Changes in personality traits in patients with Alzheimer's Disease

Abstract

Changes in personality traits in patients with Alzheimer's disease (AD) are extremely common throughout the course of the pathology, and these behavioral changes present themselves as challenges in clinical management and as a significant cause of caregivers' burden.

Objective:
Using a personality inventory based on the five-factor model of personality, this study aimed to assesses the change in these factors by comparing the premorbid and current personality of individuals recently diagnosed with AD.

Methods:
A total of 30 AD patients were recruited, and their respective family members responded to the personality inventory at home through a hosted site. The patients were also divided into two groups according to the Clinical Dementia Rating (CDR): mild dementia (CDR 1) and moderate dementia (CDR 2).

Results:
Among all patients, there was a significant increase in neuroticism factor levels and a significant decrease in the extraversion, conscientiousness, openness, and socialization factors. When comparing the groups, only the extraversion factor showed a difference, with CDR 1 group accusing a higher change in scores. Higher scores in the factor neuroticism in the premorbid personality correlated with the current severity of the disease.

Conclusions:
This research draws the attention of family members and health professionals to changes in personality traits or behavior of relatives or patients, because it can reflect an underlying neurodegenerative process.

Full text

https://doi.org/10.1590/1980-5764-DN-2021-0029
Lopes KF, et al. Personality traits in patients with AD. 1
Dement Neuropsychol
Changes in personality traits in
patients with Alzheimer’s Disease
Kaoue Fonseca Lopes1,2 , Valéria Santoro Bahia3 , Jean Carlos Natividade4 , Rafael Valdece Sousa
Bastos5 , Wanderley Akira Shiguti6 , Kátia Estevão Rodrigues da Silva1 , Wânia Cristina de Souza1
ABSTRACT. Changes in personality traits in patients with Alzheimer’s disease (AD) are extremely common throughout the course
of the pathology, and these behavioral changes present themselves as challenges in clinical management and as a signicant
cause of caregivers’ burden. Objective: Using a personality inventory based on the ve-factor model of personality, this study
aimed to assesses the change in these factors by comparing the premorbid and current personality of individuals recently
diagnosed with AD. Methods: A total of 30 AD patients were recruited, and their respective family members responded to the
personality inventory at home through a hosted site. The patients were also divided into two groups according to the Clinical
Dementia Rating (CDR): mild dementia (CDR 1) and moderate dementia (CDR 2). Results: Among all patients, there was a
signicant increase in neuroticism factor levels and a signicant decrease in the extraversion, conscientiousness, openness,
and socialization factors. When comparing the groups, only the extraversion factor showed a difference, with CDR 1group
accusing a higher change in scores. Higher scores in the factor neuroticism in the premorbid personality correlated with the
current severity of the disease. Conclusions: This research draws the attention of family members and health professionals to
changes in personality traits or behavior of relatives or patients, because it can reect an underlying neurodegenerative process.
Keywords: Alzheimer Disease; Personality Inventory; Mental Status and Dementia Tests; Neuroticism; Extraversion, Psychological.
MUDANÇAS NOS TRAÇOS DE PERSONALIDADE EM PACIENTES COM DOENÇA DE ALZHEIMER
RESUMO. Mudanças em traços de personalidade em pacientes com doença de Alzheimer (DA) são extremamente comuns ao longo
do curso da referida patologia, e essas alterações comportamentais apresentam-se como desaos no manejo clínico e como
causa signicativa de esgotamento dos cuidadores. Objetivo: Por meio de um inventário de personalidade baseado nos cinco
fatores de personalidade, este estudo avalia a mudança nos escores desses fatores comparando a personalidade pré-mórbida
e a atual dos indivíduos com DA. Métodos: O total de 30 pacientes com DA foi recrutado, e seus familiares responderam ao
inventário de personalidade. Os pacientes também foram divididos em dois grupos conforme a avaliação clínica da demência:
demência leve (CDR1) e demência moderada (CDR2). Resultados: Em todos os pacientes, houve aumento signicativo nos escores
do fator neuroticismo e decréscimos signicativos nos fatores extroversão, realização, abertura e socialização. Quandofeita a
comparação entre grupos, apenas o fator extroversão apresentou diferença, com o grupo CDR 1mostrando maiores mudanças
nos escores. Os níveis do fator neuroticismo da personalidade pré-mórbida correlacionaram-se com a gravidade da doença no
momento do diagnóstico. Conclusões: Este estudo procura esclarecer aos familiares e prossionais de saúde que mudanças
em traços de personalidade de seus parentes ou pacientes podem reetir processos neurodegenerativos subjacentes.
Palavras-chave: Doença de Alzheimer; Inventário de Personalidade; Testes de Estado Mental e Demência; Neuroticismo;
Extroversão Psicológica.
INTRODUCTION
Personality traits are generally consistent
in adulthood and old age, although small
changes in personality occur throughout life 1.
However, progressive changes are not typical
and can mean underlying neurological dis-
ease, such as Alzheimer’s disease (AD)2. us,
it is common for close relatives to observe
This study was conducted by the Department of Basic Psychological Processes, Institute of Psychology, Universidade de Brasília, Brasília, DF, Brazil.
1Universidade de Brasília, Instituto de Psicologia, Departamento de Processos Psicológicos Básicos, Brasília DF, Brazil.
2Clínica de Neurologia Neurob, Brasília DF, Brazil.
3Universidade Cidade de São Paulo, Departamento de Medicina Interna, São Paulo SP, Brazil.
4Pontifícia Universidade Católica do Rio de Janeiro, Instituto de Psicologia, Departamento de Psicologia Social, Rio de Janeiro RJ, Brazil.
5Universidade São Francisco, Instituto de Psicologia, Departamento de Psicologia Social, São Paulo SP, Brazil.
6Centro Universitário IESB, Brasília DF, Brazil.
Correspondence: Kaoue Fonseca Lopes; Email: lopeskaoue@gmail.com.
Disclosure: The authors report no conicts of interest.
Funding: none.
Received on June 04, 2021. Accepted in nal form on October 30, 2021.

2 Personality traits in patients with AD. Lopes KF, et al.
Dement Neuropsychol
signicant changes in the personality of individuals who
develop dementia3.
In the seminal case described by Alois Alzheimer,
Auguste D’s husband observed signicant behavioral
disorders, including paranoia, crying, aggression, and
other unpredictable behaviors. As described in this rst
case, changes in behavior and personality remain the
most challenging clinical symptoms in the treatment of
dementia4,5. In this context, clinical research has studied
the inuence of AD dementia syndrome on changing
personality traits6-8.
One means of assessing personality change has
been through retrospective studies in which an experi-
enced informant, usually the spouse or child, assesses
the premorbid and current personality of the person
with dementia9,10. These reports from informants
play a critical role in clinical assessments and are an
important source of information to characterize the
current state of the patient and the changes that have
occurred over time11,12. In this sense, to compare the
changes that occurred between the premorbid and
current personality, the assessment of characteristics
based on the ve-factor model of personality is widely
used (also known as the Big Five)10. is model anchors
personality to the following factors: neuroticism (the
tendency to experience negative emotions such as fear
and sadness), extroversion (tendency to be outgoing,
social, and energetic), openness (tendency to prefer new
and diverse experiences and have intellectual curiosi-
ty), socialization (tendency to being cooperative, kind,
and condent), and conscientiousness (tendency to be
organized, persistent, and careful). Narrower traits,
called facets, are part of each of the ve dimensions.
For example, neuroticism includes facets that reect
anxiety, angry hostility, depression, self-awareness,
impulsiveness, and vulnerability13-15.
As designed in this research, other studies have in-
vestigated the change in each of the ve characteristics
over the course of AD15 and have shown associations
between changes in the factors’ scores with cognitive
decline. Similar patterns were observed in individuals
diagnosed with mild cognitive impairment (MCI) but
to a lesser extent16-18. Indeed, the personality dimen-
sions or factors shape, throughout an individual’s life,
contexts of reactions to stress, engagement in physical,
cognitive, and social activities, and situations that are
related to AD19.
Thus, the objective of this study was to advance
knowledge regarding the changes in personality factors
that occur in individuals diagnosed with AD, reported
by close relatives, with the hypothesis of an increase in
the levels of the neuroticism factor and a decrease in
the levels of openness, extraversion, conscientiousness,
and socialization.
METHODS
Sample and procedures
A total of 30 individuals with cognitive complaints were
attended by a neurologist and diagnosed with dementia
due to AD based on Mckhann’s criteria15 at an outpa-
tient clinic. ey were recruited for the study with family
consensus. Mini-Mental Status Examination (MMSE)20
and Clinical Dementia Rating (CDR) scale21 were applied
to patients, and also the age and level of education data
were collected.
After medical consultation, spouse or children who
lived with the patient for at least 15 consecutive years
responded to the Personality Factorial Battery (PFB)10,
a psychometric instrument based on the model of the
ve major personality factors validated for the Brazil-
ian population with excellent internal consistency and
test–retest reliability22.
e battery comprises 126 items in a seven-point
Likert format for family members to judge how much
each statement applies to the participants, and it was
responded in patients’ home through a hosted site on
Internet. Family members responded to statements
about patients’ personalities and characteristics in
two times: thinking about 10 years ago when partici-
pants were asymptomatic (t1) and thinking about the
present when the patients received the diagnostic AD
(t2). Patients were also separated into two groups: mild
dementia (CDR 1) and moderate dementia (CDR 2).
Patients were excluded from the research if they
had CDR 3, had moderate-to-advanced cerebrovascular
disease23, or were not using psychotropic medications
in a stable manner for at least 3months. Individuals
with a positive polymerase chain reaction (PCR) test
for COVID-19 in the past 14 days or with u-like symp-
toms on the day of the medical appointment were also
excluded. In addition, patients who were analphabets
or without Internet access were excluded.
The study was approved by the Research Ethics
Committee of the Institute of Human Sciences of the
Universidade de Brasília.
Data analysis
The Statistical Package for the Social Sciences (SPSS)
software, 21st version, was used to analyze database.
e means and standard deviations for the personality
factors’ scores were calculated in t1 and t2, and paired
t-tests for one sample were performed to verify the

Lopes KF, et al. Personality traits in patients with AD. 3
Dement Neuropsychol
differences in means, assuming a significance level
equal to 5%. Scores for all factors and subfactors were
reported in relation to the normative sample of the PFB.
Comparative analyses through multivariate analysis
of variance (MANOVA) and two-sample t-test were
performed to evaluate the existence of signicant dif-
ferences of the means between group scores.
Linear regression was used to access possible con-
founders of age and schooling between the groups.
Correlations through the groups were conducted by
Pearson’s coecient.
RESULTS
As shown in Table 1, the study included 30 patients
with AD, 18 of whom were women. e mean age was
71.9years (SD=7.4), and the mean MMSE was 22.1
(SD=3.1) and 14.5 (SD=2.5) in the mild dementia group
and the moderate dementia group, respectively.
Regarding the education of patients, 9.7% had com-
pleted higher education, 9.7% had incomplete higher
education, 22.6% had completed high school, 12.9%
had completed elementary school, and 45.2% had in-
complete elementary schooling, and the groups were
homogeneous in terms of age [t(30)=-0.29; p=0.78] and
level of education [t(30)=1.30; p=0.20].
In the paired t-test analysis of the 30 patients, signif-
icant dierences were veried between the premorbid
state and the current state in all the factors (Table2).
Regarding the subfactors, kindness[t(30)=-5.37;
p<0.001], dynamism [t(30)=-8.48; p<0.001], social
interactions [t(30)=-6.80; p<0.001], competence
[t(30)=-9.53; p<0.001], and endeavor/commitment
[t(30)=-4.75; p<0.001] showed higher levels of changes.
In contrast, there was no signicant dierence between
the scores of the subfactors trust in people before and
after [t(30)=-1.49; p=0.14], arrogance before and after
[t(30)=-1.64; p=0.11], vulnerability before and after
[t(30)=0.44; p=0.66], and search for novelty before and
after [t(30)= -1.70; p=0.090].
In the MANOVA analysis (Table 3), both groups
showed signicant changes in the ve factors across t1
and t2, with an increase in the neuroticism scores and
a decrease in the other four factors.
When comparing the two groups, only the factor
extraversion showed a signicant change in the scores
across t1 and t2 (Figure 1).
When considering just the CDR, higher scores in
neuroticism in t1 correlated with more numbers of
patients with moderate dementia in t2 (Figure 2).
DISCUSSION
e present study investigated the inuence of AD on
the change in personality traits of outpatients with this
pathology. e results obtained revealed a signicant
increase in the scores of neuroticism and a signicant
decrease in the level factors, such as extraversion,
conscientiousness, openness, and socialization, when
the factors were compared between the premorbid and
current personality24,25.
e data found are consistent with most studies simi-
larly outlined in the literature. ey have shown remark-
able patterns of personality change and huge dierences
when comparing AD patients with normal aging17.
Functional neuroimaging studies correlate person-
ality factors with structural dimensions and degrees
of large networks activation. As an example, low levels
in conscientiousness correlated with an increase in
cerebral white matter lesions and in a reduced volume
of the dorsolateral prefrontal cortex13,18. In turn, it is
important to remember that characteristics of con-
scientiousness or neuroticism are factors related to
circumstances like smoking, physical inactivity, obesity,
and depressive symptoms, which are established risk
factors for dementia26,27.
Table 1. Clinical Dementia Rating, Mini-Mental Status Examination, gender, and age scores of the patients.
Female Total
Participants
Mean
Participants
Mean
Age
Mean (SD)
MMSE
Mean (SD)
Age
Mean (SD)
MMSE
Mean (SD)
8 75.9 (5) 20.6 (2) 16 70.9 (8.6) 22.1 (3.1)
10 74.1 (5.4) 13.8 (1.8) 14 73 (5.8) 14.5 (2.5)
18 74.9 (5.1) 16.8 (3.9) 30 71.9 (7.4) 18.5 (4.7)
MMSE: Mini-Mental Status Examination; SD: standard deviation.

4 Personality traits in patients with AD. Lopes KF, et al.
Dement Neuropsychol
Table 2. Comparison between premorbid and current personality factors.
Personality facets
10 years ago Currently
p-value R D
Mean (SD) Mean (SD)
Socialization 5.55 (1.02) 4.59 (1.17) <0.001 0.40 -0.87
Kindness 5.77 (1.44) 4.20 (1.52) <0.001 -0.47 -1.06
Pro-sociability 5.85 (0.90) 5.25 (1.23) 0.001 -0.27 -0.56
Trust in people 4.90 (1.35) 4.52 (1.48) 0.14* -0.13 -0.27
Extraversion 4.66 (1.06) 3.21 (0.96) <0.001 0.58 -1.43
Communication 4.56 (1.33) 3.50 (1.18) 0.001 -0.39 -0.84
Dynamism 5.34 (1.35) 2.93 (1.24) <0.001 -0.68 -1.86
Social interactions 4.93 (1.42) 2.92 (1.06) <0.001 -0.63 -1.62
Arrogance 3.96 (1.29) 3.45 (1.29) 0.11* -0.19 -0.39
Conscientiousness 5.26 (1.09) 3.03 (1.17) <0.001 0.70 -1.97
Competence 5.63 (1.23) 2.72 (1.47) <0.001 -0.73 -2.15
Reection/Prudence 4.63 (1.38) 3.60 (1.17) <0.001 -0.37 -0.80
Endeavor/Commitment 5.07 (1.31) 3.16 (1.47) <0.001 -0.56 -1.37
Neuroticism 3.52 (1.05) 4.39 (1.02) 0.001 0.84 0.39
Emotional instability 3.65 (1.80) 4.64 (1.62) 0.006 0.28 0.59
Passivity 3.63 (1.34) 4.78 (1.20) 0.001 0.41 0.90
Depression 2.85 (1.36) 4.34 (1.55) <0.001 0.45 1.02
Vulnerability 3.93 (1.11) 4.02 (1.08) 0.66* 0.04 0.08
Openness 3.69 (0.83) 3.18 (0.70) 0.002 0.31 -0.66
Openness to new ideas 3.74 (1.15) 3.12 (1.12) 0.006 0.55 -0.26
Liberalism 3.56 (1.05) 3.17 (0.96) 0.011 0.39 -0.19
Search for novelty 3.61 (1.03) 3.31 (1.09) 0.09* 0.29 -0.14
*p<0.05; SD: standard deviation.
Table 3. Comparative analysis between the groups.
Analysis
Neuroticism Extroversion Socialization Conscientiousness Openness
F p-value F p-value F p-value F p-value F p-value
MANOVA
Time 12.559 0.001 36.006 0.000 19.416 0.000 74.705 0.000 11.455 0.002
CDR×time 0.336 0.567 6.217 0.019 0.436 0.515 3.861 0.059 2.368 0.135
Paired comparison between subjects
CDR  0.009  0.644  0.378  0.775  0.880
F: statistical value; CDR: Clinical Dementia Rating; MANOVA: multivariate analysis of variance.

Lopes KF, et al. Personality traits in patients with AD. 5
Dement Neuropsychol
Figure 2. Difference in the neuroticism factor scores between the groups.
Figure 1. Difference in the extroversion factor scores between the groups.
In this sense, personality traits can also have an
impact on the concept of individuals’ cognitive reserve
due to poorly adaptive behaviors or activities related
to intellectual curiosity, creativity, interest in places,
and social ties. is concept links the resilience with
individual behaviors of AD pathologies that can be
protective or disruptive. In the other way, incipient
AD pathology can degenerate important cerebral
areas and provide deleterious effects, such as the
behavioral and psychological symptoms of dementia.
Forthese reasons, studies on neuroimaging and clini-
cal personality assessment help elucidate this intricate
relationship between personality and cerebral struc-
ture and function17,28.
Maheen etal.29, in a meta-analysis with 592 patients,
where personality changes were reported retrospectively
from the informant perspective, found a replicable evi-
dence for large changes in personality among individuals
with AD, particularly decrease in extraversion and consci-
entiousness and increase in neuroticism. Seekingfor re-
sponses or even more questions, Terraciano and Sutin17
reviewed prospective studies and found elevated scores
in neuroticism and decreased scores in conscientiousness
as independent risk factors for dementia.

6 Personality traits in patients with AD. Lopes KF, et al.
Dement Neuropsychol
Future research should continue to examine whether
dierent patterns of personality changes across eti-
ologies of dementia and prospective assessments of
personality using both self-report and informant report
are needed to interpret this mental trajectory built by
personality and cognition30.
In the context of this study, family members of pa-
tients with mild dementia noticed a greater decrease in
extroversion compared with family members of patients
with moderate AD. is fact may suggest that in mild AD,
changes in behaviors related to communication, dyna-
mism, and social interactions are perceived in a more in-
tense way by family members. ere was also a correlation
between higher levels of premorbid neuroticism, which
favors characteristics such as emotional instability and
vulnerability, with a greater severity of the disease17,18.
Some important limitations in this study include
a small sample, data collection based on information
from third parties, and the absence of a control group
and retrospective design that makes it dicult to es-
tablish causalities. For this purpose, prospective studies
are needed to be done, including individuals with MCI
and other types of dementia. However, in conclusion,
it is a research design that brings clinical information
regarding personality changes in the course of demen-
tia processes. e early identication of these changes
can assist clinicians in choosing tailored interventions
to mitigate the psychological distress of their patients
together with preventive coping strategies to avoid
harmful behaviors.
ACKNOWLEDGMENT
e authors thank professors Wânia Cristina de Souza
and Valéria Santoro Bahia for their orientations and
comments.
Authors’ contributions: VSB: conception, planning, data
interpretation, and writing– review. WCS: conception,
analysis, planning, data interpretation, and writing
– review. JCN, RVSB, and WAS: analysis, data inter-
pretation, and writing – review. KERS: data analysis
and writing – review. KFL: conception, planning, data
collection, analysis, data interpretation, and writing.
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