Characteristics Associated With Behavioral Symptoms Related to Dementia in Long-Term Care Residents

A mixed methods study on the manifestations of behavioural symptoms of dementia among veterans with and without posttraumatic stress disorder

AIMS

To explore how behavioural symptoms of dementia are manifested among veterans in residential long-term care settings, in the context of personal, interpersonal/social and environmental triggers and how the manifestations differ between veterans with and without posttraumatic stress disorder.

DESIGN

Secondary analysis using a mixed methods approach.

METHODS

We analysed text data from a stratified random sample of 66 cases derived from the programme evaluation dataset of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention from 2013 to 2016, using framework analysis. The detailed behavioural assessment descriptions in this dataset are consistent with contemporary non-pharmacologic symptom management. Qualitative categories were converted to quantitative variables for two group comparisons.

RESULTS

Four patterns emerged linking specific types of triggers and behavioural symptoms: (1) unmet physical needs or emotional distress triggers non-aggressive behaviours; (2) unsolicited direct care approach triggers care refusal, resistance or combativeness; (3) interpersonal interactions interfering with self-direction trigger aggressive behaviours; and (4) uncontrolled stimulation from environments trigger non-aggressive behaviours. The organisational culture of care influenced how staff conceptualised behavioural symptoms. Veterans with co-existing posttraumatic stress disorder and dementia tended to exhibit rejection of care with aggression compared to those with dementia alone.

CONCLUSION

Contextualised accounts of behavioural symptoms of dementia revealed symptom heterogeneity, with different clusters of multi-level triggers arising from specific personal, interpersonal and environmental circumstances. Distinct patterns of symptom manifestations between veterans with and without posttraumatic stress disorder suggest a tailored approach is required to meet each veteran's unique biopsychosocial needs.

IMPACT

Classifying behavioural symptoms with their triggers rather than solely by behaviours provides important new information for developing person-centred, non-pharmacological interventions to improve outcomes for veterans with dementia. Multi-level interventions should be considered to meet veteran's needs that account for their earlier life history and current life circumstances.

Identifying incident dementia by applying machine learning to a very large administrative claims dataset

Alzheimer's disease and related dementias (ADRD) are highly prevalent conditions, and prior efforts to develop predictive models have relied on demographic and clinical risk factors using traditional logistical regression methods. We hypothesized that machine-learning algorithms using administrative claims data may represent a novel approach to predicting ADRD. Using a national de-identified dataset of more than 125 million patients including over 10,000 clinical, pharmaceutical, and demographic variables, we developed a cohort to train a machine learning model to predict ADRD 4-5 years in advance. The Lasso algorithm selected a 50-variable model with an area under the curve (AUC) of 0.693. Top diagnosis codes in the model were memory loss (780.93), Parkinson's disease (332.0), mild cognitive impairment (331.83) and bipolar disorder (296.80), and top pharmacy codes were psychoactive drugs. Machine learning algorithms can rapidly develop predictive models for ADRD with massive datasets, without requiring hypothesis-driven feature engineering.

Taking Another Look: Thoughts on Behavioral Symptoms in Dementia and Their Measurement

This article proposes taking another look at behavioral symptoms of dementia (BSDs) both from a theoretical perspective that informs research and practice and from a measurement perspective. We discuss why this rethinking of behaviors impacts current models of care and our ability to better detect outcomes from interventions. We propose that BSDs be viewed from a pattern perspective and provide some suggestions for how to identify and measure these patterns that can influence the timing and type of intervention. Evidence suggests that BSDs are complex, sequential, patterned clusters of behavior recurring repeatedly in the same individual and escalate significantly without timely intervention. However, BSDs are frequently viewed as separate behaviors rather than patterns or clusters of behaviors, a view that affects current research questions as well as the choice, timing, and outcomes of interventions. These symptoms cause immense distress to persons with the disease and their caregivers, trigger hospitalizations and nursing home placement, and are associated with increased care costs. Despite their universality and that symptoms manifest across disease etiologies and stages, behaviors tend to be underrecognized, undertreated, and overmanaged by pharmacological treatments that may pose more harm than benefit.

A Communication Intervention to Reduce Resistiveness in Dementia Care: A Cluster Randomized Controlled Trial

Purpose of the Study

Nursing home (NH) residents with dementia exhibit challenging behaviors or resistiveness to care (RTC) that increase staff time, stress, and NH costs. RTC is linked to elderspeak communication. Communication training (Changing Talk [CHAT]) was provided to staff to reduce their use of elderspeak. We hypothesized that CHAT would improve staff communication and subsequently reduce RTC.

Methods

Thirteen NHs were randomized to intervention and control groups. Dyads (n = 42) including 29 staff and 27 persons with dementia were videorecorded during care before and/or after the intervention and at a 3-month follow-up. Videos were behaviorally coded for (a) staff communication (normal, elderspeak, or silence) and (b) resident behaviors (cooperative or RTC). Linear mixed modeling was used to evaluate training effects.

Results

On average, elderspeak declined from 34.6% (SD = 18.7) at baseline by 13.6% points (SD = 20.00) post intervention and 12.2% points (SD = 22.0) at 3-month follow-up. RTC declined from 35.7% (SD = 23.2) by 15.3% points (SD = 32.4) post intervention and 13.4% points (SD = 33.7) at 3 months. Linear mixed modeling determined that change in elderspeak was predicted by the intervention (b = -12.20, p = .028) and baseline elderspeak (b = -0.65, p < .001), whereas RTC change was predicted by elderspeak change (b = 0.43, p < .001); baseline RTC (b = -0.58, p < .001); and covariates.

Implications

A brief intervention can improve communication and reduce RTC, providing an effective nonpharmacological intervention to manage behavior and improve the quality of dementia care. No adverse events occurred.

Does self-neglect occur among older adults with dementia when unsupervised in assisted living? An exploratory, observational study

The phenomenon of older adults with dementia who develop behavioral expressions when they are unsupervised in assisted living residences is understudied. This qualitative study aimed to bridge this gap in the literature by focusing on 12 residents in various stages of dementia. Grounded Theory was followed to guide data collection and analysis. Data were collected in two special care units of an assisted living residence for 10 months. Participant observation was the primary data collection strategy. Semistructured interviews with staff and managers and review of clinical records augmented the observation data. While unsupervised, residents exhibited a wide spectrum of negative emotional states, behavioral expressions, functional difficulties, wayfinding difficulties, serious hygiene problems, and safety risks. More than half of the identified incidents represented self-neglectful behaviors. The study highlights the need for enhanced supervision and targeted interventions for residents with dementia who are susceptible to self-neglect.

Identifying the Potential for Robotics to Assist Older Adults in Different Living Environments

As the older adult population grows and becomes more diverse, so will their needs and preferences for living environments. Many adults over 65 years of age require some assistance [1, 2]; yet it is important for their feelings of well-being that the assistance not restrict their autonomy [3]. Not only is autonomy correlated with quality of life [4], autonomy enhancement may improve functionality [2, 5]. The goal of this paper is to provide guidance for the development of technology to enhance autonomy and quality of life for older adults. We explore the potential for robotics to meet these needs. We evaluated older adults' diverse living situations and the predictors of residential moves to higher levels of care in the United States. We also examined older adults' needs for assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and medical conditions when living independently or in a long-term care residence. By providing support for older adults, mobile manipulator robots may reduce need-driven, undesired moves from residences with lower levels of care (i.e., private homes, assisted living) to those with higher levels of care (i.e., skilled nursing).

Elder mistreatment in U.S. residential care facilities: the scope of the problem

Many in the United States believe elder mistreatment in long-term care is serious and widespread, but until recently few studies focused on the problem. This study was designed to describe the scope of mistreatment in assisted living facilities (ALFs) in Arizona during a 3-year period. Findings showed that receiving citations for elder mistreatment was relatively rare. However, analysis of narrative reports from only 7% of facilities showed 598 allegations of mistreatment in complaint investigations, of which 372 (62.2%) were substantiated and given citations for something other than mistreatment. Results show that elder mistreatment in ALFs is seriously underidentified, even by state inspectors.

SIRT1 represses estrogen-signaling, ligand-independent ERα-mediated transcription, and cell proliferation in estrogen-responsive breast cells

In prostate and breast cancer, the androgen receptor and estrogen receptor (ER) mediate induction of androgen- and estrogen-responsive genes respectively and stimulate cell proliferation in response to the binding of their cognate steroid hormones. Sirtuin 1 (SIRT1) is a NAD+-dependent class III histone deacetylase that has been linked to gene silencing, control of the cell cycle, apoptosis, and energy homeostasis. In prostate cancer, SIRT1 is required for androgen antagonist-mediated transcriptional repression and growth suppression of prostate cancer cells. Whether SIRT1 plays a similar role in the actions of estrogen or antagonists had not been determined. We report here that SIRT1 represses the transcriptional and proliferative response of breast cancer cells to estrogens, and this repression is ERα dependent. Inhibition of SIRT1 activity results in the phosphorylation of ERα in an AKT-dependent manner, and this activation requires phosphoinositide 3-kinase activity. Phosphorylated ERα subsequently accumulates in the nucleus, where ERα binds DNA ER-responsive elements and activates transcription of estrogen-responsive genes. This ER-dependent transcriptional activation augments estrogen-induced signaling, but also activates ER signaling in the absence of estrogen, thus defining a novel and unexpected mechanism of ligand-independent ERα-mediated activation and target gene transcription. Like ligand-dependent activation of ERα, SIRT1 inhibition-mediated ERα activation in the absence of estrogen also results in breast cancer cell proliferation. Together, these data demonstrate that SIRT1 regulates the most important cell signaling pathway for the growth of breast cancer cells, both in the presence and the absence of estrogen.

Comparing families and staff in nursing homes and assisted living: implications for social work practice

Nursing homes and residential care/assisted living settings provide care to 2.4 million individuals. Few studies compare the experience of, and relationships between, family and staff in these settings, despite ongoing family involvement and evidence that relationships are problematic. Data from 488 families and 397 staff members in 24 settings examined family involvement and family and staff burden, depressive symptoms, and perceptions; and staff absenteeism and turnover. There were few differences across setting types. Although conflict rarely occurred, there was room for improvement in family-staff relations; this area, and preparing family for their caregiving roles, are appropriate targets for social work intervention.

Correlates of agitation and depression in nursing home residents with dementia

BACKGROUND

The purpose of this study was to investigate the relationship between dementia severity, age, gender, and prescription of psychotropics, and syndromes of agitation and depression in a sample of nursing home residents with dementia.

METHODS

The Cohen-Mansfield Agitation Inventory (CMAI) was administered to residents with dementia (N = 304) of 18 nursing homes. Agitation symptoms were clustered using factorial analysis. Depression was estimated using the Dementia Mood Assessment Scale (DMAS). Dementia severity was assessed categorically using predefined cut-off scores derived from the Mini-Mental State Examination (MMSE). The relationship between agitation and its sub-syndromes, depression, and dementia severity was calculated using χ 2-statistics. Linear regression analyses were used to calculate the effect of dementia severity and psychotropic prescriptions on agitation and depression, controlling for age and gender.

RESULTS

Increasing stages of dementia severity were associated with higher risk for physically aggressive (p < 0.001) and non-aggressive (p < 0.01) behaviors, verbally agitated behavior (p < 0.05), and depression (p < 0.001). Depressive symptoms were associated with physically aggressive (p < 0.001) and verbally agitated (p < 0.05) behaviors, beyond the effects of dementia severity. Prescription of antipsychotics was correlated with depression and all agitation sub-syndromes except hiding and hoarding.

CONCLUSIONS

Dementia severity is a predictor for agitation and depression. Beyond that, depression increased with dementia severity, and the severity of depression was associated with both physically and verbally aggressive behaviors, indicating that, in advanced stages of dementia, depression in some patients might underlie aggressive behavior.

Physician perspectives on medical care delivery in assisted living

OBJECTIVES

To describe the provision of medical care in assisted living (AL) as provided by physicians who are especially active in providing care to older adults and AL residents; to identify characteristics associated with physician confidence in AL staff; and to ask physicians a variety of questions about their experience providing care to AL residents and how it compares with providing care in the nursing home and home care settings.

DESIGN

Cross-sectional descriptive study.

SETTING

AL communities in 27 states.

PARTICIPANTS

One hundred sixty-five physicians and administrators of 125 AL settings in which they had patients.

MEASUREMENTS

Interviews and questionnaires containing open- and close-ended questions regarding demographics, care arrangements, attitudes, and behaviors in managing medical problems.

RESULTS

Most respondents were certified in internal medicine (46%) or family medicine (47%); 32% were certified in geriatrics and 30% in medical directorship. In this select sample, 48% visited the AL setting once a year or less, and 19% visited once a week or more. Mean physician confidence in AL staff was 3.3 (somewhat confident), with greater confidence associated with smaller AL community size, nursing presence, and the physician being the medical director. Qualitative analyses identified differences between settings including lack of vital sign assessment in the home setting, concern about the ability of AL staff to assess and monitor problems, and greater administrative and regulatory requirements in AL than in the other settings.

CONCLUSION

Providing medical care for AL residents presents unique challenges and opportunities for physicians. Nursing presence and physician oversight and familiarity and communicating with AL staff who are highly familiar with a given resident and can monitor care may facilitate care.

Relationship between System-Level Characteristics of Assisted Living Facilities and the Health and Safety of Unlicensed Staff

This study examined system-level characteristics of assisted living facilities and the association between these characteristics and the health and safety outcomes of unlicensed staff. Forty-two unlicensed direct care workers completed a survey related to system-level stressors and the individual stress responses of staff. Measurement tools included the Work Stressor Inventory (WSI), General Health Questionnaire (GHQ-12), and Maslach Burnout Inventory (MBI). High levels of emotional exhaustion, psychiatric distress, and work-related injuries were reported by unlicensed staff. Providing care to residents with dementia-related behaviors and supporting families were the most frequently reported work stressors. System-level factors were significantly associated with staff role competence, job commitment, and emotional exhaustion. These results support the need for continued exploration, development, and evaluation of strategies to reduce occupational stressors at multiple levels in assisted living facilities.

Mistreatment in assisted living facilities: complaints, substantiations, and risk factors

PURPOSE OF THE STUDY

Use archived public data from Arizona to explore relationships among selected institutional and resident risk and situation-specific factors and complaints and substantiated allegations of various types of mistreatment in assisted living facilities (ALFs).

DESIGN AND METHODS

An exploratory/descriptive 2-group design was used. Facilities in the complaint group were identified from narrative data that appeared suspicious for mistreatment based on definitions for physical, verbal, psychological, medication, sexual abuse, neglect, financial exploitation, and physical restraint. Facilities in the comparison group were those that had no citations or complaints in 2007-2008. Narrative data were content analyzed, and chi-square analysis was used to answer 3 research questions.

RESULTS

The complaint group was comprised of significantly more assisted living centers, large facilities (51-101+), facilities licensed to provide personal care services, and facilities owned by national corporations. Substantiated allegations were significantly more frequent in assisted living centers, facilities with more than 51 beds, and those owned by national corporations. Facility risk factors were related to some types of substantiated mistreatment and not others.

IMPLICATIONS

Findings suggest the need to evaluate use of only unlicensed assistive personnel in facilities, increase oversight of care by professional nurses, rethink the practice of not licensing small facilities, and monitor more closely practices and procedures in facilities operated by national corporations.

Monitoring quality of care for nursing home residents with behavioral and psychological symptoms related to dementia

BACKGROUND

Behavioral and psychological symptoms associated with dementia are common in nursing home residents. Quality indicators (QI) assessing quality of care for these residents are minimally risk adjusted and can provide inaccurate information regarding the quality of care provided by the facility.

OBJECTIVE

Evaluate the performance of a new QI for the incidence of worsening behaviors in nursing home residents with behavioral and psychological symptoms association with dementia.

DESIGN

Retrospective cohort study.

SETTING

A total of 381 Minnesota nursing homes with 26,165 residents.

DATA SOURCES

Minimum Data Set records for the first 2 calendar quarters of 2008.

MEASUREMENTS

We calculated incidence of worsening behaviors QI by comparing items from the "behavior" section of the Minimum Data Set records from 2 consecutive quarters and reported the incidence rates by both the residents' level of cognitive impairment and the presence or absence of special care unit for dementia (SCU).

RESULTS

The incidence rates of the worsening behavior QI in SCU ranged from 14% in residents with very severe cognitive impairment (a cognitive performance score = 6) to 30% in those with moderate cognitive impairment (a cognitive performance score = 3). The incidence QI rates among residents residing in conventional unit ranged from 15% among those with very severe cognitive impairment to 20% among those with moderate cognitive impairment. These differences in QI rates between the 2 units were statistically significant with a P value = .001. After risk adjustment for level of cognitive impairment, number of facilities with SCUs that flagged for problem behaviors dropped from 18.4% to 12.4% and the number of conventional units in the low-risk category from 16.8% to 4.7%.

CONCLUSION

Resident cognitive function and the facility utility of SCU are associated with worsening behavior QI and should be adjusted for in any nursing home quality reporting measure.

Staff training in assisted living: evaluating treatment fidelity

OBJECTIVES

To investigate a protocol for identifying and evaluating treatment fidelity in Staff Training in Assisted-living Residences (STAR), a structured but flexible program to train direct care staff to improve care of residents with dementia.

DESIGN

Multisite feasibility trial.

SETTING

Assisted living facilities (ALFs).

PARTICIPANTS

Forty-four direct care staff and 36 leadership staff.

INTERVENTION

STAR is a comprehensive, dementia-specific training program to teach direct care staff in ALFs to improve care and reduce affective and behavioral problems in residents with dementia. It is conducted on-site over 2 months through 2 half-day group workshops and four individualized sessions.

MEASURES

Treatment fidelity was assessed following the National Institute of Health Behavior Change Consortium model utilizing observations and self-report of trainers, direct care staff, and leadership.

RESULTS

Each key area of treatment fidelity was identified, measured, and yielded significant outcomes. For example, significant increases included direct care staff identifying activators, behaviors, and consequences (an essential component of training); understanding basics of dementia care; and applying STAR techniques.

CONCLUSIONS

Results support that STAR is ready to be translated and disseminated into practice. Because ALFs will continue to provide care for individuals with dementia, the need for effective, practical, and sustainable staff training programs is clear. STAR offers one such option. It is hoped that this report will encourage others to conduct comprehensive evaluations of the treatment fidelity of their programs and thereby increase the availability of such programs to enhance care.

Anxiety symptoms among assisted living residents: implications of the "no difference" finding for participants with and without dementia

Anxiety is a distressing experience at any age but may be particularly disabling when coupled with dementia. Dementia-related anxiety is associated with a range of additional problems among community-dwelling older adults, but little is known about its occurrence in assisted living environments. The purpose of this article is to describe the prevalence of anxiety symptoms among older adults who participated in Phase I of the Maryland Assisted Living Study, a cross-sectional study of 198 participants who underwent comprehensive dementia evaluations. Participants with dementia diagnoses (n=134) were compared with those without dementia (n=64) using two measures of anxiety. Anxiety was common in both groups: 22% of each group were assessed to have one or more anxiety symptoms using proxyrated methods, and 45% had at least mild anxiety using direct observation and interview. Factors that contribute to variability in reports of dementia-related anxiety are reviewed.

Institutionalized ghosting: policy contexts and language use in erasing the person with Alzheimer's

The ordinary social engagement of human life would not usually be considered an arena for language policy. Yet clinical evidence mounts that social interaction improves our lives as we age. Since social engagement decreases cardiovascular risks (Ramsay et al. in Ann Epidemiol 18:476-483, 2008) and delays memory loss among those living in communities (Ertel et al. in Am J Public Health 98:1215-1220, 2008), practices that prohibit social interaction threaten human well-being. For persons who have Alzheimer's disease (AD), social interaction continues to play an integral part in cognitive function and delays in memory loss, according to a longitudinal study of social networks (Bennett et al. in Lancet Neurol 5:406-412, 2007). Increasingly, person-centered care that promotes social engagement for those with AD is promoted as an institutional policy to improve outcomes of dementia care (Edvardsson et al. in Int Psychogeriatr 20:764-776, 2008). Yet the training of caregivers may neither reflect person-centered care nor include attention to communication, suggesting covert policies in practice.

Anxiety, depression, and cognitive impairment in dementia-specific and traditional assisted living

With the rapid growth of the assisted living (AL) industry, the number of AL residences providing dementia care continues to increase. The purpose of this article is to describe and compare demographic characteristics; frequency and type of psychiatric diagnoses; level of cognition, depression, and anxiety symptoms; and use of psychotropic medication among older adults in dementia-specific assisted living (DSAL) and traditional assisted living (TAL) residences. Secondary analysis of screening data collected during a cross-sectional, descriptive pilot project compared 18 participants from two DSAL facilities and 28 participants from three TAL facilities. DSAL participants with dementia were more cognitively impaired than TAL participants with dementia (p < 0.001) and used more antipsychotic (67%), anxiolytic (60%), antidepressant (53%), and cognitive-enhancing (87%) medications. No statistically significant differences in demographic factors or levels of anxiety or depression were observed among residents in either setting.

Factors associated with aggressive behavior among nursing home residents with dementia

PURPOSE

In an attempt to more thoroughly describe aggressive behavior in nursing home residents with dementia, we examined background and proximal factors as guided by the Need-Driven Dementia-Compromised Behavior model.

DESIGN AND METHODS

We used a multivariate cross-sectional survey with repeated measures; participants resided in nine randomly selected nursing homes within four midwestern counties. The Minimum Data Set (with verification by caregivers) identified participants. We used a disproportionate probability sample of 107 participants (51% with a history of aggressive behavior) to ensure variability. Videotaped care events included four of direct care (shower baths, meals, dressing, and undressing) and two of nondirect care (two randomly selected 20-minute time periods in the afternoon and evening). The majority of participants (75%) received three shower baths, for a total of 282 videotaped baths.

RESULTS

Because the shower bath was the only care event significantly related to aggressive behavior (F = 6.9, p < .001), only those data are presented. Multilevel statistical modeling identified background factors (gender, mental status score, and lifelong history of less agreeableness) and a proximal factor (amount of nighttime sleep) as significant predictors (p < .05) of aggressive behavior during the shower bath. We found significant correlations between aggressive behavior and negative subject affect (r = .27) during the bath, and aggressive behavior and lifetime agreeableness level (r = -.192). We also found significant correlations between mental status and the amount of education (r = .212), and between negative caregiver affect and negative participant affect (r = .321).

IMPLICATIONS

We identified three background and one proximal factor as significant risk factors for aggressive behavior in dementia. Data identify not only those persons most at risk for aggressive behavior during care, but also the care event most associated with aggressive behavior. Together these data inform both caregiving for persons with dementia as well as the design of intervention studies for aggressive behavior in dementia.

Aggression in persons with dementia: use of nursing theory to guide clinical practice

With approximately four million people in the United States today diagnosed with dementia, one of the most devastating problems faced by caregivers and patients is dealing with aggressive behavior. Aggression occurs in half of persons diagnosed with dementia and is associated with more rapid cognitive decline, increased risk of abuse, and caregiver burden. This paper uses the Need-driven Dementia-compromised Behavior (NDB) model to explain aggression and discusses therapeutic approaches to care that combines non-pharmacological and pharmacological interventions targeting both the management of aggression crisis and preventing its future recurrence. A clinical algorithm guided by the NBD model is provided for practitioners.

Dementia care in assisted living: needs and challenges

Assisted living (AL) is an increasingly popular long-term care option for older adults with dementia. Recent reports suggest that as many as 68% of AL residents have dementia, and that frequency of both behavioral symptoms and psychotropic medications are high. This pilot project explored the feasibility of research methods for use in AL facilities. Findings suggest that most AL residents with dementia have moderate to severe dementia, and the majority are taking one or more psychotropic medication. Descriptive and qualitative findings related to health records, caregiver perceptions of behavioral symptoms, and practicality of assessment methods undertaken are described and implications for psychiatric nursing practice and research are reviewed.

Dementia-specific assisted living: clinical factors and psychotropic medication use

BACKGROUND

Assisted living (AL) is an increasingly popular long-term care alternative for older adults with dementia, making this setting an important focus for both clinical practice and research among psychiatric nurses.

OBJECTIVES

This article describes results from a pilot study focusing on residents' cognitive and emotional status as well as psychotropic drug use. Findings are compared to reports from larger studies in the literature.

STUDY DESIGN

A descriptive, correlational design was used to collect data from 17 residents in two dementia-specific AL facilities.

RESULTS

Thirty-one psychiatric diagnoses were identified for 17 participants. Anxiety and depression symptoms were endorsed by more than 50% of participants, and 88% were prescribed psychotropic medications.

CONCLUSIONS

AL residents may experience problems with cognition and emotional symptoms such as anxiety and depression, creating important roles for psychiatric nurses in staff education, promotion of nonpharmacologic interventions, and monitoring of psychotropic medication use in this growing population. J Am Psychiatr Nurses Assoc, 2008; 14(1), 39-49. DOI: 10.1177/1078390307310692.

Behavioral effects of current Alzheimer's disease treatments: a descriptive review

BACKGROUND

Behavioral abnormalities and neuropsychiatric symptoms are common manifestations of Alzheimer's disease (AD). Many clinical trials of cholinesterase inhibitors (ChE-Is) and memantine have included behavioral measures as primary or secondary outcomes, and most have observed behavioral benefits in conjunction with treatment. The purpose of this review was to determine the frequency of positive behavioral outcomes in AD clinical trials and clinical reports, to determine the symptoms most responsive to antidementia agents, and to explore factors that correlate with negative outcomes in clinical trials of antidementia agents with regard to behavioral measures.

METHODS

We performed a computerized search of randomized clinical trials and open-label studies of ChE-Is and memantine for AD including a behavioral outcome measure. Studies involving 10 or more patients using therapeutic doses of the target agents and including a behavioral measure as a primary or secondary outcome were included in this review.

RESULTS

One hundred fifty-seven peer-reviewed articles and 68 publicly presented abstracts were identified in the literature search. Subsequent review established that 15 publications arising from 13 randomized, double-blind, placebo-controlled AD trials met the review inclusion criteria. Positive outcomes on behavioral measures were reported in 8 of 15 publications as a primary or secondary outcome. In most blinded AD clinical trials, behavioral measures were secondary outcomes. Mood symptoms and apathy have most commonly responded to ChE-Is, whereas memantine has been associated with a reduction in irritability and agitation. However, there is substantial variability among trials in terms of behavioral outcomes. Studies that assessed patients with more severe dementia, included patients with less severe behavioral disturbances at baseline, involved institutionalized patients, or were international in scope tended to have negative outcomes. In institutionalized patients there is commonly an improvement in the placebo group that confounds the observation of any drug-placebo difference.

CONCLUSIONS

Antidementia agents have been associated with beneficial behavioral outcomes in many randomized clinical trials and open-label studies. Most studies are not designed to test the psychotropic properties of antidementia drugs. Trials with negative behavioral outcomes are most likely to involve patients who are institutionalized and have few behavioral disturbances at baseline. Clinical trials designed to assess behavioral effects of antidementia agents should anticipate these factors.

Efficacy of memantine on behavioral and psychological symptoms related to dementia: a systematic meta-analysis

BACKGROUND

The behavioral and psychological symptoms related to dementia (BPSD) are difficult to manage and are associated with adverse patient outcomes.

OBJECTIVE

To systematically analyze the data on memantine in the treatment of BPSD.

METHODS

We searched MEDLINE, EMBASE, Pharm-line, the Cochrane Centre Collaboration, www.clinicaltrials.gov, www.controlled-trials.com, and PsycINFO (1966-July 2007). We contacted manufacturers and scrutinized the reference sections of articles identified in our search for further references, including conference proceedings. Two researchers (IM and CF) independently reviewed all studies identified by the search strategy. We included 6 randomized, parallel-group, double-blind studies that rated BPSD with the Neuropsychiatric Inventory (NPI) in our meta-analysis. Patients had probable Alzheimer's disease and received treatment with memantine for at least one month. Overall efficacy of memantine on the NPI was established with a t-test for the average difference between means across studies, using a random effects model.

RESULTS

Five of the 6 studies identified had NPI outcome data. In these 5 studies, 868 patients were treated with memantine and 882 patients were treated with placebo. Patients on memantine improved by 1.99 on the NPI scale (95% Cl -0.08 to -3.91; p = 0.041) compared with the placebo group.

CONCLUSIONS

Initial data appear to indicate that memantine decreases NPI scores and may have a role in managing BPSD. However, there are a number of limitations with the current data; the effect size was relatively small, and whether memantine produces significant clinical benefit is not clear.

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.

Agitation in Dutch institutionalized patients with dementia: factor analysis of the Dutch version of the Cohen-Mansfield Agitation Inventory

BACKGROUND/AIMS

To establish the construct validity of the Dutch version of the Cohen-Mansfield Agitation Inventory (CMAI-D) in institutionalized patients with dementia.

METHODS

The CMAI-D was administered to a large sample of 1,437 patients with moderate to severe dementia, receiving nursing home or outreaching nursing home care. Exploratory factor analysis was used to examine the behavioral dimensions underlying CMAI-D observations.

RESULTS

A restricted 3-factor solution showed 3 factors, i.e. physical aggression, physically nonaggressive behavior and verbally agitated behavior, with prevalences of 62, 67 and 62%, respectively. An unrestricted factor solution revealed 3 additional behavioral dimensions: hiding/hoarding, vocal agitation and a factor of miscellaneous items (i.e. repetitious mannerisms, spitting), which occurred in 30, 28 and 35% of the patients, respectively.

CONCLUSION

The 3-factor solution of physical aggression, physically nonaggressive behavior and verbally agitated behavior corroborates earlier findings in other patient samples and therefore establishes the construct validity in institutionalized patients with severe dementia. The robustness of these findings across different care settings suggests that agitated behaviors have a common basis. In addition, unrestricted factor analysis showed 3 other important independent behavioral symptoms in dementia, but they are in fact too small to be used as a subscale. These findings might add to the taxonomy of agitation and aggression in dementia.