- Email: [email protected]
Effects of Group-Home Care on Behavioral Symptoms, Quality of Life, and Psychotropic Drug Use in Patients With Frontotemporal Dementia
11. Torn M, Bollen WLEM, van der Meer FJM, et al. Risks of oral anticoagulant therapy with increasing age. Arch Intern Med 2005;165:1527–1532. 12. Gage BF, Birman-Deych E, Kerzner R, et al. Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med 2005;118:612– 617. 13. Gage BF, Birman-Deych E, Radford MJ, et al. Risk of osteoporotic fracture in elderly patients taking warfarin. Arch Intern Med 2006;166:241–246. 14. Quilliam BJ, Lapane KL, Eaton CB, Mor V. Effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among a population of elderly nursing home stroke survivors. Stroke 2001;32: 2299 –2304. 15. Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: Physicians fears often unfounded. Arch Intern Med 2003;163:1580 –1586. 16. Bootman JL, Harrison Dl, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med 1997;157: 2089 –2096. 17. Desbiens NA. Deciding on anticoagulating the oldest old with atrial fibrillation: Insights from cost-effectiveness analysis. J Am Geriatr Soc 2002;50:863– 869.
DOI: 10.1016/j.jamda.2006.03.005
The difficulties were well brought out by a recent case study of a high-risk 83-year-old nursing home resident with atrial fibrillation and numerous comorbidities, on numerous medications from different physicians.4 Interestingly, our findings were also somewhat similar to those noticed in a survey nearly a decade ago when only a small number (12%) of providers opted to initiate anticoagulation for a frail long-term care resident with atrial fibrillation in the presence of comorbidities.5 At that time, the thought process and guidelines for anticoagulation in atrial fibrillation were less stringent than today! The findings indicate that physicians continue to think similarly today because of difficulties perceived in the frail elderly regarding risks of anticoagulation, coupled with difficulties in maintaining clotting parameters in a therapeutic range.4 We encourage providers across the country to respond and comment and to revisit their own opinions regarding anticoagulation therapy in such a setting. T.S. Dharmarajan, MD Anna S. Lebelt, MD Edward P. Norkus, PhD New York Medical College Our Lady of Mercy Medical Center Bronx, NY
Anticoagulation in Atrial Fibrillation: What Decides? Patient Status, Provider Opinion, or Both? To the Editor: We are pleased with the responses that our survey on anticoagulation for atrial fibrillation in the nursing home resident in a specific setting1 has elicited. Another recent response from a researcher commented on our survey in a teaching intuition and “welcomed future extensions of the study to different facilities with a variety of demographic characteristics as well as to NH clinicians rather than the physician community.”2 Dr Cheng brings up a number of points that are consistent with and in agreement with the overall conclusions made in our article, that long-term anticoagulation therapy for thromboembolic events in atrial fibrillation may be a beneficial option in some but not all cases, whether in long-term care facilities or elsewhere.3 Both we and Dr Cheng agree that absolute and relative contraindications for long-term warfarin use exist and that the ultimate “decisions should be individualized and based on risks, benefits, and quality of life of the resident.”1 We believe that our article, Dr Cheng’s letter, and the references cited by both of us provide a sound basis for discussions regarding the difficulties involved with decision making on anticoagulation therapy, particularly in older residents in nursing homes. Issues of coexisting disease, cognitive and functional status of the patient, prior experiences with anticoagulation, life expectancy, and quality of life play important roles in deciding the course of action. The approach always should focus on the individual resident’s requirements while considering guidelines, but the provider has the ultimate decision-making responsibility; hence we agree for the need for more studies on this subject as recently suggested.2 Further, we concur with Dr Cheng, that guidelines hardly consider the comorbid status and potential for drug interactions particularly applicable to the nursing home resident. LETTERS TO THE EDITOR
REFERENCES 1. Dharmarajan TS, Varma S, Akkaladevi S, Lebelt AS, Norkus EP. To anticoagulate or not to anticoagulate? A common dilemma for the providers: Physicians’ opinion poll based on a case study of an older long-term care facility resident with dementia and atrial fibrillation. J Am Med Dir Assoc 2006;7:23–28. 2. Messinger-Rapport BA. The nursing home physician’s point of view on warfarin use. J Am Med Dir Assoc 2006;7:133–134. 3. Cheng H. Why health care providers don’t prescribe warfarin to a frail nursing home resident with atrial fibrillation. J Am Med Dir Assoc 2006, accompanying letter. 4. Warhaftig ML. Anticoagulation in a high risk nursing home resident. Annals of Long Term Care 2005;23:36 – 42. 5. Monette J, Gurwitz JH, Rochson PA, Avorn J. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: Results of a survey of long-term care practitioners. J Am Geriatr Soc 1997;45:1060 – 1065.
DOI: 10.1016/j.jamda.2006.03.007
Effects of Group-Home Care on Behavioral Symptoms, Quality of Life, and Psychotropic Drug Use in Patients With Frontotemporal Dementia To the Editor: Patients with frontotemporal dementia (FTD), a relatively rare neurodegenerative dementia,1 present with various behavioral and psychological symptoms, including disinhibition, stereotypy, aggression, impulsivity, indifference, and aphasia. Therefore, FTD care is very difficult and distressing for caregivers. Several recent trials showed that the efficacy of atypical antipsychotic drugs and selective serotonin reuptake inhibitors reduced the behavioral and psychological symptoms LETTERS TO THE EDITOR 335
in dementia (BPSD). However, the beneficial effects of psychotropic drugs on quality of life (QOL) in long-term use have not been fully verified.2 Nonpharmacological interventions include the effects of the physical environment, social environment including interaction between staff and patients, and care philosophy in the facility. It is generally accepted that appropriate design of the care environment, especially incorporating homelike features, ameliorates the BPSD, and preserves qualities of dignity and privacy in institutionalized individuals. However, there are few studies investigating the effects of nonpharmacological interventions on FTD patients. To evaluate the influence of group-home care on cognitive function, BPSD, QOL, and the use of psychotropic drugs in FTD, we assessed 8 patients clinically diagnosed as having FTD according to the international consensus criteria for frontotemporal dementia3 (the mean age at onset, 61.5 ⫾ 8.1 years; the mean disease duration, 6.4 ⫾ 4.0 years) before and after relocation from a traditional ward in a psychiatric hospital to a group home. Before relocation, all subjects had spent more than 1 year in the traditional ward. Before their introduction to the group home specializing in treatment of patients with FTD, the clinical stages of the Clinical Dementia Rating were stage 2 in 3 patients and stage 3 in 5 patients. Remarkable behavioral stereotypy, disinhibition, aggression, and agitation were found in 5 patients, and moderate behavioral disturbances as well as apathy in 3 patients. In the ward, 60 patients, including all subjects in this study, occupied 22 rooms, and all subjects were resident in rooms for 2 or more patients. The total area of the traditional ward was 1515 m2, and that of the group home was 324 m2. The area per patient, which was calculated using all areas in a unit to which residents had continuous access, increased from 25.3 m2 in the traditional ward to 36.0 m2 in the group home. The staff/ patient ratio was changed from 0.47 in the traditional ward to 0.90 in the group home. In the philosophy of care, the traditional ward tended to give priority to medical and physical safety rather than a patient’s freedom and addressing the patients’ needs. In the ward, there was little personal furniture, few clothes and other personal belongings, and the personal space was limited to the area around the bed of each patient. Patients had set times for various daily activities, such as baths and occupational therapy, and were encouraged to join diverse special activities different from daily living activities. On the other hand, the staff of the group home gave first priority to creating a homelike and noninstitutional physical and social environment and helping residents to maintain their usual lifestyle, and patients’ freedom, hominess reflecting patients’ previous lifestyles, and patients’ needs and privacy were regarded as important. Cognitive functions were evaluated with the Hasegawa Dementia Scale-Revised version (HDS-R; range: 0 –30 points, cut off 19/20), scores of which correlate with that of the Mini-Mental State Examination.4,5 BPSD and QOL were evaluated every 2 months for 6 months using the Cohen-Mansfield Agitation Inventory (CMAI),6 the Neuropsychiatric Inventory (NPI),7 and the Health-Related Quality of Life Questionnaire for Dementia (QOL-D).8 The use of psychotropic drugs was also evaluated every 2 months. The Friedman test and Wilcoxon signed-rank test 336 Letters to the Editor
were used for the statistical analysis of the CMAI, NPI, QOL-D, the number of psychotropic drugs used, and the chlorpromazine-equivalent dose of antipsychotics. The scores of the HDS-R at 0 and 6 months were compared using the Wilcoxon signed-rank test. A significance level of .05 was used for all statistical tests. No subject dropped out during the observation period. At the end of the 6-month study period, cognitive function was not significantly changed compared with the baseline. In contrast, the mean NPI total score (28.9 to 16.0, z ⫽ ⫺2.366, P ⫽ .018) and mean CMAI total score (60.4 to 52.0, z ⫽ ⫺2.524, P ⫽ .012) were significantly improved compared with the baseline. Three of 6 subscale scores of the QOL-D, including positive affect (12.9 to 19.3, z ⫽ ⫺2.383, P ⫽ .017), restlessness (11.4 to 8.8, z ⫽ ⫺2.207, P ⫽ .027), and attachment to others (7.4 to 9.6, z ⫽ ⫺2.207, P ⫽ .027), were also significantly improved at 6 months. The number of psychotropic drugs (mean of 1.1 at the baseline) and the chlorpromazine-equivalent mean dose of antipsychotics (mean of 73.1 mg/day at the baseline) decreased gradually, and they were finally withdrawn. These preliminary results suggest the beneficial effects of a homelike physical and social environment on BPSD, QOL, and psychotropic drug use in patients with FTD. We consider that a study period of 6 months may be too short to explain the improvement by disease progression alone. The remarkable affective disturbances in patients with FTD led us to speculate that they have difficulty feeling frustration or distress about their surrounding circumstances. The present findings, however, suggest that FTD patients can be affected by their physical and social environment, and their behavior and QOL may be improved, at least in part, by using their remaining emotional and cognitive functions. Therefore, we believe that homelike physical and social environmental features should be valued more to optimize a combination of pharmacological and nonpharmacological interventions in diverse care settings for FTD patients besides group-home care. Although further controlled studies with larger size samples are needed to confirm our conclusion, we consider that the present findings have significant implications for the management strategies for behavioral disturbances of FTD. ACKNOWLEDGMENTS We thank Dr K. Tsuchiya (Department of Laboratory Medicine and Pathology, Tokyo Metropolitan Matsuzawa Hospital, Tokyo, Japan) for insightful review of the manuscript and comments, Ms H. Nakano and Ms M. Yamasaki for help in collecting clinical information, Mr A. Sasaki for help with the production of the manuscript, and all the staff members of the group home. This work was supported in part by a research grant from the Zikei Institute of Psychiatry. Osamu Yokota, MD, PhD Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan JAMDA – June 2006
Kinoko Espoir Hospital Kasaoka, Japan Yoshikatsu Fujisawa, MD, PhD Jun Takahashi, MD, PhD Kinoko Espoir Hospital Kasaoka, Japan Seishi Terada, MD, PhD Takeshi Ishihara, MD, PhD Hanae Nakashima, MD, PhD Etsuko Oshima, MD Aki Kugo, MD Toshie Ata, MA Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan Hideki Ishizu, MD, PhD Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan Department of Laboratory Medicine Zikei Institute of Psychiatry Okayama, Japan Shigetoshi Kuroda, MD, PhD Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan Ken Sasaki, MD, PhD Kinoko Espoir Hospital Kasaoka, Japan REFERENCES 1. Yokota O, Sasaki K, Fujisawa Y, et al. Frequency of early- and late-onset dementias in a Japanese memory disorders clinic. Eur J Neurol 2005;12: 782–790. 2. Ballard CG, Margallo-Lana ML The relationship between antipsychotic treatment and quality of life for patients with dementia living in residential and nursing home care facilities. J Clinical Psychiatry 2004;65(suppl 11):23–28. 3. Neary D, Snowden JS, Gustafson L, et al. Frontotemporal lobar degeneration: A consensus on clinical diagnostic criteria. Neurology 1998;51: 1546 –1554. 4. Katoh S, Simogaki H, Onodera A, et al. Development of the revised version of Hasegawa’s dementia scale (HDS-R). Jp J Geriatr Psychiatr 1991;2:1339 –1347. LETTER TO THE EDITOR
5. Folstein MF, 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. 6. Finkel SI, Lyons JS, Anderson RL. Reliability and validity of the CohenMansfield Agitation Inventory in institutionalized elderly. Int J Geriatr Psychiatry 1992;7:487– 490. 7. Cummings JL, Mega M, Gray K, et al. The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308 –2314. 8. Terada S, Ishizu H, Fujisawa Y, et al. Development and evaluation of a health-related quality of life questionnaire for the elderly with dementia in Japan. Int J Geriatr Psychiatry 2002;17:851– 858.
DOI: 10.1016/j.jamda.2006.02.012
Antipsychotic Drug Use Among Nursing Home Residents Taking Rivastigmine To the Editor: We thank Dr. Narayanan et al1 for their thought-provoking analysis of this subject. However, we would like to bring to the attention of readers of this journal that it is not clear what stages of dementia were present in those in the rivastigmine group as compared with those in the non-rivastigmine group. As we know, cholinesterase inhibitors (donepezil,2 rivastigmine,3 galantamine,4 tacrine5) are approved for use in the early to moderate stages of Alzheimer’s dementia (AD) and an N-methyl-D-aspartate receptor antagonist (memantine6) is approved for use in the moderate to advanced stages of AD. It is also known that usually incidence of behavioral disturbances increases with the advancement in the stages of dementia. Initially, when donepezil was approved for use in clinical practice, nursing home placement was one of the reasons to reevaluate its continued use. If rivastigmine was used in patients with early AD, then the outcome of this study is not surprising as patients with early AD tend to have fewer behavioral issues and therefore the effect seen in this study may not necessarily be a result of rivastigmine use but rather because of the low incidence of behavioral issues in the early stages of AD. It is also not clear whether patients in the non-rivastigmine group ever received a cholinesterase inhibitor or if they were tried on a cholinesterase inhibitor while residing at their home, which was later discontinued as their AD continued to progress to the point of requiring nursing home care. If the case is the latter, then one can argue that these patients had a higher probability of having behavioral issues to begin with as the incidence of behavioral issues increases with the advancement of stage. The authors were of the opinion that patients in the rivastigmine group at baseline had higher behavioral issues than the non-rivastigmine group. However, signs and symptoms (sadness, loss of interest, sleep issues) described by the authors are suggestive of depression rather than the neuropsychiatric symptoms for which antipsychotics may be prescribed. As we know, neuropsychiatric symptoms are common in AD especially in the later stages. These symptoms include agitation, aggression, delusion, hallucination, and wandering.7 Depression and sleep disturbance can also occur with AD.7 It is not clear what, if any, of the neuropsychiatric symptoms were present in the non-rivastigmine group. AntiLETTER TO THE EDITOR 337
DOI: 10.1016/j.jamda.2006.03.005
The difficulties were well brought out by a recent case study of a high-risk 83-year-old nursing home resident with atrial fibrillation and numerous comorbidities, on numerous medications from different physicians.4 Interestingly, our findings were also somewhat similar to those noticed in a survey nearly a decade ago when only a small number (12%) of providers opted to initiate anticoagulation for a frail long-term care resident with atrial fibrillation in the presence of comorbidities.5 At that time, the thought process and guidelines for anticoagulation in atrial fibrillation were less stringent than today! The findings indicate that physicians continue to think similarly today because of difficulties perceived in the frail elderly regarding risks of anticoagulation, coupled with difficulties in maintaining clotting parameters in a therapeutic range.4 We encourage providers across the country to respond and comment and to revisit their own opinions regarding anticoagulation therapy in such a setting. T.S. Dharmarajan, MD Anna S. Lebelt, MD Edward P. Norkus, PhD New York Medical College Our Lady of Mercy Medical Center Bronx, NY
Anticoagulation in Atrial Fibrillation: What Decides? Patient Status, Provider Opinion, or Both? To the Editor: We are pleased with the responses that our survey on anticoagulation for atrial fibrillation in the nursing home resident in a specific setting1 has elicited. Another recent response from a researcher commented on our survey in a teaching intuition and “welcomed future extensions of the study to different facilities with a variety of demographic characteristics as well as to NH clinicians rather than the physician community.”2 Dr Cheng brings up a number of points that are consistent with and in agreement with the overall conclusions made in our article, that long-term anticoagulation therapy for thromboembolic events in atrial fibrillation may be a beneficial option in some but not all cases, whether in long-term care facilities or elsewhere.3 Both we and Dr Cheng agree that absolute and relative contraindications for long-term warfarin use exist and that the ultimate “decisions should be individualized and based on risks, benefits, and quality of life of the resident.”1 We believe that our article, Dr Cheng’s letter, and the references cited by both of us provide a sound basis for discussions regarding the difficulties involved with decision making on anticoagulation therapy, particularly in older residents in nursing homes. Issues of coexisting disease, cognitive and functional status of the patient, prior experiences with anticoagulation, life expectancy, and quality of life play important roles in deciding the course of action. The approach always should focus on the individual resident’s requirements while considering guidelines, but the provider has the ultimate decision-making responsibility; hence we agree for the need for more studies on this subject as recently suggested.2 Further, we concur with Dr Cheng, that guidelines hardly consider the comorbid status and potential for drug interactions particularly applicable to the nursing home resident. LETTERS TO THE EDITOR
REFERENCES 1. Dharmarajan TS, Varma S, Akkaladevi S, Lebelt AS, Norkus EP. To anticoagulate or not to anticoagulate? A common dilemma for the providers: Physicians’ opinion poll based on a case study of an older long-term care facility resident with dementia and atrial fibrillation. J Am Med Dir Assoc 2006;7:23–28. 2. Messinger-Rapport BA. The nursing home physician’s point of view on warfarin use. J Am Med Dir Assoc 2006;7:133–134. 3. Cheng H. Why health care providers don’t prescribe warfarin to a frail nursing home resident with atrial fibrillation. J Am Med Dir Assoc 2006, accompanying letter. 4. Warhaftig ML. Anticoagulation in a high risk nursing home resident. Annals of Long Term Care 2005;23:36 – 42. 5. Monette J, Gurwitz JH, Rochson PA, Avorn J. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: Results of a survey of long-term care practitioners. J Am Geriatr Soc 1997;45:1060 – 1065.
DOI: 10.1016/j.jamda.2006.03.007
Effects of Group-Home Care on Behavioral Symptoms, Quality of Life, and Psychotropic Drug Use in Patients With Frontotemporal Dementia To the Editor: Patients with frontotemporal dementia (FTD), a relatively rare neurodegenerative dementia,1 present with various behavioral and psychological symptoms, including disinhibition, stereotypy, aggression, impulsivity, indifference, and aphasia. Therefore, FTD care is very difficult and distressing for caregivers. Several recent trials showed that the efficacy of atypical antipsychotic drugs and selective serotonin reuptake inhibitors reduced the behavioral and psychological symptoms LETTERS TO THE EDITOR 335
in dementia (BPSD). However, the beneficial effects of psychotropic drugs on quality of life (QOL) in long-term use have not been fully verified.2 Nonpharmacological interventions include the effects of the physical environment, social environment including interaction between staff and patients, and care philosophy in the facility. It is generally accepted that appropriate design of the care environment, especially incorporating homelike features, ameliorates the BPSD, and preserves qualities of dignity and privacy in institutionalized individuals. However, there are few studies investigating the effects of nonpharmacological interventions on FTD patients. To evaluate the influence of group-home care on cognitive function, BPSD, QOL, and the use of psychotropic drugs in FTD, we assessed 8 patients clinically diagnosed as having FTD according to the international consensus criteria for frontotemporal dementia3 (the mean age at onset, 61.5 ⫾ 8.1 years; the mean disease duration, 6.4 ⫾ 4.0 years) before and after relocation from a traditional ward in a psychiatric hospital to a group home. Before relocation, all subjects had spent more than 1 year in the traditional ward. Before their introduction to the group home specializing in treatment of patients with FTD, the clinical stages of the Clinical Dementia Rating were stage 2 in 3 patients and stage 3 in 5 patients. Remarkable behavioral stereotypy, disinhibition, aggression, and agitation were found in 5 patients, and moderate behavioral disturbances as well as apathy in 3 patients. In the ward, 60 patients, including all subjects in this study, occupied 22 rooms, and all subjects were resident in rooms for 2 or more patients. The total area of the traditional ward was 1515 m2, and that of the group home was 324 m2. The area per patient, which was calculated using all areas in a unit to which residents had continuous access, increased from 25.3 m2 in the traditional ward to 36.0 m2 in the group home. The staff/ patient ratio was changed from 0.47 in the traditional ward to 0.90 in the group home. In the philosophy of care, the traditional ward tended to give priority to medical and physical safety rather than a patient’s freedom and addressing the patients’ needs. In the ward, there was little personal furniture, few clothes and other personal belongings, and the personal space was limited to the area around the bed of each patient. Patients had set times for various daily activities, such as baths and occupational therapy, and were encouraged to join diverse special activities different from daily living activities. On the other hand, the staff of the group home gave first priority to creating a homelike and noninstitutional physical and social environment and helping residents to maintain their usual lifestyle, and patients’ freedom, hominess reflecting patients’ previous lifestyles, and patients’ needs and privacy were regarded as important. Cognitive functions were evaluated with the Hasegawa Dementia Scale-Revised version (HDS-R; range: 0 –30 points, cut off 19/20), scores of which correlate with that of the Mini-Mental State Examination.4,5 BPSD and QOL were evaluated every 2 months for 6 months using the Cohen-Mansfield Agitation Inventory (CMAI),6 the Neuropsychiatric Inventory (NPI),7 and the Health-Related Quality of Life Questionnaire for Dementia (QOL-D).8 The use of psychotropic drugs was also evaluated every 2 months. The Friedman test and Wilcoxon signed-rank test 336 Letters to the Editor
were used for the statistical analysis of the CMAI, NPI, QOL-D, the number of psychotropic drugs used, and the chlorpromazine-equivalent dose of antipsychotics. The scores of the HDS-R at 0 and 6 months were compared using the Wilcoxon signed-rank test. A significance level of .05 was used for all statistical tests. No subject dropped out during the observation period. At the end of the 6-month study period, cognitive function was not significantly changed compared with the baseline. In contrast, the mean NPI total score (28.9 to 16.0, z ⫽ ⫺2.366, P ⫽ .018) and mean CMAI total score (60.4 to 52.0, z ⫽ ⫺2.524, P ⫽ .012) were significantly improved compared with the baseline. Three of 6 subscale scores of the QOL-D, including positive affect (12.9 to 19.3, z ⫽ ⫺2.383, P ⫽ .017), restlessness (11.4 to 8.8, z ⫽ ⫺2.207, P ⫽ .027), and attachment to others (7.4 to 9.6, z ⫽ ⫺2.207, P ⫽ .027), were also significantly improved at 6 months. The number of psychotropic drugs (mean of 1.1 at the baseline) and the chlorpromazine-equivalent mean dose of antipsychotics (mean of 73.1 mg/day at the baseline) decreased gradually, and they were finally withdrawn. These preliminary results suggest the beneficial effects of a homelike physical and social environment on BPSD, QOL, and psychotropic drug use in patients with FTD. We consider that a study period of 6 months may be too short to explain the improvement by disease progression alone. The remarkable affective disturbances in patients with FTD led us to speculate that they have difficulty feeling frustration or distress about their surrounding circumstances. The present findings, however, suggest that FTD patients can be affected by their physical and social environment, and their behavior and QOL may be improved, at least in part, by using their remaining emotional and cognitive functions. Therefore, we believe that homelike physical and social environmental features should be valued more to optimize a combination of pharmacological and nonpharmacological interventions in diverse care settings for FTD patients besides group-home care. Although further controlled studies with larger size samples are needed to confirm our conclusion, we consider that the present findings have significant implications for the management strategies for behavioral disturbances of FTD. ACKNOWLEDGMENTS We thank Dr K. Tsuchiya (Department of Laboratory Medicine and Pathology, Tokyo Metropolitan Matsuzawa Hospital, Tokyo, Japan) for insightful review of the manuscript and comments, Ms H. Nakano and Ms M. Yamasaki for help in collecting clinical information, Mr A. Sasaki for help with the production of the manuscript, and all the staff members of the group home. This work was supported in part by a research grant from the Zikei Institute of Psychiatry. Osamu Yokota, MD, PhD Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan JAMDA – June 2006
Kinoko Espoir Hospital Kasaoka, Japan Yoshikatsu Fujisawa, MD, PhD Jun Takahashi, MD, PhD Kinoko Espoir Hospital Kasaoka, Japan Seishi Terada, MD, PhD Takeshi Ishihara, MD, PhD Hanae Nakashima, MD, PhD Etsuko Oshima, MD Aki Kugo, MD Toshie Ata, MA Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan Hideki Ishizu, MD, PhD Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan Department of Laboratory Medicine Zikei Institute of Psychiatry Okayama, Japan Shigetoshi Kuroda, MD, PhD Department of Neuropsychiatry Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan Ken Sasaki, MD, PhD Kinoko Espoir Hospital Kasaoka, Japan REFERENCES 1. Yokota O, Sasaki K, Fujisawa Y, et al. Frequency of early- and late-onset dementias in a Japanese memory disorders clinic. Eur J Neurol 2005;12: 782–790. 2. Ballard CG, Margallo-Lana ML The relationship between antipsychotic treatment and quality of life for patients with dementia living in residential and nursing home care facilities. J Clinical Psychiatry 2004;65(suppl 11):23–28. 3. Neary D, Snowden JS, Gustafson L, et al. Frontotemporal lobar degeneration: A consensus on clinical diagnostic criteria. Neurology 1998;51: 1546 –1554. 4. Katoh S, Simogaki H, Onodera A, et al. Development of the revised version of Hasegawa’s dementia scale (HDS-R). Jp J Geriatr Psychiatr 1991;2:1339 –1347. LETTER TO THE EDITOR
5. Folstein MF, 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. 6. Finkel SI, Lyons JS, Anderson RL. Reliability and validity of the CohenMansfield Agitation Inventory in institutionalized elderly. Int J Geriatr Psychiatry 1992;7:487– 490. 7. Cummings JL, Mega M, Gray K, et al. The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308 –2314. 8. Terada S, Ishizu H, Fujisawa Y, et al. Development and evaluation of a health-related quality of life questionnaire for the elderly with dementia in Japan. Int J Geriatr Psychiatry 2002;17:851– 858.
DOI: 10.1016/j.jamda.2006.02.012
Antipsychotic Drug Use Among Nursing Home Residents Taking Rivastigmine To the Editor: We thank Dr. Narayanan et al1 for their thought-provoking analysis of this subject. However, we would like to bring to the attention of readers of this journal that it is not clear what stages of dementia were present in those in the rivastigmine group as compared with those in the non-rivastigmine group. As we know, cholinesterase inhibitors (donepezil,2 rivastigmine,3 galantamine,4 tacrine5) are approved for use in the early to moderate stages of Alzheimer’s dementia (AD) and an N-methyl-D-aspartate receptor antagonist (memantine6) is approved for use in the moderate to advanced stages of AD. It is also known that usually incidence of behavioral disturbances increases with the advancement in the stages of dementia. Initially, when donepezil was approved for use in clinical practice, nursing home placement was one of the reasons to reevaluate its continued use. If rivastigmine was used in patients with early AD, then the outcome of this study is not surprising as patients with early AD tend to have fewer behavioral issues and therefore the effect seen in this study may not necessarily be a result of rivastigmine use but rather because of the low incidence of behavioral issues in the early stages of AD. It is also not clear whether patients in the non-rivastigmine group ever received a cholinesterase inhibitor or if they were tried on a cholinesterase inhibitor while residing at their home, which was later discontinued as their AD continued to progress to the point of requiring nursing home care. If the case is the latter, then one can argue that these patients had a higher probability of having behavioral issues to begin with as the incidence of behavioral issues increases with the advancement of stage. The authors were of the opinion that patients in the rivastigmine group at baseline had higher behavioral issues than the non-rivastigmine group. However, signs and symptoms (sadness, loss of interest, sleep issues) described by the authors are suggestive of depression rather than the neuropsychiatric symptoms for which antipsychotics may be prescribed. As we know, neuropsychiatric symptoms are common in AD especially in the later stages. These symptoms include agitation, aggression, delusion, hallucination, and wandering.7 Depression and sleep disturbance can also occur with AD.7 It is not clear what, if any, of the neuropsychiatric symptoms were present in the non-rivastigmine group. AntiLETTER TO THE EDITOR 337