The Profile of Behavioral and Psychological Symptoms of Dementia

in Post-stroke Vascular Cognitive Impairment

Fasihah Irfani Fitri, Aldy S. Rambe, Aida Fithrie

Department of Neurology Universitas Sumatera Utara/ Adam Malik General Hospital

Keywords: Behavioral and psychological symptoms of dementia, Vascular cognitive impairment

Abstract: Behavioral are standard features of all types of dementia, irrespective of disease etiology and stage, including

vascular cognitive impairment (VCI). The study aimed to examine the BPSD profile in post-stroke patients

with VCI. This cross-sectional study involved 76 post-stroke patients with vascular cognitive impairment.

The mean age was 57.95±10.54 years old. Thirty patients (39.47%) had at least one symptom of BPSD. The

most common symptom was apathy and indifference (15 patients; 19.7%), followed by depressive and gloomy

mood (13 patients, 17.1%). The least frequently found symptom was a violent force, which was only seen in

2 patients (2.6%). There was no significant difference in BPSD profile between ischemic and hemorrhagic

stroke. BPSD was a common finding in post-stroke VCI, with apathy being the most common symptom. Early

identification may lead to better management and may increase the quality of life.

1 INTRODUCTION

Behavioral and psychological symptoms of dementia

(BPSD), also called neuropsychiatric symptoms

(NPS), are standard features of all types of dementia,

irrespective of disease etiology and disease stage.

[Dillon et al,2013; Gupta et al,2014; Mortbya et

al,2017; Tiel, 2015; Zhang, 2012]. The presence of

BPSD in vascular cognitive impairment (VCI) has a

significant impact on the patient's functional and

cognitive status. [Dillon et al,2013; Gupta M et

al,2014; Tiel, 2015]. BPSD are associated with high

caregiver burden, poor prognosis, and higher rates of

institutionalization and drug therapy; all of which

contribute to an increased social and economic impact

on people with dementia. [Dillon, 2013] Caregivers

of dementia patients report BPSD, especially

symptoms like aggression and screaming, to be the

most difficult problem to cope with.[Gupta, 2014].

BPSD are a heterogeneous group of non-cognitive

symptoms and behaviors and are observed in high

rates across the spectrum from mild cognitive

impairment to dementia. They are among the most

challenging and costly aspects of dementia, and, if

left untreated, are associated with hastened disease

progression, worsened daily functioning, impaired

quality of life, increased health care utilization, and

accelerated placement in residential care, increased

utilization of medical resources, more caregiver

stress, diminished quality of life for the persons with

dementia and their families, and higher economic

burden on the caregivers.[Mortbya, 2017; Zhang,

2017]. Vascular cognitive impairment (VCI) refers to

the entire spectrum of cognitive impairment

occurring as a result of the cerebrovascular disease.

The present concept of VCI encompasses not only

vascular dementia (VaD) but also mixed dementia

and vascular cognitive impairment-no dementia

(VCI-ND). VCI-ND refers to that subgroup of

patients who manifest cognitive deficits resulting

from cerebrovascular disease, but do not meet the

definition of dementia.[Gupta, 2014]. The

management of BPSD has the potential to alleviate

much of the suffering of dementia patients and their

caregivers, so early identification and assessment of

BPSD is an essential part of an evaluation of patients

with cognitive impairment. The present study aimed

to examine the profile of BPSD in post-stroke VCI.

2 METHODS

This cross-sectional study involved 76 post-stroke

patients which were recruited from the Memory

Clinic Neurology Department Adam Malik General

Hospital Medan North Sumatera Indonesia, between

Fitri, F., Rambe, A. and Fithrie, A.

The Proﬁle of Behavioral and Psychological Symptoms of Dementia in Post-stroke Vascular Cognitive Impairment.

DOI: 10.5220/0010078205530556

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

553-556

ISBN: 978-989-758-449-7

553

March and June 2018. This study included patients

with a history of stroke for more than three months to

two years, had a minor physical disability, fully

cooperative, speak Bahasa Indonesia fluently, able to

read and write, and gave written consent to be

included in the study. Exclusion criteria were:

subjects with major psychiatric disorders had aphasia

or history of dementia before a stroke. All subjects

underwent neurologic evaluation and cognitive

assessment using Montreal Cognitive Assessment

Indonesian Version (MoCA-INA) and complete

neuropsychological evaluation including assessment

of attention, memory, language, executive function

and visuospatial, as listed in CERAD (Consortium to

Establish a Registry for Alzheimer’s

Disease).(Fillenbaum, 2008; Husein, 2010;

Nasreddin, 2005). The neuropsychiatric symptoms

were evaluated using Abe BPSD Score (ABS) which

assessed 10 symptoms including wandering

in/outside home, eating or toilet problem, delusion or

hallucination, offensive and abusive words, day-night

reversal, excitation and agitation, apathy and

indifference, depressive and gloomy mood, violent

force and high irritability. [Abe, 2015]. All statistical

procedures were performed with SPSS. The Health

Research Ethical Committee Medical Faculty of

Universitas Sumatera Utara/H. Adam Malik General

Hospital approved this study.

3 RESULTS

This study included 76 subjects consisted of 44

(52.9%) males and 32 (47.1%) females. The mean age

was 57.95±10.54 years old. Most of the patients aged

between 51 to 55 years old (26.3%) and had 12 years

of education or finished high school (39.5%). There

were 70 patients (92.1%) with a history of ischemic

stroke and six patients (7.9%) with hemorrhagic

stroke. Most of the patients had a positive history of

hypertension. Table 1 summarizes the clinical

characteristics of the patients.Thirty patients

(39.47%) had at least one of the BPSD symptoms.

The most common symptom was apathy and

indifference (15 patients; 19.7%), followed by

depressive and gloomy mood (13 patients, 17.1%).

The least frequently found symptom was the violent

force, which was found only in 2 patients (2.6%).

There was no significant difference in the frequency

of BPSD symptom between patients with a history of

ischemic and hemorrhagic stroke. Table 2 shows the

frequency of BPSD in both groups.

Table 1. Demographic and Clinical Characteristics of

the Patients

Variables N

(

total 76

)

Percentage

(

)

Sex

Male

Female

52.9

47.1

Age (years), mean ±

57.95±10.541

Age group, years

old

<45

46-50

51-55

56-60

61-65

66-70

71-75

76-80

>80

6.6

10.5

26.3

21.2

17.1

6.6

3.9

6.6

1.3

Educational level

Primary

Junior High

School

High School

Diploma

Universit

17.1

19.7

39.5

2.6

21.1

Occupation

Employee

Housewive

Entrepreneur

Farmer

Unem

31.6

15.8

25.0

5.3

22.4

Stroke Aetiology

Ischemia

Hemorrhage

92.1

7.9

Hypertension

Yes

88.2

11.8

Diabetes Mellitus

Yes

39.5

60.5

Atrial Fibrillation

Yes

2.6

97.4

4 DISCUSSION

Our data show that BPSD in post-stroke cognitive

impairment was relatively common, occurring in

almost 40% of the patients. This number was lower

than previous studies that reported the occurrence of

BPSD was as high as 95% in VCI and VaD.[Chiu ,

2013;Gupta, 2013; Staekenborg, 2010]. This could

partly be explained by the fact that in our study we

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

554

included all post-stroke patients who had cognitive

impairment and we did not classify the patients based

on the severity of the VCI, nor did we differentiate

patients with VCI-ND from those with VaD. Thus, it

could affect the proportion of patients with BPSD

because the severity and occurrence of BPSD are

different in various stages of dementia.[Huang,

2017;Zhang, 2012].

Table 2. Frequency of BPSD Symptoms

Symptoms Total

(76)

N (%)

Ische

mic

(70)

(

)

Haemorr

hage (6)

N (%)

Wandering

in/outside

home

(11.8)

(11.4)

(16.7)

Eating or toilet

roble

(

13.2

)

(

12.9

)

(

16.7

)

Delusion or

hallucination

(9.2)

(10)

0 NS

Offensive and

abusive words

(

9.2

)

(

)

0 NS

Day-night

reversal

(

13.2

)

(

12.9

)

(

16.7

)

Excitation and

agitation

(13.2)

(14.3)

0 NS

Apathy and

indifference

(

19.7

)

(

18.6

)

(

33.3

)

Depressive

and gloomy

moo

(17.1)

(16.7)

Violent force 2

(2.6)

(2.9)

0 NS

High

irritabilit

(

7.9

)

(

8.6

)

0 NS

We found apathy and depression were the most

common symptoms of BPSD, and violent force was

the least common symptom. This is consistent with

several previous studies. Gupta. (2014) reported that

depression was the commonest BPSD at 73.3% and

apathy was found in 35% of the cases. Disinhibition

(8%), euphoria, and hallucinations (5% each) were

the least common of the BPSD on the NPI.[Gupta,

2014]. Apathy and depression were the most common

neuropsychiatric manifestation of VCI irrespective of

the subtype and the severity of the disease. A review

of the total of 82 studies which compared several

types of VaD found that apathy and depression also

occurred sometime during the disease. From 13

articles selected in that review, four compared BPSD

in Subcortical Vascular Dementia (SVaD) versus

Cortical-Subcortical Vascular Dementia (CSVaD),

three involved comparisons between SVaD and VCI-

ND, one study analyzed differences between CSVaD

and VCI-ND, while five studies assessed BPSD in

CSVaD. Subcortical and Cortical-Subcortical VaD

were associated predominantly with apathy and

depression. VCI-ND may present fewer behavioral

symptoms than VaD.[Tiel, 2015]. Despite

considerable advances in the detection of brain

vascular-related syndromes in recent years, the

association between vascular lesions and both

cognitive symptoms and BPSD in VCI remains

controversial. For instance, data in the literature

suggests that BPSD may occur in VCI, regardless of

the development of dementia. BPSD may also appear

at any stage, induced by cerebrovascular lesions

disrupting the cortical-subcortical circuits between

prefrontal cortex connections to limbic nuclei of the

basal ganglia and thalamus, and other limbic system

structures. This suggests that better characterization

of vascular-related BPSD, and the underlying

mechanisms of brain injury associated with these

features, is still needed to allow the adoption of

effective evidence-based prophylactic and

therapeutic measures.[Tiel,2015].

Apathy typically occurs following disruption

of circuits linking subregions of the prefrontal cortex

and subcortical structures, such as the basal ganglia,

implicated in reward processing and complex

planning. Clinical definitions of apathy have

distinguished between cognitive and emotional

aspects of goal-directed behavior. Anterior cingulate

atrophy has been associated with reduced initiation

while executive dysfunction has been associated with

the pathology of the dorsolateral prefrontal cortex and

reduced reward sensitivity with underactivation of the

orbitofrontal cortex. [Gallagher, 2017]. Apathy is

known to be common in subcortical ischaemic

vascular disease owing to the occurrence of white

matter lesions and/or lacunar infarcts in the basal

ganglia and thalamus, which lead to interruption of

cortico-subcortical circuits.[Gupta, 2014] Apathy in

the context of VCI has been associated with

‘‘vascular depression’’ and depression with executive

dysfunction. It is important to differentiate apathy

from depression as apathy may occur independently

from depression. In such cases, there is typically a

relative absence of distress and negative cognitions so

commonly observed in depression.[ Gallagher, 2017].

Several mechanisms might link depression,

anxiety, and cognitive decline. Depression has long

been associated with hypercortisolemia, and recurrent

depression has previously been associated with the

reduced hippocampal volume. Cerebrovascular

disease has been particularly associated with

depression in later life and may precipitate and

perpetuate depression via disruption of corticostriatal

The Proﬁle of Behavioral and Psychological Symptoms of Dementia in Post-stroke Vascular Cognitive Impairment

555

tracts necessary for cognitive and emotional

regulation. Increased inflammation, decreased

secretion of trophic factors, and increased oxidative

stress are mechanisms that may link depression and

cognitive decline at a molecular level, while at a

behavioral level, physical inactivity and other adverse

health behaviors have been associated with

accelerated cognitive decline. [Gallagher,2017]

This study has several limitations. First, we did not

classify the patients based on the difference subtype

of post-stroke vascular cognitive impairment, which

may have a different pato-mechanism in causing

cognitive impairment. Second, we did not analyze the

presence of BPSD based on the severity of the

cognitive impairment or the impact on daily life

activities.

5 CONCLUSIONS

In conclusion, BPSD is very common in post-stroke

VCI, with apathy and depression being the most

common symptoms. Early identification and

assessment of BPSD in post-stroke patients may lead

to better management and may increase the quality of

life and lessen the caregivers’ burden.

ACKNOWLEDGEMENTS

Lembaga Penelitian Universitas Sumatera Utara

funds this research according to Kontrak Pelaksanaan

Penelitian TALENTA Universitas Sumatera Utara,

2018. Number: 2590/UN5.1.R/PPM/2018, March,

, 2018

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