Disruptive Behavior as a predictor in Alzheimer disease

Abstract

Background: Disruptive behavior is common in Alzheimer disease (AD). There are conflicting reports regarding its ability to predict cognitive decline, functional decline, institutionalization, and mortality. Objective: To examine whether the presence of disruptive behavior has predictive value for important outcomes in AD. Design: Using the Columbia University Scale for Psychopathology in Alzheimer Disease (administered every 6 months, for a total of 3438 visit-assessments and an average of 6.9 per patient), the presence of disruptive behavior (wandering, verbal outbursts, physical threats/violence, agitation/restlessness, and sundowning) was extracted and examined as a time-dependent predictor in Cox models. The models controlled for the recruitment cohort, recruitment center, informant status, sex, age, education, a comorbidity index, baseline cognitive and functional performance, and neuroleptic use. Setting: Five university-based AD centers in the United States and Europe (Predictors Study). Participants: Four hundred ninety-seven patients with early-stage AD (mean Folstein Mini-Mental State Examination score, 20 of 30 at entry) who were recruited and who underwent semiannual follow-up for as long as 14 (mean, 4.4) years. Main Outcome Measures: Cognitive (Columbia Mini-Mental State Examination score, <= 20 of 57 [approximate Folstein Mini-Mental State Examination score, <= 10 of 30]) and functional ( Blessed Dementia Rating Scale score, parts I and II, >= 10) ratings, institutionalization equivalent index, and death. Results: At least 1 disruptive behavioral symptom was noted in 48% of patients at baseline and in 83% at any evaluation. Their presence was associated with increased risks of cognitive decline (hazard ratio 1.45 [95% confidence interval (CI), 1.03-2.03]), functional decline (1.66 [95% CI, 1.17-2.36]), and institutionalization (1.47 [95% CI, 1.101.97]). Sundowning was associated with faster cognitive decline, wandering with faster functional decline and institutionalization, and agitation/restlessness with faster cognitive and functional decline. There was no association between disruptive behavior and mortality (hazard ratio, 0.94 [95% CI, 0.71-1.25]). Conclusion: Disruptive behavior is very common in AD and predicts cognitive decline, functional decline, and institutionalization but not mortality.