inductores_modificadores de los spcd

8/10/2019 Inductores_modificadores de Los SPCD

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Elena Ubis Diez

Geriatra. Hospital Sagrado Corazn de Jess

Huesca

INDUCTORES/MODIFICADORES DE

LOS SPCD (comorbilidad, iatrogenia, tratoinadecuado)


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Introduccin

Modelo terico de los factores implicados

Factores neurobiolgicos

Factores psicolgicos

Factores sociales

Factores modificadores/precipitantes de la conducta

Modelo Need- Driven Demencia Compromised (NDB)

Precipitantes y causas algunos de los SPCD


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Asociacin Internacional de Psicogeriatra(IPA) 2000

60 expertos, 16 pases

El trmino trastornos conductuales debera ser reemplazado por elde sntomas psicolgicos y conductuales en las demencias (SCPD)definido de este modo:

Sntomas de alteracin de la percepcin, del contenido del pensamiento, el

estado de nimo o la conducta, que a menudo se presentan en pacientes con

demencia


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Demencias: reas afectadas

Deterioro cognoscitivoSPCD

(Sntomas psicolgicos y

conductuales)

DEMENCIASDEMENCIAS

AVD(Actividades de la vida diaria)

FUNCIONAMIENTO GLOBAL

Sobrecarga delSobrecarga delcuidadorcuidador

+


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Clusters neuropsiquitricos en la

demencia

McShane, Int Psychogeriatr, 2000


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Formas de inicio de la demencia

Deterioro cognitivo leve

Sndrome depresivo/ Apata

Alteraciones de conducta / Personalidad

Alucinaciones / Delirio

A. Moriigo, 2010


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Impacto de los SPCD

Cummings, 2004


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Por qu algunos pacientes con

demencia desarrollan sntomas,mientras que otros no?

Modelo: Factores neurobiolgicos (neuroqumicos, neuropatolgicos o

genticos) Factores psicolgicos (personalidad premrbida, respuesta al

estrs)

Factores sociales (entorno y cuidador)


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Factores neurobiolgicos Disfuncin y muerte cerebral

Disminucin de sntesis de NT: Ach: N. Basal Meyner

NA: Locus Ceruleus

S: N.rafe Dopa: Sustancia Negra

Disfuncin de sistemas neuronales:

Sistema Lmbico Circuitos subcorticales frontales

Cummings, 2004


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Sntomas

neuropsiquitricos Neuroqumica Neuropatologa

Apata Ach Disfuncin circuitosfrontosubcorticales

Depresin NA en cortexSDopamina en prosubiculunMonoaminas

Lesiones sustancia blancaDisfuncin sistema lmbicoPrdida neuronal en locus ceruleus,n. rafe

Agitacin AchS en lbulos frontales

Disfuncin frontal y temporal

Prdida neuronal en locus ceruleus

Psicosis AchSNA en sustancia negra

Disfuncin sistema lmbicoDisfuncin temporal y parietal dchoAlteracin vas pticas y TE

Alteracin personalidad Ach frontal Disfuncin frontalN Basal de Meynert

Vagabundeo Ach y DOPA Disfuncin parieto-temporal izda


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Factores psicolgicos

Personalidad premrbida:

Suspicaces

Agresivos

Controladores

Respuesta al estrs


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Abstract

This study considers the influence of premorbid personality on the expression of behavioraldisturbances among individuals with dementia. A total of 68 outpatients with a diagnosis of

dementia were assessed for current cognitive functioning, premorbid personality traits, andnew behavioral disturbances since dementia onset. The results of this study show someevidence for the influence of personality on the expression of both irritability andwithdrawal. Specifically, increased withdrawal and irritability after dementia onset wereassociated with an inhibited premorbid personality style. In addition, a premorbidly

independent personality style was associated with less withdrawal. Further research isneeded to clarify the role of premorbid personality on behaviors in this population.

Gould SL, Hyer LA.

Dementia and behavioral disturbance: does premorbid personalityDementia and behavioral disturbance: does premorbid personalityDementia and behavioral disturbance: does premorbid personalityDementia and behavioral disturbance: does premorbid personality reallyreallyreallyreallymatter?.matter?.matter?.matter?.

Psychol Rep. 2000;95(3):1072-8.

Specifically, increased withdrawal and irritability after dementSpecifically, increased withdrawal and irritability after dementia onsetia onsetwere associated with an inhibited premorbid personality style. Iwere associated with an inhibited premorbid personality style. Innaddition, a premorbidly independent personality style was associaddition, a premorbidly independent personality style was associatedatedwith less withdrawal. Further research is needed to clarify thewith less withdrawal. Further research is needed to clarify the role ofrole ofpremorbid personality on behaviors in this population.premorbid personality on behaviors in this population.


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Carol Magai, Carl I. Cohen, Clayton Culver, David Gomberg, Chris Malatesta

Relation between premorbid personality and patterns of emotion eRelation between premorbid personality and patterns of emotion eRelation between premorbid personality and patterns of emotion eRelation between premorbid personality and patterns of emotion expression inxpression inxpression inxpression inmidmidmidmid---- to lateto lateto lateto late----stage dementiastage dementiastage dementiastage dementia

Int J Geriatr Psychiatry 1997; 12:1092-1099

AbstractTwenty-seven nursing home patients with mid- to late-stage dementia participated in astudy of the relation between preillness personality, as indexed by attachment andemotion regulation style, and current emotional behavior. Preillness measures werecompleted by family members and current assessments of emotion were supplied by

nursing home aides and family members; in addition, emotion was coded during afamily visit using an objective coding system for facial emotion expressions. Attachmentstyle was found to be related to the expression of positive affect, with securely attachedindividuals displaying more positive affect than avoidantly attached individuals. Inaddition, high ratings on premorbid hostility were associated with higher rates of

negative affect and lower rates of positive affect. These findings indicate that premorbidaspects of personality show continuity over time, even in mid- to late-stage dementia

Attachment style was found to be related to the expression ofpositive affect, with securely attached individuals displaying morepositive affect than avoidantly attached individuals. High ratings onHigh ratings on

premorbid hostility were associated with higher rates of negativpremorbid hostility were associated with higher rates of negativeeaffect and lower rates of positive affect. These findings indicaaffect and lower rates of positive affect. These findings indicate thatte thatpremorbid aspects of personality show continuity over time, evenpremorbid aspects of personality show continuity over time, even inin

midmid-- to lateto late--stage dementiastage dementia


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This study aimed to explore relationships of premorbid personality and behavioralresponses to stress with wandering behavior of persons with dementia in long-term carefacilities. Ambulatory residents (N= 108) with dementia were selected from 21 long-term care facilities. The Mini-Mental State Examination, the NEO Five-FactorPersonality Inventory, the Behavioral Responses to Stress Scale, and the Revised AlgaseWandering ScaleNursing Home Version (RAWS-NH) were used as data collectiontools. When the MMSE and age were controlled, regression analyses revealed thatpremorbid extroversion and premorbid negative verbalization stress response weresignificant negative predictors for the overall RAWS-NH and some subscales.

Jun Ah Song, Donna Algase

Premorbid Characteristics and Wandering Behavior in PersonsPremorbid Characteristics and Wandering Behavior in PersonsPremorbid Characteristics and Wandering Behavior in PersonsPremorbid Characteristics and Wandering Behavior in Personswith Dementiawith Dementiawith Dementiawith Dementia

Arch Psychiatr Nurs. 2008;22 (6):318-27

Premorbid extroversion and premorbid negative verbalization strePremorbid extroversion and premorbid negative verbalization stressssresponse were significant negative predictors for the overall RAresponse were significant negative predictors for the overall RAWSWS--

NH and some subscalesNH and some subscales


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Alow LF, Brodaty H, Draper B.

Study of premorbid personality and behavioural and psychologicalStudy of premorbid personality and behavioural and psychologicalStudy of premorbid personality and behavioural and psychologicalStudy of premorbid personality and behavioural and psychological symptomssymptomssymptomssymptomsof dementia in nursing home residents.of dementia in nursing home residents.of dementia in nursing home residents.of dementia in nursing home residents.

Int J Geriatr Psychiatry.2002 Aug;17(8):779-83.

AbstractOBJECTIVE: to investigate the relationship between pre-morbid personality and behavioural and

psychological symptoms of dementia (BPSD).

METHODS: we studied 58 subjects with dementia and depression and/or psychosis residing in 11Sydney nursing homes cross-sectionally. Informal caregivers completed ratings of residents' pre-

morbid personality on the NEP Five-Factor Inventory (NEO-FFI). Information on BPSD wasobtained using the BEHAVE-AD.

RESULTS: higher neuroticism was predictive of delusions; higher agreeableness of hallucinations,aggressiveness, affective disturbance and overall behavioural disturbance; and higher openness ofaffective disorder.

CONCLUSION: our findings are inconsistent with previous research and clinical experience.Prospective studies are needed to clarify the association between personality and behaviouraldisturbance in dementia.

RESULTS: higher neuroticism was predictive of delusions; higheragreeableness of hallucinations, aggressiveness, affective disturbanceand overall behavioural disturbance; and higher openness of affective

disorder.CONCLUSION: our findings are inconsistent with previous research

and clinical experience. Prospective studies are needed to clarify the

association between personality and behavioural disturbance indementia.


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Factores sociales:

Factores ambientales:

Cambio en la ubicacin

Factores fsicos: Luz, ruidos, temperatura

Cuidador:

Relaciones interpersonales entre el paciente y cuidador

Sobrecarga del cuidador

Lawlor B, 1996


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AbstractBackground: Guided by the need-driven dementia-compromised behavior (NDB) model, this study

examined influences of the physical environment on wandering behavior.Methods: Using a descriptive, cross-sectional design, 122 wanderers from 28 long-term care (LTC)

facilities were videotaped 10 to 12 times; data on wandering, light, sound, temperature and

humidity levels, location, ambiance, and crowding were obtained. Associations betweenenvironmental variables and wandering were evaluated with chi-square and t tests; the model wasevaluated using logistic regression.

Results: In all, 80% of wandering occurred in the residents own room, dayrooms, hallways, or diningrooms. When observed in other residents rooms, hallways, shower/baths, or off-unit locations,wanderers were likely (60%-92% of observations) to wander. The data were a good fit to themodel overall (LR [logistic regression] w2 (5) 50.38, P < .0001) and by wandering type.

Conclusions: Location, light, sound, proximity of others, and ambiance are associated with wanderingand may serve to inform environmental designs and care practices.

Donna L. Algase, PhD, Elizabeth R. A. Beattie, PhD, Cathy Antonakos, PhD,

Cynthia A. Beel-Bates, PhD, and Lan Yao, PhDWandering and the Physical EnvironmentWandering and the Physical EnvironmentWandering and the Physical EnvironmentWandering and the Physical Environment

American Journal of Alzheimers Disease & Other Dementias, 2012; 25(4) 340-

346

Conclusions: Location, light, sound, proximity of others, andConclusions: Location, light, sound, proximity of others, andambiance are associated with wandering and may serve to informambiance are associated with wandering and may serve to inform

environmental designs and careenvironmental designs and care practices.practices.


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Int J Geriatr Psychiatry 2010;25:14-22

The variance in SCU symptom prevalence (variance between SCUs)The variance in SCU symptom prevalence (variance between SCUs)accounted for 3.5accounted for 3.514.8% of the total variance in neuropsychiatric14.8% of the total variance in neuropsychiatricsymptoms. In SCUs of which the staff spent more time on care actsymptoms. In SCUs of which the staff spent more time on care act ivities didivities did

the patients show lower levels of apathy. Other environmentalthe patients show lower levels of apathy. Other environmentalcorrelates did not predict neuropsychiatric symptoms.correlates did not predict neuropsychiatric symptoms.


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Conclusions: Ambient bright light is not effective in reducing aConclusions: Ambient bright light is not effective in reducing agitation ingitation in

dementia and may exacerbatedementia and may exacerbate this behavioral symptom.this behavioral symptom.


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Conclusions: Bright light therapy is a potential alternative toConclusions: Bright light therapy is a potential alternative to drug treatmentdrug treatment

in people with dementia who arein people with dementia who are agitated.agitated.


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COMORBILIDAD

Patologa cerebrovascular

Dolor Depresin/Ansiedad

Deprivacin sensorial

Patologa endocrinometablica Alteracin hidroelectroltica

Impacto fecal

InfeccionesFARMACOS

NECESIDADES BSICAS

Factores precipitantes:


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OBrien J, Perry R, Barber R et al.

The Association between White Matter Lesions on Magnetic ResonanThe Association between White Matter Lesions on Magnetic ResonanThe Association between White Matter Lesions on Magnetic ResonanThe Association between White Matter Lesions on Magnetic Resonancececece

Imaging and Noncognitive Symptoms.Imaging and Noncognitive Symptoms.Imaging and Noncognitive Symptoms.Imaging and Noncognitive Symptoms.

Ann NY Acad Sci 2000; 903:482-9

Abstract: A number of studies have suggested that cerebral changes, particularly deep white matter lesions

(WML) visualized on magnetic resonance imaging(MRI), may be involved in the genesis of late lifedepression. This has been confirmed in a prospective study which also found a relationship between thepresence of WML and poor 3-year outcome in elderly depressed subjects. Most studies find these lesions topredominate in frontal lobe and basal ganglia, supporting the hypothesis of fronto-striatal dysfunction indepression. To investigate whether WML are associated with mood disturbance in dementia, proton densityand T2-weighted images were obtained in 80 subjects with dementia (dementia with Lewy bodies, n= 27;Alzheimer's disease, n= 28; vascular dementia, n= 25) and 26 age-matched normal controls. Periventricularlesions (PVL), white matter lesions (WML), and basal ganglia hyperintensities (BG) were visually rated blindto diagnosis using a semiquantitative scale. Frontal WML were associated with higher depression scores inpatients with dementia, implying a common pathophysiology of depression irrespective of diagnosis. Furtherstudy of the neurobiological basis of WML is needed. This can best be achieved by serial clinical assessment

combined with in vivo and in vitro MRI and neuropathological examination.

Frontal WML were associated with higher depression scores in patFrontal WML were associated with higher depression scores in patientsientswith dementia, implying a common pathophysiology of depressionwith dementia, implying a common pathophysiology of depression

irrespective of diagnosis.irrespective of diagnosis.


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Conclusion: The contribution of CVD to the pathogenesis of various NPS isstill debated. Our study, based on patients diagnosed with AD in a memoryclinic setting, suggests that there is no relationship between the extent of

CVD pathology and neuropsychiatric and behavioural measures in ADpatients. Further prospective quantitative studies are needed to assess therole of CVD, if any, in neuropsychiatric and behavioural symptoms in AD.It is possible that the relatively small pathological contribution of CVD tothe development of these symptoms is obscured by the effect of the widerneurodegeneration encountered in AD.


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Conclusion:Conclusion:

We suggest that right anterior insular dysfunction may exacerbatWe suggest that right anterior insular dysfunction may exacerbateedelusions, although it is not responsible for thedelusions, although it is not responsible for the onset of delusions.onset of delusions.


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Conclusion: There is a profound dearth of rigorous studies of thConclusion: There is a profound dearth of rigorous studies of the effect ofe effect of

pain treatment in patients with dementia and agitation. The avaipain treatment in patients with dementia and agitation. The availablelablestudies do not support the hypothesis that pain management reducstudies do not support the hypothesis that pain management reducesesagitation in nursingagitation in nursing--home patients with dementia. Randomized,home patients with dementia. Randomized,controlled parallelcontrolled parallel--groupgroup studies are needed.studies are needed.


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There are some cases of vitamin B12 deficiency that can manifestThere are some cases of vitamin B12 deficiency that can manifest

with the symptoms of frontotemporal dementia and that they arewith the symptoms of frontotemporal dementia and that they arecompletelycompletely reversible after substitution therapy.reversible after substitution therapy.


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Denis Shub MD, David M, Bass PhD, Robert O et al.

Irritability and Social Isolation in Dementia Patients With andIrritability and Social Isolation in Dementia Patients With andIrritability and Social Isolation in Dementia Patients With andIrritability and Social Isolation in Dementia Patients With and WithoutWithoutWithoutWithout

Depression.Depression.Depression.Depression.J Geriatr Psych and Neur 2011; 24 (4):229-234

Abstract

This study examined the prevalence of irritability and social isolation in veteranswith dementia, with and without depression. Participants were diagnosed withdementia and enrolled in a dementia care-coordination and support-serviceintervention. Participants were interviewed and underwent assessment with the 10-item Center for Epidemiologic Studies Depression scale, a Patient Strain Measureand the Short Blessed Test. In all, of 294 participants completing interviews, 77(26.2%) were depressed and 107 (36.4%) endorsed irritability; mean social isolationscore was 1.59 1.96. Irritability was significantly more likely to be present indepressed versus nondepressed participants (P < .0001), but this relationship was

moderated by dementia severity. The mean social isolation score was alsosignificantly more elevated in depressed rather than nondepressed patients (2.82 1.96 vs 1.15 1.76, respectively). Conclusions: Depressed persons with dementiaare significantly more likely to experience irritability and social isolation than thosewho are not depressed.

Conclusions: Depressed persons with dementia are significantlyConclusions: Depressed persons with dementia are significantlymore likely to experience irritability and social isolation thanmore likely to experience irritability and social isolation than thosethosewho are not depressed.who are not depressed.

P l J S i l M k E K ikb d L S d F G N Wil B H


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Paul J. Seignourela, Mark E. Kunikb,c,d,e, Lynn Snowd F.G, Nancy Wilson B H,

and Melinda Stanley B E.

Anxiety in dementia: A critical reviewAnxiety in dementia: A critical reviewAnxiety in dementia: A critical reviewAnxiety in dementia: A critical review

Clin Psychol Rev. 2008 October ; 28(7): 10711082.


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Movement Disorders, Vol. 26, No. 13, 2011

RegressionRegression analysis identified a variety of factors independently predictivanalysis identified a variety of factors independently predictivee

of complex visual hallucinations (e.g., dementia, visual acuity,of complex visual hallucinations (e.g., dementia, visual acuity, andanddepression), illusions (e.g., excessive daytime somnolence and ddepression), illusions (e.g., excessive daytime somnolence and diseaseiseaseseverity), and presence (e.g., rapid eye movement sleep behaviorseverity), and presence (e.g., rapid eye movement sleep behaviordisorder anddisorder and excessive daytime somnolence)excessive daytime somnolence)


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This effect was limited to the period during which the treatmentThis effect was limited to the period during which the treatment is beingis beingapplied. Half of the participants (54%) demonstrated considerablapplied. Half of the participants (54%) demonstrated considerableebehavioural improvement during the intervention (50% reduction obehavioural improvement during the intervention (50% reduction offsymptoms) and those whose functioning is best preserved showed tsymptoms) and those whose functioning is best preserved showed the besthe bestresponse to the intervention.response to the intervention.

Conclusion: This needConclusion: This need--based intervention appears promising for improvingbased intervention appears promising for improvingthe behaviour of a considerablethe behaviour of a considerable proportion of patients.proportion of patients.

Th N d D i D ti C i d


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The Need-Driven Dementia-Compromised

Behavior (NDB) model

Modificado de Algase DL 1996

FACTORES DE FONDO:FACTORES DE FONDO:

CaracterCaractersticas sociodemogrsticas sociodemogrficasficasFactores neurobiolFactores neurobiolgicosgicosCapacidad cognitivaCapacidad cognitivaEstado de saludEstado de saludFactores psicosociales (personalidadFactores psicosociales (personalidad

prempremrbida)rbida)

FACTORES PROXIMALES:FACTORES PROXIMALES:

Necesidades fNecesidades fsicassicasNecesidades psicolNecesidades psicolgicasgicasEntorno fEntorno fsicosicoEntorno socialEntorno social

TRASTORNOS CONDUCTUALES:VagabundeoAgresividad fsicaAgresividad verbal


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Agresin/agitacin fsica

Alteracin cognitiva AfasiaAgnosiaDisfuncin ejecutiva

Patologa/Sntomas psiquitricos DepresinAlucinacionesIdeacin delirante

Patologa mdica DeliriumDolorDficits sensoriales

Frmacos EsteroidesAgonistas dopaminrgicos

Factores ambientales Sobre estimulacinPobre estimulacin

Cuidador Hablar fuerteAcercarse desde atrs

Rapidez en la intervencin


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Agresin/agitacin verbal

Alteracin cognitiva Afasia (palilalia)Disfuncin ejecutivaAgnosia

Patologa/Sntomas psiquitricosDepresinAlucinacionesIdeacin delirante

Patologa mdica DeliriumDolorInfeccionesInmovilidadDficit sensoriales

Necesidades insatisfechas SedHambreDisconfort

Factores ambientales Ruido excesivoLuz brillanteEstimulacin excesiva

Cuidador Estrs del cuidador

Pobre estimulacinExcesiva estimulacin


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Resistencia al cuidado

Alteracin cognitiva AmnesiaAfasiaApraxia

AgnosiaApata

Patologa/Sntomas psiquitricos DepresinIdeacin deliranteAlucinaciones

Patologa mdica DolorDficits sensorialesIncontinencia

Frmacos Empeoran dficit cognitivo y contribuyen

Factores ambientales OscuridadRuido excesivo

Cuidador DemandanteOrdenes complejas

Expectativas no realistas


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Deambulacin errticaAlteracin cognitiva Amnesia

AfasiaApraxia

Patologa/Sntomas psiquitricos DepresinAlucinaciones/Ideacin delirante

Patologa mdica DolorRAOHipertiroidismoParkinsonDelirium

Necesidades insatisfechas Hambre, SedSoledadMiccin

Frmacos Acatisia por psicofrmacos

Teofilina, epinefrina, cafenaHormona tiroideaDiurticos

Factores ambientales Sobre estimulacin (ruido, luz) o pobreestimulacin

Cuidador Si se les impide deambular reacciones catastrficas


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Apata/AislamientoAlteracin cognitiva Amnesia

AgnosiaAfasiaApraxiaDisfuncin ejecutiva

Patologa/Sntomas psiquitricos DepresinIdeacin deliranteEsquizofreniaAgorafobia, pnico

Patologa mdica Hipoxia aguda/crnica (EPOC, SAOS)Dficits sensoriales

Cancer (pancreas)Hipotiroidismo, cushingEncefalopata heptica, insuficiencia renal, anemiaHidrocefalia, Parkinson/Huntington

Frmacos Antipsicticos, antidepresivos tricclicos,Betabloqueantes, antiarrtmicos

AlcoholAnticolinrgicos

Factores ambientales Sobre estimlacin ( ruido, luz, actividad ), hacinamientoPobre estimulacin

Cuidador Demandantes, estimulantesCrticos, desagradables, abusivos

Id i d li t


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Ideacin delirante

Alteracin cognitiva AmnesiaAgnosiaAfasiaDisfuncin ejecutiva

Patologa/Sntomas psiquitricos DeliriumDepresin

Patologa mdica IctusParkinsonDelirium

Frmacos EsteroidesAgonistas dopaminrgicosAntihistamnicosBetabloqueantes

Factores ambientales DesordenSobreestimlacin/pobreestimulacin

Cuidador Susurra, irritables, bromear

Al i i


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Alucinaciones

Alteracin cognitiva Deterioro cognitivo moderado grave

Patologa/Sntomas psiquitricos Delirium

EsquizofreniaDepresin mayor

Patologa mdica IctusDeprivacin alcohlicaAlteracin metablicaInfeccionesDficit sensorial

Frmacos BenzodiacepinaAnticolinrgicos

EsteroidesAgonistas dopaminrgicos

Factores ambientales Pobre iluminacinExceso de ruido

Cuidador Genera distrs


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Conclusiones Desconocimiento de la etiopatogenia del sd demencial y de

los SPCD

Modelos tericos basados en trabajos empricos y experienciaclnicas

Resultados contradictorios en los estudios

Aunque no se pueden modificar los factores intrnsecos delindividuo, si que podemos determinar los pacientes en riesgoy establecer en ellos estrategias de prevencin o intervencin

de los factores precipitantes

inductores_modificadores de los spcd

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