REVIEW ARTICLE

Personality changes in Alzheimers disease: a systematic

reviewy
Tarja-Brita Robins Wahlin 1,2 and Gerard J. Byrne 1,3
1
School of Medicine, The University of Queensland, Brisbane, Australia
2
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
3
Older Persons Mental Health Service, Royal Brisbane and Womens Hospital, Brisbane, Australia
Correspondence to: Dr T.-B. Robins Wahlin, E-mail: Tarja-Brita.Robins.Wahlin@ki.se
y
The submitting author certies that the authors have no previous reports that might be regarded as redundant or duplicate publications of the same or very similar work.

Objective: People with Alzheimers disease (AD) commonly exhibit changes in personality that some-
times precede the other early clinical manifestations of the condition, such as cognitive impairment and
mood changes. Although these personality changes reect the impact of progressive brain damage, there
are several possible patterns of personality change with dementia. Early identication of personality
change might assist with the timely diagnosis of AD. The objective of this study was to review studies of
personality change in AD.
Methods: Systematic searches of the PubMed, Ovid Medline, EBSCOhost, PsychINFO and CINAHL
databases were undertaken from inception to November 2009. Published studies of informant-rated
personality traits in AD patients were identied. Studies that mapped changes in traits from the ve-
factor model of personality which includes factors for Neuroticism, Extraversion, Openness, Agree-
ableness and Conscientiousness, were selected for analysis. The change in each of these ve traits was
calculated as the mean difference in score before and after the diagnosis of AD.
Results: There was a mean increase in Neuroticism of 1020 T scores (equivalent to 12 SD), a decrease
of the same magnitude in Extraversion, consistently reduced Openness and Agreeableness, and a marked
decrease in Conscientiousness of about 2030 T scores (equivalent to 23 SD). These changes were
systematic and consistent. Particularly striking was the similarity of both the magnitude and direction of
change in all studies reviewed.
Conclusions: Conscientiousness and Neuroticism are the personality traits that exhibit the most change
in dementia. These traits might be useful early markers of dementia. Copyright # 2010 John Wiley &
Sons, Ltd.
Key words: Alzheimers disease; dementia; personality; neuroticism; extraversion; openness; agreeableness; conscientiousness;
NEO-PI; NEO-PI-R
History: Received 13 April 2010; Accepted 27 September 2010; Published online 9 November 2010 in Wiley Online Library
(wileyonlinelibrary.com)
DOI: 10.1002/gps.2655

Introduction progressive brain damage, there are several possible

People with Alzheimers disease (AD) commonly
exhibit changes in personality that occur alongside,
and sometimes precede, the other clinical manifes-
tations of dementia such as cognitive impairment
and mood changes. Although it is generally accepted
that these personality changes reect the impact of
patterns of personality change with dementia.
First, as Welleford et al. (1995) have suggested,
premorbid personality might be a determining factor
so that caricature or exaggeration of original
personality emerges as AD progresses. Second, people
with AD might become similar to each other
resulting in a specic disease prole that might be

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 10191029.
1020
termed the Alzheimer personality, converging into a
unied behavioural prole with reduction in the
normal variability of traits (Petry et al., 1988;
Chatterjee et al., 1992). Third, stereotypic personality
changes might develop so that AD patients show
similar decreases or increases in personality charac-
teristics while maintaining individual variability, so
that those who were high on one trait would remain
high on that trait even after disease onset (Siegler
et al., 1991; Chatterjee et al., 1992; Welleford et al.,
1995). A fourth and nal possibility would be that
personality changes might occur without any clear
pattern or consistency (Welleford et al., 1995) and
bear no relationship to pre-existing personality
structure.
Regardless of the pattern of personality change over
time, existing evidence indicates that people with AD
often score lower than age-matched controls in the
personality domains of openness, extraversion and
conscientiousness (Siegler et al., 1991; Chatterjee et al.,
1992; Siegler et al., 1994; Dawson et al., 2000; Archer
et al., 2006). These differences contrast with the
relative stability of personality in adults aged 30 years
and over (Costa and McCrae, 1988). The high
incidence of personality change described in AD and
mild cognitive impairment makes personality change a
potential early marker for these conditions (Strauss
et al., 1993). In addition, it has been suggested that
greater neuroticism is associated with higher risk of
cognitive impairment (Crowe et al., 2006). Further-
more, there is recent evidence that premorbid
personality style might predict the likelihood of certain
behavioural and psychological symptoms of dementia
(Archer et al., 2006).
Function of personality can be measured in
various ways. The Revised NEO Personality Inven-
tory (NEO PI-R) designed to reect a ve-factor
model of personality (Costa and McCrae, 1988, 1989,
1992) is in widespread use in older and dementia
populations. The ve major personality domains
identied by these authors are Neuroticism (N),
Extraversion (E), Openness (O), Agreeableness (A)
and Conscientiousness (C). These factors represent
the most basic dimensions underlying personality
traits.
Accordingly, a systematic review of the literature was
undertaken to examine the nature and extent of change
in personality in people with AD. Because we were keen
to compare premorbid personality function with
personality function during dementia, we decided to
focus exclusively on published studies that employed
the robust ve-factor system of personality assessment
(McCRae and Costa, 1987).
Copyright # 2010 John Wiley & Sons, Ltd.
T.-B. Robins Wahlin and G. J. Byrne
Methods
Selection criteria and search strategy
Relevant studies were identied by separate searches of
the psycINFO, PubMed, Medline (Ovid and EBSCO-
host) and CINAHL databases covering the period from
database inception to November 2009. The following
search terms were used: Alzheimers disease or
dementia in combination with personality, pre-
morbid personality, behaviour and psychological
symptoms. Additional searches of each database were
undertaken with terms neuroticism, extraversion,
openness, agreeableness or conscientiousness in
combination with Alzheimers disease or dementia.
In addition, the reference lists of retrieved articles were
scrutinized for additional relevant articles. Only peer-
reviewed articles published in English were included.
Books, abstracts and conference proceedings were
excluded. Articles which reported studies in which the
patients mainly had dementia of the Alzheimers type
but also included some patients with other types of
dementia were included. Most of the published work
on personality and personality change in dementia was
found to be based on the ve-factor model and these
personality traits were most often measured by the
revised NEO PI-R or the shorter NEO Five-Factor
Inventory (NEO-FFI). Accordingly, this review will
focus on premorbid and current personality change as
measured by NEOPI-R or NEO-FFI and we will now
introduce these instruments.
NEO PI and NEO PI-R
The original 181-item NEO PI was designed to reect
the ve-factor model of personality structure (Costa
and McCrae, 1988). These factors represent the most
basic dimensions underlying personality traits origin-
ally identied from lexical analyses of dictionaries and
language samples and from psychological question-
naires. Inter-correlated traits are formed by specic
trait facets, and each cluster of facets is labelled a
domain. Summing the facet scales yields the domain
score, which gives an approximation of the factor score
(Costa and McCrae, 1992). The NEO PI is the result of
extensive research on personality change and stability,
and has well-established reliability and validity data in
older populations (McCRae et al., 1986; McCRae and
Costa, 1987; Costa and McCrae, 1992; Strauss et al.,
1993).
Subsequently, a 240-item Revised NEO PI-R and a
60-item NEO Five Factor Inventory (NEO-FFI) were
Int J Geriatr Psychiatry 2011; 26: 10191029.
Personality changes in Alzheimers disease 1021

developed using a similar structure (Costa and
McCrae, 1992). The NEO PI-R measures the level of
agreement or disagreement on 30 facet scales and ve
domains and allows a comprehensive assessment of
adult personality. There are two versions of the NEO
PI-R: a self-report item booklet (Form S) and an
observer-report item booklet (Form R). Both Forms
have 240 items and Form R is written in the third
person for peer, spouse or expert ratings (Costa and
McCrae, 1992). The NEO-FFI consists of ve 12-item
domains and also now comes in two forms for self-
rating and informant-rating (Costa and McCrae, 1992;
Archer et al., 2006). The NEO-FFI is found to be a
reliable measure of premorbid personality even in
patients with probable AD (Archer et al., 2006). Short
descriptions of the domains are presented in Table 1
and the six facets of Neuroticism, Extraversion,
Openness, Agreeableness and Conscientiousness and
their relation to dementia are presented in Table 2.
Personality ratings on the NEO personality domains
are commonly presented as standardized T scores, with
a mean of 50 and a standard deviation of 10.
The NEO Personality inventories represent person-
ality constructs on dimensional scales and ratings may
be usefully summarized in relation to ve normative
levels: very low, low, average, high and very high.
Although ndings vary somewhat from study to study,
approximately 38% of normal subjects score in the
average range (T 4555), 24% in high range (T 56
65) or low range (T 3544) and 7% in the very high
(T
66) or in the very low range (T  34) (Costa and
McCrae, 1992). Normal older individuals tend to score
slightly lower on Neuroticism, Extraversion and
Openness and slightly higher on Agreeableness and
Conscientiousness than younger adults (Costa and
McCrae, 1992). However, personality descriptions of
adult age obtained at different time points are quite
stable in the absence of illness (Costa and McCrae,
1988). It should be kept in mind that the NEO suite of
personality inventories was designed to measure
normal, stable traits of personality, not psychopathol-
ogy or state changes. However, they can be used to
measure enduring change in personality function.
Methodological aspects
Studies of personality and dementia face special
problems because people with dementia cannot often
inform reliably about their own personality (Siegler
et al., 1994). In addition to amnestic difculties,
frontal-executive function is often compromised early
in the clinical course of dementia, causing impaired
insight, poor judgement and a reduction in self-

Table 1 The domains and characteristics of NEO-PI, NEO PI-R, and NEO-FFI (Costa and McCrae, 1992)

Domain Characteristics of high scores Characteristics of Low Scores

Neuroticism High scores include susceptibility to psychological
distress such as social phobia, agitation, depression,
irrational ideas, hostility, and tendency to any negative
affects. Neurotic persons have difculties in controlling
their impulses and they cope more poorly with stress.
Higher scores reect higher risk to any psychiatric
problem.
Extraversion High scores reect sociability, friendly and open atti-
tude. Extraverts are prone to be talkative, active,
assertive, and they tend to like stimulation and excite-
ment.
Openness Openness is described as element of aesthetic sensi-
tivity, attentiveness to inner feelings, preference for
variety, active imagination, independent judgment,
unconventional and intellectual curiosity. Open individ-
uals are often prepared to consider new ideas, inde-
pendent in their judgement and willing to question
authority.
Agreeableness Agreeableness is a dimension of altruistic behaviour.
The agreeable person is sympathetic to others, eager
to help, co-operative, and willing to consider others
solutions. Also agreeable persons are often more
popular than antagonistic individuals.
Conscientiousness Conscientiousness is associated with the control of
impulses. The conscientiousness person is purposeful,
self-disciplined, striving, determined and strong-willed.
Low scores of neuroticism reect adjustment and
emotional stability. Low scores reect a calm and a
relaxed personality, which is not defensive or guarded.
Low scores of Extraversion reect reserved, less
assertive and active personality. Introversion should
be seen as the absence of extraversion, and not the
opposite pole.
Individuals with low scores prefer the familiar to the
novel. Muted emotional responses. Conventional and/
or conservative attitude.
Egocentric, sceptical, competitive. Low scores
indicate less compliant and less sympathetic person-
ality. They are less modest and less straightforward.
Lackadaisical, less exact, reliable or punctual. Low
scores reects hedonistic personality lacking order,
and will to achieve. Sometimes described as unreli-
able, negligent, and aimless.

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 10191029.
1022 T.-B. Robins Wahlin and G. J. Byrne

Table 2 The six facets of Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness and their relation to dementia

Domain Facets Relation to dementia

Neuroticism (1) Anxiety The six Facets of Neuroticism are all aspects of behavioural and psychological
(2) Angry hostility symptoms in dementia. Symptoms of psychological distress such as agitation,
(3) Depression depression, irrational ideas, hostility, and tendency to negative affects are expressed
(4) Self-consciousness in high scores of Neuroticism and seen often in early phases of AD. Dementia patients
(5) Impulsiveness have difculties in controlling their impulses and cope poorly with stress.
(6) Vulnerability
Extraversion (1) Warmth Facets like warmth, assertiveness, and gregariousness are described as diminishing
(2) Gregariousness traits as the dementia advances in narrative descriptions of dementia patientsa,b. A
(3) Assertiveness common observation by relatives is that demented persons record less activity,
(4) Activity level excitement, happiness, and love. The extraversion changes in dementia seem to
(5) Excitementseeking reect adaptive patterns that have served the patient in the pastc. The cognitive
(6) Positive emotions decline in dementia might cause a process of gradual disengagement to become
accelerated and this could give a tendency for introversiond.
Openness (1) Fantasy Facets of Openness are often compromised in early dementia as the affect gets
(2) Aesthetics blunted and memory fails. As the dementia progresses the patients emotional
(3) Receptivity to feelings behaviour get more muted and they are less able to cope in new situations. Persons
(4) Actions with dementia show decreased openness to aesthetics and increased fantasy lifeb.
(5) Ideas The approaching dementia itself causes the intellect to diminish and as Openness is
(6) Values often related to divergent, creative thinking, it is to be expected that openness would
diminish as the disease progresses.
Agreeableness (1) Trust Facets of Agreeableness are compromised in AD as the low scorers in this trait are
(2) Straightforwardness thought to be reecting unco-operative, aggressive, and deant personality. Low
(3) Altruism Agreeableness in dementia is often associated with self-centred, egoistic, and stub-
(4) Compliance born behaviour, all seen frequently in early dementia and giving considerable beha-
(5) Modesty viour problemse. Antisocial and paranoid personality disorders are often associated
(6) Tender-mindedness with low Agreeablenessf as well as advancing dementiag. In cognitive decline and
dementia the severity and number of behavioural and psychological symptoms of
dementia increase as the functions of frontal lobes are compromised.
Conscientiousness (1) Competence The facets of Conscientiousness are all aspects of personality that have strong
(2) Order connection to executive functions and frontal lobes. The basis of Conscientiousness
(3) Dutifulness is self-control, active process of planning, organizing, and carrying out planned tasks,
(4) Achievement striving all aspects of personality known to be compromised in dementia. Lackadaisical
(5) Self-discipline behaviour and disturbance in executive functions are well known early symptom of
(6) Deliberation dementia, especially in AD and dementia where the frontal lobes are affected relatively
early in the course. Facets of conscientiousness may reect mental status per se,
rather than changes of personality independent of cognitionh.

a
Siegler et al. (1991).
b
Welleford et al. (1995).
c
Kolanowski et al. (1997).
d
Williams et al. (1995).
e
Petry et al., (1988).
f
Costa and McCrae (1992).
g
Low et al., (2002).
h
Wild et al. (1994).

reective capacity (Bozeat et al., 2000). Duchek et al.,
(2007) demonstrated differences in some of the
personality factors across the groups so that informants
reported higher Neuroticism and lower Extraversion,
Openness, Agreeableness and Conscientiousness than
self-reporting individuals with mild AD (Duchek et al.,
2007) at the same time point. Thus, it is not reasonable
to assume that people with dementia can reliably
perceive their own personality function. Even if they
were able to reect accurately on their own current
personality function, it is unlikely that people with
dementia would be able to complete a lengthy
questionnaire measure without error (Seiffer et al.,
2005). Furthermore, the ability to distinguish between
current and prior function is likely to be impaired in
dementia. Hence, family members or close friends are
often trusted to provide current and premorbid
personality data.
While the ideal method of collecting longitudinal
data on personality function would involve prospec-
tively conducted interviews with each of the close
relatives of the person with dementia, the advanced age
of many people with dementia means that some of
their children, many of their siblings and virtually all of
their parents are already deceased. Hence, the ideal
study design would be longitudinal, and based on a

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 10191029.
Personality changes in Alzheimers disease
representative sample of normal ageing people
followed until some developed dementia (Siegler
et al., 1994). However, this is rarely possible (an
exception is Wilson et al., 2008) and therefore
retrospective assessments are usually used, as in most
of the studies included in this review. In many studies
of premorbid personality, informants have been asked
to describe the patient as he or she was prior to the
onset of the dementia, and then after the illness was
established (Strauss et al., 1993). The differences
between premorbid and current ratings are usually
reported as means and standard deviations for the ve
factors of personality (Strauss et al., 1993). An
informant has most often been a near relative, such
as a spouse, or an adult daughter or son (see Table 3).
Results
After conducting searches of the psycINFO, PubMed,
Medline (Ovid and EBSCOhost) and CINAHL
databases, we identied 233 unique research articles,
the abstracts of which were read by the authors (T-
BRW and GJB). A large number of these articles were
excluded as irrelevant to the topic (N 153). The next
most common exclusion category contained studies
that focused on specic diseases or syndromes
including Parkinsons disease, Huntingtons disease,
frontotemporal dementia, and HIV (N 38). Finally,
some studies explored partners or caregivers burden
and situational factors rather than the personality
function of patients with dementia (N 17). Twenty-
ve studies were identied that focused on premorbid
personality traits in AD or unspecied dementia. Of
these, 15 studies used the 181-item NEO PI, the 240-
item NEO PI-R or the 60-item NEO-FFI to assess
personality traits in dementia. However, ve of the
studies assessed only premorbid personality traits
rather than both premorbid and current traits (Wild
et al., 1994; Kolanowski et al., 1997; Kolanowski and
Garr, 1999; Low et al., 2002; Seiffer et al., 2005; Archer
et al., 2006; Wilson et al., 2008). One study (Seiffer
et al., 2005) reported only the domain of Conscien-
tiousness. Hence, only nine of these 15 studies
employing one of the NEO personality inventories
were able to report change occurring in personality
traits following the development of dementia and were
therefore chosen for further detailed inspection
(Tables 3 and 4). One of these nine studies, Williams
et al. (1995), did not provide NEO domain scores but
instead a gure. As we were not able to obtain the
domain scores from the authors, we have estimated
these values from their published gure.
Copyright # 2010 John Wiley & Sons, Ltd.
1023
Main findings
Participant characteristics for the nine included studies
that measured premorbid personality in dementia are
summarized in Table 3.
The main diagnosis was AD, although some of the
studies included a few cases of vascular dementia, mixed
dementia (Kolanowski et al., 1997), atypical dementia,
memory disorders (Siegler et al., 1991) or severe
dementia (Williams et al., 1995). The sample sizes of
these studies were usually moderate (range 1950). The
mean age of participants varied from 67 to 87 years and
mean MMSE score varied from 15 to 22. The reported
mean number of years of education was 12 to 15 years
(three studies did not report education). The average of
each personality domain and standard deviations of
premorbid and/or current personality trait T scores
measured on the NEO are summarized in Table 4 and
scores of change are summarized in Table 5. Measures of
effect size are reported as Cohens d. The effect sizes
found were variable (Cohens d 0.252.17) but three of
the ve NEO domains showed larger effect sizes than
1.00.
Neuroticism
Premorbid neuroticism T scores increased from an
average of 48.9 to high current scores 62.7. The average
rise was 13.8 (range 2.919.8). The modest increase of 2.9
reported by Kolanowski et al. (1997) might be an outlier,
perhaps reecting methodological issues in that study
(mixed diagnoses or unknown symptom duration).
Current neuroticism T scores (range 56.168.4) were all
in the high to very high range compared to premorbid
scores in average range (range 45.253.6).
Extraversion
Premorbid extraversion T scores declined around 13 T
scores (range 5.918.0) from premorbid average values
(range 44.355.7) to low values, with all except one
under 40 T scores (range 30.049.8). The exception (see
above) to this was the pilot-study by Kolanowski et al.
(1997), which showed only a modest 5.9 T score
reduction.
Openness
The current mean of Openness showed constantly
lower values than premorbid values, with an average
Int J Geriatr Psychiatry 2011; 26: 10191029.
 Table 3 Background characteristics of the studies of personality traits associated with dementia 1024
Author Year Country n Diagnosis Mean Gender Symptom MMSE Educa- Informants NEO Outcome as a
of the age Female/ Duration tion inventory change measured
study Male n Years Years in Standard
(SD) (SD) (SD) (SD) Deviations (10)
(range) (range) (range) (range)

Siegler, 1991 USA 35 13 AD, 66.6 14/21 4.0 21.8 13.7 28 spouses, NEO PI 181 Neuroticism "",
Welsh, 16 atypical (n/a) (n/a) (n/a) (n/a) 7 children Extraversion ##,
Dawson, dementia, (5188) (121) (830) (n/a) and siblings Openness #,
Fillenbaum, and Agreeableness #,
Earl, Kaplan 6 memory Conscientiousness ###.
and Clark disorders

Chatterjee, 1992 USA 38 AD 70.7 21/17 5.3 15.5 n/a 24 spouses, NEO PI Neuroticism "",
Strauss, (n/a) (n/a) (n/a) 12 children, Extraversion ##,
Smyth and (5084) (216) (326) 1 sister-in law, Openness #,
Whitehouse 1 long term Agreeableness #,
companion Conscientiousness ##.
Strauss, 1993 USA 22 AD 72.0 11/11 4.7 15.4 12.6 14 spouses, NEO PI Neuroticism"",

Copyright # 2010 John Wiley & Sons, Ltd.

Pasupathi (9.2) (2.3) (5.8) (3.2) 7 children, Extraversion##,
and (5688) (210) (425) (518) 1 housemate Openness#,
Chatterjee Agreeableness #,
Conscientiousness ###.
Strauss and 1994 USA 29 AD 68.8 12/17 4.3 15.3 13.8 23 spouses, NEO PI Neuroticism"",
Pasupathi (6.58) (2.3) (6.6) (2.5) 5 children, Extraversion##,
(5683) (110) (225) (1020) 1 other relative Openness#,
Agreeableness #,
Conscientiousness ###.
Siegler, 1994 USA 26 AD 71.4 13/13 5.4 22.2 14.6 24 spouses, NEO PI 181 Neuroticism "",
Dawson and (n/a) (n/a) (n/a) (n/a) two primary Extraversion ##,
Welsh (5484) (114) (830) (820) caregivers Openness #,
Agreeableness #,
Conscientiousness ###.
Williams, 1995 UK 36 Severe 77 n/a n/a n/a n/a 26 spouses, NEO PI 60 Neuroticism "",
Briggs and dementia (n/a) 7 children, Extraversion ##,
Coleman (5496) 1 sister, Openness #,
2 landladies Agreeableness #,
Conscientiousness ###.
Welleford, 1995 USA 36 DAT 71.2 22/14 3.4 17.9 1215 28 spouses, NEO PI Neuroticism "",
Harkins and (9.38) (1.7) (6.1) (n/a) 6 children, Extraversion ##,
Taylor (n/a) (18) (n/a) (n/a) 1 sibling, Openness #,
1 nephew Agreeableness #,
Conscientiousness ###.
Kolanowski, 1997 USA 19 AD, MID, 87.1 16/3 n/a 19 n/a Usually sons NEO PI-R Neuroticism",
Strand and and (6) (n/a) and daughters Extraversion#,
Whall un-specied 7495 Openness#,
Agreeableness #,
Conscientiousness ###.
Dawson, 2000 USA 50 AD 70.5 23/27 4.8 22.0 14.6 46 spouses, NEO PI 181 Neuroticism "",
Welsh- (n/a) (n/a) (n/a) (n/a) 3 children or Extraversion ##,
Bohmer (5289) (114) (1230) (820) sibling, Openness #,
and 1 close Conscientiousness ###.
Siegler friend

SD standard deviation; n/a not available.

" higher than premorbid, change < 1 SD; # lower than premorbid, change < 1 SD; "" higher than premorbid, change 1-2 SD; ## lower than premorbid, change 1-2 SD; """ higher than
premorbid, change > 2 SD; ### lower than premorbid, change > 2 SD.

Int J Geriatr Psychiatry 2011; 26: 10191029.

T.-B. Robins Wahlin and G. J. Byrne
 Table 4 Current and premorbid personality traits

Author Year Instrument Neuroticism (SD) Extraversion (SD) Openness (SD) Agreeableness (SD) Conscientiousness (SD)

Premorbid Current Premorbid Current Premorbid Current Premorbid Current Premorbid Current
Personality changes in Alzheimers disease

* * *
Siegler, Welsh, 1991 NEO PI 49.6(n/a) 61.5 (n/a) 52.2(n/a) 37.9 (n/a) 43.8(n/a) 40.3 (n/a) 49.3(n/a) 45.6(n/a) 54.5(n/a) 30.9*(n/a)

Copyright # 2010 John Wiley & Sons, Ltd.

Dawson, Fillenbaum,
Earl, Kaplan and Clark
Chatterjee, Strauss, 1992 NEO PI 51.5(12.1) 66.8*(12.1) 46.3(9.3) 34.5*(9.5) 38.1(9.5) 34.3*(8.6) 49.5(12.4) 44.7*(12.6) 49.6(8.3) 30.3*(11.8)
Smyth and Whitehouse
Strauss, Pasupathi and 1993 NEO PI 46.7(9.8) 64.4*(10.1) 46.2(11.1) 33.8*(10.8) 38.0(10.3) 33.5*(9.0) 53.4(12.0) 49.8(12.4) 54.6(7.2) 30.9*(15.1)
Chatterjee: primary informant
* * *
Strauss, Pasupathi and 1993 NEO PI 51.9(10.3) 66.5 (12.4) 44.3(10.8) 31.4 (11.1) 37.5(8.4) 33.4 (8.2) 51.2(10.8) 48.9(10.6) 54.0(9.1) 30.6*(12.8)
Chatterjee: secondary
informant
Strauss and Pasupathi, 1994 NEO PI 48.4(12.7) 65.2*(13.4) 47.1(10.8) 34.3*(10.6) 39.4(9.6) 34.8(9.5) 51.9(13.3) 49.3(12.9) 50.2(9.3) 29.5*(13.0)
Time I
* *
Strauss and Pasupathi, 1994 NEO PI 48.6(11.1) 68.4 (13.0) 46.0(11.8) 30.6 (10.3) 40.1(10.6) 34.5(9.2) 51.1(12.0) 47.4(11.7) 51.0(7.8) 24.7*(12.5)
Time 2 (one year later)
Siegler, Dawson and Welsh 1994 NEO PI 48.2(n/a) 63.0*(n/a) 49.6(n/a) 37.0*(n/a) 43.4(n/a) 38.9*(n/a) 51.9(n/a) 48.7*(n/a) 51.0(n/a) 30.5*(n/a)
Williams, Briggs and Colemana 1995 NEO PI Approx. Approx. Approx. Approx. Approx. Approx. Approx. Approx. Approx. Approx.
 46(n/a)  59**(n/a)  48(n/a)  30**(n/a)  38(n/a)  35(n/a)  43(n/a)  41(n/a)  51(n/a)  24**(n/a)
Welleford, Harkins and Taylorb 1995 NEO PI 45.2 56.1* 51.3 39.6* 47.3 42.7* 51.7 47.7* 49.7 28.9*
Kolanowski, Strand and Whall 1997 NEO PI 53.6(n/a) 56.5(n/a) 55.7(n/a) 49.8*(n/a) 43.0(n/a) 34.8*(n/a) 47.0(n/a) 46.9(n/a) 53.1(n/a) 21.6*(n/a)
Dawson, Welsh-Bohmer 2000 NEO PI 48.2(n/a) 62.4*(n/a) 51.2(n/a) 37.6*(n/a) 42.9(n/a) 38.9*(n/a) n/a n/a 54.0(n/a) 30.8(n/a)
and Siegler
Mean 48.9 62.7 48.9 36.0 41.0 36.5 50.0 47.0 52.1 28.4
SD (2.6) (4.1) (3.4) (5.5) (3.2) (3.1) (3.0) (2.6) (2.0) (3.3)
Minimum 45.2 56.1 44.3 30.0 37.5 33.4 43.0 41.0 49.6 21.6
Maximum 53.6 68.4 55.7 49.8 47.3 42.7 53.4 49.8 54.6 30.6

a
Williams et al. (1995) did not publish the mean scores although their study reported changes for Neuroticism, Extraversion and Conscientiousness. The values are based at approximate scores interpreted from the Figure 2 Observed Personality Change, International
Journal of Psychiatry, Vol. 10, page 233, 1995.
b
Published raw scores converted to T scores according to Costa and McCrae (1989).
*
<0.05;
**
<0.001.

Int J Geriatr Psychiatry 2011; 26: 10191029.

1025
1026 T.-B. Robins Wahlin and G. J. Byrne

Table 5 The mean NEO-PI difference measured in T scores before and after dementia onset in the domains of Neuroticism, Extraversion, Openness,
Agreeableness, and Conscientiousness, and effect sizes for each contrast

Author Year Instrument Neuroticism Extraversion Openness Agreeableness Conscien-

tiousness

Current Current Current Current Current

premorbid premorbid premorbid premorbid premorbid
difference difference difference difference difference

Siegler, Welsh, Dawson, 1991 NEO PI 11.9 14.3 3.5 3.7 23.6
Fillenbaum, Earl, Kaplan
and Clark
Chatterjee, Strauss, Smyth 1992 NEO PI 15.3 11.8 3.8 4.8 19.4
and Whitehouse
Strauss, Pasupathi and 1993 NEO PI 17.7 12.4 4.5 3.6 23.7
Chatterjee: primary informant
Strauss, Pasupathi and 1993 NEO PI 14.6 12.9 4.1 2.3 23.4
Chatterjee:
secondary informant
Strauss and Pasupathi, Time I 1994 NEO PI 16.8 12.8 4.6 2.6 20.7
Strauss and Pasupathi, Time 2 1994 NEO PI 19.8 15.4 5.6 3.7 26.3
Siegler, Dawson and Welsh 1994 NEO PI 14.8 12.6 4.5 3.2 20.5
Williams, Briggs and Coleman 1995 NEO PI 13.0 18.0 3.0 2.0 27.0
Welleford, Harkins and Taylor 1995 NEO PI 10.9 11.7 4.6 4.0 20.8
Kolanowski, Strand and Whall 1997 NEO PI 2.9 5.9 8.2 0.1 31.5
Dawson, Welsh-Bohmer 2000 NEO PI 14.2 13.6 4.0 n/aa 23.2
and Siegler
The mean of each domain 13.8 12.8 4.6 3.0 23.6
SD (4.4) (2.9) (1.4) (1.3) (3.5)
Cohens db 1.18 1.21 0.49 0.25 2.17

n/a not available.

a
b
Based on the available SD.

reduction of 4.6 T scores (range 3.08.2). All the
studies demonstrated this pattern. The current T scores
were all in very low or low range (range 33.442.7)
compared to premorbid low/average rates (range 37.5
47.3).
reduction of 23.6 T scores (range 19.431.5). All the
current T scores of Conscientiousness were around
21.630.9, which are considered extremely low values
by the norms (Costa and McCrae, 1992).

Agreeableness
Current Agreeableness (range 41.049.8) was rated
lower compared to the premorbid value (range 43.0
53.4), a consistent reduction of around 3 T scores
(range 0.14.8). The outlier was the study of Williams
et al. that reported low premorbid (approximately 43)
and current scores (approximately 41). Once again, the
study by Kolanowski et al. (1997) showed hardly any
change from premorbid scores to current score (0.1).
Conscientiousness
Conscientiousness showed considerably lower average
scores in current values (range 21.630.9) compared to
premorbid (range 49.654.6), reecting a mean
Discussion
The studies reviewed here reported systematic shifts
from premorbid to current scores, showing higher
Neuroticism between one and two standard deviation
units, a decrease of the same magnitude in Extraver-
sion, consistently reduced Openness and Agreeableness
(only modest changes under 1 SD), and a marked
decrease in Conscientiousness of between two and
three standard deviation units.
A number of longitudinal studies have explored
personality as developmental phenomena and demon-
strated the stability of personality in adult life (Conley,
1984; Haan et al., 1986). The Baltimore Longitudinal
Study on Aging (McCRae and Costa, 1987), which
extended into old age, reported stability of personality
in normal ageing. The Berkeley Older Generation
Study (Field and Millsapp, 1991) reported similar

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 10191029.
Personality changes in Alzheimers disease
ndings, but added that if there were changes, each
trait followed its own trajectory. Traits, which had
minor changes in normal aging, were Extraversion
which declined and Agreeableness which increased.
Our ndings show that changes in dementia seem to be
consistently in the opposite direction to those found in
normal ageing in Agreeableness and in the same
direction as those found in normal ageing in
Extraversion, although the Extraversion changes in
dementia are 1 SD larger than reported by normative
Berkeley Older Generation Study.
Scores on personality inventories are only mean-
ingful when they are compared with the responses of
others. Published norms are intended to serve as a
reference group, and indicate what is to be expected in
comparison with average adults. In adulthood, T scores
of 56 or higher are considered high, T scores of 5545
are considered average, and T scores of 44 or lower are
considered low. As personality in adulthood is
generally regarded to be stable after the age of 2530
(Costa and McCrae, 1988, 1989), any reported changes
in adult personality should not be assumed to be due to
normal aging (Siegler et al., 1991). Although our
ndings should be considered in relation to different
methodologies (e.g. time period over which premorbid
personality was considered) and participant charac-
teristics (e.g. type and severity of dementia), these
ndings are consistent and adds to the existing
literature of personality change in dementia (Duchek
et al., 2007).
The hypothesis that personality changes in AD occur
with a clear, consistent pattern was conrmed. A
constant and systematic pattern of change, associated
with considerably increased Neuroticism, substantial
decline in Extraversion and exceptional decline in
Conscientiousness scores, supports a stereotypic change
in personality. This stereotypic change is suggested as
the premorbid and current differences show consider-
able between-patients variability and the standard
deviations do not show any diminishing pattern for
the current rates. Our ndings add to earlier ndings
that there is no reduction in the variability of personality
traits, suggesting that individuals with dementia do not
converge in a unied personality (Welleford et al., 1995;
Dawson et al., 2000). However, it is also possible that the
underlying facets change towards opposite poles and
thus make only a minor impression in total loading.
Unfortunately, half of the studies did not report facets
and therefore we were not able to examine these
tendencies.
The effect sizes (Cohens ds) used in our calculations
were based only on the reported standard deviations
(Chatterjee et al., 1992; Strauss et al., 1993; Strauss and
Copyright # 2010 John Wiley & Sons, Ltd.
1027
Pasupathi, 1994). However, these ndings were very
similar to the Standardized Change Score ndings by
Chatterjee et al. (1992), ranging from moderate to
large effect size (Neuroticism 1.18 versus 1.27;
Extraversion 1.21 versus 1.25; Openness 0.49 versus
0.42; Agreeableness 0.25 versus 38; and Conscientious-
ness 2.17 versus 1.93).
Our ndings suggest that a marked decline in
Conscientiousness can be seen as a feature of dementia
of the Alzheimer type, and one that is likely to have
clinical signicance. It is not difcult to imagine that
the combination of low concientiousness and other
accepted features of early dementia of the Alzheimer
type such as poor memory and poor executive function
might lead to decline in instrumental and interpersonal
function. In addition, higher levels of Neuroticism are
likely to lead to a greater tendency to experience and
exhibit psychological distress. As others have noted
(Archer et al., 2006), this is likely to have important
implications for the prevalence and severity of
behavioural and psychological symptoms in people
with dementia (BPSD). Lower extraversion is likely to
further impair interpersonal function and may
promote the highly prevalent clinical symptom of
apathy, which is a major source of complaint for the
carers of people with dementia. A clear implication of
our ndings is that more attention should be paid by
clinicians to the personality changes often reported by
near relatives of older people who might be developing
dementia. Specic inquiry about personality change
might allow an earlier provisional diagnosis of AD,
which would be important once disease-modifying
treatments for AD are available for routine clinical use.
There are some potential limitations to our ndings.
The use of family members to provide premorbid
personality data is not free from complications.
Retrospective assessments may introduce faulty mem-
ories of what a person was like previously (Chatterjee et
al., 1992) and the premorbid and current personality
may be biased by the current symptoms of the patient.
Informant bias may explain some of the signicant
associations found in these studies. Strauss and
Pasupathi (1994) examined the temporal reliability
of retrospective characterizations of the premorbid
personality and personality change in AD. They found
a substantial consistency and high correlations in
caregivers retrospective characterizations, obtained
twice over a period of 1 year (Strauss and Pasupathi,
1994). A more reliable estimate might be obtained if
the information were gathered from two informants,
such as another daughter or son or a close friend.
There is also some evidence that family members
perceive patients with mild dementia as more neurotic,
Int J Geriatr Psychiatry 2011; 26: 10191029.
1028
but less extraverted, open, agreeable and conscientious
than the patients saw themselves at the rating time
(Richman, 1989). However, the mildly demented
subjects in this study by Richman (1989) demonstrated
a high consistency between the initial assessment and
re-test 714 days later. However, as previously noted,
self-reported premorbid personality relies heavily on
memory and is unlikely to be reliable in people with
more than mild dementia (Archer et al., 2006). Hence,
this kind of data-collection is often overlooked in
dementia research (Kolanowski and Whall, 1996).
Another potential confounder, the effect of prescribed
drugs, must also be considered, especially as many
patients with dementia are taking some form of
sedative, anti-depressive or behaviour-modifying
medication (Williams et al., 1995). Other methodo-
logical limitations in the reviewed studies included the
relatively small sample sizes and the failure of some
authors to indicate the severity of dementia. A
methodological limitation in our study is that Strauss
et al. (1993, 1994) may give a higher loading, but their
ndings are in concordance and independent whether
primary or secondary informants (Strauss et al., 1993),
and show stability and sensitivity to change (Strauss
and Pasupathi, 1994).
The paucity of research may be a reection of
methodological difculties in assessing personality
changes in dementia (Chatterjee et al., 1992; Rubin
et al., 1986). Varying aspects of personality have often
been measured using different assessment tools, which
makes comparison difcult. To minimize this source of
variation, we chose in this review to examine ndings
from only those studies that employed a version of the
NEO PI-R. As AD patients showed the same change
tendencies in traits, and as this group differed system-
atically from normative data, it would make sense to
develop a similar clinical prole for other causes of
dementia, with differential diagnosis in mind. However,
at present this is not feasible as the published literature
on personality and personality change in people with
dementia due to conditions other than AD is quite
limited in scope and beset with methodological issues.
Conclusion
Personality changes in people with AD assessed by
informant include increased Neuroticism, a trait which
is often associated with social dysfunction, decreased
Extraversion and Conscientiousness, which are
often socially adaptive behaviours, and stable or
slightly decreased Openness and Agreeableness.
Particularly striking is the similarity in the extent of
Copyright # 2010 John Wiley & Sons, Ltd.
T.-B. Robins Wahlin and G. J. Byrne
personality change in all the studies reviewed. The
magnitude and direction of these changes suggest that
high Neuroticism or low Conscientiousness may be
early signs of dementia of the Alzheimer type as well as
the best predictors of subsequent personality change in
dementia. The personality traits of Neuroticism and
Conscientiousness have also been found to better
discriminate healthy controls from those with mild
cognitive impairment or early stage AD than cognitive
factors based on neuropsychological tests (Duchek
et al., 2007; Wilson et al., 2007). Understanding
personality change as a correlate of both cognitive
decline and neuropsychiatric symptoms in dementia
may aid in the design of psychotherapeutic, social and
pharmacologic treatments (Rubin et al., 1987).
However, building on the work of Wilson et al.
(2008), additional studies are needed with prospective
ascertainment of personality function, longitudinal
follow-up and autopsy to verify diagnosis.
Conflicts of interest
None declared.
Ethical approval
Not needed. This is a review.
Acknowledgements
This research was supported in part by grants from the
Australian National Health and Medical Research
Council (456182) and the Royal Brisbane and
Womens Hospital Research Foundation to Gerard J.
Byrne. We thank Liz Arnold for her assistance.
Key Points
 Personality change is evident early in the clinical
course of dementia due to Alzheimers disease
(AD).
 The ve-factor model of personality has most
often been used to track personality change in
people with AD.
 The main personality changes in AD are an
increase in neuroticism and decreases in extra-
version and conscientiousness.
 Personality change might be a useful early clinical
marker of dementia.
Int J Geriatr Psychiatry 2011; 26: 10191029.
Personality changes in Alzheimers disease
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