Prevalence and clinical correlates of disinhibition in dementia

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OBJECTIVE AND METHODS: The phenomenology, main clinical correlates, and long-term evolution of disinhibition in dementia are not well known. To examine this issue, we studied a consecutive series of 272 patients with probable Alzheimer disease using a comprehensive psychiatric and neuropsychological evaluation that included the Disinhibition Scale. A subset of patients was reexamined with the same instruments between 1 and 4 years after the initial evaluation. RESULTS: A factor analysis of the Disinhibition Scale demonstrated 4 factors: (1) abnormal motor behavior, (2) hypomania, (3) loss of insight and egocentrism, and (4) poor self-care. Disinhibition was significantly associated with major and dysthymic depression, more severe negative symptoms, and loss of awareness. Most patients with disinhibition at the initial evaluation still showed disinhibition at follow-up, whereas 23% of patients without disinhibition at the initial evaluation developed disinhibition at follow-up. CONCLUSIONS: Disinhibition is a frequent and long-lasting problem in dementia. Our study demonstrates that the construct of disinhibition consists of 4 independent subsyndromes, each of which may have specific underlying mechanisms.


Starkstein SE, Garau ML, Cao A. Prevalence and clinical correlates of disinhibition in dementia. Cogn Behav Neurol. 2004 Sep;17(3):139-47.

A wide range of abnormal behaviors generically termed behavioral and psychologic symptoms of dementia (BPSD) has been reported to be frequent clinical findings.[1-5] BPSD includes physical aggression, wandering, restlessness, agitation, inappropriate social behavior, pacing, screaming, crying, cursing, lack of drive, repetitive questioning, and shadowing.[6] BPSD also includes symptoms of hypomania or disinhibition such as orality, hyperphagia, euphoria, hypersexuality, grandiose ideas, and overspending.[7]

Several studies examined the prevalence of abnormal behaviors in dementia[.8-11] Lyketsos et al[12] reported agitation-aggression in 24% of a series of 329 demented patients as compared with 3% among 672 age-comparable individuals without dementia, and 10 to 15% of the demented patients had 1 or more episodes of physical aggression during the month preceding the evaluation. Other studies reported the prevalence of physical aggression during the year prior to the evaluation to be 2 to 3 times higher.[13-19] Our group[7] reported that 12% of a consecutive series of 196 patients with probable Alzheimer disease had aggressive episodes (verbal and/or physical) during the month preceding the evaluation. One limitation of these studies is that most of them only assessed single abnormal behaviors (e.g., aggression or motor hyperactivity), and whether aggressive behaviors are part of a broader psychopathologic syndrome has been rarely examined.

We developed the Disinhibition Scale to assess a priori defined domains of abnormal behaviors such as motor behaviors (e.g., hyperactivity, wandering, utilization behavior), stereotyped behaviors (e.g., verbal stereotypies, motor routines), hypomania (e.g., euphoria, hypersexuality, irritability), psychosis (delusions, hallucinations), and poor self-care (e.g., poor hygiene, careless dressing, poor insight). The Disinhibition Scale also includes a set of items rating negative behaviors (e.g., lack of initiative, emotional flattening, loss of interests, loss of appetite), which are scored separately.

Some of the aims of the present study were to examine the reliability and validity of the Disinhibition Scale in a large series of patients with dementia, to assess whether abnormal behaviors fall into specific domains, and to determine whether positive and negative abnormal behaviors are contradictory constructs or are significantly associated. Additional aims were to examine the main clinical correlates and the longitudinal evolution of disinhibited behaviors in dementia.


PATIENTS AND METHODS


Study Sample

Dementia Group

This group included a consecutive series of outpatients attending the Dementia Clinic of the Raul Carrea Institute of Neurologic Research between January 1996 and October 2000 for evaluation and treatment of progressive cognitive decline. The inclusion criteria were: (1) National Institutes of Neurological and Communications Disorders Section-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria[20] for probable Alzheimer disease; (2) No history of closed head injuries with loss of consciousness, strokes, or other neurologic disorder with central nervous system involvement; (3) Normal results on laboratory tests (to rule out other etiologies of dementia); (4) No focal lesions on magnetic resonance imaging scan; and (5) a Hachinski Ischemic score <4.[21]

Healthy Control Group

This group included 17 healthy elderly individuals (mostly volunteers from the community), with normal neurologic and psychiatric evaluations, a negative history of neurologic disorders or closed head injuries, and a normal computed tomography or magnetic resonance imaging scan.

Psychiatric Examination

After written informed consent was obtained from patients and their respective caregivers, a psychiatrist blind to neuropsychological findings assessed patients and controls with the following instruments:

Structured Clinical Interview for DSM-IV

The Structured Clinical Interview for DSM-IV (SCID)[22] is a semistructured diagnostic interview for making the major Axis I DSM-IV diagnoses. The SCID was administered by a psychiatrist with the patient and at least 1 first-degree relative. Based on the SCID responses, DSM-IV Axis I diagnoses were made.

Mini-Mental State Examination

The Mini-Mental State Examination[23] is an 11-item examination found to be valid and reliable in assessing a limited range of cognitive functions in a global way.

Clinical Dementia Rating

The Clinical Dementia Rating[24] is a global rating device for dementia stages.

Hamilton Depression Scale

The Hamilton Depression Scale[25] is a 17-item interviewer-rated scale that measures psychological and autonomic symptoms of depression.

Hamilton Anxiety Scale

The Hamilton Anxiety Scale[26] is an 11-item interviewer-rated scale that measures the severity of generalized or persistent anxiety.

Apathy Scale

The Apathy Scale includes 14 items, which are scored by the patient's relative or caregiver. We have demonstrated the reliability and validity of the Apathy Scale in dementia.[27]

Irritability Scale

The Irritability Scale is a 14-item scale, which is rated by the patient's relative or caretaker. We have demonstrated the validity and reliability of this scale in dementia.[27]

Overt Agitation Severity Scale

The Overt Agitation Severity Scale[28] measures aspects of agitated behavior involving vocalizations and oral/facial movements, upper torso and extremity movements, and lower extremity movements. Items are rated by caregivers based on the frequency and intensity of the behaviors.

Dementia Psychosis Scale

The Dementia Psychosis Scale[29] is an 18-item caregiver-rated scale, which quantifies the severity and types of delusions in demented patients at the time of the psychiatric evaluation. We have demonstrated the validity and reliability of this scale in dementia.[29]

Overt Aggression Scale

The Overt Aggression Scale[28] measures specific aspects of aggressive behavior based on observable criteria. Informants were asked about the presence and type of aggressive outbursts during the 4 weeks preceding the psychiatric evaluation.

Social Ties Checklist

The Social Ties Checklist[30] is a 10-item scale that measures the quantity and quality of social supports.

Disinhibition Scale

This scale consists of 26 questions rating abnormal behaviors over the preceding 4 weeks. One questionnaire is assessed with the patient, and a second similar questionnaire (written in the third person) is rated by the caregiver blind to the patient's answers. Item scores range from 0 (no abnormal behavior) to 4 (extreme abnormal behavior). Items were grouped into 4 domains: (1) abnormal motor behaviors (e.g., hyperactivity, wandering, utilization behavior); (2) stereotyped routines (e.g., verbal stereotypies, motor routines, obsessive ideas and rituals); (3) psychosis (delusions, hallucinations); (4) hypomanic behavior (e.g., pressured speech, euphoria, irritability, hyperphagia, hypersexuality, overspending, grandiose ideas, inappropriate social behavior); and (5) poor self-care (e.g., poor hygiene, careless dressing, poor insight about own deficits, distractibility, excessive sleep, poor awareness of danger). The scale also includes questions about negative behaviors (e.g., emotional flatness, loss of interests, abulia), but ratings on these items were not included in the final score (the scale is provided in the Appendix).

Neurologic Examination

Patients and controls were assessed with the Unified Parkinson Disease Rating Scale[31] by a neurologist who was blind to psychiatric ratings. Parkinsonism was diagnosed whenever patients had rigidity, bradykinesia, and resting tremor, or rigidity plus bradykinesia only, or resting tremor only.[32]

Statistical Analysis

Statistical analysis was carried out using means and SDs, analysis of variance (ANOVA) with repeated measures, and forward stepwise regression analysis. A principal components factor analysis for the Disinhibition Scale items was carried out using varimax rotation. Frequency distributions were calculated using Chi-square tests with a Yates' correction for expected cell sizes <5. All P values are 2-tailed.


RESULTS

Reliability and Validity of the Disinhibition Scale

To determine interrater reliability, 10 patients were reassessed with the Disinhibition Scale by a psychiatrist blind to the first evaluation about 10 days after the initial assessment. Test-retest reliability was calculated assessing the same caregiver by the same interviewer on 2 occasions, 1 month apart. Intraclass correlations for interrater and test-retest reliability were both high (ICC = 0.94 and ICC = 0.67, respectively). There also was a high internal consistency of the Disinhibition Scale as examined using the Cronbach's alpha coefficient (α = 0.83). The validity of the Disinhibition Scale was assessed after a neurologist who was blind to the psychiatric findings classified a consecutive series of 45 demented patients into groups with or without disinhibited behaviors based on clinical judgement. Patients with a clinical diagnosis of disinhibition (n = 21) had a significantly higher score on the Disinhibition Scale (as rated by their respective caregivers) compared with patients without disinhibition (n = 24) (mean scores ± SD: Disinhibition group = 16.9 ± 10.5, No disinhibition group = 7.5 ± 6.9; t = 3.58, df = 43, P < 0.001). The Disinhibition Scale was also rated on 17 healthy individuals (70% females) by their respective partners. Mean age (±SD) of the control group was 67.3 ± 9.6 years, and their mean (±SD) Disinhibition Scale score was 2.4 ± 2.4 (range = 0 to 8 points).

Sample Characteristics

A consecutive series of 272 patients with probable Alzheimer disease were included in the present study. Mean age (years ± SD) was 71.0 ± 7.6 years, 61% were females, mean duration of illness was 2.9 ± 2.3 years, mean education was 12.3 ± 6.9 years, and mean Mini-Mental State Examination score was 21.8 ± 5.8 points.

Phenomenology of Disinhibition in Dementia

The most frequent abnormal behaviors as rated by caregivers on the Disinhibition Scale over the 4 weeks preceding the psychiatric evaluation were distractibility, poor awareness of danger, inappropriate social behaviors, loss of insight, verbal stereotypies, inappropriate dressing, irritability, and stereotyped routines (Table 1).


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Table 1. Frequency of Abnormal Behaviors in Alzheimer Disease (% of Patients)
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The Disinhibition Scale item scores of the 272 patients were entered into a principal components factor analysis. Items of the Disinhibition Scale were checked according to their frequency of being rated, and items with less than 15% positive ratings were removed. The items of hallucinations, delusions, and awareness of danger were also removed. After varimax rotation, a 4-factor solution was derived: Factor 1 had an eigenvalue of 3.54 and accounted for 27% of the variance. This factor loaded (>0.45) on the items of hyperactivity (0.81) and wandering (0.80) and was construed as an abnormal motor behavior factor. Factor 2 had an eigenvalue of 1.51 and accounted for 12% of the variance. This factor loaded on the items of overspending (0.50), grandiose ideation (0.63), irritability (0.59), and interpersonal conflicts (0.78) and was construed as an hypomanic factor. Factor 3 had an eigenvalue of 1.25 and accounted for 10% of the variance. This factor loaded on the items of poor hygiene (0.64), inappropriate dressing (0.72), and increased sleep (0.73) and was construed as a poor self-care factor. Factor 4 had an eigenvalue of 1.09 and explained 8% of the variance. This factor loaded on the items of stereotyped routines (0.47), egocentric ideas (0.57), inappropriate social behaviors (0.65), and poor insight (0.82) and was construed as an egocentrism and loss of insight factor.

Based on the factor analysis results, disinhibition was diagnosed as present whenever patients had a score of 2 or 3 (i.e., moderate or severe abnormal behavior) on at least 1 of the items included in at least 3 of the 4 domains. Using this diagnostic scheme, 30 of the 272 patients (11%) had disinhibition.
Disinhibition and Stage of Illness TOP

Based on their clinical dementia rating (CDR) scores, patients were divided into those with very mild (i.e., CDR = 0.5, n = 79), mild (CDR = 1, n = 119), moderate (CDR = 2, n = 62), or severe dementia (CDR = 3, n = 12). A 2-way ANOVA with repeated measures for Disinhibition Scale factor scores (CDR stage × Disinhibition Scale factor scores) showed a significant effect for CDR (F3,268) = 7.90, P < 0.0001): there was a significant increment on Disinhibition Scale scores across the stages of the illness; and a significant CDR × Disinhibition Scale factor scores interaction (F(9,804) = 4.48, P < 0.0001): patients with either moderate or severe dementia had significantly more severe abnormal motor behaviors than patients with very mild dementia, and patients with severe dementia had significantly worse self-care compared with the other 3 groups (Fig. 1).


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FIGURE 1. No caption available. There was a progressive increment in abnormal motor behavior and poor self care across the stages of the illness.
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Correlation Between Negative Symptoms and Disinhibition Scores

There was a significant correlation between Disinhibition Scale scores and the sum of negative symptoms rated on the Disinhibition Scale (r = 0.62, P < 0.001) (Fig. 2). A stepwise regression analysis with Disinhibition Scale scores as the dependent variable and age, Mini-Mental State Examination, Dementia-Psychosis Scale, Hamilton Depression Scale, Anosognosia Questionnaire-Dementia, Irritability Scale, Apathy Scale, Overt Aggression Scale, and Overt Agitation Severity Scale as the independent variables was statistically significant (R2 = 0.60, F(8,261) = 49.3, P < 0.0001). The variables that accounted for a significant part of the variance were the following: Hamilton Depression Scale (R2 = 0.34, P < 0.0001), Anosognosia Questionnaire-Dementia (R2 = 0.15, P < 0.0001), Overt Aggression Scale (R2 = 0.04, P < 0.0001), Apathy Scale (R2 = 0.03, P < 0.0001), and the Dementia-Psychosis Scale (R2 = 0.02, P < 0.001).


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FIGURE 2. No caption available. There was a significant correlation between Disinhibition Scale scores and negative symptoms (i.e., the more severe the disinhibition, the more severe the negative symptoms).
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Depression and Disinhibition in Dementia

Diagnoses of major depression and dysthymia were based on DSM-IV criteria and generated on the basis of SCID assessments. Forty-eight of the 272 patients (18%) had major depression; 31 of these 48 patients (65%) had disinhibition compared with 61 of the 158 patients without depression (39%). A hypothesis of unequal frequency of disinhibition based on the presence of major depression was statistically substantiated (χ2 = 10.0, df = 1, P = 0.001). Dysthymia was present in 66 of the 272 patients (24%), and 35 of these 66 patients (53%) also had disinhibition. The difference between dysthymic and nondepressed patients on the frequency of disinhibition was significant (χ2 = 3.95, df = 1, P < 0.05).

Awareness of Disinhibited Behaviors

To examine awareness of disinhibited behaviors, we compared Disinhibition Scale ratings obtained from patients' own interviews with those obtained from their respective caregivers. To reduce the number of comparisons, we added the scores of items with high loadings on each of the 4 factors derived from the factor analysis, and the product was divided by the number of items included in each factor. A 2-way repeated measures ANOVA (rater: caregiver vs. patient; Disinhibition Scale domains: abnormal motor behavior, hypomania, egocentrism/loss of insight, and poor self-care) showed a significant effect for rater (F(1,270) = 197.9, P < 0.0001): caregivers' ratings on the Disinhibition Scale were significantly higher than patients' own ratings; a significant domain effect (F(3,810) = 96.3, P < 0.0001): patients had significantly higher (i.e., worse) scores on egocentrism/loss of insight compared with the other 3 domains, and a significant rater by Disinhibition Scale domain interaction (F(3,810) = 56.0, P < 0.0001): differences in caregivers versus patients ratings were significantly higher for egocentrism/loss of insight, hypomania, and poor self care (Tukey HSD, P < 0.0001) compared with abnormal motor behaviors (Tukey HSD, P < 0.01).

Disinhibition, Frontotemporal Dementia, and Parkinsonism

Disinhibition is one of the major criteria for the clinical diagnosis of frontotemporal dementia (FTD), and it is highly likely that many of our patients with dementia and disinhibition have the pathologic changes of FTD. The Work Group on Frontotemporal Dementia and Pick's Disease[33] recently recommended clinical criteria to diagnose FTD. Core clinical criteria include an early and progressive change in personality, characterized by difficulty in modulating behavior, often resulting in inappropriate responses or activities. This criterion is further developed in a specific section on behavioral changes in FTD.[31] We used the Disinhibition Scale to operationalize the above as follows: (1) Impulsive or inappropriate behaviors: This domain was rated positive whenever patients scored 2 or higher (i.e., moderate, severe, or extreme) on the item of inappropriate social behavior, and 2 or higher on at least 1 of the items rating swearing, irritability, poor financial judgment, sexual disinhibition, and self-destructive behavior. (2) Repetitive or compulsive behaviors: This domain was rated positive whenever patients scored 2 or higher on at least 1 of the items rating repeated physical actions (verbal or motor), or repeated personal acts or routines. (3) Changes in dietary habits and personal hygiene: This domain was rated positive whenever patients score 2 or higher on at least 1 of the items rating hyperorality, lack of personal hygiene, inappropriate dressing, and inappropriate sphincter control. (4) Impaired insight: This domain was rated positive whenever patients scores 2 or higher on the item rating insight. Using this information, a clinical diagnosis of the core behavioral syndrome of FTD was made whenever patients had positive answers on all 4 domains. Based on this diagnostic scheme, only 7 of the 272 patients (3%) met the core behavioral criteria for FTD. Using a less stringent threshold (positive answers to the domain of impulsive or inappropriate behaviors and to at least 2 of the remaining 3 behavioral domains), 23 of the 272 patients (8%) met the core behavioral criteria for FTD.

Seventy-five of the 272 patients (24%) had Parkinsonism. Two of the 7 patients meeting stringent criteria for behavioral disinhibition had Parkinsonism (29%) compared with 8 of the 23 patients (35%) with behavioral disinhibition diagnosed with the less restrictive approach.

Follow-up Findings

Sixty-one patients (22% of the total sample) had a follow-up evaluation between 1 and 4 years after the initial evaluation (mean ± SD months of follow-up = 20.1 ± 8.4). The remaining patients could not be followed-up due to death (n = 11), patient's or caregiver's refusal (n = 70), change of address (n = 29), very severe dementia (n = 3), less than 12 months since the initial evaluation (n = 80), or unable to be traced (n = 18). A 2-way ANOVA with repeated measures for Disinhibition Scale domains showed a significant time × domain interaction (F(3,177) = 4.60, P < 0.01): there was a significant worsening over time for self-care (F(1,59) = 5.35, P < 0.05); and a significant decrease over time for hypomanic behaviors (F(1,59) = 4.63, P < 0.05). No significant longitudinal changes were found on the domains of egocentrism/loss of insight and abnormal motor behaviors.


DISCUSSION

This study used the Disinhibition Scale to examine the phenomenology, frequency, main clinical correlates and longitudinal evolution of the disinhibition syndrome in a large series of patients with dementia, and there were several important findings. First, we demonstrated the reliability, validity, and internal consistency of the Disinhibition Scale. Second, a factor analysis of the Disinhibition Scale demonstrated the factors of abnormal motor behaviors, egocentrism/loss of insight, poor self-care, and hypomania, and there was a significant correlation between Disinhibition Scale scores and negative symptoms, depression, delusions, anosognosia, overt aggression, and apathy. Third, patients significantly underrated the severity of their disinhibited behaviors compared with reports provided by their respective caregivers, demonstrating poor awareness about their own abnormal behaviors. Finally, a 1- to 4-year follow-up evaluation of a subgroup of 61 patients demonstrated a significant worsening in self-care and a significant decrease of hypomanic behaviors over time.

Before further discussion, several limitations of our study should be pointed out. First, 14% of the patients were on neuroleptics, which may have decreased the true severity of disinhibition. Another limitation is that less than one third of the patients had a follow-up evaluation, which may have biased the longitudinal results toward better outcomes. However, most of the patients with disinhibition at the initial evaluation were still disinhibited at follow-up.

Several studies demonstrated a significant association between disinhibition and negative behaviors (mostly apathy) in dementia,[9,34] and our present study replicates those findings. Patients with disinhibition may show abulia and apathy concomitant with hyperactivity, irritability, and inappropriate social behaviors, suggesting that negative and disinhibited behaviors in dementia should not be construed as contradictory behaviors. It remains to be examined whether pharmacological treatment of positive behaviors may also improve the negative behaviors of dementia. We also found depression to be a frequent comorbid condition of disinhibition, raising the question whether successful antidepressant treatment could also improve some of the symptoms of disinhibition.

A stepwise regression analysis demonstrated a significant association between more severe disinhibition and higher scores of depression, anosognosia, overt aggression, apathy, and delusions, suggesting that affective and behavioral disorders of dementia are not isolated findings, but may constitute cohesive psychopathologic syndromes.

Our group reported that loss of awareness of cognitive deficits and behavioral problems are independent phenomena in dementia, and we also found a significant correlation between loss of awareness of behavioral problems and higher disinhibition scores.[35] The present study extends the concept of loss of awareness to disinhibited behaviors. Differences between patients' and caregivers' ratings were significant for the domains of egocentrism/loss of insight, hypomania, and poor self-care. This finding may have an important impact on the care of demented patients, since lack of awareness could perpetuate disinhibited behaviors.

There also was a significant increment in Disinhibition Scale scores across the stages of dementia, which primarily resulted from a progressive increment in abnormal motor behaviors and poor self-care. To better examine longitudinal changes in disinhibition, we reexamined a group of 61 patients and their respective caregivers between 1 and 4 years after the initial evaluation. The main finding was that 81% of the 31 patients with disinhibition at the initial evaluation remained disinhibited at follow-up, demonstrating that disinhibition is not a fleeting disorder, but may persist over time. In a recent study that included a series of 242 patients, Tractenberg et al[36] reported that endorsement rates of abnormal behaviors such as agitation, irritability, verbal and physical aggression, restlessness, wandering, socially inappropriate behavior, and repetitive behavior were stable over a 12-month period. We found a significant worsening of self-care and a significant decrease of hypomanic behaviors during the follow-up period, demonstrating that specific domains of disinhibition have a different evolution over time.

In conclusion, the present study demonstrated the reliability, validity, and internal consistency of the Disinhibition Scale in dementia. A factor analysis demonstrated disinhibition to include domains of abnormal motor behavior, hypomania, egocentrism/loss of insight, and poor self-care. Disinhibition was significantly associated with more severe depression, anosognosia, overt aggression, apathy, and delusions. There also was a significant correlation between Disinhibition Scale scores and negative symptoms. Patients had a poor awareness of their disinhibited behaviors, and most patients with disinhibition at the initial evaluation still showed disinhibited behaviors 1 to 4 years later.


ACKNOWLEDGMENTS

The authors thank Janus Kremer, MD, Alicia Lischinski, MD, and Gustavo Petracca, MD, for their contribution to the study.


REFERENCES


1. Teri L, Larson EB, Reifler BV. Behavioral disturbance in dementia of the Alzheimer's type. JAGS. 1988;36:1-6.
[Context Link]
2. Burns A, Folstein S, Brandt J, et al. Clinical assessment of irritability, aggression, and apathy in Huntington and Alzheimer disease. J Nerv Ment Dis. 1990;178:20-26.
[Fulltext Link] [CrossRef] [Context Link]
3. Eastley R, Wilcock GK. Prevalence and correlates of aggressive behavior occurring in patients with Alzheimer's disease. Int J Geriatr Psychiatry. 1997;12:484-487.
[CrossRef] [Context Link]
4. Lebowitz BD. Consensus conference: Goals and objectives. Int Psychogeriatr. 1996;8:217-218.
[Context Link]
5. Lebowitz BD. Behavioral and psychological symptoms of dementia: A clinical and research update. Int Psychogeriatr. 2000;12:19-21.
[CrossRef] [Context Link]
6. Zaudig M. Behavioral and psychological symptoms of dementia in the International Classification of Diseases (ICD)-10 and Beyond (ICD-11). Int Psychogeriatr. 2000;12:29-40.
[CrossRef] [Context Link]
7. Chemerinski E, Petracca G, Teson A, et al. Prevalence and correlates of aggressive behavior in Alzheimer's disease. J Neuropsychiat Clin Neurosci. 1998;10:421-425.
[Context Link]
8. Bozeat S, Gregory CA, Lambon MA, et al. Which neuropsychiatric and behavioral features distinguish frontal and temporal variants of frontotemporal dementia from Alzheimer's disease? J Neurol Neurosurg Psychiatry. 2000;69:178-186.
[Fulltext Link] [CrossRef] [Context Link]
9. Kertesz A, Nadkarni N, Davidson W, et al. The Frontal Behavioral Inventory in the differential diagnosis of frontotemporal dementia. JINS. 2000;6:460-468.
[Context Link]
10. Tariot PN, Mack JL, Patterson MB, et al. The Behavioral Pathology Committee of the Consortium to Establish a Registry for Alzheimer's Disease. The Behavior Rating Scale for Dementia of the Consortium to Establish a Registry for Alzheimer's Disease. Am J Psychiatry. 1995;152:1349-1357.
[Context Link]
11. Cummings JL, Mega MS, Gray K, et al. The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994;44:2308-2314.
[Context Link]
12. Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioral disturbances in dementia: findings from the Cache Country study on memory in aging. Am J Psychiatry. 2000;157:708-714.
[CrossRef] [Context Link]
13. Aarsland D, Cummings JL, Yenner G, et al. Relationship of aggressive behavior to other neuropsychiatric symptoms in patients with Alzheimer's disease. Am J Psychiatry. 1996;153:243-247.
[Context Link]
14. Tsai SJ, Hwang JP, Yang CH, et al. Physical aggression and associated factors in probable Alzheimer disease. Alzheimer Dis Assoc Disord. 1996;10:82-85.
[Fulltext Link] [CrossRef] [Context Link]
15. Patel V, Hope T. Aggressive behavior in elderly people with dementia: a review. Int J Geriatr Psychiatry. 1993;8:457-472.
[CrossRef] [Context Link]
16. Hope T, Keene J, Fairburn C, et al. Behaviour changes in dementia 2: Are there behavioural syndromes? Int J Geriatr Psychiatry. 1997;12:1074-1078.
[CrossRef] [Context Link]
17. Hope T, Keene J, Gedling K, et al. Behaviour changes in dementia I: Point of entry data of a prospective study. Int J Geriatr Psychiatry. 1997;12:1062-1073.
[CrossRef] [Context Link]
18. Keene J, Hope T, Fairburn CG, et al. Natural history of aggressive behaviour in dementia. Int J Geriatr Psychiatry. 1999;14:541-548.
[CrossRef] [Context Link]
19. Haupt M, Jänner, Ebeling S, et al. Presentation and stability of noncognitive symptom patterns in patients with Alzheimer disease. Alzheimer Dis Assoc Disord. 1998;12:323-329.
[Medline Link] [CrossRef] [Context Link]
20. McKhann G, Drachman D, Folstein MF, et al. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer's disease. Neurology. 1984;34:939-944.
[Context Link]
21. Hachinski VC, Iliff LD, Zilhka L, et al. Cerebral blood flow in dementia. Arch Neurol. 1975;40:97-103.
[Context Link]
22. Spitzer RL, Williams JBW, Gibbon M, et al. The Structured Clinical Interview for DSM-III-R (SCID I): history, rationale, and description. Arch Gen Psychiatry. 1992;49:624-629.
[Context Link]
23. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psych Res. 1975;12:189-198.
[CrossRef] [Context Link]
24. Hughes CP, Berg L, Danziger WL, et al. A new clinical scale for the staging of dementia. Brit J Psychiatry. 1982;140:566-572.
[Context Link]
25. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
[Medline Link] [CrossRef] [Context Link]
26. Hamilton M. The assessment of anxiety states by rating. Brit J Med Psychol. 1959;32:50-55.
[Medline Link] [Context Link]
27. Starkstein SE, Migliorelli R, Manes F, et al. The prevalence and clinical correlates of apathy and irritability in Alzheimer's disease. Eur J Neurol. 1995;2:540-546.
[Context Link]
28. Yudofsky SC, Silver JM, Hales RE. Treatment of agitation and aggression. In: Shatzberg AF, Nemeroff CB, eds. Textbook of Psychopharmacology. Washington, DC: American Psychiatric Press; 1995:881-900.
[Context Link]
29. Migliorelli R, Petracca G, Teson A, et al. Neuropsychiatric and neuropsychological correlates of delusions in Alzheimer's disease. Psychol Med. 1995;25:505-513.
[Fulltext Link] [Context Link]
30. Starr LB, Robinson RG, Price TR. The Social Functioning Exam: an assessment of stroke patients. Arch Phys Med Rehab. 1983;66:496-500.
[Context Link]
31. Fahn S, Elton E. UPDRS Development Committee: Unified Parkinson's Disease Rating Scale. In: Fahn S, Marsden CD, Goldstein M, et al, eds. Recent Developments in Parkinson's Disease. Florham Park, NJ: Macmillan; 1987:153-163.
[Context Link]
32. Merello M, Sabe L, Teson A, et al. Extrapyramidalism in Alzheimer's disease: prevalence, psychiatric, and neuropsychological correlates. J Neurol Neurosurg Psychiary. 1994;57:1503-1509.
[Context Link]
33. McKhann GM, Albert MS, Grossman M, et al. Clinical and pathological diagnosis of frontotemporal dementia. Arch Neurol. 2001;58:1803-1809.
[CrossRef] [Context Link]
34. Levy ML, Cummings JL, Fairbanks LA, et al. Apathy is not depression. J Neuropsychiat Clin Neurosci. 1998;10:314-319.
[Context Link]
35. Starkstein SE, Sabe L, Chemerinski E, et al. Two domains of anosognosia in Alzheimer's disease. J Neurol Neurosurg Psychiatry. 1996;61:485-490.
[Fulltext Link] [CrossRef] [Context Link]
36. Tractenberg RE, Patterson M, Weiner MF, et al. Prevalence of symptoms on the CERAD Behavior Rating Scale for Dementia in normal elderly subjects and Alzheimer's disease patients. J Neuropsychiat Clin Neurosci. 2000;12:472-479.
[Context Link]
APPENDIX TOP
DISINHIBITION SCALE TOP

1. Initiative

0: Usual initiative in her/his daily activities.

1: Mild loss of initiative on some of her/his daily activities.

2: Marked loss of initiative in her/his daily activities.

3: Complete loss of initiative in her/his daily activities.

2. Physical activity

0: Physical activity is as usual.

1: More restless than usual.

2: Stays still only occasionally.

3: In constant motion.

3. Wandering

0: Walks as usual.

1: Walks short distances without definite purpose.

2: Walks intermittently in circles; sometimes has to be stopped.

3: Constantly tries to leave home; may wander for long hours.

4. Utilization behavior

0: Manipulates objects as usual.

1: Rarely grabs objects without using them.

2: Frequently grabs objects without using them.

3: Constantly grabs objects and uses them in purposeless activities.

5. Language stereotypies

0: Speech content as usual.

1: Frequently repeats some words.

2: Frequently repeats short phrases. 3: Frequently repeats similar stories.

6. Expletives

0: Use of expletives as usual.

1: Mild increment in the use of expletives.

2: Marked increment in the use of expletives.

3: Only utters expletives.

7. Motor routines

0: No presence of purposeless movements.

1: Frequent arms, legs, and/or head purposeless movements.

2: Frequent short purposeless motor sequences.

3: Produces only purposeless motor sequences.

8. Affective display

0: Affective display as usual.

1: Clear increment in laughing and/or crying spells triggered by emotional stimuli.

2: Crying and/or laughing spells triggered by non-emotional (neutral) stimuli.

3: Spontaneous crying and/or laughing spells (in the absence of stimuli).

9. Speech

0: Speaks normally.

1: Speaks more than usual.

2: Speaks constantly.

3: Shouts and intrudes into others' conversations.

10. Sensitivity

0: Response to pain and/or temperature as usual.

1: Mild loss of response to pain and/or temperature.

2: Marked loss of response to pain and/or temperature.

3: Bruises or health problems due to lack of response to pain and/or temperature.

11. Hallucinations

0: None.

1: Refers hearing voices or seeing non-existent objects, but acknowledges the non-reality of these (i.e., hallucinosis).

2: Refers hearing voices or seeing non-existent objects, but denies their non-reality (i.e., true hallucinations).

3: Acts on the hallucinations.

12. Apathy

0: Display of emotions as usual.

1: Mild reduction in her/his emotional display.

2: Marked reduction in her/his emotional display.

3: Never displays any emotion.

13. Cheerfulness

0: Mood as usual.

1: More cheerful than usual.

2: Cheerful most of the time

3: Euphoric most of the time.

14. Irritability

0: No more irritable than usual.

1: More irritable than usual.

2: Frequent verbal aggressions.

3: Frequent verbal and physical aggressions.

15. Feeding

0: Feeds as usual.

1: Less interest in food; no loss of weight.

2: Less interest in food; loss of weight (>2 kgs in past 6 months).

3: Complete loss of interest in food; has to be fed.

16. Orality

0: Eats normally.

1: Eats more than usual, but stops once satisfied.

2: Eats more than usual; eating is only interrupted by withdrawing food.

3: Chews non-edible objects.

17. Sleep pattern

0: Sleeps as usual.

1: Sleeps more than usual at night, but sleeps as usual during the day.

2: Sleeps more than usual both at night and during the day; does not fall asleep when stimulated.

3: Sleeps at any place.

18. Sexuality

0: Sexual interest as usual.

1: Occasional jokes or remarks with sexual content; unusual for her/him.

2: Constant jokes or remarks with sexual content, occasional flirting.

3: Promiscuous sexual activity, masturbation in public, always flirting.

19. Loss of interest

0: Interest in hobbies and daily activities as usual.

1: Mild reduction on interest in hobbies or daily activities.

2: Only interested in very few things.

3: Complete loss of interest.

20. Spending money

0: Spends money as usual.

1: Makes some purchases that are unusual for her/him.

2: Excessive spending of money; buys useless objects.

3: Has depleted relatively important sums of money.

21. Work activities

0: Works as usual.

1: Minor conflicts at work, unusual for her/him.

2: Important conflicts at work.

3: Unable to work due to the severity of the conflicts she/he triggers.

22. Plans

0: Plans are adequate.

1: Some of her/his plans are difficult to carry out, but would not result in financial or personal problems.

2: Some of her/his plans are difficult to carry out, and could result in minor financial or personal problems.

3: Plans are impossible to carry out, and could result in serious financial or personal problems.

23. Attention

0: Concentration in activities as usual.

1: Clear loss of attention, but can resume her/his activities.

2: Clear loss of attention, cannot resume her/his activities.

3: Complete loss of concentration.

24. Social interaction

0: Social interaction as usual.

1: Mild social misbehavior; unusual for her/him.

2: Frequent social misbehaviors; has to be supervised in public.

3: (any of the following):

a. Refuses to talk to guests at home.

b. Makes offensive (e.g., racist) comments in public.

c. Bullies people on the street.

d. Drives recklessly.

e. Shoplifting.

f. Invites strangers to home.

25. Hygiene

0: Keeps personal hygiene as usual.

1: Careless about her/his hygiene.

2: Only washes when asked.

3: Physically resists being washed.

26. Dressing

0: Dresses as usual.

1: Less careful in the selection of clothes.

2: Wears anything at hand.

3: Inappropriate dressing, has to be supervised.

27. Toilet behavior

0: Concern about sphincter control as usual.

1: Some unconcern about sphincter control.

2: Complete unconcern about sphincter control.

4: Occasional manipulation of excrements.

28. Insight

0: Full awareness about cognitive and behavioral problems.

1: Minimization of cognitive and/or behavioral changes.

2: Complete lack of insight into cognitive and/or behavioral changes.

3: Complete lack of insight into cognitive and/or behavioral changes; becomes irritable whenever limitations are pointed out.

29. Delusions

0: All her/his ideas are coherent.

1: Rarely shows some incoherent ideas (people stealing things, strange people at home).

2: Incoherent ideas are present most of the time.

3: Acts on her/his incoherent ideas.

30. Obsessions

0: Adaptation to changes as usual.

1: More rigid on some of the daily routines.

2: More rigid on most of the daily routines.

3: More rigid on most of the daily routines; easily irritated if routines are changed.

31. Egocentrism

0: Generosity is as usual.

1: Less interested in others (e.g., refuses to spend money on presents).

2: Complete loss of interest in others (e.g., only buys things for her/him).

3: Complete loss of interest in others; becomes aggressive when her/his belongings are touched.

32. Awareness of danger

0: Aware of danger as usual.

1: Slight loss of awareness of danger.

2: Severe loss of awareness of danger; major risks of physical harm.

3: Extremely dangerous behaviors; needs constant supervision.

[Context Link]
Keywords:

disinhibition; dementia; depression; awareness; frontal lobes