Natural history of aggressive behaviour in dementia

Measurement of aggression in older adults

Aggressive behaviors are prevalent in late-life and are associated with important consequences for older adults, caregivers, and healthcare providers. Age-related changes in the manifestation of aggression are precipitated in part by the rise of cognitive impairment. Such changes necessitate the use of psychometrically sound measures. The present article identifies existing measures of aggression for older adults, highlights the strengths and limitations of these measures, and proposes avenues for future research in this area. Five full-scale measures of aggression, as well as five subscales of aggression embedded within larger non-aggression measures in older adults were identified. Overall, measures of aggression specific to late-life are predominately observational and limited to individuals with dementia or older adults living in long-term care settings. The psychometric properties of aggression scales in late-life generally indicate adequate internal consistency, interrater reliability, and concurrent validity. In contrast, the reliability and validity of subscales of aggression contained within larger neuropsychiatric measures are more difficult to ascertain due to limited research. Future investigations would benefit from examining the psychometric properties of widely-used self-report measures of aggression among older adults, further evaluating the psychometric properties of aggression subscales, and developing additional measures which are predictive of aggressive behaviors.

Vocally disruptive behaviour in nursing home residents in Ireland: a descriptive study

BACKGROUND

Vocally disruptive behaviour (VDB) is relatively common in nursing home residents but difficult to treat. There is limited study on prevalence and treatment of VDB. We hypothesise that VDB is a result of complex interaction between patient factors and environmental contributors.

METHODS

Residents of nursing homes in south Dublin were the target population for this study. Inclusion criteria were that the residents were 65 years or over and exhibited VDB significant enough for consideration in the resident's care plan. Information on typology and frequency of VDB, Interventions employed and their efficacy, diagnoses, Cohen-Mansfield Agitation Inventory scores, Mini-Mental State Examination scores, and Barthel Index scores were obtained.

RESULTS

Eight percent of nursing home residents were reported to display VDB, most commonly screaming (in 39.4% of vocally disruptive residents). VDB was associated with physical agitation and dementia; together, these two factors accounted for almost two-thirds of the variation in VDB between residents. One-to-one attention, engaging in conversation, redirecting behaviour, and use of psychotropic medication were reported by nurses as the most useful interventions. Analgesics were the medications most commonly used (65.7%) followed by quetiapine (62.9%), and these were reportedly effective in 82.6% and 77.2% of residents respectively.

CONCLUSIONS

VDB is common, challenging, and difficult to manage. The study of VDB is limited by a variety of factors that both contribute to this behaviour and make its treatment challenging. Issues relating to capacity and ethics make it difficult to conduct randomised controlled trials of treatments for VDB in the population affected.

The use of pasung for people with mental illness: a systematic review and narrative synthesis

Background

Pasung is the term used in Indonesia and a number of other countries for seclusion and restraint of people with mental illness in the community, usually at home by their family. While pasung has been banned because it is contrary to human rights, its practice continues to exist within the community, particularly where community mental health services are limited, and in the absence of adequate social support, and pervasive negatives beliefs about mental illness. It is essential to understand the reasons for the ongoing use of pasung and to examine potential solutions.

Methods

A systematic review and narrative synthesis of peer-reviewed international literature was conducted to identify the socio-cultural contexts for pasung use, and interventions to address it. The analysis draws on the socio-ecological framework, which focused on relationships between the individual and their environment.

Result

Fifty published articles were included in the review; all studies were conducted in Asia and Africa, with 32 undertaken in Indonesia. Most studies were qualitative (n = 21). Others included one case–control study, one cross-sectional study, and seven surveys; only four studies examined the application of an intervention, and each used a pre and post methodology. Of these, two studies tested psychoeducational interventions which aimed to overcome family burden due to pasung, and each suggested a community mental health approach. The remaining two studies evaluated the intervention of ‘unlocking’; one study used a community-based culturally sensitive approach, and the other used a community-based rehabilitation program. Reasons for pasung given by family appear to be as a last resort and in the absence of other supports to help them care for the person with severe mental illness.

Conclusion

The findings highlight that a mixture of individual, interpersonal, community and policy interventions are needed to reduce the use of pasung. While consumer and carer involvement as part of a socio-ecological approach is understood to be effective in reducing pasung, an understanding of how to elaborate this in the management of pasung remains elusive.

Review Registration CRD42020157543: CRD

Caregiver Reactions to Aggressive Behaviors in Persons With Dementia in a Diverse, Community-Dwelling Sample

Purpose: To describe caregiver challenges with and confidence managing three aggressive behavior types in persons with dementia: verbal aggression, destroying property, and threatening to hurt others. Design and Method: Secondary analysis of baseline data from the 2001-2004 Resources for Enhancing Alzheimer's Caregiver Health II (REACH II) initiative. Results: One or more aggressive behaviors within 1 week were reported by more than a third of caregivers, with most expressing upset but fewer expressing confidence managing the behaviors. Caregiver distress and confidence differed by race/ethnicity in response to verbal aggression, with more White/Caucasian caregivers expressing upset than Hispanic/Latinos or Black/African Americans. Fewer Hispanic/Latinos expressed confidence managing verbal aggression, compared with White/Caucasians or Black/African Americans. Discussion: Aggressive behaviors challenge caregivers, with reactions varying by behavior type and race/ethnicity. Cultural and contextual factors suggest the need to tailor interventions, especially skill-building interventions that increase confidence managing aggressive behaviors while decreasing upset.

Differential Association of Aggression With Sadness for People With Moderate and Severe Dementia

Little is known about how individual behavioral and psychological symptoms of dementia (BPSD) impact the person with dementia. This cross-sectional, retrospective study examined the association between one BPSD, aggressive behavior, and a patient-identified outcome, sadness, among people with moderate and severe dementia (n = 5001) using clinical administrative Resident Assessment Instrument 2.0 data. For people with moderate or severe cognitive impairment, the odds of sadness were significantly higher if verbal aggression was exhibited 4 to 6 (adjusted odds ratio [aOR] = 2.85, P < .001) or 1 to 3 (aOR = 2.28, P < .001) times per week, or daily (aOR = 1.77, P = .003). People with severe cognitive impairment and who displayed physical aggression either daily (OR = 2.16, P = .002) or 1 to 3 times per week (OR = 1.45, P = .023) also had an increased odds of sadness. Aggression may harm the person with dementia's mental well-being, depending on the level of cognitive impairment, and type and frequency of aggression. Prospective studies can build on these correlational findings.

Finding the fundamental needs behind resistance to care: Using the Fundamentals of Care Practice Process

A person living with Alzheimer's disease (PA) can experience difficulty during bodily care and therefore may show resistance to care behaviours (RTCBs). Nurses must take a clinical approach to planning care that meets the person's needs. Therefore, it is necessary to identify training strategies for bedside nurses and nursing students.

AIMS AND OBJECTIVES

To describe and discuss how the FOC practice process (FOC-PP) can help nurses understand PAs who show RTCBs during bodily care.

BACKGROUND

Resistance to care behaviour phenomenon and the importance of bodily care as fundamental care are described. The FOC-PP enables nurses to apply the FOC framework in their practice.

DESIGN

This discursive paper is based on the literature of the FOC framework and PP.

METHOD

A clinical scenario that develops through the five stages of the FOC-PP.

RESULTS

The scenario centres on Mrs. Emily Morgan, 81, who lives in a nursing home and is not receiving the bodily care that she needs. Camille, a nursing student, and her supervisor Florence collaborate with Mrs. Morgan's family to improve the quality of her care. Three particular aspects of nursing practice based on the FOC-PP are described: the critical thinking process, relational process and pedagogical process.

CONCLUSION

The FOC-PP promotes holistic care centred on the person and his or her needs and encourages the nurse to use his or her skills and knowledge. All these dimensions are fundamental for high-quality nursing care.

RELEVANCE TO CLINICAL PRACTICE

Mrs. Morgan's scenario enables us to perceive that the FOC-PP is very useful for nursing students and bedside nurses. However, given the amount of specific and diverse knowledge required by the FOC-PP, it is necessary to identify avenues for teaching them. Using clinical scenarios could facilitate the integration of the FOC-PP, with taking into account the specific characteristics of individual clients.

Impact of three dementia-related behaviors on caregiver depression: The role of rejection of care, aggression, and agitation

OBJECTIVE

The relationship of specific dementia-related behaviors to caregiver depression and moderating factors is unclear. We examined the role of rejection of care, aggression, and agitation to caregiver depression and if social support and mastery independently moderated associations.

METHODS

The method used was a cross-sectional, secondary analysis using baseline data from two community-based clinical trials. We examined frequency of occurrence of presenting behaviors and their combinations in persons with dementia. Multiple logistic regression analyses examined associations between nonoverlapping behavioral clusters (agitation alone, agitation + rejection, agitation + aggression, and agitation + rejection + aggression) and caregiver depression. Multiple logistic regression with interaction terms was also used to investigate whether social support or caregiver mastery moderated the relationship between behavioral symptom clusters and caregiver depression.

RESULTS

Three of four symptom clusters (all three behaviors [adjusted odds ratio (AOR) = 2.22; 95% CI, 1.02-4.83], agitation + rejection of care [AOR = 2.55; 95% CI, 1.06-6.13], and agitation + aggression [AOR = 2.63; 95% CI, 1.17-5.89]) had a positive association with caregiver depression, whereas agitation alone was not significantly associated with caregiver depression. Neither social support nor mastery significantly moderated the relationship between these three behavioral clusters and caregiver depression.

CONCLUSION

Caregiver depression was associated with different combinations of behaviors but not with agitation alone. These results have implications for intervention development and identifying caregivers at risk for depression. Level of social support and mastery does not appear to moderate impact on caregiver depression.

African-American caregivers' perspectives on aggressive behaviors in dementia

Purpose

Although African-American dementia caregivers report less upset and more confidence managing aggressive behaviors when compared to whites, their contextual experience remains unclear and this study explores that context.

Methods

Semi-structured interviews with 13 African-American family caregivers were analyzed using content analysis.

Results

Two themes emerged, “It’s the disease…not the person” and “You got to pick your battles.” “It’s the disease…not the person,” reframing aggressive behavior, included three sub-themes. Sometimes the person with dementia seemed like a stranger but caregivers remembered “In there somewhere is that person.” Aggressive behavior made this perspective difficult as they reported, “Sometimes it’s hard not to take it personal.” Premorbid dyadic conflict made caregiving difficult but caregivers remembered they were “Not who they were then.” “You got to pick your battles,” reflecting cognitive and behavioral strategies, also included three sub-themes. Participants prioritized caregiving over other commitments by reminding themselves “I got to do what I gotta do.” Preventing aggressive behaviors was most successful when “We didn’t argue…we didn’t insist” and caregivers remembered “Don’t put her in a position to fail” when involving the person with dementia in activities.

Implications

African-American caregivers described substantial challenges when confronted by aggressive behaviors. Strategies employed by caregivers enabled them to maintain a caring perspective and the person with dementia to maintain calm. Interventions that help caregivers manage aggressive behaviors may benefit by considering the challenges, cultural values, and effective strategies used by African-Americans.

Physical aggression among patients with dementia, neuropathologically confirmed post-mortem

OBJECTIVE

To investigate the prevalence of physical aggression among patients with dementia of different types and to analyze potential differences in clinical traits, in terms of singular or repetitive behavior and occurrence in early or late stage of the disease. We also aimed at examining against whom the physical aggression was exerted.

METHODS

We included 281 cases with a neuropathological dementia diagnosis from the brain bank at the Department of Pathology, Lund University, for this retrospective medical records review. The study covers cases with a post-mortem examination performed between 1967 and 2013.

RESULTS

Of the 281 patients studied, 97 (35%) patients had a history of exerting physical aggression during the course of their disease. The patients with frontotemporal dementia exerted physical aggression earlier in the course of their disease than Alzheimer's disease patients. The most frequent victims of the patients' physical aggression were health staff and other patients. The aggression also affected family members as well as (to the demented patient) unknown people. The frequency of the physical aggression differed among the different diagnostic groups; frontotemporal dementia patients exhibiting a higher physical aggression frequency score than did Alzheimer's disease patients.

CONCLUSIONS

The patterns of manifested physical aggression thus differ between the frontotemporal dementia and Alzheimer's disease patient groups in this study. Knowledge about such differences may be of value in decision making in patient care.

Co-Occurrence and Predictors of Three Commonly Occurring Behavioral Symptoms in Dementia: Agitation, Aggression, and Rejection of Care

OBJECTIVE

To investigate co-occurrences of agitation, aggression, and rejection of care in community-dwelling families living with dementia.

METHODS

Cross-sectional, secondary analysis from a randomized controlled trial testing a nonpharmacological intervention to reduce behavioral symptoms. We examined frequency of occurrence of presenting behaviors at baseline and their combination. Omnibus tests compared those exhibiting combinations of behaviors on contributory factors. Multinomial logistic regression analyses examined relationships of contributory factors to combinations of behaviors.

RESULTS

Of 272 persons with dementia (PwDs), 41 (15%) had agitation alone (Agi), 3 (1%) had aggression alone, 5 (2%) had rejection of care alone. For behavioral combinations, 65 (24%) had agitation and aggression (Agi+Aggr), 35 (13%) had agitation and rejection (Agi+Rej), 1 (0%) had aggression and rejection, and 106 (39%) had all three behaviors (All). Four behavioral subgroups (Agi, Agi+Aggr, Agi+Rej, and All) were examined. Kruskal-Wallis tests showed that there were significant group differences in PwD cognition, functional dependence, and caregiver frustration. PwDs in Agi+Rej and All were more cognitively impaired than those in Agi and Agi+Aggr. Also, caregivers in All were more frustrated than those in Agi. In logistic regression analyses, compared with Agi, greater cognitive impairment was a significant predictor of Agi+Rej and All, but not Agi+Aggr. In contrast, greater caregiver frustration was a significant predictor of Agi+Aggr and All, but not Agi+Rej.

CONCLUSIONS

We found that agitation, aggression, and rejection are common but distinct behaviors. Combinations of these behaviors have different relationships with contributory factors, suggesting the need for targeting treatment approaches to clusters.

Longitudinal course of behavioural and psychological symptoms of dementia: systematic review

BACKGROUND

More information about the pattern of behavioural and psychological symptoms of dementia (BPSD) in the course of dementia is needed to inform patients and clinicians and to design future interventions.

AIMS

To determine the persistence and incidence of BPSD and their relation to cognitive function, in individuals with dementia or in cohorts investigated for dementia onset.

METHOD

A systematic literature review analysed the baseline prevalence, persistence and incidence of 11 symptoms. The review was conducted according to established guidelines with the exception that we could not exclude the possibilities of bias in the studies examined.

RESULTS

The 59 included studies showed considerable heterogeneity in their objectives and methods. The symptoms hyperactivity and apathy showed high persistence and incidence; depression and anxiety low or moderate persistence and moderate incidence; and psychotic symptoms low persistence with moderate or low incidence.

CONCLUSIONS

Despite heterogeneity across studies in terms of setting, focus and length of follow-up, there were clinically relevant differences in the longitudinal courses of different BPSD. Apathy was the only symptom with high baseline prevalence, persistence and incidence during the course of dementia.

Resistiveness to care during assistance with activities of daily living in non-institutionalized persons with dementia: associations with informal caregivers' stress and well-being

OBJECTIVES

Resistiveness to care (RTC) refers to behavior problems that co-occur during assistance with activities of daily living (ADL). RTC are considered challenging, but are mostly studied in institutions with implications for patients and formal caregivers. RTC is associated with agitation, but agitation is considered a separate construct. Detection of RTC may be left out of common assessments of persons with dementia in studies of informal caregiving (e.g. global assessments of dementia behavioral symptoms, standard assessments of ADL function). This study examines how RTC (frequency and caregivers' stress appraisals of RTC) is related to caregivers' well-being.

METHOD

234 caregivers of people with dementia reported care receivers' ADL impairment (eating, bathing, dressing), RTC frequency (of eating, bathing dressing), and their stress appraisals of these behaviors (RTC appraisals). Caregivers also self-reported their role overload, role captivity, and depressive symptoms. Hierarchical linear regression models included independent variables (demographics, ADL impairment, RTC frequency, RTC appraisals) with three separate dependent variables (overload, captivity, depressive symptoms).

RESULTS

Two-thirds of informal caregivers reported RTC. Care recipients' ADL impairment was associated with caregiver outcomes, but only before RTC was entered into the models. RTC frequency significantly predicted caregivers' overload, captivity, and depression. RTC appraisals predicted overload and captivity.

CONCLUSION

RTC is common in persons with dementia residing at home, and RTC has more negative association with informal caregivers' well-being than assistance with ADL. Adding RTC frequency and appraisal items to standard ADL measures may better estimate caregivers' needs and risk, and identify modifiable environmental features by assessing behavioral symptoms in context.

Inappropriate behaviors and hypersexuality in individuals with dementia: An overview of a neglected issue

Behavioral and psychological symptoms of dementia are very common in patients affected by dementia, and are associated with high rates of institutionalization. Behavioral and psychological symptoms of dementia consist of aggressive behavior, delusions, hallucinations, depression, apathy, wandering, stereotyped and inappropriate sexual behavior. Interestingly, the latter has been reported to be relatively uncommon, but causing immense distress to patients and their caregivers. The genesis of inappropriate behavior is considered a combination of neurological, psychological and social factors. Although assessment is mainly carried out by clinical observation and interviews with caregivers, the most appropriate management of behavioral and psychological symptoms of dementia, including hypersexuality, is a combination of pharmacological and non-pharmacological interventions, according to specific symptoms, degree of cognitive dysfunction and subtype of dementia. The present narrative review will mainly focus on aggressiveness, disinhibition, aberrant motor, and sexually inappropriate behavior diagnostic work-up and treatment, in an attempt to provide both the patients and their caregivers with useful information to better manage these symptoms and improve their quality of life. Space is particularly dedicated to inappropriate sexual behavior, which is still considered a neglected issue. Geriatr Gerontol Int 2017; 17: 865-874.

Putting Residents First: Strategies Developed by CNAs to Prevent and Manage Resident-to-Resident Violence in Nursing Homes

PURPOSE OF THE STUDY

Resident-to-resident violence (RRV) in nursing homes (NHs) is common and threatens the safety and quality of life of both residents and caregivers. The purpose of this portion of a larger qualitative study was to explore strategies developed by certified nurses' assistants (CNAs) to prevent and manage RRV in NHs.

DESIGN AND METHODS

Semistructured interviews were used to collect data. Data were analyzed utilizing content analysis and constant comparison.

RESULTS

Analysis revealed one overriding theme, "Putting Residents First" which the CNAs described as a conscious effort to put themselves or a beloved family member in the place of the resident while administering care. Within this theme, there were three related subthemes: (a) Knowing the Residents, (b) Keeping Residents Safe, and (c) Spending Quality Time.

IMPLICATIONS

Together, these themes suggest that the formulation of strategies for decreasing and managing RRV was influenced significantly by the ability of the CNAs to empathize with the residents for whom they were caring. The results indicate that in the absence of evidence-based interventions, CNAs have developed their own strategies for the management and prevention of RRV. These strategies may provide a foundation for the development and testing of interventions aimed at preventing and managing RRV in NHs.

Prevalence of Behavioural and Psychological Symptoms of Dementia in Individuals with Learning Disabilities

A review of 23 studies investigating the prevalence of Behavioural and psychological symptoms of dementia (BPSD) in the general and learning disability population and measures used to assess BPSD was carried out. BPSD are non-cognitive symptoms, which constitute as a major component of dementia regardless of its subtype Research has indicated that there is a high prevalence of BPSD in the general dementia population. There are limited studies, which investigate the prevalence of BPSD within individuals who have learning disabilities and dementia. Findings suggest BPSDs are present within individuals with learning disabilities and dementia. Future research should use updated tools for investigating the prevalence of BPSD within individuals with learning disabilities and dementia.

Impact of caregivers' behaviors on resistiveness to care and collaboration in persons with dementia in the context of hygienic care: an interactional perspective

BACKGROUND

The role played by various physical and verbal behaviors of professional caregivers in the onset of resistiveness to care (RTC) and collaborative behaviors of nursing home residents with dementia was assessed in a daily hygienic care routine context.

METHODS

Two hundred and forty hygienic care routines, observed in eight nursing home residents, were analyzed with a video-assisted systematic observation methodology and a sequential statistical analysis strategy.

RESULTS

Caregiver and care recipient behaviors are interdependent in the hygienic care routine context. Physical instrumental behavior, neutral, negative and positive statements, positive and negative instructions, and verbal distraction emitted by caregivers are significantly and moderately associated with the onset of RTC in persons with dementia (PWD), but the strength of relationships observed depends on the care recipient's behavior prior to the caregiver's action. Positive instructions are moderately associated with the onset of collaboration in residents with preserved language abilities. However, for residents with severe language impairment, these same instructions were linked to RTC behaviors.

CONCLUSIONS

Although antecedents to RTC can be identified, the risk that caregiver behaviors trigger resistive responses is higher when care recipients are already exhibiting RTC, and is low when no particular behavior or collaboration is shown. Antecedents to collaboration are also identified and discussed. Although different caregiver behaviors may be more or less likely to elicit resistiveness or collaboration, it is the pre-existing state of the care recipient that will determine its reaction to the caregiver's behavior. Clinical implications emerging from these influential findings are elaborated.

Disease Staging and Milestones

This new section to the guidelines was added due to the recognition that clinical milestones are useful indices of the progression of dementia in patients with Alzheimer's disease and could help in the development of stage-specific targeted therapy. This review specifically looks at clinical milestones that could be used in clinical trials, such as global function, function, behaviour, caregiver burden, and quality of life milestones. It also addresses the possible use of biological and surrogate markers for use as milestones - which may eventually replace clinical milestones. It concludes that current definitions of dementia must be broadened beyond cognition alone to include some of the domains listed.

Individualized guidelines for the management of aggression in dementia - Part 1: key concepts

BACKGROUND

Clinical guidelines have the potential to assist in the management of aggression in dementia. This study aims to develop a conceptual framework for the construction of individualized guidelines for this group.

METHODS

A concept map of the topic "How to manage aggression in dementia" was developed by reviewing research papers, clinical guidelines, and gray literature. Titles and abstracts of papers that met search criteria were manually scanned in an iterative process for the extraction of key ideas and terminology commonly used to describe the field. Essential ideas and concepts were recorded on a concept map and hierarchically arranged. The concept map was converted into an interactive PDF document for easy distribution and sharing.

RESULTS

Ten key concepts were found to be important when managing aggression in dementia clustered along three major dimensions: Patient, Disorder and Treatment. The dimension Patient was defined by the "Patient's individual characteristics," the "Personal life story," and the "Patient's environment." Disorder was defined by the "Presentation of symptoms" and "Theory of causation." Treatment was defined by "Goals and expectations," "Non-pharmacological interventions," "Pharmacological interventions," "Ethics and Restraint Use," and "Emergency treatment." Concepts relating to clinical guidelines themselves were also included in the interactive map, including "Support from evidence-based medicine," "Regular updates," "Disclosures," and "Usability."

CONCLUSION

Managing aggression in dementia requires consideration of a wide range of factors relating to the patient, the dementia and behavioral disturbance, and possible treatment options. An interactive and hierarchical concept map provides a framework to develop individualized clinical guidelines.

Managing pain to prevent aggression in people with dementia: a nonpharmacologic intervention

Aggression is a common form of behavioral disturbance in dementia. Strategies to prevent and treat aggressive behavior are underdeveloped. However, recent work points to several modifiable risk factors that may be targets for intervention. Pain management is an evidence-based, feasible, but potentially underused, strategy that may be incorporated with other behavioral interventions to prevent aggression. In this article, we review areas of overlap in interventions for pain and for behavioral disturbances and describe an intervention concept that may hold promise for older adults with dementia who are at risk of developing aggressive behavior.

Perceptions and implications of violence from care home residents with dementia: a review and commentary

AIMS AND OBJECTIVES

This paper presents a critical review of the literature related to the violence staff in care homes experience from people with dementia. It attempts to identify the psychological consequences abuse has on care workers and the implications this has for practice.

BACKGROUND

Abuse in the form of violence or aggression against healthcare professionals is not new. However, when this is from residents with dementia in care homes it is considered to be part of the job. Consequently it is largely underreported and ignored which masks its true extent.

CONCLUSION

The magnitude of violence in care homes crosses cultural boundaries. Fear of being blamed, job insecurity and resignation that abuse should be accepted as part of the job is unique to this care setting. The cumulative effect of psychological abuse leads to emotional exhaustion and depersonalisation which results in care workers emotionally and physically withdrawing from residents. Being subjected to abuse, feeling undervalued, unsupported and lacking essential skills may compromise a workforces' ability to provide person-centred care. A rising ageing population and prevalence of dementia will place demands on commissioners and providers to deliver high quality care. Consistent recording and reporting procedures, dementia specific training and infrastructures to support staff is therefore crucial.

Psychometric evaluation of a proposed Alzheimer's aggression scale

The purpose of this study was to evaluate a popular measure of Alzheimer's disease (AD) memory and behavior problems and to determine whether its aggressive behavior items coalesced empirically as a subscale to form a psychometrically viable AD aggression measure for clinicians. Data from self-report questionnaires were examined from 419 informal AD caregivers in the southern United States. Principal axis factoring revealed a unidimensional solution with robust item loadings on the single factor. Three forms of reliability analysis indicated moderately strong internal consistency on this proposed measure. Evidence of convergent validity analysis was suggested via the measure's significant correlations to theoretically linked constructs. The proposed measure emerged as a reliable and valid tool for health care practitioners for the appraisal of problematic AD aggression behaviors from the caregiver perspective.

Factors associated with problematic vocalizations in nursing home residents with dementia

PURPOSE OF THE STUDY

Problematic vocalizations (PVs) are the most frequent and persistent disruptive behaviors exhibited by nursing home residents with dementia. Understanding factors associated with these behaviors are important to prevent or reduce them. We used the Need-Driven Dementia-Compromised Behavior model to identify the characteristics of persons with dementia who are likely to display nonaggressive and aggressive PVs and the conditions under which these behaviors are likely to occur and persist.

DESIGN AND METHODS

This multisite descriptive study included 138 residents of 17 nursing homes, and approximately half had a history of PVs. Background data were gathered through interviews, chart reviews, and administration of physical and neuropsychological assessments. Proximal data were obtained from observations and videotapes.

RESULTS

When the 2 subscales of the Verbal Behavior Scale were used as the dependent variables, agreeableness and conscientiousness, positive affect, and discomfort were associated with nonaggressive vocalizations, and general health state (GHS), age, and negative and positive affect were associated with aggressive vocalizations. When the verbally agitated (nonaggressive) section of the Cohen-Mansfield Agitation Inventory was the dependent variable, the background factors of gender, agreeableness, GHS, and age remained predictors, as did the proximal factors of affect and discomfort.

IMPLICATIONS

We identified 5 background factors and 3 proximal factors as risk factors for PVs in persons with dementia, with variation between nonaggressive or aggressive PVs. These data provide direction for caregiving for persons with dementia and design of interventions to prevent or reduce PVs.

Psychological trauma and fear for personal safety as a result of behaviours that challenge in dementia: The experiences of healthcare workers

Few studies have systematically documented the psychological effects of exposure to aggression on healthcare workers. In 2007 an exploratory study invited 96 nurses and 228 care assistants from nine care homes to complete a questionnaire that incorporated the Impact Events Score — Extended (IES-E). Of the 112 returned (response rate 34.56%), 77 (68.8%) staff had been involved in an incident where they feared for their personal safety and 80 (71.4%) witnessed an incident where they feared for the safety of a colleague. Over the previous year 34% felt ‘very unsafe’ and almost 18% felt ‘terrified’. Violence against care home staff are not isolated incidents and irrespective of length of time working in dementia care staff lack the skills to identify triggers factors or appreciate the role they play in activating aggression. Their reluctance to engage with aggressive residents compromises care. An increasing ageing population combined with prevalence rates for dementia will place greater demands on care homes. Nationally agreed accredited qualifications for care assistants based on knowledge, and skills and attitudes specific to dementia care, may raise the standard of care. Infrastructures to support assaulted staff may reduce feelings of isolation, assist with recruitment and retention problems and provide social support.

Changes in nursing burden following memantine for agitation and aggression in long-term care residents with moderate to severe Alzheimer's disease: an open-label pilot study

BACKGROUND

Agitation and aggression are common neuropsychiatric symptoms of Alzheimer's disease (AD) with a negative impact on caregivers.

OBJECTIVE

The aim of the study was to determine whether changes in agitation and aggression would follow memantine treatment and, if so, be associated with changes in nursing burden in institutionalized patients with moderate to severe AD.

STUDY DESIGN

This was a 3-month open-label trial of memantine.

SETTING

The setting was two long-term care facilities.

PATIENTS

Thirty-one institutionalized patients with moderate to severe AD and significant behavioural and psychiatric symptoms were included in the study.

INTERVENTION

Memantine was titrated to a target dose of 10 mg twice daily.

MAIN OUTCOME MEASURE

Effectiveness was assessed by the change in the Neuropsychiatric Inventory-Nursing Home (NPI-NH) agitation/aggression subscale and Clinical Global Impression of Change (CGI-C) scale using the intent-to-treat population. To establish caregiver impact, the effect on nursing burden was measured by the Modified Nursing Care Assessment Scale (primary outcome). As a secondary analysis, the caregiver distress subscale of the NPI-NH was examined, as well as changes in as required (pro re nata [prn]) psychotropic medication use.

RESULTS

Twenty-four patients completed the study. A significant decrease in agitation and aggression (F-test with 3 and 90 degrees of freedom [F(3,90)] = 3.721, p = 0.014) was demonstrated following memantine, with 48% of patients improving (either much improved or minimally improved) on the CGI-C scale. In addition, nursing burden (t-test with 30 degrees of freedom [t(30)] = 3.02, p = 0.005), caregiver distress (F(3,90) = 4.125, p = 0.009) and the use of prn psychotropics decreased following memantine treatment (Z = -1.99, p = 0.046). Fourteen patients experienced at least one adverse event during memantine treatment. The most common adverse event associated with treatment was somnolence (n = 5).

CONCLUSION

The results of this study suggest that the decreased agitated and aggressive behaviour in institutionalized patients with moderate to severe AD following treatment with memantine was accompanied by improvements in nursing burden and decreased psychotropic use. These findings should be confirmed in a larger, controlled trial.

Alzheimer's aggression: influences on caregiver coping and resilience

This study assessed impact of Alzheimer's patients' aggressive behavior (AD aggression) on caregiver coping strategies (task-, emotion-, and avoidance-focused) and caregiver resilience, and examined whether coping strategy moderated the AD aggression-caregiver resilience relationship. Informal caregivers across Louisiana (N = 419) completed surveys with measures of demographics, AD aggression, caregiver coping strategies, and caregiver resilience. Task-focused coping positively related to resilience. Aggression negatively predicted caregiver resilience. Emotion- and avoidance-focused coping strategies separately interacted with aggression and increased its negative relationship to caregiver resilience. Task-focused coping showed no moderation. Implications for social work professionals are discussed.

Nursing home structure and association with agitation and use of psychotropic drugs in nursing home residents in three countries: Norway, Austria and England

BACKGROUND

Understanding the underlying mechanisms and risk factors leading to agitation is crucial to reduce the severity of agitation and increase quality of life. International comparative studies offer special advantages in elucidating environmental risk factors by providing a wider diversity of environmental exposures such as nursing home structures, health care systems and genetic diversity.

METHODS

Baseline data for three different intervention studies in Austria (n = 38), England (n = 302) and Norway (n = 163) were combined posthoc. Patients were grouped according to their dementia severity using the global deterioration scale (GDS), functional assessment staging (FAST) and clinical dementia rating (CDR) scales. For the measurement of agitation, the Cohen-Mansfield Agitation Inventory (CMAI) was used. Data analysis was performed using one-way ANOVA, multivariate and linear regression analysis.

RESULTS

CMAI scores were available for 503 subjects with dementia. There were significant differences between the nursing home residents in the three countries regarding age, gender and dementia severity (all p values < 0.001). In the multivariate analyses, the level of agitation differed with higher mean scores in the Austrian (mean (SD) score 51.9(21.8)) compared to UK (43.3(16.1)) and Norwegian (41.6(13.2)) nursing homes (p = 0.002). Similarly, the use of psychotropic drugs differed significantly, with a higher proportion of neuroleptics in UK (48%, p < 0.001) and Austrian (52.6%; p = 0.001) compared to Norwegian (19%) nursing homes.

CONCLUSION

We found differences in agitation and antipsychotic drug use which are likely related to structural and cultural differences in nursing homes in three European countries. These findings suggest that structural changes can improve quality of care and quality of life for nursing home residents.

The pharmacotherapy of neuropsychiatric symptoms of dementia: a cross-sectional study in 18 homes for the elderly in Berlin

BACKGROUND

The neuropsychiatric symptoms of dementia, including aggressiveness, agitation, depression, and apathy are often treated with psychotropic drugs and are a frequent reason for hospitalization, placing an economic burden on the health care system. International guidelines recommend syndrome-specific pharmacotherapy. We studied the question whether drug-prescribing practices are, in fact, syndrome-specific.

METHODS

In a cross-sectional study in 18 homes for the elderly in Berlin, we used syndrome-specific scales to determine the prevalence of apathy, depression, and aggressiveness and the quantity of psychotropic drugs prescribed, in defined daily dosages (DDD), among 304 demented inhabitants. The diagnosis of dementia was ascertained by chart review and confirmed by administration of a mini mental status test.

RESULTS

More than 90% of the demented patients had neuropsychiatric symptoms, most commonly apathy (78%). 52% were treated with neuroleptic drugs, 30% with antidepressants and 17% with anti-dementia agents. There was no significant difference between the frequency of neuroleptic treatment given to apathetic and depressed patients and that given to aggressive patients (chi(2) = 7.03; p = 0.32).

CONCLUSION

Although our sample of patients was not representative, these findings suggest that neuropsychiatric symptoms in demented patients are not being treated in syndrome-specific fashion. This is troubling, because neuroleptic medications administered to demented patients can have serious adverse effects, including an elevated mortality. The German guidelines for the treatment of neuropsychiatric disturbances were recently published; the findings presented here suggest that their implementation would be advantageous.

Female caregivers' experiences of exposure to violence in nursing homes

Although earlier studies have examined caregivers' experiences of exposure to violence, few have investigated female caregivers working in nursing homes with a specific focus on experiences throughout the entire scenario of a violent situation. This study illuminates female caregivers' experiences of being exposed to violence in nursing homes. Twenty caregivers working in three nursing homes located in northern Sweden were asked to narrate about a situation in which they had been exposed to violence. Their narratives were analysed by using qualitative content analysis. We found that the caregivers had preconceived ideas about violent behaviour, that they experienced a loss of control over the situation, and that they then strove to regain control. Experiences such as these may influence caregivers' interactions with residents who display violent behaviour. As a result of violent interactions, caregivers may distance themselves from the residents, an attitude that may decrease the quality of care. There is a risk that violence in nursing homes is accepted and normalized as a part of the job and hence persists.

Resident-to-resident aggression in long-term care facilities: insights from focus groups of nursing home residents and staff

OBJECTIVES

To more fully characterize the spectrum of resident-to-resident aggression (RRA).

DESIGN

A focus group study of nursing home staff members and residents who could reliably self-report.

SETTING

A large, urban, long-term care facility.

PARTICIPANTS

Seven residents and 96 staff members from multiple clinical and nonclinical occupational groups.

MEASUREMENTS

Sixteen focus groups were conducted. Content was analyzed using nVivo 7 software for qualitative data.

RESULTS

Thirty-five different types of physical, verbal, and sexual RRA were described, with screaming or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents' rooms, and in the afternoon, although it occurred regularly throughout the facility at all times. Although no proven strategies exist to manage RRA, staff described 25 self-initiated techniques to address the problem.

CONCLUSION

RRA is a ubiquitous phenomenon in nursing home settings, with important consequences for affected individuals and facilities. Further epidemiological research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies.

Aggression in individuals newly diagnosed with dementia

Aggression is often associated with dementia. In this study, aggression in veterans newly diagnosed with dementia was examined and characterized. Participants were >or=60 years diagnosed with dementia at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from 2001 to 2004. Aggression was defined as a positive caregiver response to 1 or more of 3 probes from the Ryden Aggression Scale, administered during a telephone screen. Of 1276 contacts, 385 (30%) were eligible and agreed to participate; at initial screening, 75 (19.5%) were aggressive (23 [31%] verbally, 9 [12%] physically, 24 [32%] verbally and physically, and 19 [25%] with unspecified aggression). The surprisingly high prevalence of aggression in individuals newly diagnosed with dementia suggests the potential usefulness of early screening for aggression in this population.

Resident-to-Resident Aggression in Long-Term Care Facilities: An Understudied Problem

Resident-to-resident aggression (RRA) between long-term care residents includes negative and aggressive physical, sexual, or verbal interactions that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Although this problem potentially has high incidence and prevalence and serious consequences for aggressors and victims, it has received little direct attention from researchers to date. This article reviews the limited available literature on this topic as well as relevant research from related areas including: resident violence toward nursing home staff, aggressive behaviors by elderly persons, and community elder abuse. We present hypothesized risk factors for aggressor, victim, and nursing home environment, including issues surrounding cognitive impairment. We discuss methodological challenges to studying RRA and offer suggestions for future research. Finally, we describe the importance of designing effective interventions, despite the lack currently available, and suggest potential areas of future research.

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.

A placebo-controlled trial of valproate for agitation and aggression in Alzheimer's disease

BACKGROUND/AIMS

To assess the efficacy and tolerability of valproate for the treatment of agitation and aggression in moderate-to-severe Alzheimer's disease (AD).

METHODS

This was a randomized, double-blind, placebo-controlled crossover trial of valproate in institutionalized AD patients. Patients were assessed with the Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory at baseline and after 6 weeks of treatment with valproate and placebo, with 2 weeks between phases to allow for placebo washout and tapering.

RESULTS

Fourteen patients (8 male/6 female) aged 85.6 +/- 4.5 years with baseline Mini Mental State Examination scores of 4.5 +/- 4.6 and NPI agitation/aggression scores of 6.4 +/- 3.5 were randomized to treatment. NPI agitation/aggression treatment change scores significantly worsened during valproate treatment compared with placebo (Z = -2.03, p = 0.04). Tolerability of valproate was also poor, with patients experiencing a significantly greater mean number of adverse events during valproate therapy compared to placebo (Z = -2.82, p = 0.005).

CONCLUSION

Valproate is not effective for the management of agitation in moderate-to-severe AD, and may be poorly tolerated in this population.

Caring for Residents with Dementia and Aggressive Behavior: Impact of Life History Knowledge

Aggressive behavior is a frequent occurrence in the care of individuals with dementia. In this pilot study, the authors explored the impact of sharing patients' life histories with staff on four patients' aggression and interviewed nursing staff and families to determine the impact that developing and learning about the life history had on them. There was some evidence of decrease in aggression among the patients who demonstrated frequent aggressive behavior at baseline. Life history information affected some staff members profoundly, leading toward a greater empathy for the patient. This study demonstrates the feasibility and potential value of using life histories with residents who demonstrate aggressive behavior.

Aggressive behaviour by people with dementia in residential care settings: a review

This paper considers the phenomenon of aggressive behaviour perpetrated by people with dementia in residential care settings. Aggressive behaviour is defined in the context of people with dementia, and the problem of ascertaining the incidence of aggression among people with dementia is discussed. The emotional impact of assaults on nurses and other professionals is highlighted, and differing perspectives on the causation of aggressive behaviour are considered. Management strategies derived from the physical/pharmacological; environment management; behaviour modification and person-centred approaches are reviewed. Our conclusion is that while certain strategies appear to reflect good and common sense practice, in particular those deriving from the person-centred approach, there is no clear research evidence for the general effectiveness of any one management approach, and each has drawbacks of a practical or ethical nature. There is also little empirical information about how professional carers actually manage aggressive behaviour in practice.

Involvement of the GABAergic system in depressive symptoms of Alzheimer's disease

Cognitive and neuropsychiatric (BPSD) symptoms seen in Alzheimer's disease (AD) probably result from differential neurotransmitter alterations. The involvement of the glutamatergic and GABAergic system in cognitive and behavioral and psychological symptoms of dementia (BPSD) has been studied in post-mortem frontal and temporal cortex from AD patients who had been prospectively assessed with the Mini-Mental State Examination (MMSE) for cognitive impairment and with the Present Behavioral Examination (PBE) for BPSD. In addition to cholinergic deficits, significant decreases in gamma-amino butyric acid (GABA) content, with no changes in glutamate content, were found in frontal and temporal cortex. Both GABA levels and the glutamate/GABA ratio showed significant correlations with depression in AD. In the temporal cortex, higher densities of GABA(A)/benzodiazepine receptors also correlated with more severe depression. It can be suggested that in a situation of cholinergic deficit, such as AD, an imbalance between the excitatory glutamatergic tone and inhibitory GABAergic tone may be responsible for non-cognitive behavioral disturbances.

Challenging behaviour in the elderly-monitoring violent incidents

OBJECTIVE

To explore the frequency and nature of violent incidents in psychogeriatric wards and nursing homes in terms of type and severity of incidents, what provoked the incidents, and what kind of measure was needed to stop the aggression.

MATERIAL AND METHODS

Aggressive behaviour of the study group was monitored using the Staff Observation Aggression Scale-Revised (SOAS-R( in two Norwegian nursing homes and two geriatric psychiatric wards for a period of three months. Severity of incidents were monitored with the built-in severity scoring system in SOAS-R.

RESULTS

During the study period 32 out of the 82 patients were reported to be violent. The majority of the incidents were generated by a minority of the patients. Physical injury to the staff as a consequence of the aggression was extremely rare. Situations where the client was denied something were the most provocative ones and a substantial number of incidents occurred at bath/shower times. Talking to the patient was the most frequent measure used to stop the aggression, but more intrusive measures were also used.

CONCLUSIONS

A substantial proportion of the incidents were associated with personal care tasks, suggesting a crucial role for communication difficulties and a focus for staff training. We suggest that personal care situations should be added to the variable list in future research.

Positive affect among nursing home residents with Alzheimer's dementia: the effect of recreational activity

The experience of positive emotions is an integral component of quality of life. Research suggests that cognitive deficits in persons with dementia may impede their ability to generate pleasurable moments and hence decrease their positive affect. Therefore, structured recreation activities may have the potential to significantly improve resident affect. However, differences in affect between ordinary time and recreation time are not well known. The present study used previously published structured-observation instruments to measure affect and behaviour among 35 dementia residents at two nursing homes in Japan during ordinary time and during recreation time. A total of 3,854 one-minute observations were coded. Dementia residents expressed happiness over seven times more often during recreation time than during ordinary time. Over 60% of ordinary time was solitary, with 65.72% of all observed affect being 'Null Affect'. A total of 43.75% of residents expressed happiness only during recreation time. In addition 48.9% of all behaviour during 'Ordinary Time' was coded as 'Null Behaviour', which indicated that the resident was sitting and doing nothing. Findings indicate that recreation time is significantly higher in positive affect than ordinary time and that virtually all residents benefited from recreation.

Components of behavioral pathology in dementia

OBJECTIVE

The purpose of this study was to examine the occurence of the noncognitive behavioral and psychological symptoms and signs of dementia in a geriatric chronic-care hospital and to separate agitated and affective components of behavioral pathology using factor analysis.

METHODS

The frequency and severity of Alzheimer's disease, vascular dementia, mixed dementia and Lewy Body dementia was assessed in 145 consecutive residents of a chronic-care hospital. The presence of noncognitive behavioral symptoms was evaluated with the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) and the Cohen-Mansfield Agitation Inventory (CMAI). A Factor analysis on the BEHAVE-AD subscores was performed to create symptom clusters. Analysis of covariance and post hoc tests were used to compare means of factor variables between different types of dementia.

RESULTS

Statistical analysis showed a significant correlation between severity of dementia and BEHAVE-AD total score and between severity of dementia and CMAI total score. Factor analysis with Varimax rotation revealed the presence of three behavioral subsyndromes: agitation, affectivity and day/night disturbances.

CONCLUSIONS

The finding of three factors of behavioral pathology in demented patients reflects the possibility that different etiological mechanisms could explain the expression of the symptoms and signs of psychosis in demented patients.

Prevalence and clinical correlates of disinhibition in dementia

OBJECTIVE AND METHODS

The phenomenology, main clinical correlates, and long-term evolution of disinhibition in dementia are not well known. To examine this issue, we studied a consecutive series of 272 patients with probable Alzheimer disease using a comprehensive psychiatric and neuropsychological evaluation that included the Disinhibition Scale. A subset of patients was reexamined with the same instruments between 1 and 4 years after the initial evaluation.

RESULTS

A factor analysis of the Disinhibition Scale demonstrated 4 factors: (1) abnormal motor behavior, (2) hypomania, (3) loss of insight and egocentrism, and (4) poor self-care. Disinhibition was significantly associated with major and dysthymic depression, more severe negative symptoms, and loss of awareness. Most patients with disinhibition at the initial evaluation still showed disinhibition at follow-up, whereas 23% of patients without disinhibition at the initial evaluation developed disinhibition at follow-up.

CONCLUSIONS

Disinhibition is a frequent and long-lasting problem in dementia. Our study demonstrates that the construct of disinhibition consists of 4 independent subsyndromes, each of which may have specific underlying mechanisms.

Evaluating hospital care for individuals with Alzheimer's disease using inpatient quality indicators

The purpose of this study was to determine whether persons with Alzheimer's disease (AD) were at greater risk for in-hospital mortality than non-AD patients as a result of poor quality of care. The study focused on six common medical conditions that result in hospital mortality. Using 1995 to 2000 data from New York state (n = 7,021,065), analysts compared mortality risk for individuals with and without AD. Among men, adjusted odds of death were greater for those with AD for gastrointestinal (GI) hemorrhage (+52 percent), congestive heart failure (CHF) (+42 percent), hip fracture (+35 percent), and acute myocardial infarction (AMI) (+30 percent) (all p < .0001). Among women, AD did not affect risks for most conditions. The results of the study show that men with AD are at higher risk of hospital mortality for common medical conditions, which may indicate poor quality of care. Their risk of hospital death was greater than that of men without AD for AMI, CHF, hip fracture, and GI hemorrhage. Their risk was also greater than that of women with AD for CHF, pneumonia, hip fracture, and GI hemorrhage. With the exception of pneumonia, this risk difference notably exceeded the analogous difference between women and men without AD. Hospital staff should be alerted to greater mortality risk for men with AD, as this risk may indicate lower quality of care.

Noradrenergic activity is associated with response to pindolol in aggressive Alzheimer's disease patients

Loss of noradrenergic (NE) neurones in the locus ceruleus and compensatory changes in NE activity have been described in Alzheimer's disease (AD), but have never been linked to treatment. The hypothesis of this study was that central NE responsivity would predict aggression response to treatment with a NE medication, pindolol. Fifteen institutionalized AD subjects [Mini-Mental State Examination (MMSE), mean 3.3 +/- 4.6] with significant behavioural disturbances (Neuropsychiatric Inventory Score, mean 30.6 +/- 14.6) were studied. Growth hormone (GH) response to clonidine challenge (5 microg/kg) was used as a measure of central NE responsivity. Subjects were then randomized to 7 weeks of treatment with pindolol, maximum dose 20 mg b.i.d., or an identical placebo capsule in a cross-over design. The primary outcome measure was change on the retrospective Overt Aggression Scale (r-OAS). Five of 11 completers (45%) had decreased total r-OAS scores. There was significant improvement noted on the r-OAS verbal aggression subscale (paired t = -2.5, p = 0.03) compared to placebo, but not r-OAS total. Higher baseline aggression, higher MMSE and lower GH response predicted improvement in aggression, accounting for 82% of the variance (r = 0.91, F = 10.5, p = 0.006). Changes in NE responsivity, as reflected by a blunted GH response to clonidine challenge and more severe aggression, were associated with better response to the NE agent pindolol. Individual patient characteristics, including underlying neurotransmitter changes, may be useful for predicting response to therapy.

Differential involvement of 5-HT(1B/1D) and 5-HT6 receptors in cognitive and non-cognitive symptoms in Alzheimer's disease

Growing evidence suggests that a compromised serotonergic system plays an important role in the pathophysiology of Alzheimer's disease (AD). We assessed the expression of 5-HT(1B/1D) and 5-HT(6) receptors and cholinacetyltransferase (ChAT) activity in post-mortem frontal and temporal cortex from AD patients who had been prospectively assessed for cognitive function using the Mini-Mental State Examination (MMSE) and behavioral changes using the Present Behavioral Examination (PBE). 5-HT(1B/1D) and 5-HT(6) receptor densities were significantly reduced in both cortical areas. 5-HT(1B/1D) receptor density was correlated to MMSE decline in the frontal cortex, supporting its implication in memory impairment. The best predictor for lowered 5-HT(6) receptor density in the temporal cortex was the PBE measure of overactivity. The 5-HT(6)/ChAT ratio was related to aggression both in the frontal and temporal cortex. Therefore, antagonists acting at 5-HT(6) receptors could be useful in the treatment of non-cognitive symptoms associated to AD.

Allopurinol for the treatment of aggressive behaviour in patients with dementia

Aggressive behaviour is commonly observed in patients with dementia, and current pharmacological treatments are still deficient in terms of efficacy and tolerability. Allopurinol is an inhibitor of the enzyme xanthine oxidase, with previously suggested anti-aggressive effects. After successful treatment of aggression in two patients, we performed a case-series study with allopurinol 300 mg a day orally for 6 weeks (increasing 300 mg every 2 weeks if the response was less than 50%) in six patients with dementia associated with prominent aggressive behaviour who failed to respond to two previous treatment strategies. Five patients were considerably responsive to allopurinol (four with 300 mg within 2 weeks and one with 600 mg), apparently without side-effects, which is in accordance with its well-established safety and tolerability profile. The observed therapeutic effect of allopurinol might be due to the inhibition of the enzyme xanthine oxidase, possibly decreasing production of oxygen-free radicals or promoting the accumulation of purines. Controlled studies are warranted to confirm these preliminary observations.