Behavioral and Personality Changes May Precede Alzheimer Disease

Personality and behavioral changes may be an early indicator of Alzheimer disease before memory symptoms are present, according to researchers who have developed a 38-point checklist that could be used to help identify such changes.

“In some instances, there may be the initial presentation of dementia in advance of cognitive impairment,” said lead study author Zahinoor Ismail, MD, of the Hotchkiss Brain Institute, University of Calgary.
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Present in about half of people with mild cognitive impairment (MCI), neuropsychiatric symptoms (NPS) are associated with faster conversion to dementia, the researchers said. Older people with normal cognition and NPS have a higher risk of progressing to MCI, suggesting that NPS are an early manifestation of neurodegeneration.

“An Alzheimer’s Association international expert consensus panel recently proposed that mild behavioral impairment (MBI) defines a syndrome of later-life acquired NPS that is a harbinger of neurodegeneration and progression to MCI and/or dementia,” the authors said. “The NPS seen in MBI are described in the domains of apathy/drive/motivation; mood/affect/anxiety; impulse control/agitation/reward; social appropriateness; and thoughts/perception. Rating scales for NPS in dementia, especially the Neuropsychiatric Inventory (NPI), have been used to estimate MBI prevalence. However, MBI is by definition a pre-dementia syndrome in individuals who are functionally independent and younger than typical dementia patients. A rating scale specifically designed for MBI is necessary to develop accurate prevalence estimates and as a later outcome measure of preventive therapies.”

The researchers developed the MBI Checklist (MBI-C) via an iterative Delphi process involving members of the NPS Professional Interest Area of the International Society to Advance Alzheimer’s Research and Treatment. They used the clinician rating version of the NPI as a starting point. Delphi panel participants added and modified questions based on their clinical and research experience, and the investigators specifically designed questions to address a younger pre-dementia population and to emphasize that the emergence of NPS was a significant change from prior behavior, present for at least 6 months.

At this point, the MBI-C is best used to identify symptoms that may be of concern and perhaps to monitor over time, said Dr Ismail, noting the checklist should be completed by a family member who has known the person for a long time.

“When there is a sustained change in personality or behavior in older adults, it should trigger a medical workup and possibly cognitive testing or referral to a specialist clinic in dementia,” Dr Ismail said. “Often, these symptoms are ignored, but in fact, they may be early warning symptoms.”

Numerous validation studies for the MBI-C are ongoing, as it remains unclear what the risk stratification will be for the scoring, he said. Also, imaging and biomarker studies will work to determine the neural correlates of these symptoms in people with normal cognition and MCI.

—Mike Bederka

Reference:

New concept - mild behavioral impairment (MBI) - and checklist of symptoms could support earlier Alzheimer's/dementia diagnosis [press release]. Toronto, Canada: Alzheimer’s Association; July 24, 2016. https://www.alz.org/aaic/releases_2016/sun_445_ET.asp. Accessed July 28, 2016.