420-8008 (Print)
eISSN: 1421-9824 (Online)

For additional information: http://www.karger.com/DEM


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Finkel S, Burns A: Behavioral and Psychological Symptoms of Dementia (BPSD): a clinical and research update. IPA Bulletin 1999;16:2.
  2. Davis KL, Marin DB, Kane R, Patrick D, Peskind ER, Raskind MA, Puder KL: The Caregiver Activity Survey (CAS) development and validation of a new measure for caregivers of persons with Alzheimer’s disease. Int J Geriatr Psychiatry 1997;12:978–988.
  3. Marin DB, Green CR, Schmeidler J, Harvey PD, Lawlor BA, Ryan TM, Aryan M, Davis KL, Mohs RC: Noncognitive disturbances in Alzheimer’s disease: frequency, longitudinal course, and relationship to cognitive symptoms. J Am Geriatr Soc 1997;45:1331–1338.
  4. Lawlor B: Managing behavioural and psychological symptoms in dementia. Br J Psychiatry 2002;181:463–465.
  5. Finkel S: Behavioral and psychological signs and symptoms of dementia: implications for research and treatment. Int Psychogeriatr 1996;8(suppl 3):215–255.

    External Resources

  6. McShane R: What are the symptoms of behavioural and psychological symptoms of dementia? Int Psychogeriatr 2002;12(suppl 1):147–154.
  7. Mirakhur A, Craig D, Hart DJ, McLlroy SP, Passmore A: Behavioural and psychological syndromes in Alzheimer’s disease. Int J Geriatr Psychiatry 2004;19:1035–1039.
  8. Petrovic M, Hurt C, Collins D, Burns A, Camus V, Liperoti R, Marriott A, Nobili F, Robert P, Tsolaki M, Vellas B, Verhey F, Byrne EJ: Clustering of behavioural and psychological symptoms in dementia: a European Alzheimer’s Disease Consortium (EADC) study. Acta Clin Belg 2007;62:426–432.
  9. Robert P, Verhey FR, Byrne EJ, Hurt C, De Deyn PP, Nobili F, Riello R, Rodriguez G, Frisoni GB, Tsolaki M, Kyriazopoulou N, Bullock R, Burns A, Vellas B: Grouping for behavioural and psychological symptoms in dementia: clinical and biological aspects – consensus paper of the European Alzheimer Disease Consortium. Eur Psychiatry 2005;20:490–496.
  10. Aalten P, Verhey F, Boziki M, Bullock R, Byrne EJ, Camus V, Caputo M, Collins D, De Deyn PP, Elina K, Frisoni GB, Girtler N, Holmes C, Hurt C, Marriot A, Meccoci P, Nobili F, Ousset PJ, Reynish E Salmon E, Tsolaki M, Vellas B, Robert PH: Neuropsychiatric syndromes in dementia: results from the European Alzheimer’s Disease Consortium (EADC). I. Dement Geriatr Cogn Disord 2007;24:457–463.
  11. Frisoni GB, Rozzini L, Gozetti A, Binetti G, Zanetti O, Bianchetti A, Trabucchi M, Cummings JL: Behavioural syndromes in Alzheimer’s disease: description and correlates. Dement Geriatr Cogn Disord 1999;10:130–138.
  12. Donaldson C, Tarrier N, Burns A: The impact of the symptoms of dementia on caregivers. Br J Psychiatry 1997;170:62–68.
  13. Tariot PT: Agitation; in Qizilbash N, Schneider LS, Chui H, Tariot P, Brodaty H, Kaye J, Erkinjuntti T (eds): Evidence-Based Dementia Practice. Oxford, Blackwell Publishing, 2002, pp 705–707.
  14. Donaldson C, Tarrier N, Burns A: Determinants of carer stress in Alzheimer’s Disease. Int J Geriatr Psychiatry 1998;13:248–256.
  15. Ballard CG, Neill D, O’Brien J, McKeith I, Ince P, Perry R: Anxiety, depression and psychosis in vascular dementia: prevalence and associations. J Affect Disord 2000;59:97–106.
  16. Burns A: The burden of Alzheimer’s disease. Int J Neuropsychopharmacol 2000;3:31–38.
  17. Pruchno RA, Resch NL: Husbands and wives as caregivers: antecedents of depression and burden. Gerontologist 1989;29:159–165.
  18. Matsui T, Nakaaki S, Murata Y, Sato J, Shinagawa Y, Tatsumi H, Furukawa TA: Determinants of the quality of life in Alzheimer’s disease patients as assessed by the Japanese version of the Quality of Life – Alzheimer’s Disease Scale. Dement Geriatr Cogn Disord 2006;21:182–191.
  19. Banerjee S, Smith SC, Lamping DL, Harwood RH, Foley B, Smith P, Murray J, Prince M, Levin E, Mann A, Knapp M: Quality of life in dementia: more than just cognition – an analysis of associations with quality of life in dementia. J Neurol Neurosurg Psychiatry 2006;77:146–148.
  20. Karlawish JHT, Casarett D, Klocinski J, Clark CM: The relationship between caregivers’ global ratings of Alzheimer’s disease patients’ quality of life, disease severity, and the caregiving experience. J Am Geriatr Soc 2001;49:1066–1070.
  21. Selai CE, Trimble MR, Rossor M, Harvey RJ: Assessing quality of life in dementia: preliminary psychometric testing of the Quality of Life Assessment Schedule (QOLAS). Neuropsychol Rehabil 2001;11:219–243.
  22. Monteiro IM, Auer SR, Boksay I, Reisberg B: New and promising modalities for assessment of behavioural and psychological symptoms of dementia. Int Psychogeriatr 2000;12(suppl 1):175–178.

    External Resources

  23. Logsdon RG, Gibbons LE, McCurry SM, Teri L: Quality of life in Alzheimer’s disease: patient and caregiver reports. J Mental Health Ageing 1999;5:21–32.
  24. Godlove-Mozley C, Huxley P, Sutcliffe C, Bagley H, Burns A, Challis D, Cordingley L: ‘Not knowing where I am doesn’t mean I don’t know what I like’: cognitive impairment and quality of life responses in elderly people. Int J Geriatr Psychiatry 1999;14:776–783.
  25. Ready RE, Ott BR, Grace J: Patient versus informant perspectives of quality of life in mild cognitive impairment and Alzheimer’s disease. Int J Geriatr Psychiatry 2004;19:256–265.
  26. Jönsson L, Andreasen N, Kilander L, Soininen H, Waldemar G, Nygaard H, Winblad B, Jönhagen M, Hallikainen M, Wimo A: Patient- and proxy-reported utility in Alzheimer’s disease using the EuroQoL. Alzheimer Dis Assoc Disord 2006;20:49–55.
  27. Sprangers MAG, Aaronson NK: The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease: a review. J Clin Epidemiol 1992;45:743–760.
  28. Karlawish JH, Casarett DJ, James, BD, Tenhave T, Clark CM, Asch DA: Why would caregivers not want to treat their relative’s Alzheimer’s disease? J Am Geriatr Soc 2003;51:1391–1397.
  29. International Psychogeriatric Association: Behavioural and Psychological Symptoms of Dementia Educational Pack 2003. Illinois, IPA, 2003.
  30. McShane R, Gormley N: Assessment and management of behavioural and psychological symptoms of dementia (BPSD); in Copeland J, Abou-Saleh MT, Blazer DT (eds): Geriatric Psychiatry. Chichester, Wiley, 2002, pp 241–244.
  31. Cohen-Mansfield J, Werner P: Longitudinal changes in behavioural problems in old age: a study in an adult day care population. J Gerontol A Biol Sci Med Sci 1998;53:M65–M71.
  32. Awata S: A practical study on the early diagnosis and early care system for the elderly with dementia living in depopulated regions: a network system of public mental health services connected with local general hospital in north-western Miyagi. Jpn J Geriatr Psychiatry 1999;10:339–346.
  33. Mahoney E, Volicer L, Hurley A: Challenging Behaviors in Dementia. Baltimore, Health Professional Press, 2000.
  34. Omelan C: Approach to managing behavioural disturbances in dementia. Can Fam Physician 2006;52:191–199.
  35. Robert PH, Clairnet S, Benoit M: The apathy inventory: assessment of apathy and awareness in Alzheimer’s disease, Parkinson’s disease and mild cognitive impairment. Int J Geriatr Psychiatry 2002;17:1099–1105.
  36. Cummings J, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J: The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308–2314.
  37. Folstein ME, Folstein SE, McHugh PR: ‘Mini-Mental State’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.
  38. Sands L, Ferreira P, Stewart AL, Brod M, Yaffe K: What explains differences between dementia patients’ and their caregivers’ ratings of patients’ quality of life? Am J Geriatr Psychiatry 2004;12:272–280.
  39. Levy ML, Cummings JL, Fairbanks LA, Bravi D, Calvani M, Carta A: Longitudinal assessment of symptoms of depression, agitation, and psychosis in 181 patients with Alzheimer’s disease. Am J Psychiatry 1996;153:1438–1443.
  40. Thorgrimsen L, Selwood A, Spector A, Royan L, de Madariaga Lopez M, Woods RT, Orrell M: Whose quality of life is it anyway? The validity and reliability of the Quality of Life-Alzheimer’s Disease (QoL-AD) Scale. Alzheimer Disease Assoc Disord 2003;17:201–208.
  41. Cohen-Mansfield J: Non-pharmacological interventions for inappropriate behaviours in dementia. Am J Geriatr Psychiatry 2001;9:361–381.