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.     

Aggressive behaviors among demented nursing home residents in Japan

This study investigates the frequency of aggressive behaviors in a sample of elderly nursing home residents with dementia in Japan. Behavioral data were collected on 391 residents using the Cohen-Mansfield Agitation Inventory (CMAI). Data were also gathered on residents' age, sex, and ability to perform self-care. Another scale was used to code the degree of resistance that each resident manifested during bathing, toileting, dressing and eating. In addition, qualitative data were collected from caregivers regarding their main caregiving problems with dementia residents. Findings show that 45.4% of the sample manifested aggressive behavior during the 2-week study period. Men were significantly more likely to manifest physically aggressive behavior, but there was no gender difference for verbal aggression. Age had no relationship to aggressive behavior. Residents who were most dependent in self-care had significantly higher frequencies of aggressive behaviors. Caregivers reported that most aggressive behavior took place during personal care. The majority of caregivers identified verbal agitation rather than physical aggression as their main caregiving problem. This study represents the first time that the CMAI has been translated and used in Japan and the first time empirical data has been collected on the behavior of dementia patients in Japanese nursing homes.     

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.     

The validation of a caregiver assessment of dementia: the Dementia Severity Scale

OBJECTIVE: The objective of this study was to refine and validate the Dementia Severity Scale (DSS), a newly developed assessment of dementia severity from a caregiver's perspective. The Dementia Severity Scale is designed to measure deficits in activities of daily living (ADL), behavioral disturbances, and the caregiver's perception of the patient's current cognitive abilities. METHODS: Community dwelling caregiver/patient dyads were recruited from 12 clinical sites. Patients had a primary dementia diagnosis for at least one year. In this cross-sectional study, caregivers were administered the Dementia Severity Scale, the Quality of Life-Alzheimer's Disease (QOL-AD), the Progressive Deterioration Scale (PDS), and the Neuropsychiatric Inventory (NPI). Patients were administered the Mini-Mental State Examination (MMSE) and the QOL-AD. To evaluate test-retest reliability, 25% of caregivers were randomized to a second visit. RESULTS: One hundred eighty-three caregiver/patient dyads were recruited. Mean caregiver age was 67.5; mean patient age was 78.8; 93% of patients had probable Alzheimer disease. Eighty-eight (48.1%) patients were male. Exploratory factor analysis established 6 subscales (Activities of Daily Living [ADL], Instrumental ADL [IADL], Communication, Agitation, Memory, and Disorganized Thinking). Cronbach's alphas ranged from 0.82 to 0.90 for the 6 subscales. Test-retest reliability was good with intraclass correlation coefficients ranging from 0.79 to 0.89. DSS subscales were moderately-to-highly correlated with the QOL-AD, NPI, MMSE, and PDS. Subscales significantly discriminated among severity levels of dementia, identified by both physician ratings and MMSE scores. CONCLUSION: The Dementia Severity Scale demonstrated excellent psychometric properties and appears to be useful both in clinical practice and research endeavors. Further research is needed to establish the longitudinal sensitivity of the Dementia Severity Scale to the progression of dementia.     

Measurement and correlates of family caregiver self-efficacy for managing dementia

Researchers in the aging field are paying increasing attention to the importance of perceived self-efficacy in understanding experiences and health-related outcomes of family caregivers. This paper details the strategy we used to measure family caregiver self-efficacy for managing dementia, and reports on observed associations between the resulting self-efficacy measures, caregiver depressive symptoms, and caregiver physical health symptoms. Family caregivers (n = 197) were interviewed after calling a local Alzheimer's Association chapter in the mid-western USA. Nine items inquiring about caregivers' certainty that they could carry out specific behaviors related to dementia care clustered into two distinct self-efficacy factors: symptom management self-efficacy (4 items) and community support service use self-efficacy (5 items). Internal consistency reliability for both factors was high (Cronbach's alpha = 0.77 and 0.78, respectively). Symptom management self-efficacy demonstrated a much stronger correlation with a published global caregiver competence measure than did service use self-efficacy (r = 0.49 and 0.27, respectively). In a multivariate regression model predicting caregiver depression symptoms, higher symptom management self-efficacy scores were associated with fewer depressive symptoms (beta = -0.17, p < 0.05). In a separate model, higher service use self-efficacy scores (beta = -0.20, p < 0.01) and higher symptom management self-efficacy scores (beta = -0.16, p < 0.05) were associated with fewer physical health symptoms. These new measures of dementia management self-efficacy hold promise for use in future studies.     

A randomized, controlled study of an Alzheimer's caregiver skills training program

This study was an attempt to improve the quality of the relationship between dementia caregivers and their loved ones by decreasing the gap between caregivers' expectations and patients' actual functional abilities and by teaching supportive skills. Although a group of 49 caregiver-patient dyads were recruited, the outcome measures of only those dyads (47) that completed the week seven session were used for analysis. Half of the dyads were randomized to an intervention group and the other half to a waiting list. The intervention group (N = 24) completed a four-session caregiver training program in which caregivers first watched investigators administering to their loved ones the Texas Functional Living Scale and later progressed to helping their loved ones by appropriate cueing to perform the tasks involved. Comparisons were made between baseline scores, scores at seven weeks, and scores at the end of 17 weeks on the congruence between caregiver estimates and patients' actual performance on the Independent Living Scale and measures of cognition, function, preillness quality of relationship, caregiver mood, feeling of self-efficacy, and several other measures. We were not able to increase the congruence between caregiver estimates and patients' actual performance and found no change in any other measure. We didfind the expected relationship between depression and caregiver sense of self-efficacy.     

Psychosocial predictors of dementia caregiver desire to institutionalize: caregiver, care recipient, and family relationship factors

Several factors influence dementia caregiver desire to institutionalize; however, little is known about differences in caregivers who desire institutionalization versus those who do not. The current study compares predictors of desire to institutionalize in dementia caregivers. Seventy-two caregivers completed the Desire to Institutionalize Scale (DIS) and several psychosocial measures, including burden, dementia knowledge, self-efficacy, depression, health, care recipient daily functioning and memory/behavior problems, family functioning, and social support. Based on DIS responses, caregivers were divided into No DI versus DI groups. DI caregivers had significantly higher burden, greater dementia knowledge, more family dysfunction, and decreased social support compared with No DI caregivers. Findings emphasize the importance of caregiver and family relationship variables in DIS, suggesting potentially modifiable targets for caregiver interventions. Dementia knowledge was associated with higher DIS, suggesting that educational programs alone may not be helpful to delay institutionalization.     

社区痴呆患者的家庭照料者心理状况研究

目的：为了社区痴呆患者的家庭照料者心理状况及相关因素，方法：采用MMSE，ADL，GDS，Be-AD和GHQ对103例社区痴呆患者的家庭照料者心理状况进行调查并分析。结果：家庭照料者的焦虑失眠症状明显，主要是痴呆患者的精神／行为问题相关，与照料者本身的年龄，文化和对痴呆知识的了解程度有关。结论：对老年痴呆的照料以及照料者的心理健康状况值得重视。     

Premorbid relationship satisfaction and caregiver burden in dementia caregivers

Dementia caregiver appraisal of the quality of their current and premorbid relationship with the care recipient is associated with caregiving behaviors, caregiver mood, and the decision to end home care. This study examined the contribution of premorbid relationship satisfaction to caregiver burden in dementia caregivers. Live-in dementia caregivers (n = 72) completed several psychosocial measures. Caregiver responses were used to divide them into low premorbid relationship satisfaction group (low) versus high premorbid relationship satisfaction group (high). Results indicate that premorbid relationship satisfaction is negatively associated with caregiver burden and quality of family functioning. Caregivers with high satisfaction demonstrated significantly less burden and less reactivity to memory and behavior problems, and better problem solving skills and more effective communication compared with the low caregivers. Findings are independent of length of caregiving, disease severity, care recipient daily functioning, and relationship type. Relationship satisfaction may be an important contributor to caregiver burden.     

Understanding caregiver health behaviors: depressive symptoms mediate caregiver self-efficacy and health behavior patterns

Previous research on female caregivers of elderly relatives with dementia has demonstrated that caregiving self-efficacy (SE) is associated with reduced cumulative health risk. The overarching aim of the current study was to expand on that research by exploring whether depressive symptoms mediate the relationship between 3 domains of caregiving SE and cumulative health risk associated with health behavior patterns. Data from 256 female family caregivers of patients with dementia are presented. Path analysis revealed a significant mediated effect for depressive symptoms as both SE for obtaining respite and SE for controlling upsetting Thoughts had a significant, indirect effect on cumulative health risk. There were no direct effects between caregiver SE and cumulative health risk. The current study sheds light on the complex pathway between caregiver SE and health and speaks to the importance of skills-based interventions designed to enhance efficacy beliefs and minimize depression in dementia caregivers.     

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.     

Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: a randomized pilot study.

OBJECTIVE: To test whether the Tailored Activity Program (TAP) reduces dementia-related neuropsychiatric behaviors, promotes activity engagement, and enhances caregiver well-being. DESIGN: Prospective, two-group (treatment, wait-list control), randomized, controlled pilot study with 4 months as main trial endpoint. At 4 months, controls received the TAP intervention and were reassessed 4 months later. SETTING: Patients' homes. PARTICIPANTS: Sixty dementia patients and family caregivers. INTERVENTION: The eight-session occupational therapy intervention involved neuropsychological and functional testing, selection, and customization of activities to match capabilities identified in testing, and instruction to caregivers in use of activities. MEASUREMENTS: Behavioral occurrences, activity engagement, and quality of life in dementia patients; objective and subjective burden and skill enhancement in caregivers. RESULTS: At 4 months, compared with controls, intervention caregivers reported reduced frequency of problem behaviors, and specifically for shadowing and repetitive questioning, and greater activity engagement including the ability to keep busy. Fewer intervention caregivers reported agitation or argumentation. Caregiver benefits included fewer hours doing things and being on duty, greater mastery, self-efficacy, and skill enhancement. Wait-list control participants following intervention showed similar benefits for reductions in behavioral frequency and caregiver hours doing things for the patient and mastery. Caregivers with depressed symptoms derived treatment benefits similar to nondepressed caregivers. CONCLUSIONS: Tailoring activities to the capabilities of dementia patients and training families in activity use resulted in clinically relevant benefits for patients and caregivers. Treatment minimized trigger behaviors for nursing home placement and reduced objective caregiver burden. Noteworthy is that depressed caregivers effectively engaged in and benefited from the intervention.     

Collaborative memory intervention in dementia: Caregiver participation matters

The aim of the study was to examine the effectiveness of a collaborative memory intervention for persons with dementia and their spousal caregivers, where the couple acquired and practised memory supportive strategies (spaced-retrieval and hierarchical cuing) to learn a face–name association and to set a table for coffee/tea. The collaborative intervention was compared to an individual intervention where the person with dementia received the same training but without the participating caregiver and to a control group of couples receiving no training. The results showed that following collaborative intervention recall performance in two collaborative tasks became more equally shared between the spouses, reflected in a decrease in recall for the caregiver and in an increase in recall for the spouse with dementia between pre- and post-test; whereas for the other two groups the caregivers dominated collaborative recall both at pre- and post-test. The results also showed that the persons with dementia in the collaborative group improved their individually assessed episodic memory performance as compared to the persons with dementia in the other two groups. Finally, training had no effects on episodic memory, perceived burden or depressive symptoms for the caregivers. These results suggest that the active participation of the caregiver matters in cognitive dementia rehabilitation.     

Early frontal executive impairment as a predictor of subsequent behavior disturbance in dementia.

OBJECTIVE: To determine the extent to which frontal executive impairment early in the course of dementia is predictive of subsequent disturbed behavior. METHODS: This was a prospective follow-up study set in the Memory Clinic, Leicester, United Kingdom. A patient cohort (N = 42) diagnosed with mild to moderate dementia was followed up between three and six years after initial assessment. Executive function at baseline was assessed using the The Cambridge Examination for Mental Disorders of the Elderly-Revised (CAMCOG-R) Executive Function score. Disturbed behavior and caregiver distress at follow-up were assessed on the Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation Inventory (CMAI), and Dementia Apathy Interview and Rating (DAIR). RESULTS: After adjustment, the Executive Function score at baseline was predictive of disturbed behavior and caregiver distress (NPI, CMAI, DAIR) at follow up, with higher levels of executive impairment associated with higher levels of disturbance/distress. Baseline measures of global cognitive impairment (Mini-Mental State Exam, CAMCOG) were not predictive of subsequent disturbed behavior or caregiver distress. CONCLUSION: Executive impairments identifiable relatively early in the clinical course of dementia are predictive of disturbed behavior and associated caregiver distress at long-term follow-up, which supports the view that executive dysfunction is important in the etiology of these problems.     

The relation between the perceived role of family and the behavior of the person with dementia

The purpose of this study was to investigate the relation between the perceived role of family and the behavior of the person with dementia in a sample of older adults. Two instruments were used in data collection: The Family Perceptions of Caregiving Role (FPCR) and the Cohen-Mansfield Agitation Inventory (CMAI). A total of 40 persons with dementia were included in the study. Each had a family respondent and a nurse respondent. The data analyses produced three major findings. First, it was revealed that there was no significant difference between agitation levels of persons with dementia who received more frequent family visits and those who did not. Second, the study revealed that family caregivers did not perceive a partnering relationship with staff. Finally, correlational analysis provided little evidence of a link between the family's perceived role in partnering and the behavior of the person with dementia, specifically in relation to agitation levels. Although no significant relation was established between the family's perceived role in partnering and the behavior of the person with dementia, there was high family and caregiver satisfaction. The clearest element of the family's perspective was the desire that staff members care about the individual with dementia as a person.     

The influence of stressors, appraisal and personal conditions on the burden of spousal caregivers of persons with dementia

OBJECTIVES: The aim of this study was to explore the main and mediating influences of stressors, a caregiver's appraisal, coping, personal conditions and social resources on the burden of dementia caregivers. METHOD: The study sample consisted of 95 spousal caregivers of non-institutionalized persons with dementia. A path-analytic approach was used to test the conceptual model. RESULTS: The most important factors that were related to burden were the social and behavioural problems of the person with dementia; perceiving the caregiver role as a threat; perceived instrumental support; and the caregiver's functional health status and self-efficacy. The results showed no support for the mediating role of appraisal and coping on the relationship between the demands of the caregiving situation and burden. CONCLUSION: Although we found insufficient support for the empirical tenability of the hypothesised model, this study revealed some new findings of practical interest. The relationships found suggest that it might be possible to reduce the caregiving burden by improving the social functioning of the person with dementia, the caregiver's perceptions and the caregiver's capacity to function in daily life.     

Impact of frontal systems behavioral functioning in dementia on caregiver burden

Behavioral problems in the dementia patient are some of the strongest predictors of caregiver burden, though the impact of specific types of behavioral problems on burden is limited. This study investigated the contribution of frontal systems behavioral functioning (i.e., apathy, executive dysfunction, and disinhibition) on caregiver burden. Seventy-two family caregivers completed the Frontal Systems Behavior Scale and measures of mood, perceived burden, and patient ratings of functional impairment. Regression analyses indicated that frontal systems behavioral problems were predictive of caregiver burden after controlling for dementia severity and caregiver depression. Analyses of subscales revealed that executive dysfunction and disinhibition were predictors of caregiver burden. Results argue for including strategies for managing frontal systems behavioral problems, particularly executive dysfunction and disinhibition, in dementia caregiver interventions.     

Preliminary pilot study of cyproterone acetate for the treatment of aggressive behavior associated with severe dementia

INTRODUCTION: Behavioral symptoms are common in dementia, and seem to be more frequent in men than in women. Agitation is frequently responsible for caregiver burn-out and leads to institutionalization. The dramatic increase in the prevalence of Alzheimer's disease and related disorders requires better management of behavior symptoms. Although environmental adaptation has been proposed recently, for many years, psychoactive medications and physical restraints were the primary approach. However, in severely demented patients, both pharmacologic and non-pharmacologic treatments are inoperative. In this situation, alternative pharmacologic approach should be tested. Cyproterone acetate, an antiandrogen and progestative steroid has never been proposed to prevent aggressive behavior in dementia, but its favorable effect is well described in rat and monkey aggressivity. PATIENTS AND METHODS: Cyproterone acetate was proposed for 19 demented patients who developed severe aggressive behaviors or an agitation unresponsive to psychoactive drugs (even in association) or to environmental adaptation. Clinical and behavioral analysis was carried out using the Cohen-Mansfield agitation inventory associated with an assessment of dependency in daily life activities, before and during treatment with cyproterone acetate. The behavioral status was stable, with permanent or repetitive agitation. Seven patients had vascular dementia, 7 had Alzheimer's disease, 2 had fronto-temporal degeneration, 2 had Huntington's disease and 1 a probable diffuse Lewy bodies disease. Fifteen patients had prominent aggressive behavior and 4 had predominant aberrant motor behavior with aggressive behavior. RESULTS: Cyproterone (50 to 100mg - mean: 92.5mg daily) improved significantly aggressive and impulsive behavior related to Alzheimer's disease or vascular dementia but had no effect on aberrant motor behavior. When cyproterone was stopped, aggressive behaviors reappeared more rapidly in vascular dementia. CONCLUSION: Cyproterone acetate is then an interesting choice when aggressive behavior is not improved with psychotropic drugs. A detailed clinical analysis is required to avoid the use of cyproterone in non-aggressive and non-impulsive patients. The results of this preliminary study suggest a randomized double-blind study should be carried out in the near future. The behavior improvement could be related to the blockage of androgen receptors, and simultaneously to the sedative effect of progestative drugs.