Aggressive behaviour in elderly people with dementia: A review

The progressive degeneration of the brain seen in dementia is often accompanied by behavioural disturbances. Aggressive behaviour is one of the most serious of these disturbances and is a common cause for psychiatric referral, admission to hospital and drug treatment. In this article, we discuss the conceptual issues associated with defining aggressive behaviour in cognitively impaired patients. We then review the aetiology, epidemiology, methods of assessment, and management of aggressive behaviour in elderly people with dementia.     

Subtle imitation behaviour in convenience samples of normal, demented, and currently depressed elderly subjects

BACKGROUND: The clinical significance of imitation behaviour (IB) is unclear. The aim of this study was to investigate the prevalence of subtle na?ve and obstinate IB in convenience samples of normal elderly, demented, and depressed subjects. METHOD: Subtle IB was assessed using a protocol constructed ad hoc in 146 patients, consecutively referred to a memory clinic having received an ICD-10 diagnosis of either dementia or depression, and in 241 healthy subjects. The prevalence of IB in the three groups was determined and the association with possible demographic, cognitive, and non-cognitive variables analysed. RESULTS: Subtle na?ve IB was frequent in the elderly with dementia, intermediate in the depressed, and rare in the normal elderly except that the latter frequently stretched out their arms. Obstinate IB never occurred in the normal elderly. IB was predicted by none of the variables used. LIMITATIONS: The groups included were convenience samples with the depressed being a small group precluding further distinction of depressive subtypes. CONCLUSION: Although na?ve IB is a frequent clinical feature in the demented, it also accompanies depressive disorders in the elderly. It can be observed as context-specific IB in the normal elderly. Obstinate IB does not occur in the normal elderly.     

Effect of psychopharmacotherapy on suicide risk in discharged psychiatric inpatients.

We investigated 64 former psychiatric inpatients who had committed suicide within 1 year after their discharge and compared them with a carefully matched control group of patients who did not commit suicide. One third of the patients in both groups were no longer in treatment at the time of the suicide or, for controls, at the corresponding point in time. At that time, a significantly higher proportion of controls had been receiving psychopharmacotherapy and a significantly higher proportion of them were on lithium.     

Ultrasonography detected a higher incidence of gallstones in psychiatric inpatients.

A total of 105 psychiatric inpatients (55 men, 50 women) were investigated for gallstones and associated factors by means of ultrasonography. Gallstones were detected in 27 (26%) of the 105 patients. The overall incidence tended to be higher in female patients than in males. The duration of mental illness and neuroleptic medication in patients with gallstones was significantly longer than in those without gallstones. A stepwise discriminant analysis revealed that the duration of neuroleptic medication was the most informative for discrimination between the 2 groups. These results, in combination with previous studies on the effects of neuroleptics on the bile and biliary system, suggests that neuroleptics may accelerate the formation of gallstones.     

A questionnaire to screen for cognitive impairment among elderly people in developing countries.

Most questionnaires designed to assess cognitive impairment among elderly people are constructed in the West, where literacy is high. However, such questionnaires may not be applicable in developing countries because of cultural differences or low literacy. The Elderly Cognitive Assessment Questionnaire (ECAQ) is derived from items in the Mini-Mental State Examination and Geriatric Mental State Schedule. It is a satisfactory scale for quantitative assessment of cognitive impairment among elderly people living in developing countries. This 10-item questionnaire shows a sensitivity of 85.3%, specificity 91.5%, positive predictive value 82.8% and overall miscalculation rate 10.5%. In a sample of 105 elderly subjects from 2 day centres and a psychiatric outpatient clinic in Singapore, the ECAQ was compared with Kahn's Mental Status Questionnaire. The sensitivity of the scales was found to be similar but the ECAQ had a higher specificity and positive predictive value, and lower overall miscalculation rate.     

REM sleep behaviour disorder in the elderly

REM sleep behaviour disorder is a recently described parasomnia characterized by a history of excessive motor activities during sleep and is associated with pathological absence of muscle atonia during REM sleep. There is very limited literature on the condition. Two out of 349 elderly patients referred to a psychogeriatric unit were identified to have REM sleep behaviour disorder. These two patients are presented to illustrate the clinical features of the condition. Both of them showed a good response to clonazepam treatment. © 1997 John Wiley & Sons, Ltd.     

Personality disorder and the Temperament and Character Inventory in the elderly.

OBJECTIVE: The aim of this study was to determine the prevalence of personality disorders in a group of elderly patients without an organic mental disorder and to examine the relationship between the Temperament and Character Inventory (TCI) and personality disorder symptoms in psychogeriatric clinical practice. METHOD: A total of 91 subjects completed the Structured Clinical Interview for DSM-III-R personality questionnaire and the 125-item TCI. RESULTS: Of the 91 subjects, 34 individuals (31%) had at least one DSM-III-R personality disorder diagnosis, with avoidant, dependent and paranoid personality disorder being the most common. The trends and correlations between the temperament and character dimensions and the correlations between individual personality disorder symptoms and the dimensions were similar to those in the original model. The most significant findings were the strong negative correlations of the character scores of self-directedness and co-operativeness with the total number of personality disorder symptoms, and the fact that the self-directedness scores predicted the number of personality disorder diagnoses. CONCLUSION: The reported prevalence rate is comparable to studies of both younger and older patient populations using similar methodology. The TCI provides a useful framework for further research on personality disorders in the elderly.     

Occurrence of high concentrations of postdexamethasone cortisol in elderly psychiatric inpatients

The authors retrospectively studied 161 psychiatric inpatients who had received a dexamethasone suppression test (DST). The majority of the patients were over 60 years old, female, and had concurrent chronic medical illnesses. Age was significantly correlated with log-transformed postdexamethasone cortisol concentrations in the 118 nondemented patients with major depression. Four p.m. cortisol concentrations greater than 15 micrograms/dl occurred in 15 patients. All were over 60 years old; all but one had major depressive disorder (MDD); and five had dementia plus MDD. In the same population, a 5 micrograms/dl criterion did not distinguish MDD from non-MDD patients. The results support the existence of a clinically relevant age effect on the DST in patients with MDD. Elderly depressed patients with markedly elevated cortisol concentrations occur frequently, and warrant further clinical and pathophysiological study.     

Does psychiatric morbidity predict mortality in continuing care geriatric inpatients?

All patients in continuing care geriatric beds in a London Health District were screened for psychiatric morbidity and physical dependency in 1990. This sample was followed up 1 year after screening. Forty-four per cent (32/72) were dead at follow-up. Patients in hospital-based continuing care beds had higher mortality than those in health authority beds in a private nursing home. Dementia, physical dependency and depression measured by Depressive Signs Scale (DSS) were associated with mortality. Using multivariate analysis, to partial out independent effects, depressive signs score measured by the DSS was the only significant predictor of mortality.     

Adolescence-limited versus life-course-persistent criminal behaviour in adolescent psychiatric inpatients

 A nation-wide sample of 1072 Norwegian adolescent psychiatric inpatients were followed up 15–33 (mean 23.8) years after hospitalisation, by record linkage to the National Register of Criminality. Defining criminal behaviour as entry into the criminal registry, 481 patients (45%) had an adolescent criminal debut, entering the registry before the age of 21. Of these, 130 (27%) had no criminal record after the age of 21 and were consequently considered as adolescence-limited criminal offenders, as opposed to the remaining 351 (73%) individuals who continued their criminal behaviour beyond the age of 21 and were considered as life-course-persistent criminal offenders. On the basis of hospital records, all patients were rediagnosed according to DSM-IV and scored on factors hypothesised to have predictive power as to persistence of criminal behaviour. We found that 79.6% of the male, and 58.8% of the female adolescent delinquents went on to life-course-persistent criminality. In females, intravenous use of illegal drugs, and being discharged from the hospital elsewhere than to the family home, were strong and independent predictors of life-course-persistent criminal behaviour. In males, the following were significant and independent predictors of life-course-persistent criminality: a high number of conduct disorder criteria fulfilled, comorbidity of psychoactive substance use disorder, and having attended correctional school. Accepted: 8 March 1999     

Cognitive assessment and diagnosis of dementia by camdex in elderly general hospital inpatients

One hundred and eight patients aged 70 and older randomly chosen from those admitted to the departments of medicine and surgery in a university hospital were examined for dementia by the Cambridge Mental Disorders of the Elderly Examination (CAMDEX) and DSM-III-R criteria. Cognitive impairment was assessed by the cognitive section of the CAMDEX (CAMCOG) and the Mini-Mental State Examination (MMSE). Fifty-one per cent of the sample met DSM-III-R criteria for at least one psychiatric disorder, dementia being the most common (35%). The cut-off point of CAMCOG (60/61) was more effective (100% sensitivity and 97% specificity) than the cut-off point of MMSE (21/22) (95% sensitivity and 86% specificity) in detecting dementia, although the optimal cut-off point of CAMCOG for our sample was lower than that suggested in previous studies.     

Time for change—psychiatric morbidity in residential homes for the elderly

Previous studies of psychiatric morbidity in Local Authority Social Services Part III homes have shown high rates of depression and dementia. Our study of Part III homes in Leicester city shows higher rates and greater severity of dementia than these studies. Eighty-two per cent were diagnosed as suffering from dementia to some degree and 53% showed severe levels of cognitive impairment and dependency. A rate of depression (17%) was found, lower than in previously reported studies. These results seem to reflect the changing role of Part III homes in service provision for the elderly population.     

The prevalence of dementia in elderly Chinese.

A stratified random sample of 612 Chinese aged 65 years and more and living in the community in Singapore was interviewed in 1985, using the Geriatric Mental State Schedule. The overall prevalence of dementia was 1.8%. The rate increased to 4.8% for those 80-84 years and 12.0% for those 85 years and more. An epidemiological survey of dementia in Beijing in 1986, also using the Geriatric Mental State Schedule, reported a similar rate of 1.8% for those 65 years and more. However, the prevalence of senile dementia was higher and multi-infarct dementia lower in Singapore than in Beijing.     

The Canberra Interview for the Elderly: a new field instrument for the diagnosis of dementia and depression by ICD-10 and DSM-III-R

The Canberra Interview for the Elderly (CIE) has been developed as a field instrument for identifying cases of dementia and depression, doing so strictly according to the diagnostic criteria in both the draft ICD-10 and DSM-III-R. It has been designed to be administered by lay interviewers. Information is gathered from the subject and an informant, and is then processed by computer algorithm to generate diagnoses. In a sample of 76 elderly patients attending a hospital clinic, test-retest reliability was found to be high at the level of individual items. For the diagnoses made on two occasions, agreement was comparable with other standardized psychiatric interviews designed for lay administration in the community. Validity, other than content validity, remains to be assessed. The CIE and its diagnostic algorithms are an efficient tool for clinical and epidemiological research on dementia and depression among elderly people, where close adherence to international criteria is required.     

Illness behaviour in neurological inpatients with psychiatric morbidity.

OBJECTIVE: The aim of the present study was to examine whether psychiatric morbidity can influence the type of illness behaviour of neurological inpatients. METHODS: For this purpose, we compared neurological inpatients with and without psychiatric disorders (DSM-IIIR criteria) for the seven scales of Illness Behaviour Questionnaire (IBQ) and searched for possible differences between the two patient subgroups. RESULTS: Of the 105 neurological inpatients who participated in the study, 54 (51.4%) were diagnosed as having some type of psychiatric disorder. These patients scored significantly higher than patients without psychiatric morbidity in the scale of Irritability. A suggestive trend for higher scores in the scales of Hypochondriasis, Disease Conviction, and Affective Disturbance, and significantly lower score in the scale of Denial, in patients with psychiatric morbidity, were also found. CONCLUSION: The present study has shown that neurological inpatients with psychiatric morbidity tend to develop more intense illness behaviour than those without. The effect of psychiatric morbidity on certain components of illness behaviour in neurological patients can be taken into account when therapeutic strategies are planned.     

Suicidal behaviour and electrodermal activity in depressive inpatients.

Within the context of a habituation experiment, the electrodermal activity (EDA) of suicidal depressed patients was measured. Twenty-four patients had a suicide attempt in their most recent history; these attempts were divided into attempts with violent or nonviolent methods. All the patients who had used a violent method habituated quickly, as was the case for 4 of 5 patients who committed suicide in the year following the experiment. Just as many patients who used nonviolent methods habituated quickly or slowly. There was no indication that age, sex or medication had any influence. For 18 of these 24 patients, comparable groups, in terms of age and sex distribution, were formed containing either nonsuicidal depressed patients or patients with suicidal thoughts. No differences between groups concerning any of the EDA variables could be found. In accordance with these results, EDA cannot be considered to be a valid predictor for suicide-proneness. The relations between violent suicide attempts and nonreactivity should, however, be further examined and the group of nonreactive patients in EDA should be treated as a risk group for clinical reasons.     

Aggressive behaviour in a psychiatric observation ward

Episodes of aggression were monitored, using a questionnaire, for a 6-month period in the female observation ward of a General Psychiatric Hospital. The results show that: a small group of schizophrenic patients were responsible for most of the incidents; nursing staff and other patients fell victim equally frequently; few of the incidents were predictable. Psychotic symptoms appear to be the main cause. More effective treatment of some persistently psychotic, apparently neuroleptic-resistant, aggressive patients should reduce the prevalence of violent behaviour. Drug-free observation periods in more recently admitted patients, or patients involved in pharmacological studies, however, were not associated with violent incidents.