Dementia is currently the seventh leading cause of death and one of the major causes of disability and dependency among elderly. In Taiwan, there are at least 300,000 people live with dementia. However, only 1.64% of people with dementia received palliative care. In this paper, we describe a real-world experience of palliative care for people with advanced dementia.

Case report.

Mrs. H, A 90-year-old illiterate woman, was referred to Home Care team after several admissions for urinary tract infection. Her past medical history included cerebral infarction with left hemiparesis 4 years ago. Over one year prior our first visit, her family had begun to notice a problem with her recent memory. Thorough investigation for dementia was arranged. She scored 11/30 on the Mini-Mental State Examination. Mixed Alzheimer’s and vascular dementia was impressed.

The Home Care service consisted of a once-monthly visit by physician and nurse. In the first year of service, we delivered active directed treatment for dementia. We also discussed nonpharmacological approaches for dealing with physical and behavior symptoms in each visit.

Then Mrs. H was hospitalized again due to fever and abdominal pain. Abdominal aortic aneurysm was diagnosed along with urinary tract infection. She had hypoactive delirium for two months after discharge. Meanwhile, Home Care team arranged a family meeting to discuss prognosis and appropriateness of palliative care. In the following two years, we focused on deprescribing and interventions for pain, dyspnea, eating problem, infection, and agitation to promote Mrs. H’s comfort and quality of life. Psychological support was crucial to facilitate continuity in carer and care setting. Mrs.H did not have burdensome transition anymore and passed away peacefully at home as her preference.

The need for palliative care in dementia is anticipated to increase over the next decades in Taiwan. In the patient presented, Home Care team acknowledged and offered palliative care to help her to live as comfortably as possible until death and to help carers cope during the course. A multidisciplinary health care is highly recommended for complex needs in dementia.

By 2030, 1 in 6 people in the world will be aged 60 years or over (World Health Organization, 2022). This Manifesto is the result of the work undertaken by the Task Force of the Italian Association of Psychology working in the field of Clinical Psychology of Ageing. There is a general belief that older people do not benefit from psychological interventions, due to the prejudice that they may be less psychologically flexible or unable to change and/or improve their functioning. However, current evidence suggests that psychological interventions, including both more and less structured ones, are equally effective for older and working-age adults. Therefore, the aim of this Manifesto was to highlight the specific role of the Clinical Psychology in enabling older adults to overcome the multiple challenges associated with the ageing process and disease-related issues.

We reviewed existing empirical and conceptual literature on main issues in clinical work with older adults.

We identified and thoroughly described areas of major interest, such as theoretical models on how we think, feel and act towards age and ageism; prevention of emotional distress and cognitive decline and promotion of older adults’ psychological health in community; multidimensional assessment and evidence-based psychological interventions, also mediated by technology, for healthy older adults and those living with chronic disease such as dementia. Attention to psychological issues related to informal and formal caregiving, as well as the need for education, training and public engagement will be highlighted.

With a population living longer worldwide, it is essential to introduce and formalize initiatives to reduce health inequities and improve the lives of older people and their families. This should take place in communities able to foster the abilities of older people, while providing them with access to quality long-term care, if needed.

All older adults, including those already living with dementia, should be provided with adequate knowledge about dementia and be aware of how to navigate the social resources available to them. The purpose of this study was to develop a practical program to help older adults living in the community learn about cognitive decline and how to use related social resources.

Program participants included attendees of a community center for dementia support in a major Japanese city, as well as the residents of a large housing complex in the local area. Within the cohort, there were participants who willingly disclosed to having dementia. The program began in February 2021 and was held once a month for a total of 15 hour-long sessions. A participant survey was administered at each session to gather the demographic information of participants and their understanding of the program. Additionally, the staff conducted recorded verbal discussions about the program, which were then reviewed using thematic analysis.

The program structure was as follows: (1) participants decided the theme; (2) the first half of each session comprised lectures, while the second half included discussion and group work; and (3) rules for discussion were established (do not interrupt, do not unilaterally deny what people say, maintain confidentiality). The average number of participants per session was 12.1. Survey results indicated that 70.5% of participants were female and, in terms of age, the largest number of attendees were 81-90 years old (48.5 ). Most participants “understood the program content well” (72.5%) and indicated that “they would strongly like to participate again” (64.2%). The recorded participant discussions about the program were suggested, after review, to be more superficial as a result of Japanese people's particular attitude of not wanting to bother others.

Participants were highly satisfied with the program and were able to help develop a practical program for people living with dementia to learn effectively. A challenge was that participants had a “do not want to bother others” mindset, which could inhibit them from expressing their true wishes and make them less likely to use social resources.

Episodes of lucidity (EL) are clinically and potentially epidemiologically significant events that occur among individuals with advanced dementia. EL are characterized by a spontaneous return of abilities previously thought to have been lost and are predominantly reported near end of life. Audiovisual observation offers a valuable approach to studying EL, providing opportunities to characterize verbal/non-verbal features of EL as well as their surrounding contexts. Approaches to capturing and characterizing audiovisual data and potential verbal/non-verbal indicators of EL near end of life are lacking.

This study determined the acceptability and feasibility of a multi-faceted observational study protocol to characterize potential observable indicators of EL among people with advanced dementia near end of life.

This study incorporated longitudinal audiovisual observation, informant field interviews/case review of potential EL events by informants. We examined enrollment and retention rates, task load and usability ratings from clinician and research staff across data collection and processing tasks, and surveys and qualitative appraisal from participants and staff regarding feasibility and acceptability. The NASA TLX Task Load Index measures workflow assessment to generate a combined score between 0-20, with 0 indicating higher workflow assessment. The modified System Usability Scale (SUS) measures usability with a score of 0-100, with 100 indicating higher usability and a target score ≥68 indicating usability higher than 50% of the average score.

Five eligible individuals were enrolled, yielding a 100% enrollment/retention rate, and 103 observations totaling 280 hours of observation across participants. NASA TLX Task Load Index scores of 2.9 over 4 months, with vast improvement over time indicate study procedures with iterative refinements were feasible. Average modified SUS score for clinician and research staff was 96 and 82.4 respectively, indicating high usability with notable improvement over time. Surveys and qualitative appraisal from participants and staff endorse high rates of acceptability and feasibility. Additionally, the study team identified 9 potential EL across 3 participants. Seven caregivers and two clinicians participated in case reviews to review the corresponding audiovisual data, resulting in 3 endorsed EL.

Depression and anxiety persist in a large number of patients after stroke. Anxiety affects around one third of patients during the first year. Nowadays, this phenomenon receives significantly less attention compared to other psychological problems, and poor psychological services after the onset of the disease were reported in previous studies. Some patients have access to specialized rehabilitation units (“Integrated Continuing Care Unit, UCCI”) that can ameliorate anxiety and significantly improve health-related quality-of-life (QoL), avoiding depression and improve patients' functional disability.

To analyze the associations between anxiety/depression symptoms and QoL in patients with chronic stroke, during and after discharge from UCCI.

An observational, longitudinal and descriptive study was carried out with patients with a clinical history of stroke discharged from hospitals in Portuguese central area, aged ≥65 years, without dementia diagnosis. Patients were observed at admission at the rehabilitation unit, discharge, and 6 and 12 months after discharge, and data were collected through a protocol composed of several self- completion instruments, namely the Hospital Anxiety and Depression Scale (HADS) and Stroke Specific Quality-of-Life Scale (SS-QoL). Data on clinical and demographic variables were collected and analyses performed to describe associations with HADS scores. Data were collected from August/2020 to July/2022 and analyzed using SPSS®,V.26.0.

A cohort of 154 stroke patients was assessed (M/F ratio=1.8, age 75±9 years). Anxiety scores were 6.8(4.8) (6 months) and 5.8(4.1) (12 months). Depression scores were 8.7(5.3) (6 months) and 8.1(4.7); (12 months). Anxiety total score at 6 months was significantly related (p<0.05) with 3 domains of SS- QoL (Personality, Social Role and Work/Productivity). However, no differences were found at 12 months. Depression was significantly related with all domains of SS-QoL except Vision (p<0.05).

HADS score for anxiety were normal (0-7) at 6 and 12 months; however, depression remain in the Borderline abnormal classification (8-10), 6 and 12 months after stroke, which appear to have a negative impact in almost all SS-QoL domains of patients with chronic stroke. The current study highlights the need to prevent depression symptoms after stroke as this can negatively affect the functional recovery of the entire ongoing rehabilitation process.

Capgras syndrome is a delusion in which the patient believes that a particular individual has been replaced by an imposter. It is observed in patients with psychiatric disorders such as schizophrenia but also occurs in patients with a neurodegenerative disease including Lewy body disease and Alzheimer’s disease. Here we report a patient with early-onset Alzheimer’s disease who presented with a unique form of Capgras syndrome.

An early 60’s right-handed woman with 12 years of education, visited our outpatient clinic for evaluation of her memory impairment. Neurological examination was not remarkable. A MMSE score was 25/30 and a neuropsychological examination indicated mild impairment of attention and episodic memory, and relatively preserved visuospatial function. Six months after the initial visit of our clinic, she started to claim that she met several imposters of her husband. She called each imposter in different name, described each as a slightly different appearance, and expressed different level of sense of familiarity. An additional examination of face recognition using photographs of her husband revealed that there was a difficult to recognize her husband especially viewed from the side of his face. In addition, she showed a difficulty in discriminating between two different unknown faces and in judging approximate age of face in photographs. Brain MRI showed no significant atrophy and IMP-SPECT showed an extensive hypoperfusion in the bilateral, right-side dominant temporal, parietal, and occipital lobes. Both FP-CIT SPECT and MIBG scintigraphy were negative. Florbetapir PET was positive. Thus, a diagnosis of early-onset Alzheimer's disease was made. Acetylcholinesterase inhibitors and antipsychotics were used to treat her Capgras syndrome, but the symptom lasted for more than a year.

There are several possible factors that may induced patient’s unique Capgras syndrome: (1) psychodynamic background- the patient and her husband had been in a long-term common-law relationship; (2) mild impairment in face recognition; (3) dysfunction of right hemisphere, which is known to be strongly related to Capgras syndrome. The combination of these factors may result in the occurrence of multiple imposters of her husband with different degrees of familiarity.

In the past decade, researchers and advocates have taken important steps toward understanding the full costs of Alzheimer’s disease and related dementias. However, our current approach to framing these costs does not fully consider the behavioral symptoms of dementia, notably agitation. Agitation in Alzheimer’s disease contributes to negative social and financial outcomes for people with the condition, their care partners, and health systems. When left untreated, the negative impact of these outcomes is exacerbated, yet the full scale of this impact is unknown. “Cost Considerations of Untreated Agitation” seeks to propose a framework to help in evaluating the variables that impact these costs.

We created a model that investigates each stage of Alzheimer’s disease with agitation. This model assesses direct, indirect, and intangible costs of the disease. Direct costs include professional caregiving, non-pharmacological intervention, nursing home costs, healthcare professional consultations, and hospitalizations. Indirect costs included loss of income and value of unpaid caregiving. Intangible costs include the mental health impact of agitation on individuals living with Alzheimer’s and their care partners. Additionally, we used quality-adjusted life years to measure disease burden and health outcomes. Finally, we leveraged qualitative research to overlay the experience of care partners and individuals with lived experience to bring their voice to this work.

Results are a tentative framework and describe what additional research and input is necessary in order to create a version with which one can assess the comprehensive costs of untreated agitation in Alzheimer’s. This framework will include perspectives and feedback from individuals with lived experience, care partners, and key opinion leaders in Alzheimer’s research from across the world.

Agitation has severe consequences on individuals, families, and health systems. Oftentimes one of the first symptoms of Alzheimer’s or dementia, agitation can increase the caregiving responsibilities, trigger placement into nursing homes, and cause severe emotional and physical toll on care partners. We cannot understand the full costs of dementia or AD until we account for untreated agitation vis-à-vis a multi-symptom assessment, therefore an accepted framework is necessary in order to fully consider the costs of untreated agitation.

To test vitamin D3 and omega-3s for late-life depression prevention under the National Academy of Medicine framework for indicated (targeting subthreshold depression) and selective (targeting presence of high-risk factors) prevention.

VITamin D and OmegA-3 TriaL (VITAL) is a 2x2 factorial trial of vitamin D3 (2000 IU/day) and/or omega-3s (1 g/day) for cardiovascular and cancer prevention (enrollment: November 2011-March 2014; end date: December 31, 2017). In this targeted prevention study, we included 720 VITAL clinical sub-cohort participants who completed neurobehavioral assessments at baseline and 2 years (91.9% retention). High-risk factors were: subthreshold or clinical anxiety, impaired activities of daily living, physical/functional limitation, medical comorbidity, cognitive impairment, caregiving burden, problem drinking, and low psychosocial support. Co-primary outcomes were: incident major depression (MDD), adjudicated using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition); change in mood (Patient Health Questionnaire-9 [PHQ-9]). We used exact tests to determine treatment effects on MDD incidence and repeated measures models to determine treatment effects on PHQ-9.

11.1% had subthreshold depression, 60.8% had ≥1 high-risk factors, MDD incidence=4.7% (5.0% among completers), and mean PHQ-9 change=0.02 points. Among those with subthreshold depression, the MDD risk ratio (95% confidence intervals)=0.36 (0.06 to 1.28) for vitamin D3 and 0.85 (0.25 to 2.92) for omega-3s, compared to placebos; results were also null among those with ≥1 high-risk factors [vitamin D3 vs. placebo: 0.63 (0.25 to 1.53); omega-3s vs. placebo: 1.08 (0.46 to 2.71)]. There were no significant differences in PHQ-9 change comparing either supplement with placebo.

Neither vitamin D3 nor omega-3s showed benefits for indicated and selective prevention of late-life depression; statistical power was limited.

Observer rating scales are necessary to evaluate the risk of suicide because individuals at risk for suicide are often unwilling to seek help on their own. Reliability and validity were evaluated for the newly developed Suicide Screening Questionnaire-Observer Rating (SSQ-OR).

Preliminary items were assessed by 251 experts online and 25 questions were selected. 328 individuals at high-risk and 661 controls from 12 Crisis Response Centers and 5 university counseling centers were recruited to complete SSQ-OR, Beck Scale for Suicide Ideation (BSSI) and Patient Health Questionnaire-9 (PHQ-9). In a 6 months follow-up, we reached out to 176 participants to ask whether they had experienced a suicidal thought, plan, or attempt since the baseline assessment. Cronbach's 慣, Mann-Whitney U test, Spearman's correlation, factor analyses, Receiver operating characteristic (ROC) analysis and logistic regression analysis were used to verify the SSQ-OR.

Structural validity was supported by a two-factor solution using exploratory and confirmatory factor analyses. Excellent model fit indices for the two-factor structure using exploratory factor analysis were confirmed (RMSEA = 0.033, TLI = 0.980, CFI = 0.983). The SSQ-OR demonstrated strong internal consistency. The concurrent validity based on the correlations with other self-reported indicators of suicidal potential-BSSI and PHQ-9- revealed substantial relationships. The high-risk group was effectively characterized by a cut-off point of 4, with a sensitivity of 0.73 and a specificity of 0.79. The SSQ-OR scores were significant predictors of suicidal thoughts and behaviors within 6 months.

The SSQ-OR exhibits sound psychometric properties, and could be used as a complement to a self-report or clinical-administered scale to screen suicide risk comprehensively.

COVID-19 is notorious for its neuropsychiatric sequelae. Some patients present with anosmia and cognitive and attention deficits, also known as “brain-fog”. In COVID-19 survivors, psychiatric manifestations such as depression, fatigue, anxiety, and neurocognitive impairments, also known as the “post-acute COVID-19 syndrome” or “long COVID”, were reported in 35% of the patients after the infection. New-onset anxiety, depression, psychosis, seizures, and even suicidal behaviors are also reported. Inflammation was proposed to be the pathophysiology.

The 68 year-old married female who lived with her husband did not have psychiatric history before this year. She had covid-19 infection 3 months prior to her psychiatric hospitalization. Although she had recovered, she started to have depressed mood, disrupted sleep and anhedonia since then. She became easily anxious and could hardly feed her cats as usual. She was not able to make decisions. She no longer did house chores that she had been doing. Poor appetite led to a loss of body weight from 46 to 40kgs. She had blunted emotional response, and could not cry after her cat died. She went to clinic for help, BZD and antidepressants were given, but the condition persisted. One week prior to hospitalization, her speech became weak, murmuring and could not finish a long sentence. The physiological change can be observed using wearable device. After 3 weeks of treatment, her heat rate, activity and sleep improved. The progress was also recorded via wearable devices and clinical scales.

In our patient, the depression was associated with circadian rhythm disruption, suicidal ideations and psychomotor slowing. This may reveal some special features of post-COVID depression. In previous studies, antidepressants have proved to be effective in treating post-COVID-19 depression. Sigma receptors are one of the possible mechanisms. Besides, agomelatine, with its melatonergic activity of regulating circadian rhythm, is proposed to have the potential to inhibit the virus from entering CNS. The activity pattern and circadian rhythm change will be discussed.

In recent years, the significance of robust social networking is being increasingly recognized due to its association with better cognitive performance. On the other hand, social isolation is linked to higher risk of developing dementia in mid-life and in older age groups. Only few studies have examined social networking in individuals with Mild Cognitive Impairment (MCI). The lack of social connectedness could increase the chances of these individuals progressing to dementia.

We cross-sectionally assessed social networking among 122 subjects with MCI and 2403 cognitively healthy subjects, aged 45 years and above, from the Srinivaspura Aging, NeuroSenescence and COGnition (SANSCOG) study cohort in rural southern India. Cohen’s Social Network Index (SNI) was used to assess social networking, wherein three dimensions are assessed: network diversity, number of people in social network, and number of embedded networks. The diagnosis of MCI was made using the Clinical Dementia Rating (CDR) instrument. This is an extensively validated 5-point scale, wherein six cognitive and functional domains are assessed: Memory, Orientation, Judgment & Problem Solving, Community Affairs, Home & Hobbies, and Personal Care. The overall CDR score of ‘0’ was interpreted as cognitively normal and CDR score of ‘0.5’ as MCI. The SNI dimension scores were compared between subjects with MCI and cognitively healthy subjects using t-test and a p-value of <0.05 was considered significant.

The mean scores of all three SNI domains were significantly lower in MCI compared to cognitively healthy subjects: network diversity (5.30 ± 1.54 vs. 5.94 ± 1.60, p < 0.001), number of people in social network (18.4 ± 8.61 vs. 20.3 ± 8.87, p = 0.023), and number of embedded networks (1.80 ± 1.26 vs. 2.03 ± 1.14, p = 0.038).

Aging rural Indians with Mild Cognitive Impairment (MCI) have poorer social networks than their cognitively normal counterparts. Hence, social connectedness should be routinely evaluated in individuals with MCI and prompt social interventions should be instituted to enhance their social functioning. Social isolation may indeed be a contributory risk factor for developing cognitive impairment. However, causal relationships and reverse causality should be evaluated in further longitudinal studies.

The use of health care technology to support informal and formal caregivers in decision making for proper guidance of care for people with dementia, is rising over the last decade. For example, (tools within) electronic health records systems, technological devices such as wearables and devices using sensor technology (domotics) are more and more available in health care. Recent developments of artificial intelligence (e.g. machine learning, deep-learning, text mining) can be useful to provide a more advanced use of sensor and other data, and contribute to a better guidance of (person)centered care. However, the use of health care technology (and the data it accumulates) could – when used appropriately and meeting the needs of (in)formal care workers who use this technology- help to relieve the burden of care (in times of lack of staff resources), delay nursing home admission and reduce corresponding costs. Unfortunately, some of these developments, not always meet the needs of care workers and informal caregivers caring for people with dementia.

For health care technology to be able to contribute to personalized dementia care, a combination of innovation (novel technology) and implementation is necessary. A wider use of novel technology on a broader scale is necessary to generate impact. For a proper implementation, several factors such as staff opinions that may be reluctant to using novel technology, data safety and ethical issues have to be taken into account. In addition, a proper training guiding the process of implementation is crucial.

In this workshop, we will provide several examples of applications in health care based on data usage and sensor technology: (1) the use of (the combination of) qualitative and quantitative data for personalized health care, (2) wearable sensors to measure stress, a phenomenon that is regarded as an early warning for the onset of challenging behavior in people with dementia, (3) combination of ambient and body mounted sensors to monitor challenging behavior and to prevent further deterioration, (4) the practical use of communication, tracking and sensor technology to support welfare to people with dementia and caregivers in the community.

In conclusion, this symposium will give insight in the challenges of designing novel technology and its implementation into daily practice, to assist informal and formal cares to be able to deliver person-centered care.

We have reported parkinsonism and psychiatric symptoms were the most important treatment needs of patients with dementia with Lewy bodies (DLB) and their caregivers, respectively 1). However, the frequency presenting clinical symptoms and the onset time vary among patients. We investigated the impact of the disease duration on clinical symptoms, prescribed medication and treatment needs of patients and their caregivers.

Disease duration was defined as time after diagnosis with DLB. Patient-caregiver pairs were classified into two groups; one with a disease duration <24 months (S-group) and the other with a disease duration ≥24 months (L-group). Comparisons were made between two groups regarding background characteristics and treatment needs of patients and caregivers. Treatment needs were defined as symptom domains most distressing to patients and caregivers.

S-group and L-group were consisted of 126 and 137 pairs of patients and their caregivers, respectively. Regarding patientsʼ current symptoms, parkinsonism and autonomic dysfunction were significantly higher in L-group than S-group. MDS-UPDRS Part III total score and the frequency of prescription for memantine and antiparkinsonian were also significantly higher in L-group than in S- group. The treatment needs most frequently selected by patients was cognitive impairment (20.6%) followed by autonomic dysfunction (16.7%) and parkinsonism (11.9%) in S-group, and parkinsonism (24.6%), followed by cognitive impairment and autonomic dysfunction (11.1% each) in L-group, suggesting no significant difference in the tendency of symptom domains to desire treatment between groups (P=0.056). However, residual analysis showed that patients in S-group were more likely to select cognitive impairment than in L-group (P=0.045), and those in L-group were more likely to select parkinsonism than in S-group (P=0.003). The treatment needs most frequently selected by caregivers in S-group was cognitive impairment (29.4%) followed by psychiatric symptoms (20.6%) and parkinsonism (10.3%) in S-group, and psychiatric symptoms (24.6%), followed by parkinsonism (16.7%) and cognitive impairment (14.3%) in L-group, suggesting significant difference in the tendency of patientsʼ symptom domains to desire treatment between groups (P=0.032). Dara from the onset will be added at the poster presentation.

It was suggested that the treatment needs of patients and their caregivers might change with duration after diagnosis.

Individual differences in the timing of dementia have been attributed to cognitive reserve (CR), thought to reflect lifelong engagement in stimulating experiences, which provide resilience against brain pathology. In older adults, dementia and depression are closely related, and some studies have linked CR with depression risk in old age. It is unclear if different ways of operationalizing CR exhibit similar association with old-age depression. We examined the association of two measures of CR with depressive burden in older adults: activity-based CR, capturing engagement in stimulating activities using proxy variables, and residual-based CR, indicating residual variance in cognition, not explained by the brain status.

We used data on 354 adults aged 60+ from the Swedish National Study on Aging and Care in Kungsholmen, followed for 15 years. Residual-based reserve was computed from a regression predicting episodic memory with a brain-integrity index incorporating six structural neuroimaging markers (white- matter hyperintensities volume, whole-brain gray matter volume, hippocampal volume, lateral ventricular volume, lacunes, and perivascular spaces), age, and sex. Activity-based reserve incorporated education, work complexity, social network, and leisure activities. Depressive burden was captured over the follow- up with the Montgomery-Åsberg Depression Rating Scale and time until clinically relevant level of symptoms (>6) was modelled using Cox proportional hazard models.

Preliminary results indicate that, upon minimal adjustment (age, sex, brain integrity status), top tertiles (ref: bottom tertile) of both activity-based (HR: 0.77; 95% CI: 0.61-0.98) and residual-based CR (HR: 0.62; 95% CI: 0.44-0.98) were associated with a lower risk of depressive burden onset over 15 years. Upon further adjustment for anthropometrics, health behaviors, and chronic disease burden, the association of activity-based CR was attenuated, whereas residual-based CR preserved its effect on depressive burden (HR [fully adjusted model]: 0.59; 95% CI: 0.40-0.88). Next steps include evaluating the ability of reserve measures to attenuate the association of brain integrity with depressive burden using interaction analysis.

Preliminary findings suggest that CR may be linked with depression development in older adults, although the association may vary depending on measurement of reserve. Association of activity- based reserve may be attributed to somatic disease pathways.

BPSD is typically treated as a singular entity. Yet it is heterogeneous and challenges simple phenotyping by behavioral inventory. Some investigators recognize BPSD more as ‘obstreperous,’ disruptive behavior, or unwanted behavior. Others conceptualize it as a neuropsychiatric entity with an underlying pathobiology, or as the expression of an unmet need. Treatments for BPSD have been challenging since before the first clinical trials with chlorpromazine.

We systematically reviewed interventional studies to understand the successes, limitations, and knowledge gaps in terms of methodology that might misinform practice. Questions addressed included: What do these studies look like? How is BPRS operationalized, and does it vary between studies? What interventions have been tested? How are we measuring eligibility and outcomes? Are there methodological factors that influence the outcomes and validity of these trials? Are the trials methods fit for purpose and how can we better test interventions?

From a search yielding 6497 candidate studies, we included 474 of which 413 were randomized, 340 parallel group, 197 double-blinded, 51 unblinded. About 30% were in nursing homes only and 20% outpatient only. Most NH studies were drug studies; most outpatient studies were non-pharmacological. Over time, study durations consolidated to 6–12-week treatment periods and samples grew exceptionally large, involving 400 to 1200 participants.

Of studies that specified a target, 171 were for ‘agitation.’ 50 investigated sleep disturbance, 25 apathy, 25 depression, 21 psychosis. 150 described only ‘BPSD’ or ‘neuropsychiatric symptoms.’ Two-thirds of the agitation studies were single drug interventions; most used a scale score cut-off to define agitation. Important characteristics, secular trends in design, and quality of the BPSD studies will be detailed.

The important trends in methods for interventions and assessment of BPSD are not necessarily toward quality. Eligibility criteria have become designed for convenience, are misspecified relying on the same scales used for outcomes, although randomization is the rule, allocation concealment and treatment blinding is poor. There is marked autoregression of outcomes. Studies have become larger and designed to detect small effects even when clinical meaning is uncertain. BPSD studies need reconsideration and a few simple fixes to better discover effective treatments. Only a little care is needed to improve the quality and reliability of studies. This includes study management that is independent of patient selection and outcomes and from most procedures, and truly blinded assessments.