Agitation in Chinese elderly: validation of the Chinese version of the Cohen-Mansfield Agitation Inventory.

The reliability and validity of the Chinese version of the Cohen-Mansfield Agitation Inventory (CCMAI) were studied in 164 demented patients. The agitation pattern in Chinese elderly was also examined in this study. The CCMAI demonstrated high validity, test-retest reliability, and interrater reliability. Eighty-five percent of demented patients manifested one or more agitated behaviors at least once a week. Factor analysis yielded three subtypes of agitation: physically aggressive behaviors, physically nonaggressive behaviors, and verbally agitated behaviors. There was a linear upward trend in physical aggression as one progressed from one Global Deterioration Scale stage to the next. Community-living patients showed higher physically nonaggressive and verbally agitated behaviors, whereas institution residents exhibited a significantly higher level of physical aggression. The differences between residential and institutionalized patients need further research. Future study should focus not only on the behavioral disturbances; medical, psychological, and environmental factors should be taken into account to provide a more accurate profile.     

Agitated behaviours among the institutionalized elderly with dementia: validation of the Korean version of the Cohen-Mansfield Agitation Inventory

OBJECTIVES: To analyze the factor structure, the criterion validity, the internal consistency, inter-rater reliability and test-retest reliability of the Korean version of Cohen-Mansfield Agitation Inventory, to provide data on the frequency and distribution of agitated behaviours, and to compare patterns of agitated behaviours among the institutionalized elderly with Alzheimer's disease (AD) or Vascular dementia (VaD). METHODS: The Korean version of the Cohen-Mansfield Agitation Inventory (CMAI-K) was administered to a total of 257 elderly with AD or VaD in a nursing home in Seoul, Korea. Three kinds of reliability and criterion validity were tested. Factor analysis using principal component analysis with the varimax rotation was performed. To identify different patterns of agitated behaviours, multiple logistic regression analysis was used. RESULTS: This study demonstrated satisfactory reliability and validity for the CMAI-K as an instrument measuring agitation in Korean dementia sufferers in nursing homes. Eighty-three percent of the subjects manifested one or more agitated behaviours at least once a week. Factor analysis yielded four subtypes of agitation: physically aggressive behaviours, physically nonaggressive behaviours, verbally agitated behaviours, and hiding/hoarding behaviours. CONCLUSION: These results indicate that the CMAI-K is a reliable and valid instrument to measure agitated behaviours in Korean elderly with AD or VaD. These results validate and expand previous research on the agitation in dementia, and guide in the development of interventions.     

Verbal and physical non-aggressive agitated behaviors in elderly persons with dementia: robustness of syndromes

OBJECTIVE: More than a decade ago, different syndromes of agitation were identified in elderly nursing home residents, and it was found that these syndromes correlate with medical, cognitive, and psychosocial functioning. The present study was conducted to examine the robustness of two major syndromes, verbal agitation and physical non-aggressive agitation, as assessed via direct observations. METHODS: Study participants were 175 elderly persons with dementia recruited from 11 nursing home facilities in Maryland. Observations of the participants' behavior were conducted using the agitated behaviors mapping instrument. RESULTS: The profiles that emerged for physically agitated residents and for verbally agitated residents were remarkably similar to those originally reported. Specifically, verbally agitated behaviors correlated with female gender, with cognitive decline, poor performance of activities of daily living, impaired social functioning, and signs of depressed affect. Physically non-aggressive agitated behaviors correlated with cognitive impairment and with fewer concurrent medical diagnoses. CONCLUSIONS: Examining correlates of different syndromes of agitated behaviors may provide researchers with valuable information that can be used for in-depth analysis of both the characterization and etiology of agitation, thus paving the way for the development of interventions that target particular types of problem behaviors.     

Neuropsychiatric symptoms in nursing home patients: factor structure invariance of the Dutch nursing home version of the neuropsychiatric inventory in different stages of dementia

BACKGROUND/AIMS: To examine the influence of dementia stage and psychoactive medication use on the factor structure of the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) in Dutch nursing home patients. METHODS: The NPI-NH was administered to a large sample of 1,437 patients with mild to severe dementia receiving nursing home care. Exploratory factor analysis was used to examine behavioural dimensions underlying neuropsychiatric symptoms indicated by the NPI-NH across dementia stages (as assessed with the Global Deterioration Scale - GDS) and in patients with or without psychoactive medication prescribed. RESULTS: In GDS stages 4/5, 6 and 7, a 4- or 5-factor solution was found, with factors referred to as agitation/aggression, depression, psychosis, psychomotor agitation and apathy. These symptom clusters were replicated in the group of drug-naive patients, but only partially in the group of patients on psychoactive medication. CONCLUSION: The factor structure of the NPI-NH in nursing home patients is consistent with the clinical taxonomy of symptoms, is relatively stable across dementia stages, and is only moderately influenced by psychoactive medication use. The division of depression and apathy into separate behavioural dimensions - also in patients with severe dementia - may have important therapeutic consequences.     

Agitation and other noncognitive abnormalities in Alzheimer's disease.

Agitation and other noncognitive abnormalities in patients with Alzheimer's disease are present in at least 50% of patients and are a serious problem for caregivers. Agitation can be divided into aggressive agitation, physically nonaggressive agitation, and verbal agitation. Persecutory delusions of suspiciousness and stealing are the most common psychotic symptoms. Auditory and visual hallucinations are also associated with delusions. Similar to delusions are misidentifications, which are false beliefs probably secondary to agnosia. They occur in one third of patients with dementia of the Alzheimer type in the form of the belief that strangers are living in the home and misidentification of the patient's home and reflection in the mirror. Passive personality changes are present early in the disease, whereas agitation and psychotic symptoms occur with disease progression and predict a more rapid rate of cognitive decline. Agitation and wandering are related to more severe cognitive impairment and psychosocial variables, and neurochemical variables that may be related to behavior disturbance require further study. There are few systematic studies of behavioral or environmental interventions for behavioral symptoms in patients with Alzheimer's disease. Current treatment emphasizes education of families, the formation of Alzheimer units in the nursing home, and adjunctive psychotropic agents to treat well-defined target symptoms.     

Agitated behavior in persons with dementia: the relationship between type of behavior, its frequency, and its disruptiveness

Objective

To examine the relationship between type, frequency, and level of disruptiveness of physically aggressive agitated behaviors, physically non-aggressive agitated behaviors, verbally aggressive agitated behaviors, and verbally non-aggressive agitated behaviors in persons with dementia.

Methods

The study was conducted in 11 nursing homes in Maryland, one of which housed two participating buildings. Participants were 191 older nursing home residents with dementia. Cohen-Mansfield Agitation Inventory (CMAI) data provided information on frequency and level of disruptiveness of the different types of agitated behavior.

Results

The highest overall frequencies were reported for verbal non-aggressive behaviors and the highest average disruptiveness was for verbal aggression. Frequency and disruptiveness of behaviors were highly correlated. Disruptiveness was highly correlated across shifts for all syndromes; a difference in magnitude of disruptiveness between shifts was only evident for physically non-aggressive behaviors (such as pacing), which were more disruptive on the day shift than on the evening shift. When controlling for frequency of behavior, physically aggressive behaviors were the most disruptive across both shifts.

Conclusion

In understanding the impact of agitated behaviors, it is important to take into account both the type of behavior and its frequency. Overall disruptiveness of a type of behavior is different from disruptiveness when the frequency of the behavior is controlled.     

Agitation and aggressiveness among the elderly population living in nursing or retirement homes in France

The aim of this study was to describe the epidemiological features of agitation and aggressiveness in elderly individuals living in French nursing and retirement homes in the year 2000. Data were collected on the type, time of onset, and duration of symptoms, medical evaluation and treatment, and medical and psychiatric comorbidities of the elderly patients. The most frequently reported behavior was verbal aggressiveness and the least reported behavior was physical aggressiveness. A triggering factor initiating the symptoms of agitation or aggressiveness was reported in 61% of the cases. In 61% of the study population, there were several morbidities reported as caused by the agitated or aggressive behavior (anorexia, weight loss, dehydration). A specialist was consulted for nearly half of the agitated or aggressive patients. For 55% of the patients, a new medication regimen was started or the administration of previous medications was modified, the most frequently prescribed drugs being antipsychotics. The results of our study and others show that agitation and aggression have a substantial impact on the lives of the elderly population, as well as on the lives of their family members and caretakers.     

Behavioral interventions for agitation in older adults with dementia: an evaluative review

BACKGROUND: Older adults with dementia commonly exhibit agitated behavior that puts them at risk of injury and institutionalization and is associated with caregiver stress. A range of theoretical approaches has produced numerous interventions to manage these behavior problems. This paper critically reviews the empirical literature on behavioral interventions to reduce agitation in older adults with dementia. METHOD: A literature search yielded 23 articles that met inclusion criteria. These articles described interventions that targeted wandering, disruptive vocalization, physical aggression, other agitated behaviors and a combination of these behaviors. Studies are summarized individually and then evaluated. RESULTS: Behavioral interventions targeting agitated behavior exhibited by older adults with dementia show considerable promise. A number of methodological issues must be addressed to advance this research area. Problem areas include inconsistent use of functional assessment techniques, failure to report quantitative findings and inadequate demonstrations of experimental control. CONCLUSIONS: The reviewed studies collectively provide evidence that warrants optimism regarding the application of behavioral principles to the management of agitation among older adults with dementia. Although the results of some studies were mixed and several studies revealed methodological shortcomings, many of them offered innovations that can be used in future, more rigorously designed, intervention studies.     

Agitated behavior in persons with dementia: The relationship between type of behavior,its frequency,and its disruptiveness

ObjectiveTo examine the relationship between type, frequency, and level of disruptiveness of physically aggressive agitated behaviors, physically non-aggressive agitated behaviors, verbally aggressive agitated behaviors, and verbally non-aggressive agitated behaviors in persons with dementia.MethodsThe study was conducted in 11 nursing homes in Maryland, one of which housed two participating buildings. Participants were 191 older nursing home residents with dementia. Cohen-Mansfield Agitation Inventory (CMAI) data provided information on frequency and level of disruptiveness of the different types of agitated behavior.ResultsThe highest overall frequencies were reported for verbal non-aggressive behaviors and the highest average disruptiveness was for verbal aggression. Frequency and disruptiveness of behaviors were highly correlated. Disruptiveness was highly correlated across shifts for all syndromes; a difference in magnitude of disruptiveness between shifts was only evident for physically non-aggressive behaviors (such as pacing), which were more disruptive on the day shift than on the evening shift. When controlling for frequency of behavior, physically aggressive behaviors were the most disruptive across both shifts.ConclusionIn understanding the impact of agitated behaviors, it is important to take into account both the type of behavior and its frequency. Overall disruptiveness of a type of behavior is different from disruptiveness when the frequency of the behavior is controlled.     

Psychometric evaluation of the Cohen‐Mansfield Agitation Inventory in an acute general hospital setting

Objectives

The Cohen‐Mansfield Agitation Inventory (CMAI; (Cohen‐Mansfield and Kerin, 1986)) is a well‐known tool for assessing agitated behaviours in people with dementia who reside in long‐term care. No studies have evaluated the psychometric qualities and factor structure of the CMAI in acute general hospitals, a setting where people with demand may become agitated.

Method

Longitudinal study investigating pain, agitation and behavioural problems in 230 people with dementia admitted to acute general hospitals in 2011–2012. Cohen‐Mansfield Agitation Inventory was completed as part of a battery of assessments including PAINAD to measure pain.

Results

A nine‐item two‐factor model of aggressive and nonaggressive behaviours proved to be the best‐fitting measurement model in this sample, (χ² = 96.3, df = 26, p<0.001; BIC [Bayesian Information Criterion] = 4593.06, CFI [Comparative Fit Index] = 0.884, TLI [Tucker Lewis Index] = 0.839, RMSEA [Root Mean Square Error of the Approximation] = 0.108). Although similar to the original factor structure, the new model resulted in the elimination of item 13 (screaming). Validity was confirmed with the shortened CMAI showing similar associations with pain as the original version of the CMAI, in particular the link between aggressive behaviours and pain.

Conclusion

The factor structure of the CMAI was broadly consistent with the original solution although a large number of items were removed. Scales reflecting physical and verbal aggression were combined to form an Aggressive factor, and physical and verbal nonaggressive behaviours were combined to form the Nonaggressive factor. A shorter, more concise version of the CMAI was developed for use in acute general hospital settings. Copyright © 2017 John Wiley & Sons, Ltd.     

Agitation in demented patients in an acute care hospital: prevalence, disruptiveness, and staff burden

BACKGROUND/LITERATURE REVIEW: The prevalence of agitated behaviors in different populations with dementia is between 24% and 98%. Although agitated behaviors are potentially disruptive, little research attention has been focused on the effects of these behaviors upon nursing staff. The objectives of this study of demented patients in long-term-care beds at an acute care community hospital were to determine the frequency and disruptiveness of agitated behaviors; to investigate the associations of patient characteristics and interventions with the level of agitation; and to explore the burden of these agitated behaviors on nursing staff. METHOD: The study sample comprised 56 demented patients in the long-term-care unit during the study period. Twenty-seven staff who cared for these patients during three shifts over a 2-week period were interviewed to rate the frequency and disruptiveness of agitated behaviors using the Cohen-Mansfield Agitation Inventory, and the burden of care using a modified version of the Zarit Burden Interview. Data on patient characteristics and interventions extracted from the hospital chart included scores on the Barthel Index and Mini-Mental State Examination, the use of psychotropic medication, and the use of physical restraints. RESULTS: Ninety-five percent of the patients with dementia were reported to have at least one agitated behavior; 75% had at least one moderately disruptive behavior. A small group of six patients (11%) had 17 or more disruptive behaviors. The frequency of most behaviors did not vary significantly by shift. Length of stay on long-term care, Barthel Index score, and the use of psychotropic medications were significantly associated with the number of agitated behaviors. The number of behaviors, their mean frequency, and their mean disruptiveness were all significantly correlated with staff burden. DISCUSSION: The prevalence of agitated behaviors in patients with dementia in long-term-care beds at an acute care hospital is similar to that reported in long-term-care facilities. These behaviors are associated with staff burden.     

Factor analysis of the Cohen-Mansfield Agitation Inventory in three large samples of nursing home patients with dementia and behavioral disturbance.

OBJECTIVE: Limited work has addressed the construct validity of the Cohen-Mansfield Agitation Inventory (CMAI) in nursing home patients. The authors tested the CMAI factor structure by use of data from three samples of nursing home patients categorized a priori as having at least mild behavioral and psychological symptoms of dementia. METHODS: CMAI data were from the baseline assessment of three randomized, placebo-controlled trials of risperidone for treating elderly nursing home patients. Exploratory factor analyses were conducted on two trials (N = 304; N = 344), and the results of these exploratory factor analyses were then tested with confirmatory factor analysis by use of data from a third trial (N = 617). RESULTS: Principal-components analysis suggested the presence of four factors: 1) Aggressive Behavior (hitting, kicking, scratching, biting, pushing, grabbing, throwing things, cursing or verbal aggression, spitting, tearing things/destroying property, hurting self or others, screaming); 2) Physically Non-Aggressive Behavior (pacing, trying to get to a different place, general restlessness, inappropriate dressing or disrobing, handling things inappropriately, performing repetitious mannerisms); 3) Verbally Agitated Behavior (complaining, constant requests for attention, repetitive questions, negativism); and 4) Hiding and Hoarding. Confirmatory factor analysis indicated that the four-factor solution was a reasonable fit to the data. CONCLUSION: Four factors emerged on the CMAI in nursing home patients with behavioral and psychological symptoms of dementia. The results obtained converge reasonably with previous publications concerning the factor structure of the CMAI, which, taken together, suggest a fairly robust factor structure for the instrument.     

The relationship between cognitive function and agitation in senior day care participants

The relationship between cognitive impairment and functional status with agitation was assessed in 200 participants of senior day care programs. Results revealed better than 85% agreement in measures of cognitive impairment (BCRS, MMSE, physician assessment of dementia). Regression analyses showed that physically non-aggressive and verbally aggressive behaviors were related to level of cognitive impairment (BCRS, MMSE). These results showed that physically non-aggressive behaviors were manifested at earlier stages of dementia than physically aggressive behaviors, which were not manifested until late stages of dementia. Verbally non-aggressive behaviors increased with severity of dementia up to moderate-severe levels of impairment and then diminished. In contrast, verbally aggressive behaviors tended to be manifested fairly consistently across levels of dementia with a small increase at the severest levels. Findings are discussed in relation to previous findings for nursing home residents.     

New Treatments for Agitation

Acute agitation is a frequent reason for emergency psychiatric intervention. It is important to intervene early to avoid escalation of agitation to aggression. Reducing risk by using effective treatments will result in fewer instances of seclusion and restraint, and fewer injuries to staff and patients. This paper will first review the epidemiology of aggressive behavior and mental disorders, followed by a discussion of assessment and diagnostic considerations. The pathophysiology of safety risk is discussed within the context of the model of the "triune brain." Pharmacological treatment strategies for acute episodes of agitated behavior will be discussed in detail. This includes newer formulations of novel antipsychotics such as liquids and rapidly disintegrating tablets, as well as intramuscular preparations.     

Withdrawal from controlled carbamazepine therapy followed by further carbamazepine treatment in patients with dementia.

BACKGROUND: The aim of this study was to assess the effects of withdrawal from placebo and carbamazepine administered for agitation associated with dementia and to assess safety, tolerability, and efficacy of subsequent ongoing carbamazepine therapy. METHOD: We previously reported the results of a 6-week, randomized, parallel-group study of placebo versus carbamazepine in 51 nursing home patients with dementia who were agitated; 47 subjects completed that study. This report first presents the results of withdrawal from that experimental treatment assessed by (blinded) observations 3 weeks later (N = 45 remaining). The primary outcome measure was the Brief Psychiatric Rating Scale. Secondary outcome measures addressed other aspects of behavior, cognition, function, safety, and tolerability. Patients were then treated with carbamazepine for an additional 6 weeks (N = 32 remaining) or 12 weeks (N = 25 remaining), with the same assessments performed. RESULTS: Patients who had previously shown behavioral improvement with carbamazepine therapy reverted to their baseline state after washout, whereas there was no change in the patients previously treated with placebo. There were no other significant effects of washout. During subsequent therapy with carbamazepine at a modal dose of 300 mg/day, there were 2 deaths and 4 other adverse events resulting in dropout. Neither of the deaths, and only 1 serious adverse experience, was judged to be related to carbamazepine. There were a variety of nonserious adverse experiences during the trial. Behavior ratings showed ongoing improvement in agitation and aggression, as well as in other aspects of psychopathology. CONCLUSION: The washout data provided independent confirmation of efficacy found in the prior placebo-controlled phase of this trial. Ongoing treatment was not associated with unexpected toxicity and was associated with improvement in measures of agitation and aggression that appeared to continue for up to 12 weeks. These findings confirm and extend results from earlier placebo-controlled studies.     

Agitation in nursing home residents: the role of gender and social context

We investigated the relationship among gender of resident, staff social interaction, and agitation in 46 (31 male and 15 female) nursing home residents with clinically significant agitation. Direct observations were conducted of resident behaviors and environmental contextual events using a computer-assisted, real-time observational system. The system recorded frequency, duration, and temporal sequencing of events. Results show that female residents displayed almost three times the amount of agitation as male residents (35% vs. 13% of total observation time, respectively), although men in the study were more likely to receive psychoactive drugs for their agitation. Staff spent similar amounts of time verbally interacting and touching male and female residents. Sequential analyses were conducted to examine the likelihood of staff verbal and touch interactions both preceding and following resident agitation using Bakeman and Quera's (1995) SDIS-GSEQ program. Results suggest that staff touch and verbal interaction elicit agitation in a significant proportion of residents. Once agitation occurs, staff were likely to respond by interacting verbally, but not physically, with the resident.     

Risperidone in the management of agitation and aggression associated with psychiatric disorders.

OBJECTIVE: This review provides an overview of the prevalence and treatment of agitation and aggression, and focuses on the use of risperidone to treat these symptoms in patients from different age groups. METHODS: MEDLINE and EMBASE databases were used to identify controlled studies of risperidone in the treatment of disruptive behavior disorders and pervasive developmental disorders in pediatric patients, acute agitation or aggression in adults, and psychological and behavioral symptoms of dementia in the elderly. Additionally, key open-label, long-term trials assessing the efficacy and safety of risperidone were considered. RESULTS: The results of the 19 double-blind studies identified showed that risperidone is effective in treating agitation and aggression in the different populations, regardless of age. The safety and tolerability of risperidone appear to be good overall but certain safety issues, such as a higher risk of cerebrovascular adverse events in the elderly with dementia, were highlighted. CONCLUSIONS: Risperidone is useful for treating aggression and agitation associated with various psychiatric disorders in patients from different age groups.     

Prevalence and correlates of disruptive behavior in patients in Norwegian nursing homes

BACKGROUND: Although Behavioral and Psychological Symptoms of Dementia (BPSD) increase with increasing dementia severity, and institutionalization of an individual with dementia is often caused by behavioral symptoms, relatively few studies have explored the prevalence of BPSD in nursing homes. OBJECTIVE: To study the prevalence and correlates of agitation in residents with dementia, in Norwegian nursing homes. METHODS: This study has taken place in dementia wards in four Norwegian nursing homes. To measure agitation in residents with dementia we used the Cohen-Mansfield Agitation Inventory (CMAI), consisting of 29 agitation items. Dementia stage was measured by Functional Assessment Staging (FAST). RESULTS: Two hundred and eleven patients (71% female) were included in the study: mean (SD) age 85.5 (8.4), FAST 4.7 (2.1), CMAI total sumscore 39.5 (12.6). Dementia was present in 167 (79%) subjects. Among those with dementia, weekly occurrence of at least one CMAI item (i.e. a score of 3 or higher) occurred in 75.4% (95% CI 68.4-81.4). Six of the items occurred at least weekly in 20% of the residents with dementia, and 11 of the items, including physical aggression, occurred in less than 5% of the residents. Agitation was associated with more severe dementia (p = 0.001), but not with age and gender. CONCLUSION: Symptoms of agitation were common, but may nevertheless be lower compared to findings in other geographical areas. Further studies are warranted to test this hypothesis, and if confirmed, to explore possible causes for such differences.