A description of agitation in a nursing home

Fenfluramine challenge test as a marker of serotonin activity in patients with Alzheimer's dementia and agitation

BACKGROUND

Changes in serotonin (5-HT) have been described in both Alzheimer's disease (AD) and aggressive/agitated behaviors. This paper explores a possible association between 5-HT deficits and agitation in AD, using prolactin response to d,1-fenfluramine administration as a probe for 5-HT activity.

METHODS

Five AD patients with agitation and 5 without agitation received a 60-mg oral dose of d,1-fenfluramine. Prolactin levels were obtained at baseline, and 2 and 3 hours following administration.

RESULTS

Change in prolactin levels from baseline to 3 hours was significantly larger among the agitated than the nonagitated Alzheimer's patients. Further, there was a positive and significant correlation between change in prolactin levels from baseline and level of agitation.

CONCLUSIONS

These findings suggest an association between 5-HT responsiveness and agitation in AD.

Incidence and relationship between behavioural and psychological symptoms in Alzheimer's disease

OBJECTIVES

To evaluate the frequency and type of psychological and behavioural symptoms in Alzheimer's disease (AD) patients in Poland, in various stages of the disease.

METHOD

One hundred and sixty-nine patients with a diagnosis of probable AD in Global Deterioration (GDS) stages 3, 4, 5, 6 and 7 of dementia were examined in a search for behavioural and psychological symptoms.

RESULTS

Behavioural and psychotic symptoms were most often found in GDS stages 5 and 6 of AD, except for depressive disorder, which was observed most frequently in GDS stage 4 and whose frequently decreased towards the terminal stages of dementia. From an analysis of the relationship between behavioural symptoms in the Polish AD patients, the following syndromes may be discriminated: psychotic syndrome (delusions and hallucinations), delusions with aggressive behaviour and hallucinations and anxiety. With more severe dementia, the syndromes, which could be the result of delirium, became more common.

CONCLUSIONS

Diagnosis of delirium should be considered in moderately severe and severe dementia whenever a sudden change in patients' behaviour occurs.

Environmental correlates of resident agitation in Alzheimer's disease special care units

OBJECTIVE

To determine the point prevalence of agitated behaviors in a representative sample of Alzheimer's disease Special Care Units, and to determine the extent to which agitation is associated with aspects of the treatment environment.

DESIGN

A cross-sectional study in which nonparticipant observers recorded 3723 observations of resident behaviors in 53 Alzheimer's disease Special Care Units. Observational data were gathered on the physical environment and staff treatment in these settings, and resident characteristics were extracted from a data base developed in the study states by the Health Care Financing Agency. Analyses studied the association between aspects of the staff and physical environment and resident agitation levels, controlling for resident cognitive and functional status.

SETTING

Special Care Units in nursing homes in Kansas, Maine, Mississippi, and South Dakota.

PARTICIPANTS

All residents and staff of the participating units.

MAIN OUTCOME MEASURES

Eight specific agitated behaviors and two indexes of resident agitation were measured by direct observation by research assistants on three to four data collection walk-throughs in each of the study facilities.

RESULTS

The most common agitated behaviors noted were repetitive mannerisms (4.5% of resident observations) and non-loud verbal excess (3.8%). Wandering, which frequently reflects agitation, was noted in 6.5% of resident observations. The proportion of residents exhibiting an agitated behavior varied from none in some units to 38% in one unit. Independent correlates of low unit agitation levels included favorable scores on measures of the physical environment and of staff treatment activities, low rates of physical restraint use, a high proportion of residents in bed during the day, small unit size, low levels of resident functional dependency, and fewer numbers of comorbid conditions.

CONCLUSIONS

While the prevalence of agitation tends to increase as Alzheimer's disease progresses, modifiable treatment factors appear to have a strong influence on the prevalence of agitation. Both physical design and staff treatment appear to influence agitation rates, as do some measures consistent with a low stimulus approach to Alzheimer's care.

Psychometric characteristics of the minimum data set II: validity

OBJECTIVE

To determine the validity of the Minimum Data Set (MDS).

DESIGN

MDS domain scores were correlated with a variety of independently obtained measures of basic behavioral and mental health functions of 513 nursing home residents.

SETTING

All participants were residents of the Philadelphia Geriatric Center.

PARTICIPANTS

One group of residents (n = 260) represented consecutive admissions who were able to respond to formal testing. The other group of residents (n = 253) represented presumably cognitively impaired residents whose data did not depend on self-report.

MEASUREMENTS

MDS item-composite scores based on a confirmatory factor analysis were derived for the domains of cognition, activities of daily living (ADL), time use, depression, and problem behaviors. Hypotheses stating how these MDS domains should be related to standard measures of cognitive function, ADL, depression, agitation, social behavior, and irritability were tested.

CONCLUSIONS

The majority of the hypotheses were upheld, thus suggesting that the MDS is usable as a source of research data. The sizes of the validity coefficients were modest, however. Depression and problem behavior were less well affirmed than cognition, ADL, and Time Use. There is a clear need for improvement in training and probably in the form of MDS measurement in some areas.

Contribution of cognitive impairment, depression, and psychosis to the outcome of agitated geropsychiatric inpatients with dementia

This study investigated the correlates of change in behavioral disturbance in geropsychiatric inpatients with dementia. It was hypothesized that improvement in specific psychiatric symptoms, such as psychosis and depression, contribute to the improvement of specific behavioral disturbances. All admissions between October 1993 and May 1995 were reviewed to identify those patients admitted to the Houston VA geropsychiatry unit with a diagnosis of dementia; 233 patients were included in the study. Improvement in behavioral disturbance symptoms was associated with decreases in depression, thought disorder, and hostility. However, the relative importance of depressive and psychotic symptoms varied depending upon the type of behavioral disturbance examined. These results may support a focused approach employing therapies specific to the type of behavioral disturbance.

Prevalence of dementia, delirium and psychiatric symptoms in various care settings for the elderly

A prevalence study of psychiatric symptoms was performed in parts of a hospital catchment area in Mid-Sweden. In total 717 patients, aged 75 years and above, who were receiving care in an emergency hospital, three nursing homes, five old people's homes and two home medical care districts were included. All patients were examined using the OBS-scale (Organic Brain Syndrome Scale). Anxiety (51%), psychomotor slowing (45%), delirium (44%), depressed mood (41%), irritability (40%) and dementia (33%) were the most prevalent psychiatric symptoms or diagnoses in the sample but there were wide differences between the four care settings. The present study shows that the prevalence of dementia, delirium and psychiatric symptoms is high in all types of care settings for the elderly. It also demonstrates the need for psychiatric medical and nursing competence in all types of care for the elderly.

Reliability and validity of the Overt Agitation Severity Scale in adult psychiatric inpatients

An instrument, that validly and reliably identifies and measures agitation is required to evaluate environmental modifications, interpersonal strategies, psychopharmacological interventions, directed toward managing these commonly occurring and highly-disabling emotions and behavior. The conceptualization of agitation on a continuum from anxiety to aggression provides a practical framework for guiding clinical practice toward the early identification and intervention of agitation. The results of this study established the reliability and validity of the Overt Agitation Severity Scale (OASS) in measuring agitation severity in young adult psychiatric inpatients based on objectifiable vocalizations and motoric upper and lower body behaviors. The OASS differs from other agitation scales in its ability to capture both the intensity and frequency of observable behavioral manifestations of agitation, as opposed to subjective interpretations and a diffuse range of symptoms and problem behaviors.

Depression in male geropsychiatric inpatients with and without dementia: a naturalistic study

The authors compared the presentation and course of major depression in male geriatric inpatients with and without a diagnosis of dementia. Of 326 consecutive admissions to an inpatient geropsychiatry unit, 22 (7%) had a diagnosis of major depression without dementia, 35 (11%) had major depression with dementia. Both groups presented with similar types and severity of depressive symptoms, which improved substantially with treatment in both groups, as measured by Hamilton Depression Rating Scale scores. In addition, agitation, psychiatric, and side-effects symptoms decreased significantly in both groups. Our naturalistic results suggest the clinical value of intensive treatment of depressive symptoms in elderly demented patients, whether or not they meet the criteria for major depressive episode.

Agitation

Agitation is a frequent clinical problem that adds significant morbidity to the hospital course. Agitation is usually part of an ambiguous constellation of cognitive and psychiatric symptoms, with a fluctuating clinical course. Observation of vastly different symptoms occurring at different times leads to misdiagnosis or underrecognition of serious underlying disorders. The most common causes of agitation include delirium, dementia, and acute psychosis. Risk factors attributable to hospitalization include pain, anxiety, and stressors endemic to intensive care. Agitated states may have multiple causes, and each potential contributor must be pursued and treated independently. Definitive diagnosis is dependent on a comprehensive history, patient observation, physical examination, and selective diagnostic studies.

Physical aggressive resident behavior during hygienic care

Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Act (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was identified as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.

Outcome of psychiatric hospitalization for very low-functioning demented patients

The authors determined the outcome of geropsychiatric hospitalization for 73 very low-functioning demented patients (GAF score < 21). General psychiatric symptoms, depression, and agitation decreased significantly, and mean GAF scores increased significantly, with no significant change in cognitive function. Psychiatric hospitalization can meaningfully improve function and quality of life even in this very impaired population. Despite these improvements many patients are discharged to more restrictive settings.

Management of geriatric behavior problems

Agitation has many causes, and we have no way of classifying it that dictates the choice of the right agents or methods of treatment. It is also difficult to judge the effectiveness of any method. Because agitation is an intermittent phenomenon one can seldom be certain if improvement or worsening is merely incidental to the form of treatment instituted. The complexity of behavior disturbances demands an approach that enlists the cooperation of all involved in the care of the patient, and the use of a broad range of remedies. With regard to prevention, we should help people anticipate infirmity and even dementia. If good health is not taken for granted, this encourages that the present be used more purposefully. More than ever before in history, it is important to plan for the last stages of life. A greater percentage of people can expect to live into the years of frailty than ever before. It may not seem like an attractive thing to do, but a periodic mental review of one's future may be prudent. The consequences of a lack of foresight are seen in too many elderly. A small dose of reality now can result in a better old age.

Lessons from geriatric psychiatry in the long-term care setting

Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.

The effects of language used by caregivers on agitation in residents with dementia

In this study, We addressed the problem of whether residents with a diagnosis of dementia would become agitated if given verbal commands at a level of language complexity above their comprehension ability. The study used an A-B-A research design. The convenience sample of 15 subjects was comprised of 11 men and 4 women who resided in a long-term care institution. Their mean age was 86.6 years, and their average length of stay in the institution was 317.3 days. The results lent support to the hypothesis that exposing residents with dementia to language beyond their comprehension ability could result in agitated behavior. The predominant manifestations of agitation were general restlessness, strange noises, and negativism. An important implication for nursing practice is that the language used by caregivers should match the comprehension ability of residents. Caregiving can thereby facilitate communication and, potentially, prevent agitation.

Delirium in geropsychiatric patients: patient characteristics and treatment outcomes

The authors examined the effect of hospitalization on cognitive and behavioral symptoms in delirious elderly patients with and without dementia. Forty-four (13%) of the patients admitted to a Veterans Affairs Medical Center geropsychiatric unit were diagnosed with delirium and were administered the Mini-Mental State Examination, the Hamilton Depression Rating Scale, the Brief Psychiatric Rating Scale (BPRS), the Rating Scale for Side Effects, and the Cohen-Mansfield Agitation Inventory. The total sample significantly improved on all measures. When patients with delirium were divided into subgroups with and without dementia, both subgroups improved similarly. Patients discharged to more restrictive environments improved significantly on the BPRS only.

Issues related to behavior and the physical environment: bathing cognitively impaired patients

Twenty-two patients in moderate and late stages of dementia were observed for 8 weeks by caregiving staff of a special care unit. Results indicated that bathing in a typical institutional tub is both a source of apprehension and obstreperous behavior and a considerable departure from prior lifelong bathing experiences. Given information about the habits and idiosyncrasies of patients, staff can play an important role in minimizing obstreperous behaviors. Staff training and awareness of the physical environment, which included attention to the interrelationship between environment and behavior, were found to be instrumental in successful bathing.

The benefits of psychiatric hospitalization for older nursing home residents

OBJECTIVE

To examine the demographic characteristics and treatment outcomes of nursing home residents admitted to a geropsychiatric inpatient unit.

DESIGN

A retrospective cohort design based on an ongoing data base effort.

SETTING

The geropsychiatric inpatient unit of the Houston Veterans Affairs Medical Center Hospital.

PARTICIPANTS

All admissions to the unit from nursing homes during an 18-month period.

MEASUREMENTS

Mini-Mental State Examination, Brief Psychiatric Rating Scale, Hamilton Rating Scale for Depression, Cohen-Mansfield Agitation Inventory, Rating Scale for Side Effects, and Global Assessment of Functioning were administered on admission and discharge.

RESULTS

Paired t tests comparing change scores revealed significant decreases in general psychiatric symptoms (P < .001), depression (P < .001), and agitation (P < .001); significant improvement in global functioning (P < .001); with no significant changes in cognitive status (P = .485) or side effects (P = .120). When the patients were subgrouped according to reasons for admission, paired t tests revealed decreases in violence (CMAI Factor 1; P = .000), psychosis (BPRS thought disorder scale; P = .000 and hostility subscale; P < .008), and depression (HAM-D; P = .002). Four patients were discharged to less restrictive environments, all with chronic mental illnesses.

CONCLUSION

Inpatient psychiatric hospitalization significantly benefits nursing home residents with and without dementia who are admitted for severe behavior problems.

Association of serum cholesterol and triglyceride levels with agitation and cognitive function in a geropsychiatry unit

Several studies have reported an association between aggression and cholesterol levels. The purpose of this study was to investigate the relationship of serum cholesterol and triglyceride levels with aggression and cognitive function in elderly inpatients. One hundred ten patients consecutively admitted to the Geriatric Psychiatry inpatient unit at Houston's Veterans Affairs Hospital received comprehensive evaluations by a multidisciplinary team. Fasting serum cholesterol and triglyceride levels were obtained within 3 days of admission. In addition, two geriatric psychiatrists administered the Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). Correlation coefficients were calculated between lipid levels, CMAI total and subscale scores, and MMSE scores. Multiple linear-regression analyses were done to further investigate the relation between lipid concentrations and various confounders. We found no significant correlation between serum triglyceride levels and MMSE, CMAI total, and CMAI factor scores. In addition, we found a significant positive correlation between serum cholesterol levels and physical nonaggressive behavior, and a significant negative correlation between serum cholesterol levels and MMSE scores. We found no relationship between aggressive behavior and serum cholesterol or triglyceride levels. However, an association between high cholesterol levels and agitation exists, which may be mediated by the association between high cholesterol levels and impaired cognition.

Restlessness: the anatomy of a neuropsychiatric symptom

OBJECTIVE

The aim of this paper is to review the literature on restlessness and related syndromes in order to examine the different causes and clinical descriptions, and to present a pathogenetic model that would incorporate its diverse aetiology.

METHOD

A literature search was undertaken with restlessness, agitation, akathisia, hyperactivity, fidgetiness and jitteriness as key words.

RESULTS

Causes of restlessness are diverse, and its distinction from other descriptions, such as agitation and hyperactivity, is poorly defined in the literature. Detailed descriptions of the syndromes are therefore lacking. The neuroanatomical basis of restlessness may consist of abnormalities in the cortico-subcortical neuronal circuits, the complex regulation of which may explain why different causes often lead to a common end result.

CONCLUSIONS

The terms used to describe restlessness and related disorders should be standardised, and the clinical manifestations investigated pedantically. Human and animal studies should investigate the pathophysiology so that intervention can be based on the underlying mechanisms.

A randomized trial of dementia care in nursing homes

OBJECTIVE

To evaluate the efficacy of a dementia care program to reduce behavior disorders in nursing home patients with dementia.

DESIGN

Randomized controlled clinical trial with 6-month follow-up.

SETTING

A 250-bed community nursing home.

PATIENTS

The nursing home was screened to identify patients with dementia and behavior disorders. A total of 118 patients were eligible for randomization. Of these, 89 (75.4%) were randomized, and 81 of these (91.0%) completed the trial.

INTERVENTION

The A.G.E. dementia care program consisted of Activities, Guidelines for psychotropic medications, and Educational rounds. The control treatment was usual nursing home care.

MEASUREMENTS

Behavior disorders, antipsychotic drug and physical restraint use, patient activity levels, and cognitive and functional status.

RESULTS

After 6 months, 12 of 42 (28.6%) intervention patients exhibited behavior disorders compared with 20 of 39 (51.3%) controls (OR = 0.38; 95% CI [0.15, 0.95]; P = .037). Controls were more than twice as likely to receive antipsychotics (OR = 2.55, 95% CI [0.96, 6.76]; P < .056), to be restrained during activity times (OR = 2.98, 95% CI [1.10, 8.04]; P < .028), and to be restrained on nursing units (OR = 2.14, 95% CI [0.9, 5.3]; P < .10). Intervention patients were much more likely to participate in activities (OR = 13.71; 95% CI [4.51, 41.73]; P = .001).

CONCLUSIONS

The A.G.E. program reduces the prevalence of behavior disorders and the use of antipsychotic drugs and restraints. It is practical, feasible, and appears to improve the lives of patients with dementia in nursing homes.

Everyday functioning in Alzheimer's disease: contribution of neuropsychological testing

COGNITIVE AND BEHAVIORAL problems associated with Alzheimer's disease are variable and complex; consequently, each patient should be managed by an advanced practice nurse (APN) so that everyday functioning is maximized and excess disabilities are prevented. Neuropsychological testing is sensitive to neuropathological conditions and holds promise for assisting APNs in the care of the Alzheimer's patient by pinpointing areas of cognitive and behavioral impairment. In this article, an overview is given of the essentials of a neuropsychological assessment for the Alzheimer's patient as performed by the neuropsychologist. Use of assessment results by the APN for designing interventions that compensate for losses but which preserve remaining abilities is discussed.

Functional Incidental Training, mobility performance, and incontinence care with nursing home residents

OBJECTIVE

To determine if an exercise intervention, Functional Incidental Training (FIT), results in improvements in mobility endurance and physical activity when compared with prompted voiding (PV) among cognitively and mobility impaired nursing home residents.

DESIGN

Residents from four nursing homes were randomized into either a PV only (PV) or a PV plus FIT (FIT) intervention group for 8 weeks. Research staff implemented all intervention and measurement protocols.

PARTICIPANTS

Seventy-six incontinent nursing home residents completed all phases of the trial.

MEASURES

The standing, walking, and wheelchair endurance, physical activity, and frequency of agitation of all residents were assessed before, during, and after the 8-week intervention.

RESULTS

The average length of time that subjects could walk or wheel was 2.6 and 4.6 minutes, respectively, at baseline. There was a significant group x time interaction after intervention, with only the FIT group showing improvements in walking, wheelchair, and standing endurance (Manova F = 4.56, 2.62, and 5.98, respectively; P < .05 in all cases). The frequency with which agitation was observed showed a significant drop over time in both groups (F = 14.3, P < .001), with no significant group x time interaction.

CONCLUSION

The FIT intervention, which requires 6 minutes more nurses' aide time than does PV, increases both physical activity and mobility endurance in extremely frail and deconditioned nursing home residents. The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.

Behavioral disturbance in dementia

Fifty-seven subjects with moderate to severe dementia (49 with Alzheimer's disease) were rated twice, 8 weeks apart, using the Mini-Mental State Examination (MMSE), the Blessed Information-Memory-Concentration Test (BIMC), and the Stockton Geriatric Rating Scale (SGRC). Only three subjects lived at home; the rest were in long-stay hospital beds or nursing homes. For 29 subjects, the first rating coincided with their referral to a comprehensive geriatric psychiatry service. The main hypothesis, that the level of behavioral disturbance would correlate positively with the level of cognitive impairment, was strongly confirmed. This finding may reflect the severity of dementia in the study sample. The correlations between MMSE and BIMC scores were .87 at entry and .92 at exit, suggesting that the two measures were broadly equivalent, although both had marked floor effects. Test-retest reliability was high for all three measures. Overall, medication was of limited effectiveness in managing severe behavioral disturbance, highlighting the need for introducing effective behavioral programs.

Methodologic issues regarding outcome measures for clinical drug trials of psychiatric complications in dementia

Selecting outcome measures that are both psychometrically sound and sensitive to change is a very important aspect of clinical outcome research. A variety of measures have been introduced in recent years to assess behavioral complications in dementia, but few have been adequately tested in clinical trials. This article provides a discussion of factors to consider in selecting measures, including psychometrics, item content, assessment source, and sensitivity to change. A review of behavioral and psychiatric measures for dementia patients is provided, including measures of general behavioral disturbance, and measures specifically developed for agitation and depression. Each measure's psychometric characteristics, prior use with demented patients, and strengths and weaknesses with regard to treatment outcome research is summarized. The importance of linking measures to the investigators' hypotheses is discussed, along with recommendations for evaluating and selecting outcome measures depending on the needs of the specific investigation.

Neuroleptic treatment of agitation and psychosis in dementia

Neuroleptics remain the mainstay for the treatment of behavioral disturbance and psychotic symptoms in demented patients. The limited available data suggest that low-dose neuroleptics are significantly more efficacious than placebo, though the magnitude of the effect is moderate in most published studies. Demented patients are particularly prone to neuroleptic side effects, and individualized dose titration may be necessary to achieve the optimal trade-off between efficacy and side effects. Target behavioral symptoms and side effects, including effects on cognition and activities of daily life, should be identified and assessed serially during neuroleptic treatment. The choice of neuroleptic depends more on likely side effects than differential efficacy, and non-response or intolerable side effects should lead to dose adjustment or a switch to an alternative class of neuroleptic (or an alternative type of medication). Further studies of optimal neuroleptic dosage, the optimal duration of continuation neuroleptic treatment, and placebo-controlled studies comparing neuroleptics to other classes of medications are needed.

Agitation: measurement, management, and intervention research

Strategies for controlling and managing agitation of patients in long-term care populations has been identified as a research priority. Unfortunately, there is a paucity of literature on empirically tested therapeutic interventions for agitation. This manuscript summarizes the literature related to the measurement, management, and interventions for agitation and identifies a nursing research agenda for conducting research in this area. Nonpharmacological and nonrestraint interventions are highlighted and categorized by (1) alterations in care given, (2) environmental adaptations, and (3) behavioral approaches. Future research areas identified by the authors focus on additional types of environmental, interpersonal, and behavioral interventions as well as theoretical predictors of agitation; the influence and role of nursing personnel and caregiver; and the legal and ethical issues involved in caring for patients who manifest agitation.

Tolerability of divalproex sodium in elderly psychiatric patients with mixed diagnoses

This study addresses the tolerability of divalproex sodium in elderly psychiatric inpatients with various Axis I diagnoses, using structured assessments. A chart review for a 7-month period on a geropsychiatry inpatient unit identified 13 patients who had been treated with divalproex sodium. All 13 patients received standardized ratings on the Cohen-Mansfield Agitation Inventory (CMAI), Brief Psychiatric Rating Scale (BPRS), Rating Scale for Side Effects (RSSE), and Mini-Mental State Examination (MMSE) on admission and discharge, which were compared using paired t-tests for 12 of the 13 patients. The thirteenth patient was withdrawn from valproate prior to discharge after developing a delirium thought to be secondary to a divalproex-phenytoin interaction. All of the remaining 12 patients tolerated divalproex sodium well with no significant change in MMSE scores (P = .486), CMAI scores (P = .0546), or RSSE scores (P = .124). The change in BPRS score was found to be significant (P = .004). Based on the present study and previously reported case series, divalproex sodium appears to be well tolerated in an elderly psychiatric population.

Disturbing behaviors in demented elders: a concept synthesis

This article describes the use of concept synthesis, as defined by Walker and Avant, to extract meaningful syndromes of disturbing behaviors as they are manifested in demented elders. The process resulted in the identification of five distinct behavioral clusterings: Aggressive Psychomotor Behavior, Nonaggressive Psychomotor Behavior, Verbally Aggressive Behavior, Passive Behavior and Functionally Impaired Behavior. These synthesized concepts are an initial attempt at clarifying nursing perspective on disturbing behaviors in dementia.

Psychotropic drug use in Sydney nursing homes

OBJECTIVE

To determine the pattern of use of psychotropic drugs in Sydney nursing homes.

DESIGN

Survey of data from medical records of residents and interviews with residents and staff.

SETTING

Central Sydney Health Area, June to December 1993.

PARTICIPANTS

All residents of 46 of the 47 nursing homes in the western sector of the health area.

MAIN OUTCOME MEASURES

Psychotropic drugs used regularly or as required. Degree of cognitive impairment and depression rated on interview with residents, using Mini-Mental State Examination and Geriatric Depression Scale. Behavioural disturbances reported by staff.

RESULTS

Most residents (58.9%) were taking one or more psychotropic drugs regularly and another 7% were prescribed these drugs as required. Neuroleptics were taken regularly by 27.4% and as required by a further 1.4% (at least one dose in the previous four weeks), but doses were equivalent to more than 100 mg/day of chlorpromazine for only 8.8%. Neuroleptics were more likely to be given to residents with greater cognitive impairment and more disturbed behaviour. Other psychotropic drugs in regular use were: benzodiazepines (32.3%); hypnotics (26.6%); antidepressants (15.6%); and anxiolytics (8.6%). At least half of antidepressant doses were subtherapeutic. Of 874 residents who responded to a depression questionnaire, 30% scored as significantly depressed; one-third of these were taking antidepressants.

CONCLUSIONS

The percentage of residents in Central Sydney nursing homes who were taking neuroleptics, hypnotics or anxiolytics is among the highest reported from geriatric institutions around the world. Prescribing practices in Australian nursing homes need to be reviewed.

Interventions for decreasing agitation behaviors in persons with dementia

1. High stress is one of the possible causes of agitation behaviors in persons with dementia; use of stress management interventions may be helpful in reducing the stress level. 2. Two nursing interventions, hand massage and therapeutic touch, were effective in producing a relaxation response in persons with dementia who had a history of agitation behaviors; they did not, however, decrease agitation behavior. 3. Hand massage was more effective in producing relaxation than was therapeutic touch.

Dementia: diagnosis and emergency behavioral complications

Dementia is a relatively common syndrome seen in the elderly emergency department population. The emergency physician usually sees demented patients secondary to behavioral complications. Diagnosing the syndrome of dementia principally consists of ruling out treatable causes, which can be performed either in an in-patient or out-patient location. The emergency presentations of dementia include disturbances of activity, aggression, and psychosis. Complications that are primarily treated non-pharmacologically include circadian rhythm disturbance, catastrophic reaction (excessive emotional response), and wandering, as well as some mild verbal outbursts and delusions. Pharmacologic interventions are usually necessary for agitation, physical attacks, and significant delusions or hallucinations. Neuroleptic medication is the principal pharmacologic class with which to treat these symptoms, although benzodiazepines are also effective.

Effect of bright light treatment on agitated behavior in institutionalized elderly subjects

This study examined whether exposure to bright light treatment would reduce agitated behavior in institutionalized elderly subjects. Six demented elderly subjects (mean age = 89.2 years) living in a skilled nursing facility were studied. Light (2500 lx) was administered for 2 hours in the morning for two 10-day periods. The Bliwise Agitation Behavior Rating Scale was used to rate agitated behavior once every 15 min between 16:00 h and 20:00 h during 3 days of baseline, the light treatment periods, and 5 days of posttreatment follow-up evaluation. The entire protocol was then repeated in an ABABA design. A planned comparison revealed a significant difference between light treatment days and nontreatment days, with less agitation being observed on treatment days. The study suggests the efficacy of the clinical use of bright light treatment to reduce agitation.

Responses of noninterviewable long-term care patients before and after interinstitutional relocation

This study investigated the health consequences of an interinstitutional relocation on a sample of 103 noninterviewable, cognitively impaired patients in long-term care. Relocated patients functioned as their own controls. Specifically, data were abstracted from the patients' medical records on 16 health indicators for the 6 months prior to and following relocation as well as for the same months in the year before. Multivariate analysis indicated patients in general exhibited good health pretransfer but worse health posttransfer. In addition, less impaired patients were somewhat more affected by relocation.

The influence of environmental factors in incidents of disruptive behavior

1. Disruptive behavior is an annoying and potentially dangerous problem in most nursing homes. Disruptive behaviors can be both physical and verbal. 2. Changes associated with termination of disruptive behaviors included the reduction of external environmental stimuli, reduction of perceived threats to the patient's personal freedom and fulfillment of basic physical needs, fulfillment of needs for interpersonal support, a simple request to the disruptive person that the behavior be discontinued, provision for increased freedom by releasing the person from a gerichair or wheelchair with rollbar, separation of residents involved in disputes, and resolution of disputes over belongings. 3. In order to initiate changes that will reduce the frequency of such behavior or mitigate its harmful effects, nurses must have a better understanding of how environmental factors influence the evolution of disruptive episodes and plan appropriate and specific nursing interventions.

Behavioral symptoms in dementia: an update

A descriptive literature review was done to identify research conducted in both community and institutional settings and published from 1986 to 1993 on the correlates of behavioral symptoms associated with dementia. Critical appraisal and synthesis of the 40 studies revealed theoretical and methodological problems that tempered conclusions about the relationships between behavioral symptoms and the correlates under study. While direct relationships were found in studies in which relationships between behavioral symptoms and cognitive impairment and contextual factors were examined, contradictory results were found in studies of demographic and functional variables. Recommendations for research-based practice are advanced, including the development and testing of alternatives to physical and chemical restraints in the care of persons with dementia.

Assessing disruptive behaviors of nursing home residents: use of microcomputer technology to promote objectivity in planning nursing interventions

1. Simultaneous recording of multiple behaviors, as well as their antecedents and consequences, is made possible with the use of microcomputers. 2. Objective identification of key environmental events provides significant assessment data to plan care for the person with dementia. 3. With a more precise assessment base through naturalistic observation of disruptive behaviors, management of these behaviors can affect, more positively, the quality of life of the nursing home resident.