Behavioral symptoms in dementia: an update

Passive behaviors in Alzheimer' disease: A descriptive analysis

Fifteen empirical studies investigating passive behaviors (PB) in Alzheimer's disease (AD) were examined. Results indicated that PB are distinct from depression; they tend to increase over the course of the disease; and they can be related to cognitive status and personality changes. Absence of theoretical frameworks, lack of an instrument specifically designed to measure PB in AD, and no clearly established operational concept capable of describing and unifying behaviors into a syndrome of passivity represent problem areas for researchers. Future research to determine whether PB are a “default” mechanism brought on by AD itself or the result of a need to isolate or withdraw in order to cope with multiple stressors is indicated. Antecedent behaviors, those associated with passivity itself as well as caregiver responses and interventions also warrant investigation.

Determinants of Neuroleptic Drug Use in Long-Term Facilities for Elderly Persons

Neuroleptics, also called antipsychotic drugs (e.g., haloperidol, risperidone) are the cornerstone drug therapy for psychiatric disorders. Despite the fact that they are widely used in nursing homes, little is known about their clinical determinants. The goal of this cross-sectional study was to determine the prevalence rate of neuroleptic administration and to identify their determinants among 2,332 elderly residents in nursing homes. Among the residents, 649 (27.8%) had taken at least one neuroleptic drug. According to the logistic regression, the factors associated with neuroleptic drug consumption were younger age, few hours of family visits, severe cognitive impairment, insomnia, physical restraint, and disruptive behavior. In conclusion, neuroleptic drugs are administered to more than a quarter of residents in nursing homes. Alternative solutions to sleep problems and disruptive behaviors of the elderly living in long-term-care facilities should be implemented in order to reduce unnecessary use of neuroleptics.

Validation of a causal model of agitation among institutionalized residents with dementia in Taiwan

The aim of this study was to test a causal model of the predictors of agitation among 405 nursing home residents in Taiwan with varying degrees of cognitive impairment. Chart review and behavioral observations were used to assess residents' physical and psychosocial condition. The final version of the model had a good fit. Cognitive function and depression had direct effects on agitation, and pain and functional ability had indirect effects on agitation via depression. Additionally, cognitive function and pain influenced functional ability directly, which in turn influenced depression and ultimately influenced agitation. The results suggest that effective management of agitation in demented residents requires identifying the needs underlying the behavior rather than directly treating the behavior itself.

Validité et fidélité de l'Inventaire d'agitation de Cohen-Mansfield

Agitation in older persons is a major problem for the agitated individual and those around him/her. French-language measures of agitation with demonstrated validity and reliability are necessary for research and interventions in the French-speaking community. The goal of this study is to verify the reliability and validity of the “Inventaire d'agitation de Cohen-Mansfield” (IACM), a French version of the Cohen-Mansfield Agitation Inventory. The IACM measures the frequency of 29 agitated behaviours during a two-week period. Ninety-nine residents of a long-term care facility participated in this study. Results demonstrate the inter-rater reliability (r = .72), test-retest reliability (r = .72), internal consistency (Cronbach's alpha from .75 to .77), concurrent validity (r = .74) and construct validity (all r are significant, p < .05) of the IACM.

Geropharmacology: a primer for advanced practice. Acute care and critical care nurses, part II

In the first part of this 2-part continuing education series, sources of medication errors were discussed. A predominant source of errors was the prescribing of potentially inappropriate medications for older adults. In this second part, drug classifications and drugs posing problems for older adults and cautions for advanced practice acute care and critical care nurses in their medication therapy management are highlighted. Cautions are advanced for anticholinergics, antihypertensives, analgesics, and psychotropics because of the severity of adverse reactions, including anticholinergic symptoms; mental status changes (especially confusion, sedation, delirium, and cognitive impairment); orthostatic hypotension; gastrointestinal tract problems (especially hemorrhage); depression; and neurobehavioral disturbances (agitation and aggressiveness). Risks of life-threatening outcomes associated with medications and adverse reactions are highlighted.

Agitation and resistiveness to care are two separate behavioral syndromes of dementia

OBJECTIVES

To distinguish two behavioral syndromes of dementia: Agitation and resistiveness to care.

DESIGN

Analysis of Minimum Data Set (MDS) data.

SETTING

MDS data from Veterans Administration nursing homes collected from October 13, 2000, through October 14, 2004.

PARTICIPANTS

Participants were 23,837 residents with a positive diagnosis for Alzheimer's disease or dementia other than Alzheimer's.

MEASUREMENTS

Presence of agitation in each patient was based on the recorded value for 6 MDS variables: repetitive questions, repetitive verbalizations, expressions of what appear to be unrealistic fears, repetitive health complaints, repetitive anxious complaints or concerns, and repetitive physical movements. Patients who exhibited the MDS variable "resists care; resisted taking medications/injections, ADL assistance or eating" anytime within the last 7 days of the assessment and whose behavior was not easily altered were considered "resistive to care." Severity of dementia was measured by the Cognitive Performance Scale using 3 MDS items: short-term memory, cognitive skills for daily decision making, and making self understood.

RESULTS

Agitation alone was present in 17%, resistiveness to care alone in 9%, and both syndromes in 8% of residents. Agitation was present in a significant number of residents who were borderline intact, was most common in subjects with moderate cognitive impairment, and decreased thereafter. In contrast, resistiveness to care was relatively rare in borderline intact and mildly impaired residents and increased gradually, with the highest prevalence in those with very severe cognitive impairment. The prevalence of resistiveness to care increased as the ability to understand deteriorated. Most residents who were rated as having abusive symptoms were also resistive to care.

CONCLUSION

Agitation and resistiveness to care are 2 separate behavioral syndromes that may also occur together. It is important to distinguish between agitation and resistiveness to care because these syndromes require different management strategies.

Measurement and relevance of personality characteristics in persons with dementia: a longitudinal perspective

Studies of personality and outcomes in persons with dementia (PWD) have focused primarily on disease stages or change from premorbid personality following diagnosis. Data from a longitudinal study of 96 caregiver/PWD dyads was used to evaluate psychometric properties of two personality measures: one rated by proxies, the other by PWD. Proxy ratings indicate change in strength of personality traits across disease stages; self-ratings were stable, excepting decreased extroversion. Items detracting from reliability of some subscales reflected disease-related changes in PWD rather than true shifts in personality. Findings support importance of collecting both proxy and self-ratings of personality, examining individual items contributing to low reliability, and evaluating change in personality within the context of expected changes inherent in dementia.

Managing disruptive behaviors with neuroleptics: treatment options for older adults in nursing homes

Disruptive behaviors are frequent among elderly individuals in long-term care centers. Neuroleptics remain the most common pharmacological treatment for controlling these challenging behavioral manifestations. However, their effectiveness is a subject of controversy and it is unclear what specific behaviors are more likely to be managed with neuroleptic medications. The objective of this study was to identify the types of disruptive behaviors for which neuroleptics are given to elderly individuals in long-term care facilities and determine if the frequency of these behaviors increases the risk of being prescribed neuroleptics. A cross-sectional study was conducted with 2,332 participants ages 65 or older living in 28 long-term care facilities. Among them, 27.8% had taken at least one neuroleptic drug in the prior week. The administration of neuroleptics was not linked to the presence of any one specific disruptive behavior. However, a significant finding was that the greater the frequency of disruptive behavior exhibited by an elderly individual, the greater the risk of them being administered a neuroleptic medication. A multi-dimensional approach to the assessment of disruptive behaviors is recommended to facilitate the identification of the underlying causes of those behaviors. Accordingly, it is suggested that non-pharmacological treatment plans be adapted to each situation and then implemented to potentially reduce the use of neuroleptics.

A LRPAP1 intronic insertion/deletion polymorphism and phenotypic variability in Alzheimer disease

Alzheimer disease (AD) is a neurodegenerative disorder, characterized by dementia. AD exhibits variability in age at onset, rate of progression, and specific cognitive, functional, and behavioral features. Genetic variants are potential modulators of phenotypic variability. The purpose of this study was to explore the relationship between a polymorphism in the Low Density Lipoprotein Receptor Related Protein-Associated Protein (LRPAP1) gene (4p16.3) and repeated measures of cognition, function, and behavior in persons with AD, using outcome data collected in two caregiver intervention studies. Thirty-seven subjects diagnosed with probable or possible AD were recruited. All subjects were genotyped for a 37 basepair insertion/deletion polymorphism in intron 5 of the LRPAP1 gene. No differences in allele or genotype frequencies by gender or by age at onset were identified. No statistically significant genotype effects upon cognition or behavior were identified. However, trends were noted in measures of language, with the LRPAP1 insertion-positive subjects exhibiting poorer language scores (average score difference = 28%, p = .158). LRPAP1 insertion-positive subjects also were more functionally impaired than subjects without the LRPAP1 insertion allele (F1,7 = 7.36, p = .030). These results suggest genetic variations at the LRPAP1 locus may modulate AD phenotype beyond risk for disease.

Nurses' attitudes towards older residents with long-term schizophrenia

BACKGROUND

In institutional care, a symptom-oriented approach is a frequently used but seldom-discussed method for treating people with severe mental illness.

AIM

To investigate whether nurses' approach could be explained with reference to a client's individual clinical picture or the fact that they had a diagnosis of schizophrenia.

METHODS

An exploratory study of the staff's view of a caring approach for a fictitious older long-term schizophrenic resident was conducted. All nurses working in the field of psychiatry at seven different units in one municipality in northern Sweden were an integral part of the study. The units were divided into two groups and classified as 'dwelling' or 'support'. The 'dwelling group' was characterized by nurses working at traditional group dwellings, and the 'support group' by nurses working in small teams and visiting people with long-term mental illness in their homes. Responses were received from 62 women and 23 men, of whom 14 were Registered Nurses and 69 were Enrolled Nurses. A questionnaire was used, developed from a case description of a 68-year-old woman with typical symptoms of severe cognitive decline, with problematic behaviour and a diagnosis of long-term schizophrenia.

FINDINGS

The main finding was that nurses with long experience became less sensitive in their relationship with the resident than less experienced nurses. There appeared to be a tendency for long work experience to have a negative effect on nurses' attitudes towards the resident.

CONCLUSIONS

The nurses could be interpreted as being caught in a moral dilemma between ends and means. This dilemma could be represented on the one hand as the 'conformist mode', with an acceptance of ends and means, and on the other hand as the 'innovation mode', with acceptance of ends but with few legitimate means to achieve them.

Improving geriatric mental health nursing care: making a case for going beyond psychotropic medications

Providing high-quality mental health nursing care should be an important and continuous preoccupation in the gerontological nursing field. As the proportion of elderly people in our society is growing, the emphasis on high-quality care will receive increasing attention from administrators, politicians, organized groups, researchers and clinical nurses. Recent findings illustrate unequivocally the important contribution of nurses to achieving the goal of high-quality geriatric care. However, the quality of care for the elderly with psychological difficulties has not been addressed. The objective of this article is to illustrate that while nurses can accomplish much to improve the well-being and mental health of the elderly, their skills are often underutilized. Psychotropic drugs are often the first-line interventions used by health-care professionals to treat mental health concerns of elderly persons. Alternative therapies that could be implemented and evaluated, such as psychological counselling, supportive counselling, education and life review, are infrequently used. Nevertheless, current scientific data suggest that it would be very advantageous if nurses were to play a dominant role in the care of elderly people who are depressed or experiencing sleep pattern disturbances. The same can be said about elderly chronic users of benzodiazepines, as well as those with cognitive impairment. Evidence for the use of psychotropic medications as a viable treatment option for the elderly both in the community and in the long-term care setting who are experiencing mental health challenges is examined. Alternative non-pharmacological approaches that nurses can use to augment care are also briefly discussed.

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.

Mental health consultation in a nursing home

As the world's population ages, increasing numbers of people can anticipate spending their latter years in long-term care settings. Many of these nursing home residents will also present psychiatric illnesses as primary or secondary diagnoses. The resulting behavioral problems may present challenges to nursing staff that they are ill-prepared to meet. This article illustrates the application of the Blake and Mouton consultation model to a Veterans Administration (VA) nursing home situation by a team of psychiatric mental health nurse specialists. The consultation is described and interpreted in terms of the Blake and Mouton model. The focal conflicts addressed in the consultation included issues of morale/cohesion, power/authority, and norms/standards. Interventions used were acceptant, prescriptive, confrontation, and theories/principles. The model provided a useful structure for conceptualizing and organizing assessment and intervention in the consultation situation.

Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers

OBJECTIVE

To conduct a controlled investigation to examine the effects of an abilities-focused program of morning care on the interaction behaviors and functioning of residents with dementia and on caregivers' interaction behaviors and perceptions of caregiving.

DESIGN

A quasi-experimental, repeated measures design.

SETTING

The study was conducted on four, nursing-home-level cognitive supports units in a geriatric care center. One of the units was randomly selected as the experimental unit; the other three served as controls.

PARTICIPANTS

The final sample consisted of 40 residents (20 each in the experimental and three control groups) and 44 caregivers (16 on the experimental unit and 28 on the three control units).

INTERVENTION

An educational program on delivering abilities-focused morning care, designed by the authors, was provided to caregivers on the experimental unit.

MEASUREMENTS

Measures were taken at baseline and at 3 and 6 months postintervention with regard to residents' interaction behaviors, level of agitation, and level of function and to caregivers' interaction behaviors, perceived ease of caregiving, and level of stress.

RESULTS

Repeated measures analysis of variance (RM-ANOVA) was used to compare the experimental and control groups in regard to changes in the outcomes over time. Results indicated that the abilities-focused program had statistically significant effects on (a) residents' personal attending and calm/functional behaviors, level of agitation, and levels of overall and social function, and (b) caregivers' verbal relevance and personal attending, relaxed, and social/flexible behaviors.

CONCLUSIONS

The evidence suggests that both residents and caregivers benefit from morning care that is oriented toward the abilities of people with dementia.

Attitudes of registered nurses towards patients with severe dementia

Meeting the needs and wishes of people with severe dementia is difficult and demanding for carers, and a number of approaches can be used in encounters with dementia sufferers. The aim of this study was to explore how registered nurses in a northern Norwegian county thought about approaching people with severe dementia. A patient case was used as a vignette, followed by a questionnaire with 13 sets of statements, each set containing two alternative approaches (one reality orientation approach and one personhood focused approach). In 12 out of the 13 sets of statements the reality orientation alternative was usually chosen, but responses to the statement regarding the meaning of confusion tended more towards the personhood focused approach. RNs with more than the basic education and staff nurses working in a team nursing system, chose the personhood focused approach significantly more often than RNs with no post-basic education and nurses working in a primary nursing system. The article discusses how reflection on daily experiences can improve one's ability to reflect on one's own experiences and encourage a personhood focused approach. Working in a team means gaining opportunities to reflect together with coworkers, while working in a primary nursing care system might afford fewer such opportunities.

Development and testing of the Resistiveness to Care Scale

A conceptual model and objective scale for measuring resistiveness to care in individuals with advanced dementia of the Alzheimer type (DAT) were empirically generated from the perspective of nursing staff caregivers and through observation of residents with DAT. The resistiveness to care scale (RTC-DAT) was judged to have content validity and reduced to 13 items. Quantifiable scoring procedures and methods for rating videotapes and conducting clinical observations were developed. The RTC-DAT was tested with 68 subjects at three sites. The RTC has a range of 0-156. Initial testing provided reliability estimates of .82-.87 for internal consistency and good to excellent kappas. Criterion-related validity with observed discomfort and construct validity by factor analysis support the RTC-DAT. Measurement issues and recommendations for use in research are discussed.

Living with dementia from the patient's perspective

This study describes the illness experience of dementia from the patient's perspective. Five people with Alzheimer's disease and their spouses were interviewed and observed during home visits. Thematic analysis revealed two themes: being unsure and trying to be normal. Being unsure describes people's fluctuating experience of symptoms that leaves them feeling unsure of themselves in a world that is increasingly unfamiliar. Trying to be normal describes people's efforts to counter the impact of dementia to maintain continuity in their lives. These findings point to the importance of taking into account the patient's perspective to better understand the experience of living with dementia and develop improved treatment and care practices.

Toileting: a biobehavioral challenge in Alzheimer's dementia care

As the trajectory of Alzheimer's disease (AD) progresses, problems with toileting become evident. This research addresses the range and variation of toileting problems, management strategies used by family and employed caregivers, and interactive and contextual conditions associated with toileting. Qualitative ethology was used to analyze data from over 120 hours of participant observation at an Alzheimer's Day Care Center, in clients' homes, and support groups; and interviews with families (n = 16) and staff members (n = 13). Toileting emerged as a complex event with many stages, as unaesthetic and unpleasant for caregivers and clients, and as occasionally resulting in catastrophic reactions. Caregivers read cues and interpret toileting behaviors. They provide physical and cognitive assistance while attempting to avoid accidents and catastrophic events. Client, staff member, and contextual variables affect toileting events. Recommendations for practice and research are proposed.

Agitation: measurement, management, and intervention research

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