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.

Anxiety and depressive disorders are among the most frequently diagnosed mental health problems in older adults. Despite the availability of effective treatments, underutilization of mental health care services is problematic and more pronounced in the older population compared to young adults. Stigma of mental illness may be one explanation for this underutilization as it may impede help-seeking and participation in treatment. The objective of this study was to compare older and young adults on different types of stigma related to depression and anxiety while adjusting for potentially confounding variables.

Young adults aged 18 to 36 years (n = 96) and older adults aged 60 years and over (n = 103) completed questionnaires measuring self-stigma, personal stigma, and perceived stigma related to anxiety and depression.

We found that older adults have higher levels of personal stigma but lower levels of perceived stigma and self-stigma than young adults.

The results provide some support for the idea that older adults have greater stigma for mental illness and suggest the importance of age-differentiated interventions for reducing the stigma of mental illness.

Virtual Reality (VR)-based Biofeedback (BF), a relatively new intervention, is rapidly increasing for the treatment of mood disorders. However, research on whether VR-based BF is more effective than traditional BF is still lacking.

A total of 131 adults from the community enrolled in the study. Participants scored ≥10 on Patient Health Questionnaire-9 (PHQ-9) or ≥9 on Panic Disorder Severity Scale (PDSS) were randomly assigned to VR or BF group. Those who have not met the criteria of PHQ-9 and PDSS were classified as the control group. All participants visited three times across 3 months and received either VR-based or conventional BF intervention. The control group received the same treatment as the VR group. Also, on each visit, the participants completed Montgomery-Asberg Depression Rating Scale (MADRS), State-Trait Anxiety Inventory (STAI), and Visual Analogue Scale (VAS).

The analysis included 118 participants in total (VR: 40, BF: 38, Control: 40). There was no significant difference in demographic variables among the 3 groups. After the treatment, VR and BF groups exhibited significant decreases in MADRS, PHQ-9, STAI, and VAS compared to the baseline within each group (p<0.005). Importantly, compared to the BF group, the VR group showed a significantly greater decrease in STAI (p<0.05). Further analyses revealed that scores of MADRD, PHQ-9, STAI, and VAS also significantly decreased in highly stressed group compared to the control group.

Findings suggest that the application of VR-based BF was effective in reducing anxiety and depressive symptoms in highly stressed people. Compared to conventional BF, VR-based BF can be a cost-effective treatment option especially for relieving anxiety.

To evaluate and synthesise the evidence base on barriers and facilitators to accessing and using community-based social care in dementia.

Mixed-methods systematic review

Community-based social care

People living with dementia and unpaid carers

Seven databases were searched in March 2022, including English and German evidence published from 2005 focusing on inequalities in community-based social care for dementia across the globe. Titles and abstracts were screened by two reviewers, with all full texts screened by two reviewers also. Study quality was assessed using QualSyst.

From 3,904 screened records, 39 papers were included. The majority of studies were qualitative, with 23 countries represented. Barriers and facilitators could be categorised into the following five categories/themes: Situational, psychological, interpersonal, structural, and cultural. Barriers were notably more prominent than facilitators, and were multi-faceted, with many factors hindering or facilitating access to social care linked together.

People with dementia and carers experience significant barriers in accessing care in the community, and a varied approach on multiple levels is required to address systemic and individual-level barriers to enable more equitable access to care for all.

Appropriate and personalized pharmacologic management of behavioral and psychologic symptoms in dementia (BPSD) is among the most complex clinical challenges in dementia care. Use of antipsychotics and mood stabilizers is common but accompanied by risk, including high likelihood of adverse effects that can lead to hospitalization or institutionalization. Information to support decision-making in these scenarios is typically obtained from self-report/caregiver report. This presentation will focus on demonstrating how data obtained through digital phenotyping may augment clinical decision making.

This presentation will include information from 3 completed or ongoing studies. The first looks at radio wave based sensing as a way of passively monitoring behavior and dementia. The second uses wearables to track the impact of psychopharmacologic changes in dementia. The third study focuses on incorporating data from electronic media (e-mail, text messages) impact psychotherapy in early and late life

Preliminary results indicate that passive sensing is able to accurately identify patterns of behavior as well as circumscribed clinical events with a precision that exceeds the current standard of care. Data and insights gained from these three ongoing studies are helping develop best practice models that can impact clinical outcomes.

Collectively, the data in this presentation will demonstrate to clinicians a range of approaches towards developing precision care for older adults with dementia and psychiatric diagnosis. These approaches share the common theme of emphasizing the human element in care, while augmenting it with a range of data that provide objective collateral information to guide more precise decision making. The session will also discuss issues that will impact precision care, including the potential for creating inequities, translation to low income settings and countries as well as the matter of data privacy and security.

The Intensive Initial Support Team for Dementia (IPIST) is a multidisciplinary outreach team that provides intensive initial assessment and support for dementia in Japan, introduced based on the Memory Service in the UK. All municipalities are required to establish at least one team, which consists of at least one physician and two professional staffs such as public health nurses and care workers. IPIST usually complete the work within approximately six months, including consultation with medical specialists and introduction of public supports. IPIST sometimes faces “complex case” that is difficult to manage. Because complex cases often have psychiatric problems, accessibility to psychiatric resources is important for IPIST. This study investigated the percentage of psychiatric professionals among IPIST members and the characteristics of complex cases they face.

Through all 1741 municipalities in Japan, a questionnaire was distributed to each IPIST regarding the complex cases they experienced during April-September 2020. The questionnaire asked for the characteristics of each IPIST (e.g., specialty of the team physician, availability of staff with psychiatric expertise, etc.) and which of the 12 categories each complex case fit into, allowing multiple choice.

We could collect responses from 1291 IPISTs. 43.3% of IPISTs had a psychiatrist, 43.1% had an internal medicine physician, 13.4% had a neurologist, and 17.0% had some other physician as their team physician. In addition, 59.4% of the teams had medical staff members with psychiatric experience, including psychiatrists. A total of 7340 cases were reported as complex cases. While the most common category for difficulties in case management was “refusal of services” (19.5%), factors requiring psychiatric intervention such as “behavioral and psychological symptoms of dementia” (16.0%), “co-occurring mental illness” (7.3%), “complaints from neighbors” (7.1%), and “trash-house” (4.3%) were also frequently observed.

The survey revealed that many IPISTs already had psychiatrists and other professionals with clinical psychiatric experience, and that they managed a lot of complex cases with issues that would be the target of psychiatric intervention. We believe early psychiatric engagement is important in many complex cases in outreach support for community residents with suspected dementia.

We aimed to examine the profile and severity of mild behavioral impairment (MBI) in a sample of β-amyloid positive individuals with amnestic mild cognitive impairment (aMCI)compared to cognitively normal older adults (CN). Within aMCI, we further examined the potential influence of APOE and BDN Frisk genetic polymorphisms on MBI severity.

We included 64 β-amyloid positive aMCI participants and 50 CN older adults from the Czech Brain Aging Study. The participants underwent neurological, comprehensive neuropsychological examination, APOE and BDNF genotyping, and magnetic resonance imaging.MBI was diagnosed with the Mild behavioral impairment checklist (MBI-C) developed for MBI case detection, and the diagnosis was based on the MBI-C total score ≥7. Additionally, self-report instruments for anxiety (the Beck Anxiety Inventory) and depressive symptoms (the Geriatric Depression Scale-15) were administered. The participants were stratified based on the presence of at least one risk allele in genes for APOE (i.e., e4 carriers and non-carriers) and BDNF (i.e., Met carriers and non-carriers). We used linear regressions to examine the between-group differences.

MBI symptoms (MBI-C total score ≥1) were present in 28% CN and 83% aMCI. Almost half (48.4%) of the aMCI individuals met the criteria for the MBI syndrome. Compared to the CN, the aMCI group displayed more affective, apathy, and impulse dyscontrol symptoms (p<0.001) but not social inappropriateness or psychotic symptoms. Furthermore, aMCI participants reported more depressive (p<0.01) but similar anxiety symptoms to CN on self-report measures. Within the aMCI group, APOE e4 and BDNF Met carriers did not differ from non-carriers in the severity of NPS in either instrument. However, the results suggested that an interaction between these polymorphisms influenced self-reported anxiety (p=0.034), with Met carriers/e4 non-carriers reporting the highest anxiety levels.

MBI is frequent in prodromal Alzheimer´s disease and characterized by affective, apathy, and impulse dyscontrol symptoms. APOE and BDNF risk genetic polymorphisms did not influence the NPS severity when considered separately; however, their interaction might influence anxiety, which warrants further investigation.

The research has received funding from the EEA/ Norway Grants 2014-2021 and the Technology Agency of the Czech Republic – project number TO01000215, Ministry of Health of the Czech Republic, grant no. 19-04-00560, National Institute for Neurological Research (Programme EXCELES, ID Project No. LX22NPO5107) - funded by the European Union – Next Generation EU and GAČR 22-33968S.

Caring for a person with dementia is a chronic stress situation. The quality of the relationship between the family caregiver and the persona with dementia (PWD) is a relevant variable to understanding caregivers ́ well-being. However, there are no specific scales that measure this variable in this context. This study aims to analyze the preliminary psychometric properties of the Relationship Quality Scales in Caregiving” (RQSC) ” which measures caregivers ́ perception of different aspects of the relationship in the dyad before the onset of dementia and the present moment.

The sample was composed of 55 family caregivers of people with dementia. The Relationship Quality Scales in Caregiving (RQSC) include two subscales assessing the quality of the relationship, respectively, before the dementia onset (Past Relationship; PR) and in the present moment (Current Relationship; CR), and it also provides an index of the perception of change (Change score) in the relationship quality, namely: Actual Quality minus Past Quality. Internal consistency and factor validity (through exploratory factor analysis and parallel analysis) were explored. Construct validity of the instrument was also explored, analyzing its correlation with caregivers’ reactivity to behavioral and psychological symptoms of dementia (BPSD), caregivers’ ambivalent feelings towards the care recipient, and caregivers’ depressive symptoms.

The results from the EFA and parallel analyses suggest that both RQSC subscales have a unidimensional structure. Both the PR subscale and the CR subscale show good to excellent reliability and validity indexes. Significant negative correlations between both PR and CR subscales and reactivity to BPSD, ambivalent feelings, and depression have been found

The instrument seems to show good psychometric properties that recommend its use. The results support the relevance of caregivers ́ perception of their relationship with the PWD for understanding caregivers’ wellbeing. However, these are preliminary results that should be replicated in future studies using a bigger sample and additional psychometric data.

It is well known that natural disasters such as earthquakes negatively affect physical and mental health by exposing people to excessive stress. The aim of this study was to investigate determinants of psychosocial health status among the pregnant and postpartum women who experienced earthquake in Türkiye.

Pregnant and postpartum women (n = 125) living in tent cities in the Kahramanmaraş region formed the study sample. Data were collected between February 20 and 26, 2023, through face-to-face interviews. The instruments used for data collection were the Introductory Form, the Depression Anxiety Stress Scale, the Traumatic Childbirth Perception Scale, and the Post-Traumatic Stress Disorder–Short Scale.

A moderate positive relationship was found between stress and posttraumatic stress and traumatic childbirth perception in pregnant and postpartum women, and a high positive relationship was found between anxiety and depression. A high level of relationship was found between anxiety and stress and depression.

It is seen that the psychosocial health of pregnant and postpartum women, who belong to the risk group in the earthquake zone, is at high risk. Psychological support is urgently needed to preserve and improve their psychosocial health.

During the spread of infectious diseases, social isolation increases among the elderly with cognitive impairment. The telephone may be a traditional but realistic and reliable tool to prevent social isolation. We report here a pilot study to examine the effects of regular telephone communication on elderly people with cognitive decline living in urban areas.

Seventeen elderly people (including four males) who attended a session for recruiting participants for a class using the board game “Go” in Tokyo were paired and talked on the phone once a week about Go issues and other interests during the 3-month class period, starting January 2022. At the end of the class in April 2022, a self-administered questionnaire (5 items, 4-point scale) and semi-structured interview were conducted. The Ethics Committee of the Tokyo Metropolitan Institute of Gerontology approved the study, and the participants’ written consent was obtained.

The participants’ mean age was 80.1 ± 5.5 years, and the mean score of the Montreal Cognitive Assessment, which screens for mild cognitive impairment, was 21.3 ± 3.1, with 16 subjects (94.1%) scoring below the cut-off value of 25. The percentages of “agree” or “somewhat agree” responses indicated that the telephone interaction was “enjoyable” (94.1%), “had a positive effect” (88.2%), and they “would like to talk on the phone sometimes in the future” (76.5%). In the interviews, the positive responses were “(Because I was looking forward to the phone call so eagerly) I couldn't wait for the phone call,” “I enjoyed playing Go,” “It was easy to talk about Go because it was a common topic,” “We talked about things other than Go,” and “I want to go out with my pair partner,” while others were “I was careful about what talk about” and “It was difficult to maintain psychological distance from my pair partner.”

The results suggest that telephone communication may be effective for preventing social isolation among the elderly with cognitive impairment. We believe that promoting telephone interaction during normal times between residents in the community with common interests will build supportive relationships and lead to a Dementia-friendly society.

Older patients (≥65yo) admitted to general hospitals have increased in the past years. This resulted in an increase in hospitalization periods, health costs, and morbi-mortality rates in this group of patients.

Previous evidence points that the reduced time to referral (TTR) to Consultation-Liaison Psychiatry Units (CLP) leads to a reduced length of stay (LOS) in GH improving long-term prognosis of medical conditions.

This study aims to explore whether a prior disability in older patients leads to delay the search for psychiatric help. And to explore whether early referral to CLP is associated with reduced LOS in general hospitals.

This is an observational, cross-sectional, multicentre study. We obtained a complete data set from a sample of 152 patients (≥65 years old) admitted to 7 general hospitals in Spain referred to CLP unit for 1,5 months.

Mean age of the sample was 76.3 (±6.4). TTR was 14.5 (±18.0) days. LOS was 26.7 (±22.4) days, and length of stay after consultation was 12.3 (±10.3) days. Barthel Index before admission was 87.3 (±18.0) and Lawton&Brody Index before admission was 5.3 (2.7). We found a significant positive association of Barthel Index (r=0.17, p=0.042) and Lawton&Brody Index (r=0.20, p=0.014) before admission with TTR, which indicates that patients with a worse clinical status were attended earlier. Similarly, antecedents of both falling episodes (r=-0.2, p= 0.013) and walking difficulties (r=-0.24, p= 0.003) were associated with shorter TTR. TTR in Medical Departments was 11.7 (±15.0) days and in Surgical Departments was 24.0 (±22.8) days (t=-3.5, p= 0.001). TTR showed a highly significant positive correlation with LOS (r=0.89, p<0.0001) and a more discrete positive correlation with length of stay after consultation (r=0.20, p=0.016).

We confirm that a shorter TTR to CLP was related to a shorter LOS. Also, patients in medical wards had shorter TTR. In contrast to our hypothesis, we found that a higher disability prior to hospitalization led to earlier referral to CLP, meaning that these patients were assessed and treated earlier leading to better long- term prognosis and lower health costs.

By the end of the session, participants will be able to:

1. 1. Describe the Baycrest Quick-Response Caregiver Tool

2. 2. Describe the role for the Baycrest Quick Response Caregiver Tool in BPSD

3. 3. Describe the results of studies to date

Behavioral and Psychological Symptoms of Dementia (BPSD) are common and are associated with poor outcomes and caregiver burden. A variety of frameworks and tools exist to assess and understand the symptoms and to plan interventions. The Baycrest Quick-Response Caregiver Tool TM (BQRCT) is different than other tools as it assists the caregiver in real time as the BPSD are occurring. A mixed methods feasibility study in family caregivers found favorable results. Scaling up this tool for long term care (LTC) staff can potentially benefit residents living with dementia. The goal of this presentation is for participants to describe this novel tool, its evidence, and its place within the known tools and frameworks for BPSD.

Participants will interactively learn about the BQRCT, how it is applied with caregivers, and how it works with other tools for BPSD. The training videos will be viewed and discussed. The evidence from a mixed methods study of this tool will be presented and compared to evidence for other tools. The methods and preliminary results (if available) for an ongoing study of the BQRCT in the LTC context with be presented.

A mixed methods study of family caregivers and health-care providers of persons with dementia and BPSD found that the BQRCT was helpful and participants reported high feasibility ratings. The group of health-care providers found the tool useful and most would recommend it to peers and clients. Participants also provided specific suggestions for improvement, such as including more examples of complex behaviours. The current study in LTC involves the creation of new videos of complex situations in LTC. Participants in LTC homes will complete the online training, and surveys pre/post and at 4 weeks post-intervention. A focus group of a sample of 20 participants will be conducted.

The BQRCT complements and works synergistically with existing strategies for managing BPSD. Care teams can use various frameworks and tools flexibly either concurrently or at different times in the episode of care of persons with dementia and BPSD. These tools must address the diversity and personal background of the person with dementia and caregivers.

Bridging the gap between clinical practice and research in health care is a challenging task. Living Labs are academic practice partnerships to stress the ambition to start up a longstanding collaboration, which have been developed and implemented in the Netherlands (Verbeek et al., 2020). The “PraWiDem” (“Living Lab Dementia”) project aims to adapt the Maastricht Living Lab approach to long-term dementia care in different regions in Germany.

A mixed methods approach was used to guide the adaptation of the Maastricht Living Lab. A focus group study investigated perspectives of people with dementia, informal carers and professionals on expectations and experiences concerning collaboration and networking between research and practice. A scoping review mapped international experiences in knowledge transfer practices and collaboration approaches in nursing care. Experts from the Maastricht Living Lab supported the research team in adapting the approach to the German national context. Parts of the German “Living Lab Dementia” concept were discussed with members of a recently formed research participation group of people with dementia (“experts by experience”).

In total, 10 focus groups and 5 individual interviews were conducted. Key themes include researchers’ and professionals’ skills, participation of people with dementia and informal carers, and multi-professional requirements. The scoping review identified 17 different approaches of knowledge translation and collaboration. Few approaches address the common development and implementation of knowledge and networking. Dutch experts recommend the early development of long-lasting strategies for collaboration. Experts by experience wish to participate, but traditional research methods may need to be adapted to allow their participation.

The “Living Lab Dementia” is currently under investigation in collaboration with institutional and community care services in three regions in Germany.

Reminiscence therapy is the examination of past memories to improve current mood and psychological functioning and is an evidence-based treatment for symptoms of late life psychological distress. Music is sometimes used in such therapy to prompt or enhance the recollection of memories; however, there is limited empirical research on the use and value of using music in reminiscence therapy. This presentation will discuss the findings of two studies exploring the feasibility and use of verbal reminiscence therapy (VRT) and music-assisted reminiscence therapy (MRT) from the perspectives of the older adult and the staff who care for them.

Study one surveyed 110 Australian workers in aged care to explore the extent to which VRT and MRT were used, how such interventions were delivered and viewed, and the benefits. Study two randomly assigned 8 older adults experiencing psychological distress to a single session of VRT or MRT. Pre and post measures of affect, memory experience, and a brief satisfaction interview were collected, along with measures of treatment fidelity.

For staff, simple reminiscence was the most frequently used approach across both VRT and MRT. Staff reported that both VRT and MRT are viewed as successful and regularly used interventions, that occur in spontaneous and creative ways in response to older clients’ needs. Staff reported outcomes such as enhanced social connections, improved affect and mood, and better care practices. Older adults reported that that VRT and MRT were equally acceptable and well tolerated. A pre-post pattern of improvement was observed for affect following VRT, and particularly MRT, suggesting both as promising interventions. MRT resulted in higher scores on memory experience characteristics such as vividness, coherence, and accessibility. The high treatment fidelity achieved in this study indicates that the interventions can be successfully implemented with this population.

VRT and particularly MRT were viewed as successful, feasibility and acceptable interventions by older adults experiencing psychological distress, and direct care staff in Australia. These preliminary findings indicated MRT may provide therapeutic changes above and beyond VRT for older adults, and therefore large-scale clinical trials are warranted.

Treatments trials for apathy in Alzheimer’s disease assess change scores on widely used assessment scales. Here, we aimed to determine whether such change scores on the Neuropsychiatric Inventory - Apathy (NPI-A) scale indicate clinically meaningful change.

Participants completing the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) were included. Participants in this randomized trial received methylphenidate or placebo for 6- months along with a psychosocial intervention. Assessments included Clinical Global Impression of Change in apathy (CGIC-A) and the NPI-A. Participants in both groups with complete data at the six-month visit were included. CGIC-A was assessed as improved (minimal, moderate or marked), no change, or worsened (minimal, moderate or marked). For CGIC-A levels, mean and standard deviation (SD) of the change in NPI-A from baseline was calculated. Spearman correlation determined the association between change in NPI-A and CGIC-A, and Mann-Whitney U tests determined differences between the ‘no change’ group and the ‘improved’ and ‘worsened’ groups. Effect size (mean NPI-A difference between either ‘improved’ and ‘no change’/ SD of overall change) were calculated. Differences were also assessed at 3 months as a sensitivity analysis.

Overall, 177 participants were included (median age: 77years, Mini Mental State Examination score: 19.3 (4.8), baseline NPI-A [mean, SD]: 7.9, 2.3), change in NPI-A: -3.7 (3.9). On the CGIC-A, 69 were improved, 82 showed no change, and 26 worsened. The Spearman correlation between NPI-A change and CGIC-A was 0.41 (p= 1x 10-8). The change in NPI-A among participants who improved was -5.3 (4.1) [W=1873, p= 3x10-4], among those who worsened was -1.2 (3.1) (W= 1426.5, p= 0.009) compared to those with no change (-3.2 [3.4]),. The NPI-A score for minimal clinical improvement was -4.5 (4.6) with a small effect size of -0.32, which was consistent at 3-months (-0.31).

A minimal clinically significant improvement over 3 and 6-months corresponded to a mean decline of 4.5 points on the NPI-A; however, there is considerable overlap in the NPI-A between levels of clinical impression of change.