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Disruptive Behavior as a Predictor in Alzheimer Disease
Nikolaos Scarmeas, MD, MS;
Jason Brandt, PhD;
Deborah Blacker, MD, ScD;
Marilyn Albert, PhD;
Georgios Hadjigeorgiou, MD;
Bruno Dubois, MD;
Davangere Devanand, MD;
Lawrence Honig, MD, PhD;
Yaakov Stern, PhD
Arch Neurol. 2007;64(12):1755-1761.
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, 1.10-1.97]). 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.
Author Affiliations: Cognitive Neuroscience Division, Taub Institute for Research in Alzheimer's Disease and the Aging Brain, the Gertrude H. Sergievsky Center (Drs Scarmeas, Devanand, Honig, and Stern), and the Departments of Neurology (Drs Scarmeas, Honig, and Stern) and Psychiatry (Drs Devanand and Stern), Columbia University Medical Center, New York, New York; Departments of Psychiatry and Behavioral Sciences and Neurology, The Johns Hopkins University, Baltimore, Maryland (Drs Brandt and Albert); Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Dr Blacker); and Departments of Neurology, University of Thessaly, Larissa, Greece (Dr Hadjigeorgiou), and Hospital de la Salpêtrière, Paris, France (Dr Dubois).
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