A community-based study of aggressive behaviour in dementia

Aggressive behaviour is a serious care problem for families looking after patients with dementia. The aim of this study was to investigate, in a community sample of patients with dementia, the nature of aggressive behaviour and the settings in which it occurred. Thirty-seven subjects known to be aggressive were studied. The results show that the acts of aggression can be usefully classified on the basis of the circumstances in which they occur. It is argued that such a classification is likely to be of more value in understanding aetiology than is a classification based on the nature of the acts themselves.     

Behaviour changes in dementia 1: Point of entry data of a prospective study

Objective. This article analyses behaviour changes in dementia at the point of entry to a longitudinal study. Design. Prospective, longitudinal study of behaviour in dementia, with autopsy follow-up. Setting. Subjects with dementia, living at home with a carer. All lived in Oxfordshire, UK. Participants. Ninety-seven people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer. Measures. At 4-monthly intervals, the carers were interviewed and the subjects with dementia were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections covering many different aspects of behaviour. The 121 main questions, with 66 further ‘nested’ questions, have been shown to have high reliability. Results. This article analyses the types of behaviour change reported by carers at the point of entry to this long-term study. Few correlations were found between behaviour and age, gender and time since onset of dementia. Some types of behaviour were significantly more prevalent in those with greater cognitive impairment. Conclusions. Many of these changes create problems for carers, for example increased aggressive behaviour, wandering, wakefulness at night, incontinence and persecutory ideas. In general, they are more prevalent in people with more severe dementia. © 1997 John Wiley & Sons, Ltd.     

Behavioral profile of Alzheimer's disease in Chinese elderly--a validation study of the Chinese version of the Alzheimer's disease behavioral pathology rating scale

OBJECTIVES: This study aims to examine the psychometric properties of the Chinese version of the Alzheimer's disease behavioral pathology rating scale (CBehave-AD) and the behavioral profile of Chinese patients with AD. METHODS: Seventy-one subjects with NINCDS-ADRDA diagnosis of probable and possible AD were assessed for validation of the CBehave-AD. A behavioral symptom frequency checklist, the Chinese version of the Blessed Roth dementia scale (CDS) and the Cantonese version of the Mini-Mental State Examination (CMMSE) were used for comparison. An extended sample of 120 AD patients was then evaluated with the CBehave-AD. RESULTS: High correlations between the CBehave-AD and checklist scores were found (paranoid and delusional ideation, hallucinations, activity disturbances, aggressiveness and diurnal rhythm disturbances). The scale also demonstrated satisfactory inter-rater and test-retest reliabilities. The mean (SD) CMMSE score of the 120 patients was 9.4 (7.1). Among them, 32% have delusions, 15% had hallucinations, 54% had activity disturbances, 61% had aggressive behavior, 44% had sleep disturbance, 24% had affective disturbances, 19% had anxiety and phobias. Delusional ideation was significantly associated with hallucinations, aggressiveness, and affective disturbances. Diurnal rhythm disturbances were associated with activity disturbances and aggressiveness. CBehave-AD total scores were not significantly correlated with severity of AD, but individual symptom categories showed different pattern of correlation. Delusions, hallucinations, anxiety and phobias were significantly correlated with dementia staging. CONCLUSION: The findings suggest that the CBehave-AD is a valid assessment tool for behavioral disturbances in patients with AD. Variable associations between different symptom categories and dementia staging suggest a need for further exploration of the complex interactions between behavioral and cognitive disturbances in dementia.     

Natural history of aggressive behaviour in dementia.

OBJECTIVE: This article analyses changes in aggressive behaviour throughout the course of dementia. DESIGN: Prospective, 10 year, longitudinal study of aggressive behaviour in dementia, with autopsy follow-up. SETTING: Subjects with dementia, living at home with a carer, Oxfordshire, UK. PARTICIPANTS: Ninety-nine people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer. MEASURES: At 4-monthly intervals, the carers were interviewed about the subjects and the subjects were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections monitoring behavioural and psychological change. Eight different aspects of aggressive behaviour were assessed in detail and comparison made with other relevant factors. RESULTS: Verbal aggression is the most common and longest lasting form of aggressive behaviour. Aggressive resistance and physical aggression are most likely to persist until death. Intimate care is the main factor precipitating aggressive behaviour. There are no correlations between any type of aggressive behaviour and age, gender or time since onset of dementia. CONCLUSIONS: Aggressive behaviour creates problems for carers. In general, the physical types of aggressive behaviour are most prevalent in people with more severe dementia.     

Behaviour changes in dementia 2: Are there behavioural syndromes?

Objective. To establish whether robust behavioural ‘syndromes’ can be identified from among the widely heterogeneous behavioural changes which occur in dementia. Design. Longitudinal, prospective study with follow-up at 4 and 8 months. Setting. Community settings in Oxfordshire, UK. Participants. 97 elderly people with a diagnosis of Alzheimer's disease or vascular dementia (in many cases confirmed by postmortem examination) and who were living at home with a carer. Measures. Each subject's behaviour was assessed in detail at each interview using the Present Behavioural Examination to assess subject's behaviour over the preceding 4 weeks. Seventeen key behaviour items which were both common and clinically important were selected for further analysis. Results. Three syndromes were identified: (a) overactivity (walking more, walking aimlessly, trailing the carer or checking where the carer was); (b) aggressive behaviour (physical aggression, aggressive resistance, verbal aggression); (c) psychosis (anxiety, persecutory ideas and hallucinations). The same syndromes were found using data collected at three different time points and by using a variety of statistical techniques, confirming their robustness. Conclusions. Overactivity, aggressive behaviour and psychosis form three distinct behavioural syndromes in dementia. © 1997 John Wiley & Sons, Ltd.     

Behavioural disturbances in dementia patients and quality of the marital relationship

OBJECTIVES: To investigate the relationship between behavioural problems in patients with dementia and changes in the marital relationship. METHODS: Fifty-three spouse caregivers of patients with dementia participated in the study. Questionnaires and interviews were used to examine caregiver perception of changes in the quality of their relationship. Behavioural disturbances in the patient were measured with the NeuroPsychiatric Inventory (NPI). RESULTS: Caregivers experienced a deterioration of their relationship, yet at the same time most felt closer to their spouse now than in the past. Regression analysis revealed that patient behavioural problems were, independent of patient cognitive status or functional impairment, associated with deterioration in the quality of the relationship between patient and caregiver. Patient apathy rather than depressive mood was associated with this deterioration. Apathy diminished the amount and reciprocity of interactions between partners. CONCLUSIONS: These results show that passive behaviour rather than excessive behaviour has most impact on the deterioration of the marital relationship. Intervention programmes should target relationship problems when problem behaviour, especially apathy, is present in patients with dementia.     

Do caregiver management strategies influence patient behaviour in dementia?

OBJECTIVES: Little is known about the effectiveness of caregiver management strategies on the functioning of the demented patient. However, identification of specific caregiver strategies may provide useful information on the management and manifestation of behavioural problems in dementia. METHODS: Ninety-nine patients with dementia and their informal caregivers were followed up for one year. Interviews were used to assess differences in caregiver management strategies. Behavioural disturbances in the patient were measured with the Neuropsychiatric Inventory (NPI). Repeated measures analysis were carried out to investigate the relationship between caregiver management strategies and patient behaviour. RESULTS: Three caregiver management strategies were identified, based on whether caregivers accepted, or not, the caregiving situation and dementia related problems. Caregivers characterized by non-acceptance were typified as 'Non-adapters'; caregivers characterized by acceptance were further subdivided into two groups typified as 'Nurturers' and 'Supporters'. Caregiver characteristics such as sex, education and personality were important determinants of management strategies. MANOVA showed that non-adapters reported significantly more hyperactivity symptoms in patients and felt less competent than did supporters. CONCLUSIONS: Caregiver management strategies would appear to be associated with behavioural problems in dementia, and are important in predicting patient behaviour and caregiver burden. Intervention programmes should aim at teaching caregivers adequate management strategies.     

Use of constraints and their correlates in Norwegian nursing homes

OBJECTIVE: To analyse the effect of patient and ward characteristics on the use of constraints in nursing homes. METHOD: Primary carers in 222 wards in Norwegian nursing homes were asked about use of constraints towards 1926 patients during seven days. Constraints were grouped as mechanical restraints, non-mechanical restraints, electronic surveillance, force or pressure in medical examination or treatment, and force or pressure in ADL. The patients' mental capacity (CDR score), activity in daily living (ADL) and behaviour (BARS score) were rated. Type and size of ward, staffing level and educational level of the staff was recorded. RESULTS: In all 758 of the patients were subjected to any constraint. Degree of dementia, aggressive behaviour and loss of function in ADL had significant impact on all types of constraint except for electronical surveillance. The strongest associations were found between degree of dementia and mechanical restraint (OR 5.14), impaired ADL and mechanical restraint (OR 9.23) and aggression and force or pressure in ADL (OR 3.75). Mechanical restraint was less used towards patients in special care units for persons with dementia (SCU) (OR 0.38) compared to patients in regular units (RU), whereas non-mechanical restraint was more frequent used in SCUs (OR 2.28). Type of ward had no significant impact on use of other types of constraints. Staff level and education level of the staff had no significant impact on the use of constraint. CONCLUSION: Constraint is frequently used in nursing homes, and most frequent toward patients with severe dementia, aggressive behaviour or low ADL function.     

Determinants of aggression, and adaptive and maladaptive behaviour in older people with Down's syndrome with and without dementia

In a cross-sectional study of aggression, and adaptive and maladaptive behaviour in 128 subjects with Down's syndrome (DS), 29 of whom had dementia, the current authors found that the presence of dementia was not predictive of aggression or maladaptive behaviour. However, the level of adaptive behaviour was shown to be lower in subjects with dementia, and in those with lower levels of cognitive functioning, as measured on a rating instrument, the Test for Severe Impairment. Although the presence of aggressive behaviours is not higher in subjects with dementia and DS on cross-sectional review, it remains to be seen whether aggression will increase in individual cases with the onset or progression of dementia. The decline in adaptive behaviour shown in the present study confirms the findings of previous studies and indicates a direction for service development for persons with the dual diagnosis of dementia and DS.     

Clinical predictors of aggressive behaviour in Alzheimer's disease

Objectives. To examine the level and clinical correlates of aggressive behaviour in Alzheimer's disease (AD). Method. Seventy patients with probable AD were rated using validated assessment instruments including the Rating Scale for Aggressive Behaviour in the Elderly (RAGE). Results. Thirty-one subjects were rated as at least mildly aggressive during the 3-day period prior to assessment. RAGE scores correlated significantly with delusions and activity disturbance scores. Aggressive behaviour was not associated with age, sex, dementia severity, hallucinations or depression. Conclusions. Aggressive behaviour occurs frequently in patients with AD. Our results confirm the findings of previous studies that the presence of delusions increases the risk of aggression in this population. © 1998 John Wiley & Sons, Ltd.     

Suicide as a result of stereotypic behaviour in a case with semantic dementia

Semantic dementia (SD) is characterized by semantic aphasia and prosopagnosia, but it may also include behavioural disturbances such as stereotypic behaviour. We report the case of a 50‐year‐old man with SD accompanied by stereotypic behaviour who committed suicide despite not being in a depressive state. He initially had major depressive disorder accompanied by suicide attempts, but he gradually showed remarkable impairment in single‐word semantic comprehension, naming memory, and facial recognition memory. After the diagnosis of SD, his suicidal behaviour by hanging with a cord became stereotypic and lacked seriousness. He repeatedly attempted to hang himself and finally completed suicide. The present report suggests that the risk for suicide in SD is increased not only by the presence of a depressive state, but also by stereotypic behaviour related to suicide attempts before the onset of the disorder.     

PREVALENCE AND CORRELATES OF AGGRESSIVE BEHAVIOURS OCCURRING IN PATIENTS WITH ALZHEIMER'S DISEASE

Objectives. To determine the prevalence and clinical correlates of verbal and physical aggression occurring in Alzheimer's disease sufferers. Design. A retrospective note review was performed to classify the subjects according to whether they were verbally or physically aggressive (assaultive) or non-aggressive. The characteristics of the three groups were compared. Subjects. The subjects were 262 patients who were living in non-institutional settings and had been diagnosed as suffering from dementia of Alzheimer's type. Results. Fifty-two per cent exhibited some aggressive behaviour. Ninety-one (35%) patients were reported to be verbally aggressive and a further 46 (18%) were assaultive to their carers. Male gender (relative risk 2.17, 95% confidence interval 1.11–4.17) and the presence of dyspraxia (relative risk 2.89, 95% confidence interval 1.43–5.88) both increased the likelihood of assaultive behaviour. Verbal aggression was not associated with any of the clinical features measured. Conclusion. Aggressive behaviour is a common phenomenon in AD and approximately one in five sufferers is assaultive. Assaultive behaviour is associated with male gender and dyspraxia. © 1997 by John Wiley & Sons, Ltd.     

Challenging behaviours in nursing home residents with dementia: a randomized controlled trial of multidisciplinary interventions.

OBJECTIVES: To test the premise that individually tailored psychosocial, nursing and medical interventions to nursing home residents with dementia will reduce the frequency and severity of behavioural symptoms. METHODS: A four-member team comprising a psychiatrist, psychologist and nurses conducted detailed assessments of 99 nursing home residents with advanced dementia who were rated by staff as having frequent, severe behavioural disturbances. Residents were then randomly assigned to an 'early' or 'late' intervention group and observed for four weeks. Interventions encompassed psychosocial strategies, nursing approaches, psychotropic medications and management of pain. Outcome measures included the frequency and severity of disruptive behaviours and assessments of change by senior nursing home staff. RESULTS: While improvements in behaviour were noted in both groups from the outset of observations, pointing to a powerful Hawthorne effect, consultancies were associated with a modest but statistically significant decrease in challenging behaviours. Staff assessments of the interventions were highly favourable. CONCLUSIONS: The consultancies were effective and well received by staff. The change-inducing nature of any new endeavour is an integral part of research in a long-term setting.     

AGGRESSIVE INCIDENTS TOWARDS STAFF BY ELDERLY PATIENTS WITH DEMENTIA IN A LONG-STAY WARD

Frequent requests to medical staff from nurses on a long-stay ward for patients with dementia and associated behavioural problems to review patients were felt to reflect a sense of dissatisfaction and isolation in managing difficult patients. In addition, the recent admission of particularly aggressive patients had heightened awareness among both medical and nursing staff of the management problems posed by these patients. The aims of this study were to review the systems of recording aggressive incidents by patients with dementia on the long-stay ward, to introduce a new reporting system and review all cases reported by this means over a 3-month period. The impact of aggressive behaviour on staff was also explored. Forty-seven incidents were reported during the study period, and all staff on the ward had been the target of aggressive behaviour while working on the unit. Aggression by patients with dementia is common on the ward although most aggressive behaviour is not of a serious nature. Staff require support and acknowledgement of their difficulties in dealing with such patients. A reporting system may assist nursing staff by highlighting factors associated with aggression, and may provide a focus for planning interventions by the multidisciplinary team.     

Contextual variables affecting aggressive behaviour in individuals with mild to borderline intellectual disabilities who live in a residential facility

Background   Aggression is a common type of problem behaviour in clients with mild to borderline intellectual disability who live in a residential facility. We explored contextual events that elicit aggressive behaviour and variables that were associated with such events.
Method   Respondents were 87 direct-care staff members of 87 clients with aggressive behaviour who lived in a residential facility. Staff members completed the Contextual Assessment Inventory (CAI) and a questionnaire on demographic information and types, frequency and severity of aggressive behaviour. Internal consistency of the total CAI was excellent ( α  = 0.95), and Cronbach alpha's for the CAI sub-scales ranged from 0.75 to 0.93. Inter-rater agreement for the CAI could be considered good (mean intra-class correlation coefficient = 0.63).
Results   Both social and task-related events were reported to evoke aggressive behaviour of clients most often. Negative interactions, task characteristics and daily routines relatively often evoked aggressive behaviour while an uncomfortable environment, medication, illness and physiological states (i.e. physical and biological events) evoked aggressive behaviour least often. Mean CAI sub-scale scores were significantly related to gender, IQ and frequency of aggressive behaviour.
Conclusion   The present study extends our knowledge regarding events that are associated with an increased probability of aggressive behaviour. Knowledge of these contextual variables may be helpful in designing programmes (e.g. applied behaviour analysis, social skills training and cognitive behavioural therapies) for the management and prevention of aggressive behaviour in clients with mild to borderline intellectual disability who live in a residential facility.     

Prevalence and types of aggressive behaviour among adults with intellectual disabilities

Background Aggressive behaviours represent major obstacles to the integration into society of individuals with intellectual disability (ID) and pose significant management issues for carers. Methods The present study assessed the prevalence and severity of five types of aggressive behaviours in 3165 adult men and women with ID receiving services from three rehabilitation agencies in Québec by surveying their carers using the Modified Overt Aggressive Scale. Results The 12‐month prevalence of aggressive behaviour was 51.8%: 24% property damage, 37.6% verbal, 24.4% self‐oriented and 24.4% physical aggression, and 9.8% sexually aggressive behaviour, most of which being mild in severity. Only 4.9% of individuals displayed aggressive behaviour leading to injury of the victim. Few gender differences were observed. Conclusions The capacity to document and assess the types as well as the severity of aggressive behaviour is thus critical, not only to better understand the correlates of various types of behaviours but also to orient intervention programmes whether they be prevention, assessment, monitoring or management of aggressive behaviour.     

Sexual disinhibition and dementia

To describe inappropriate sexual behaviour (ISB) observed in patients with dementia, we conducted searches using the Cochrane Library, PubMed, and Web of Science to find relevant articles, chapters, and books published from 1950 to 2014. Search terms used included ‘hypersexuality’, ‘inappropriate sexual behaviors’, and ‘dementia’. Publications found through this indexed search were reviewed for further relevant references. Sexuality is a human's need to express intimacy, but persons with dementia may not know how to appropriately meet their needs for closeness and intimacy due to their decline in cognition. Generally, the interaction among brain, physical, psychological, and environmental factors can create what we call ISB. The most likely change in the sexual behaviour of a person with dementia is indifference. However, ISB in dementia appear to be of two types—intimacy‐seeking and disinhibited—that differ in their association with dementia type, dementia severity and, possibly, other concurrent behavioural disorder. Tensions develop from uncertainties regarding which, or when, behaviours are to be considered ‘inappropriate’ (i.e. improper) or abnormal. While most ISB occur in the moderate to severe stages of Alzheimer's dementia, they may also be seen in early stages of frontotemporal dementia because of the lack of insight and disinhibition. ISB are often better managed by non‐pharmacological means, as patients may be less responsive to psychoactive therapies, but non‐pharmacological interventions do not always stop the behaviour.     

The character of behavioural symptoms on admission to three Canadian long-term care homes

Objectives: We determined the prevalence and nature of behavioural symptoms at the time of admission to a long-term care home (LTCH) and occurrence of resident-to-resident aggressive behaviour associated with behavioural symptoms within three months following admission.

Method: The Cohen-Mansfield Agitation Inventory and Aggressive Behaviour Scale were completed at the time residents were admitted into the LTCH. A chart review, conducted three months after admission into the LTCH, abstracted documented resident-to-resident aggression. Three LTCHs located in Ontario, Canada participated in the study.

Results: During a 16-month period, 339 individuals admitted to the LTCHs comprised the study sample. A comparison was made between residents with and without dementia. At admission, residents with dementia had a greater number of behavioural symptoms than those without dementia (mean = 3.79, SD = 3.32 versus mean = 2.56, SD = 2.24, respectively; t(200) = 1.91; p = 0.059). Residents with and without dementia exhibited similar behaviours but differed on the prevalence of these behaviours. The most frequently reported behavioural symptoms for residents in both groups were verbal agitation and non-aggressive physical behaviours. The most frequently recorded aggressive behaviour for all residents was ‘resisting care’. In the three months post admission, 79 (23%) residents were involved in a documented incident that involved aggressive behaviour to another resident.

Conclusion: A standardized comprehensive assessment for admission to a LTCH is an important strategy that can be used to identify behavioural symptoms and plan appropriate care management.