Longitudinal predictors of non-aggressive agitated behaviors in the elderly

Using Structured Observations to Evaluate the Effects of a Personalized Music Intervention on Agitated Behaviors and Mood in Nursing Home Residents With Dementia: Results From an Embedded, Pragmatic Randomized Controlled Trial

OBJECTIVE

The objective of this research was to determine if a personalized music intervention reduced the frequency of agitated behaviors as measured by structured observations of nursing home (NH) residents with dementia.

DESIGN

The design was a parallel, cluster-randomized, controlled trial.

SETTING

The setting was 54 NH (27 intervention, 27 control) from four geographically-diverse, multifacility NH corporations.

PARTICIPANTS

The participants were 976 NH residents (483 intervention, 493 control) with Alzheimer's disease or related dementias (66% with moderate to severe symptoms); average age 80.3 years (SD: 12.3) and 25.1% were Black.

INTERVENTION

The intervention was individuals' preferred music delivered via a personalized music device.

MEASUREMENT

The measurement tool was the Agitated Behavior Mapping Instrument, which captures the frequency of 13 agitated behaviors and five mood states during 3-minute observations.

RESULTS

The results show that no verbally agitated behaviors were reported in a higher proportion of observations among residents in NHs randomized to receive the intervention compared to similar residents in NHs randomized to usual care (marginal interaction effect (MIE): 0.061, 95% CI: 0.028-0.061). Residents in NHs randomized to receive the intervention were also more likely to be observed experiencing pleasure compared to residents in usual care NHs (MIE: 0.038; 95% CI: 0.008-0.073)). There was no significant effect of the intervention on physically agitated behaviors, anger, fear, alertness, or sadness.

CONCLUSIONS

The conclusions are that personalized music may be effective at reducing verbally-agitated behaviors. Using structured observations to measure behaviors may avoid biases of staff-reported measures.

Generation and Characterization of a Human-Derived and Induced Pluripotent Stem Cell (iPSC) Line from an Alzheimer's Disease Patient with Neuropsychiatric Symptoms

Agitation is one of the most eminent characteristics of neuropsychiatric symptoms (NPS) affecting people living with Alzheimer's and Dementia and has serious consequences for patients and caregivers. The current consensus is that agitation results, in part, from the disruption of ascending monoamine regulators of cortical circuits, especially the loss of serotonergic activity. It is believed that the first line of treatment for these conditions is selective serotonin reuptake inhibitors (SSRIs), but these are effective in only about 40% of patients. Person-specific biomarkers, for example, ones based on in vitro iPSC-derived models of serotonin activity, which predict who with Agitation responds to an SSRI, are a major clinical priority. Here, we report the generation of human-induced pluripotent stem cells (iPSCs) from a 74-year-old AD patient, the homozygous APOE ε4/ε4 carrier, who developed Agitation. His iPSCs were reprogrammed from peripheral blood mononuclear cells (PBMCs) using the transient expression of pluripotency genes. These display typical iPSC characteristics that are karyotypically normal and attain the capacity to differentiate into three germ layers. The newly patient-derived iPSC line offers a unique resource to investigate the underlying mechanisms associated with neuropsychiatric symptom progression in AD.

Pain, Neuropsychiatric Symptoms, and Quality of Life of Nursing Home Residents With Advanced Dementia in The Netherlands: A Cross-sectional Study

BACKGROUND

Many studies have investigated factors associated with quality of life (QoL) in nursing home residents with dementia. Both pain and neuropsychiatric symptoms (NPS) are clinically relevant and individually associated with a lower QoL; however, there are no studies that investigated pain and NPS together in relation to QoL.

PURPOSE

In this study, we explored the relationship of pain and NPS with QoL in nursing home residents with dementia by investigating the association between pain concurrently with NPS, and QoL.

METHODS AND PATIENTS

Secondary data analyses of cross-sectional data from 199 residents were collected by observations at dementia special care units of 10 nursing homes. QoL was measured with Qualidem, pain with the Mobilization Observation Behavior Intensity Dementia (MOBID-2) Pain Scale and NPS with the Neuropsychiatric Symptoms Inventory. The relation of pain and NPS to QoL was studied using multiple linear regression analyses. Analyses were adjusted for age, sex, activities of daily living, comorbidity, medication use, and dementia severity.

RESULTS

Regression models with pain and NPS, showed no independent relationship between pain and QoL subdomains, but NPS, in particular agitation and depressive symptoms, were significantly associated with lower QoL subdomain scores. Agitation was related to lower scores on the subdomains "relationship" [95% confidence interval (CI), -0.083 to -0.059], "positive affect" (95% CI, -0.037 to -0.013), "restless tense behavior" (95% CI, -0.003 to -0.004), and "social relations" (95% CI, -0.033 to -0.009), whereas depression was related to lower scores on the subdomains "positive affect" (95% CI, -0.054 to -0.014), "negative affect" (95% CI, -0.114 to -0.074), "restless tense behavior" (95% CI, -0.075 to -0.025), and "social relations" (95% CI, -0.046 to -0.002).

CONCLUSIONS

Only NPS were significantly associated with QoL in nursing home residents with dementia. Further longitudinal research is needed to estimate the nature of the relationship between pain, NPS, and QoL.

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background

Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.

Objectives

To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.

Review methods

Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.

Design

ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.

Settings

ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.

Participants

ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.

Intervention

An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.

Main outcome measures

ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.

Results

ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.

Limitations

Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.

Conclusions

A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.

Future work

There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.

Trial registration

Current Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

An RCT to evaluate the utility of a clinical protocol for staff in the management of behavioral and psychological symptoms of dementia in residential aged-care settings

OBJECTIVES

Behavioral and psychological symptoms of dementia (BPSD) cause significant stress and distress to both aged-care residents and staff. This study evaluated a training program to assist staff to manage BPSD in residential care.

METHOD

A randomised controlled trial (RCT) was employed. The study was included in the Australian and New Zealand Clinical Trial Register residential care facilities. Staff (n = 204) and residents (n = 187) were from 16 residential care facilities. Facilities were recruited and randomly assigned to four staff training conditions: (1) training in the use of a BPSD-structured clinical protocol, plus external clinical support, (2) a workshop on BPSD, plus external clinical support, (3) training in the use of the structured clinical protocol alone, and (4) care as usual. Staff and resident outcome measures were obtained pre-intervention, three months and six months post-intervention. The primary outcome was changes in BPSD, measured using the Cohen-Mansfield Agitation Inventory (CMAI) as well as frequency and duration of challenging behaviors. Secondary outcomes were changes in staff adjustment.

RESULTS

There were improvements in challenging behaviors for both intervention conditions that included training in the BPSD instrument, but these were not maintained in the condition without clinical support. The training/support condition resulted in sustained improvements in both staff and resident variables, whereas the other conditions only led to improvement in some of the measured variables.

CONCLUSION

These results demonstrate the effectiveness of the BPSD protocol in reducing BPSD and improving staff self-efficacy and stress.

Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: a longitudinal cohort study

Pain was common but difficult to detect in hospitals in patients with dementia who had difficulties with self-report. It was associated with aggression and anxiety.

Pain is underdetected and undertreated in people with dementia. We aimed to investigate the prevalence of pain in people with dementia admitted to general hospitals and explore the association between pain and behavioural and psychiatric symptoms of dementia (BPSD). We conducted a longitudinal cohort study of 230 people, aged above 70, with dementia and unplanned medical admissions to 2 UK hospitals. Participants were assessed at baseline and every 4 days for self-reported pain (yes/no question and FACES scale) and observed pain (Pain Assessment in Advanced Dementia scale [PAINAD]) at movement and at rest, for agitation (Cohen–Mansfield Agitating Inventory [CMAI]) and BPSD (Behavioural Pathology in Alzheimer Disease Scale [BEHAVE-AD]). On admission, 27% of participants self-reported pain rising to 39% on at least 1 occasion during admission. Half of them were able to complete the FACES scale, this proportion decreasing with more severe dementia. Using the PAINAD, 19% had pain at rest and 57% had pain on movement on at least 1 occasion (in 16%, this was persistent throughout the admission). In controlled analyses, pain was not associated with CMAI scores but was strongly associated with total BEHAVE-AD scores, both when pain was assessed on movement (β = 0.20, 95% confidence interval [CI] = 0.07-0.32, P = 0.002) and at rest (β = 0.41, 95% CI = 0.14-0.69, P = 0.003). The association was the strongest for aggression and anxiety. Pain was common in people with dementia admitted to the acute hospital and associated with BPSD. Improved pain management may reduce distressing behaviours and improve the quality of hospital care for people with dementia.

The character of behavioural symptoms on admission to three Canadian long-term care homes

OBJECTIVES

We determined the prevalence and nature of behavioural symptoms at the time of admission to a long-term care home (LTCH) and occurrence of resident-to-resident aggressive behaviour associated with behavioural symptoms within three months following admission.

METHOD

The Cohen-Mansfield Agitation Inventory and Aggressive Behaviour Scale were completed at the time residents were admitted into the LTCH. A chart review, conducted three months after admission into the LTCH, abstracted documented resident-to-resident aggression. Three LTCHs located in Ontario, Canada participated in the study.

RESULTS

During a 16-month period, 339 individuals admitted to the LTCHs comprised the study sample. A comparison was made between residents with and without dementia. At admission, residents with dementia had a greater number of behavioural symptoms than those without dementia (mean = 3.79, SD = 3.32 versus mean = 2.56, SD = 2.24, respectively; t(200) = 1.91; p = 0.059). Residents with and without dementia exhibited similar behaviours but differed on the prevalence of these behaviours. The most frequently reported behavioural symptoms for residents in both groups were verbal agitation and non-aggressive physical behaviours. The most frequently recorded aggressive behaviour for all residents was 'resisting care'. In the three months post admission, 79 (23%) residents were involved in a documented incident that involved aggressive behaviour to another resident.

CONCLUSION

A standardized comprehensive assessment for admission to a LTCH is an important strategy that can be used to identify behavioural symptoms and plan appropriate care management.

The response of agitated behavior to pain management in persons with dementia

OBJECTIVES

Behavioral disturbances and pain are common in nursing home (NH) patients with dementia. An association between pain and increased agitation has been suggested, and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia. We now examined which specific agitated behaviors respond to individualized pain treatment.

DESIGN

Cluster randomized clinical trial.

SETTING

60 clusters (i.e., clusters defined as single independent NH units) in 18 NHs within five municipalities of Western Norway.

PARTICIPANTS

352 patients with moderate to severe dementia and clinically significant behavioral disturbances.

INTERVENTION

The control group received usual treatment and care. According to a predefined scheme for 8 weeks, all patients in the intervention group received individual daily pain treatment with acetaminophen, extended release morphine, buprenorphine transdermal patch, and/or pregabaline.

MEASUREMENTS

Cohen-Mansfield Agitation Inventory subscales and items.

RESULTS

Analyses demonstrated that Factor 3 (Verbally agitated behaviors) showed the largest significant difference (DF = 1204.0, t = -4.308, p <0.001), followed by Factor 2 (Physically non-aggressive behaviors) (DF = 1198.0, t = -2.672, p = 0.008), and Factor 1 (Aggressive behaviors) (DF = 1196.0, t = -2.093, p = 0.037) after 8 weeks, by a linear random intercept mixed model in two-way repeated-measures configuration with adjustment for heteroscedasticity.

CONCLUSION

We found that verbal agitation behaviors such as complaining, negativism, repetitious sentences and questions, constant request for attention, and cursing or verbal aggression responded to pain treatment. In addition, restlessness and pacing were sensible to analgesics. Such behaviors should therefore lead to an assessment of pain, and pain treatment. Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed.

Relationship-based care and behaviours of residents in long-term care facilities

Introduction. In long-term care (LTC), person-centred approaches are encouraged. One such approach, relationship-based care (RBC), aims among other things to reduce residents' agitated behaviours. RBC has been used in numerous Quebec LTC facilities over the past decade but it has never been studied. Objective. Explore correlations between use of RBC by trained caregivers and the frequency of agitated and positive behaviours of residents with cognitive impairments. Methods. Two independent raters observed fourteen caregiver/resident dyads in two LTC facilities during assistance with hygiene and dressing. Checklists were used to quantify caregivers' RBC use and residents' agitated and positive behaviours. Results. Scores for RBC use were high, suggesting good application of the approach by caregivers. Correlation analyses showed that offering residents realistic choices and talking to them during care were associated with both positive and agitated behaviours (P from 0.03 to 0.003). However, many other components of RBC were not associated with residents' behaviours during care. Conclusions. There were only a few quantitative links between the RBC checklist items and the frequency of agitated or positive behaviours. Other studies with a more rigorous research design are needed to better understand the impact of relationship-based care on residents' behaviours.

Apolipoprotein E genotypes and neuropsychiatric symptoms and syndromes in late-onset Alzheimer's disease

Neuropsychiatric symptoms (NPS) in dementia, previously denominated as behavioural and psychological symptoms of dementia, are often more distressing, impairing, and costly than cognitive symptoms, representing a major health burden for older adults. These symptoms are common features of Alzheimer's disease (AD), and are one of the major risk factors for institutionalization. There is a high prevalence of neuropsychiatric disturbances in patients with AD, including depression, anxiety, apathy, psychosis, aggression, and agitation. At present, the role of the apolipoprotein E (APOE) genotypes in the development of NPS or neuropsychiatric syndromes/endophenotypes in AD patients is unclear. In this article, we summarized the findings of the studies of NPS and neuropsychiatric syndromes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between the APOE polymorphism and NPS in late-onset AD, other studies reported a significant association between the APOE ɛ4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. However, current cumulative evidence coming from the few existing longitudinal studies shows no association of APOE genotypes with NPS as a whole in AD. Some negative studies that focused on the distribution of APOE genotypes between AD patients with or without NPS further emphasized the importance of sub-grouping NPS in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, possible lack of statistical power to detect associations in the negative studies, and small sample sizes generating false positives that cannot be consistently replicated. Finally, many reviewed studies were cross-sectional, whereas it would be of paramount importance to evaluate the risk for incident NPS in relation to the APOE genotype in prospectively followed cohorts of AD patients. In fact, identifying predisposing genetic risk factors may allow us to understand the pathophysiological features of neuropsychiatric syndromes or symptoms in AD, so optimizing possible therapeutic options.

Neuropsychiatric Symptoms, Endophenotypes, and Syndromes in Late-Onset Alzheimer's Disease: Focus on APOE Gene

Neuropsychiatric symptoms, previously denominated as behavioural and psychological symptoms of dementia, are common features of Alzheimer's disease (AD) and are one of the major risk factors for institutionalization. At present, the role of the apolipoprotein E (APOE) gene in the development of neuropsychiatric symptoms in AD patients is unclear. In this paper, we summarized the findings of the studies of neuropsychiatric symptoms and neuropsychiatric syndromes/endophenotypes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between APOE and neuropsychiatric symptoms in late-onset AD, other studies reported a significant association between the APOE ε4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. Furthermore, some negative studies that focused on the distribution of APOE genotypes between AD patients with or without neuropsychiatric symptoms further emphasized the importance of subgrouping neuropsychiatric symptoms in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, and possible lack of statistical power to detect associations in the negative studies.

Acute pain management in hospitalized patients with cognitive impairment: a study of provider practices and treatment outcomes

BACKGROUND

Despite new guidelines and nationally mandated regular assessments, managing pain in cognitively impaired patients remains a complex and challenging task. Numerous studies have focused on assessing pain in this population; however, studies of treatment are limited.

PURPOSE

The purpose of this article was to characterize assessment and pain management strategies used by providers caring for hospitalized cognitively impaired patients with acute pain, and to assess for associations between amount of opioid received and specific adverse outcomes in this patient population.

METHODS

Medical records of patients admitted to the Geriatrics Service or Orthopedic Service or evaluated by the Geriatrics Consult Service at an urban tertiary care hospital between September 01, 2006 and September 30, 2007 with cognitive impairment and an acute pain problem on admission were reviewed.

RESULTS

Participants (N=100) had a mean age of 86 years (range=68-99), and were mostly female (83%) with fracture-related pain (62%). A numeric pain score was recorded in 67% of nursing assessments vs <5% of physician assessments. Opioids were prescribed for 100% of the surgical patients vs 43% of the medical patients. Only 15% of patients were placed on a standing analgesic regimen. Nonpharmacological management was employed for 75% of surgical patients vs 43% of medical patients. Delirium occurred in 27% of patients, and 33% experienced an interruption of physical therapy. Neither, however, was associated with level of opioid use.

CONCLUSIONS

Current assessment and treatment practices in acute pain management for cognitively impaired patients vary widely (to include service and provider type). Implementation of evidence-based guidelines is needed to improve patient care.

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.

Étude préliminaire d'une intervention non-pharmacologique pour réduire l'agitation verbale chez les personnes atteintes de démence

Verbally agitated behaviours are among the behavioural symptoms of dementia most commonly encountered in long-term care facilities. These behaviours may be related to unmet needs that cannot be expressed adequately because of cognitive impairment. The objective of this preliminary study is to assess an intervention, based on the needs of social attention, sensory stimulation, and comfort, for managing verbally agitated behaviours in long-term care demented patients. A multiple baseline case study design was used, with two participants.

Research agenda for DSM-V: diagnostic categories and criteria for neuropsychiatric syndromes in dementia

Neuropsychiatric symptoms in dementia represent a major health burden for older adults. These symptoms are often more distressing, impairing, and costly than cognitive symptoms in dementia, yet they have been less coherently categorized in the various versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The preponderance of literature on psychiatric symptoms in dementia has been in patients with Alzheimer's disease. Diagnostic criteria have been proposed for psychosis, depression, and sleep disturbance in Alzheimer's disease. "Agitation" also appears to be a clinically important behavioral complication of dementia that warrants further study. Beginning with further validation of these proposed diagnostic criteria, future research can guide a more clinically meaningful description of these syndromes in DSM-V. Advancing biotechnology offers promise for discoveries related to the etiology and treatment of these syndromes. New research in this field should encompass diverse populations and different types of dementia. The high emotional and economic costs of neuropsychiatric symptoms in dementia implore diagnostic refinement to facilitate improved treatment.

The Relationship Between Pain, Neuropsychological Performance, and Physical Function in Community-Dwelling Older Adults with Chronic Low Back Pain

OBJECTIVE

Chronic pain and cognitive impairment are prevalent and disabling in older adults (OA), but their interrelationship has not been rigorously tested. We did so in OA with chronic low back pain (CLBP).

DESIGN

A total of 323 OA (160 pain-free, 163 CLBP; mean age 73.5 years, 45% female) had neuropsychological (NP) testing with the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test, and the Grooved Pegboard Test. Pain intensity was measured with the McGill Pain Questionnaire Short Form. Physical performance (gait speed, functional reach, chair rise, trunk rotation, and static/dynamic lifting), psychosocial disruption (Geriatric Depression Scale, the Short Form-36 Mental Health and Role Limitations-Emotional Composite scale), and self-reported disability (Functional Status Index, the Short From-36 Physical Functioning/Role-Physical Composite scale) were also measured.

SETTING

Outpatient research laboratory.

RESULTS

There were no group differences in age, gender, or educational level, but significant differences in NP scores (P = 0.01) were found. Five scales accounted for the differences: immediate memory (P = 0.002), language (P = 0.004), delayed memory (P = 0.04), mental flexibility (Trails B [P = 0.02]), and Grooved Pegboard (P = 0.05). NP scores were significantly correlated with physical performance (R2= 0.30, P < 0.001), but not self-reported disability (R2= 0.04, P = 0.52) or psychosocial disruption (R2= 0.05, P = 0.46). NP function was correlated with pain intensity (R2= 0.17, P < 0.001), and NP function mediated the relationship between pain and physical performance.

CONCLUSIONS

OA with CLBP demonstrated impaired NP performance as compared with pain-free OA. Further, pain severity was inversely correlated with NP performance, and NP performance mediated the relationship between pain and physical performance. Future research should examine whether cognitive function and impaired physical performance can be improved with pain reduction.

Factors Associated with Self- and Caregiver Report of Pain among Community-Dwelling Persons with Dementia

BACKGROUND

Among cognitively intact patients, self- and caregiver report of patient pain has been associated with worse psychological health for both the patient and caregiver. Little existing research examines factors associated with patient self-report of pain and caregiver report of patient pain among community-dwelling persons with dementia.

OBJECTIVE

To identify patient and caregiver factors associated with self- and caregiver report of patient pain among community-dwelling persons with dementia.

DESIGN

Cross-sectional analysis of a longitudinal study using structured interviews with dementia patients and their family caregivers.

SETTING AND SUBJECTS

Urban outpatient geriatrics clinics affiliated with a university hospital. Dyads composed of dementia patients and their family caregivers were approached prior to routine clinic visits to participate in the study.

MEASUREMENTS

Relevant patient measurements included self-report of pain; cognitive, functional, and comorbidity assessments; a screen for depression; and demographic information. Relevant caregiver measurements included their report of patient pain and agitation, screens for depression and strain, and demographic information.

RESULTS

Of 115 dyads, 37 patients (32%) and 57 caregivers (53%) reported the patient to be in pain. No patient or caregiver factors were significantly associated with patient self-report of pain. In the univariate analysis, caregiver reports of patient pain were associated with the patient not being depressed (p = .036), caregiver reports of patient agitation (p = .038), higher level of education in the caregiver (p = .029), and caregiver depression (p = .019). In multivariate logistic regression analyses, caregiver depression and patient agitation remained significantly associated with caregiver report of patient pain.

CONCLUSIONS

In community-dwelling persons with dementia, self-report of pain was not associated with any other variables measured, suggesting that pain should be assessed through direct self-report and treated accordingly. Caregiver report of patient pain was associated with both caregiver report of patient agitation and caregiver depression. These findings suggest that clinicians may need to routinely assess patient pain, patient agitation, and caregiver depression. More research is needed to understand the relationship between these conditions.

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

OBJECTIVE

More than a decade ago, different syndromes of agitation were identified in elderly nursing home residents, and it was found that these syndromes correlate with medical, cognitive, and psychosocial functioning. The present study was conducted to examine the robustness of two major syndromes, verbal agitation and physical non-aggressive agitation, as assessed via direct observations.

METHODS

Study participants were 175 elderly persons with dementia recruited from 11 nursing home facilities in Maryland. Observations of the participants' behavior were conducted using the agitated behaviors mapping instrument.

RESULTS

The profiles that emerged for physically agitated residents and for verbally agitated residents were remarkably similar to those originally reported. Specifically, verbally agitated behaviors correlated with female gender, with cognitive decline, poor performance of activities of daily living, impaired social functioning, and signs of depressed affect. Physically non-aggressive agitated behaviors correlated with cognitive impairment and with fewer concurrent medical diagnoses.

CONCLUSIONS

Examining correlates of different syndromes of agitated behaviors may provide researchers with valuable information that can be used for in-depth analysis of both the characterization and etiology of agitation, thus paving the way for the development of interventions that target particular types of problem behaviors.

Vocally disruptive behaviour in dementia: development of an evidence based practice guideline

Vocally Disruptive Behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests. It is one of the most challenging behaviours for nursing home staff, caregivers for people with dementia, and other nursing home residents. As with other behavioural disturbances, multiple causal factors have been identified in the literature and individual cases may have a number of interacting factors. There is a lack of consensus about how to treat VDB. Systematic treatment studies are few and there is a lack of empirical data supporting the effectiveness of specific interventions commonly used in clinical practice. This hinders clinicians and may result in the use of inappropriate treatments. Our aim was to systematically review the literature in order to develop a practice guideline for the assessment and management of VDB. The review will examine the typology, risk factors and management of VDB.

Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management

OBJECTIVES

To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.

DESIGN

Cross-sectional study.

SETTINGS

A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina).

PARTICIPANTS

A total of 2,078 RC/AL residents aged 65 and older.

MEASUREMENT

Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined.

RESULTS

Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness).

CONCLUSION

Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting.

Special Care Facility Compared with Traditional Environments for Dementia Care: A Longitudinal Study of Quality of Life

OBJECTIVES

To compare the effect of a specialized care facility (SCF) on quality of life (QoL) for residents with middle- to late-stage dementia over a 1-year period with residence in traditional institutional facilities.

DESIGN

A prospective, matched-group design with assessments of QoL every 3 months for 1 year.

SETTING

Twenty-four long-term care centers and four designated assisted living environments in an urban center in western Canada.

PARTICIPANTS

One hundred eighty-five residents with Global Deterioration Scores of 5 or greater were enrolled: 62 in the intervention SCF group and 123 in the traditional institutional facilities groups.

INTERVENTION

The SCF is a 60-bed purpose-built facility with 10 people living in six bungalows. The facility followed an ecologic model of care that is responsive to the unique interplay of each person and the environment. This model encompasses a vision of long-term care that is more comfortable, more like home, and offers more choice, meaningful activity, and privacy than traditional settings.

MEASUREMENTS

QoL outcomes were assessed using the Brief Cognitive Rating Scale, Functional Assessment Staging, Cohen-Mansfield Agitation Inventory, Pleasant Events Scale-Alzheimer's disease, Multidimensional Observation Scale of Elderly Subjects, and Apparent Affect Rating Scale.

RESULTS

The intervening SCF group demonstrated less decline in activities of daily living, more sustained interest in the environment, and less negative affect than residents in the traditional institutional facilities. There were no differences between groups in concentration, memory, orientation, depression, or social withdrawal.

CONCLUSION

The present study suggests that QoL for adults with middle- to late-stage dementia is the same or better in a purpose-built and staffed SCF than in traditional institutional settings.

Escalation/de-escalation patterns of behavioral symptoms of persons with dementia

Behavioral and psychological symptoms of dementia (BPSD) may be framed within the Needs Driven Dementia-Compromised Behavior (NBD) Model. Current literature suggests that BPSD may escalate. Several researchers have described a sequence of behavioral escalation that has a clear starting point and ending point. This 'ideal' or concatenated sequence is used to explain behavior that begins with relatively calm behavior and progresses through a prescribed sequence of behaviors that end in violence. This article presents two studies, a descriptive study and an intervention study that examine the escalation and de-escalation patterns of BPSD. Results of the descriptive study indicate a dominant pattern of agitation, aggression, and agitation while results of the intervention study, using sequential analysis indicate persistence of behavior from one 20-minute period to another. The persistence of vocalization at intensity level 2 changed from pre-intervention (mean conditional probability 29%) to post-intervention (mean conditional probability 13%). Taken together these studies shed light on the pattern of escalation and de-escalation of BPSD and suggest an intervention to alter behavior persistence. This article discusses methodological challenges of measuring the escalation and de-escalation of BPSD and offers suggestions for analysis and design such as time series and sequential analysis.

Acoustic properties of vocally disruptive behaviors in the nursing home

BACKGROUND

Disruptive vocalizations are among the most common behavior problems in the nursing home. However, their acoustic properties have not been previously investigated.

OBJECTIVE

This paper examines the acoustic properties of disruptive vocalizations and attempts to link them to resident and verbalization characteristics.

METHODS

This study characterizes the sounds emitted by 26 nursing home residents who manifested disruptive vocalizations. Verbalizations were audiotaped and then used in a sonographic evaluation and an acoustic analysis.

RESULTS

Vocalizations of verbally agitated nursing home residents were characterized by their relatively short duration. Consistent positive correlations were found between seemingly disturbing types of vocalizations, such as yelling and howling, and higher levels of several parameters of the fundamental frequency. A similar positive correlation was also found between acoustic parameters and medical disease indicators. With the exception of the length of stream of utterances, the indicators did not differentiate between types of dementia.

CONCLUSIONS

Because of the large number of comparisons undertaken, it is difficult to conclude which associations between acoustic properties and resident or vocalization characteristics are attributable to real underlying trends and which are due to chance and error. Consistencies that deserve further research pertain to the perceptions of the types of vocalizations the person tends to emit and to the physical health of the person.

Correlates of behavioral disturbances and pattern of psychotropic medication use in five skilled nursing facilities

There are several treatment options for behavioral disturbances (BDs) in dementia. However, the choice of a specific psychotropic agent is directed by personal preferences and local community practice patterns. We examined the relationship between common clusters of BDs and the use of different classes of psychotropic agents in our community. A cross-sectional study of 430 long-term care residents from 5 nursing homes was undertaken. The Behavior Measurement Scale (BMS) was used to measure the frequency of BDs grouped in 4 categories. Residents with > 4 BD episodes in at least one category during a 2-week observation period were the behavior group and were considered to have clinically significant BDs. A sample of patients who had < 4 BDs in all BMS categories during the same observation period defined the nonbehavior group. A BD cluster was defined as > 4 BDs occurring in one or more BMS categories during the 2-week observation. Data on functional status, comorbidity, use of benzodiazepines, antidepressants, and neuroleptic agents were collected with chart review. The chi-square test was used to examine the correlation between variables. Clinically significant BDs were identified in 27.2% (117/430) of the residents in the sample. Five of 15 behavior clusters accounted for 73% of all clinically significant BDs. The 5 clusters were verbally nonaggressive behaviors (cluster 1, 20.5%), behaviors from all 4 categories (cluster 2, 17.9%), verbally and physically nonaggressive behaviors (cluster 3, 14.5%), physically nonaggressive behaviors (cluster 4, 12.8%), and verbally aggressive and nonaggressive behaviors (cluster 5, 7.7%). Cluster 5 had a negative correlation with functional impairment (P = .009). There was a significant correlation between cluster 2 and benzodiazepine use (P = .014). No other significant correlation was found between any of the 5 clusters and demographic variables, comorbidity status, and use of antidepressant or neuroleptic medications. Residents in the behavior group had higher impairment in self-feeding (P = .036) and bathing (P < .001) and were more likely to be treated with benzodiazepines (P = .004) and neuroleptic agents (P = .009) than residents in the nonbehavior group (n = 116). The higher use of neuroleptics and benzodiazepines in the behavior group compared with the nonbehavior group indicates that BDs are being identified for treatment, but the medications used may not be efficacious. The lack of association between specific classes of psychotropic medications and distinct behavior clusters indicates that clinicians are not using a standardized approach to target the neurochemical abnormalities that may underlie certain behavior clusters. Some behavior clusters correlate with impairment in specific activities of daily living categories such as bathing and feeding, making room for nonpharmacologic interventions.

Prevalence and correlates of behavioral and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive impairment: the Memory and Medical Care Study

BACKGROUND

Little is known about the prevalence and correlates of behavioral and psychiatric symptoms of dementia in community-dwelling elders with dementia or mild cognitive impairment (MCI).

METHODS

512 people with Mini-Mental State Examination (MMSE) scores < 24 or a decline of at least 4 points over two administrations, and their knowledgeable informants (KIs) were enrolled in the MMCS. The classification of subjects as having dementia or MCI was based on a neuropsychological battery of four tests, not a clinical diagnostic evaluation. The sample for this study included 454 subjects (dementia n = 333; MCI n = 121) and their KIs. Demographic and health-related characteristics of subjects and KIs were obtained during KI interviews. Multivariate logistic regression was used in statistical analysis.

RESULTS

Compared to dementia subjects, those classified as MCI had a lower prevalence (47.1% vs 66.1%) of any symptoms (psychosis, depression, or agitation), and of agitation (24.8% vs 45.1%). Symptoms of psychosis and depression also were less prevalent, even though differences did not reach statistical significance. In the dementia group symptoms were associated with a report of a physician's diagnosis of dementia, greater functional impairment, and a KI who was a child/child-in-law. In those with MCI, symptoms were correlated with being white, greater functional impairment, and a younger, less educated, KI.

CONCLUSIONS

Psychiatric and behavioral symptoms were common in community-residing elders with cognitive impairment, but their prevalence and correlates differed by study classification as having dementia or MCI. Identifying and treating these symptoms may benefit patients with cognitive impairment and their families. Longitudinal studies on the predictors, changes in prevalence, and effectiveness of treatments for psychopathology of dementia are needed.

Pain Assessment for the Dementing Elderly (PADE): reliability and validity of a new measure

OBJECTIVES

To establish the reliability and validity of a measure to assess pain in individuals with advanced dementia.

DESIGN

Sixty-five residents of long-term care facilities were assessed using a new rating tool, the Pain Assessment for the Dementing Elderly (PADE), in two separate studies: (1) Residents were assessed simultaneously by two different raters, at Time 1 and 2, to establish interrater reliability, stability, and internal consistency. (2) Validity was established by assessing the correlation between an agitation scale and the PADE; by comparing groups with pain as a significant clinical factor (as assessed by an independent rater) versus not a significant factor, and by assessing individuals receiving versus not receiving psychoactive medications.

SETTING

Four different long-term care facilities, three skilled nursing facilities, and a locked dementia assisted-living facility.

PARTICIPANTS

Twenty-five residents of long-term care facilities with advanced levels of dementia in Study 1, and 40 residents with similar level of dementia in Study 2; 42% of the total sample were rated as having significant painful conditions.

MEASUREMENTS

For Study 1, the PADE was administered; for Study 2, the PADE and the Cohen-Mansfield Agitation Inventory (CMAI) were administered.

RESULTS

Reliability coefficients were adequate (interrater = 0.54-0.95; stability = 0.70-0.98; and internal consistency = 0.24-0.88). Validity coefficients were likewise encouraging, with the PADE demonstrating the expected relationship with a measure of agitation. The PADE also differentiated between groups that were independently judged to suffer clinically problematic pain versus those who were not.

CONCLUSION

The PADE is a reliable and valid tool to assess pain in dementing elderly residents of long-term care facilities.