Agitated Behavior Research Articles

Factor Analysis of the Short Form Cohen Mansfield Agitation Inventory and Measurement Invariance by Gender

Background: The Cohen-Mansfield Agitation Inventory (CMAI), available in both long and short versions, is a widely used measure to assess and evaluate agitation among older adults. There has been less psychometric testing of the short-form CMAI particularly with regard to the factor structure of this shorter measure. Purpose: The purpose of this study was to test the internal consistency, reliability and validity of short-form CMAI in a sample of nursing home residents and examine if it is invariant across gender. Specifically, it was hypothesized that consistent with the long form CMAI, the short-form CMAI would have three factors with acceptable internal consistency and item reliability. In addition, it was hypothesized that there would be no difference in factor structure and factor means across gender. Methods: This study utilized baseline data from a randomized trial including 553 residents from 55 nursing homes. Data was analyzed using structural equation modeling. Results: Confirmatory factory analysis supported the three-factor structure of short-form CMAI including aggressive (α= 0.794), physically non-aggressive (α= 0.617), and verbally agitated (α= 0.718) behaviors; three items loading on physically non-aggressive behaviors had R2 close to 0.3 suggesting low reliability. Invariance testing confirmed that the shortened measure is invariant across gender. Conclusions: Short-form CMAI is a valid and reliable scale to assess agitation and gender differences in agitation in nursing home population. However, it could benefit from rewording the items with low reliability or, merging them with other similar items. Future work could also consider a four-factor structure for this shortened measure.

Agitation, confusion, and aggression in critically ill traumatic brain injury-a pilot cohort study (ACACIA-PILOT)

BackgroundAgitated behaviors are problematic in intensive care unit (ICU) patients recovering from traumatic brain injury (TBI) as they create substantial risks and challenges for healthcare providers. To date, there have been no studies evaluating their epidemiology and impact in the ICU. Prior to planning a multicenter study, assessment of recruitment, feasibility, and pilot study procedures is needed. In this pilot study, we aimed to evaluate the feasibility of conducting a large multicenter prospective cohort study.MethodsThis feasibility study recruited adult patients admitted to the ICU with TBI and an abnormal cerebral CT scan. In all patients, we documented Richmond Agitation Sedation Score (RASS) and agitated behaviors every 8-h nursing shift using a dedicated tool documenting 14 behaviors. Our feasibility objectives were to obtain consent from at least 2 patients per month; completion of screening logs for agitated behaviors by bedside nurses for more than 90% of 8-h shifts; completion of data collection in an average of 6 h or less; and obtain 6-month follow-up for surviving patients. The main clinical outcome was the incidence of agitation and individual agitated behaviors.ResultsIn total, 47 eligible patients were approached for inclusion and 30 (64% consent rate) were recruited over a 10-month period (3 patients/month). In total, 794 out of 827 (96%) possible 8-h periods of agitated behavior logs were completed by bedside nurses, with a median of 24 observations (IQR 28.0) per patient. During the ICU stay, 17 of 30 patients developed agitation (56.7%; 95% CI 0.37–0.75) defined as RASS ≥ 2 during at least one observation period and for a median of 4 days (IQR 5.5). At 6 months post-TBI, among the 24 available patients, an unfavorable score (GOS-E < 5 including death) was reported in 12 patients (50%). In the 14 patients who were alive and available at 6 months, the median QOLIBRI score was 74.5 (IQR 18.5).ConclusionsThis study demonstrates the feasibility of conducting a larger cohort study to evaluate the epidemiology and impact of agitated behaviors in critically ill TBI patients. This study also shows that agitated behaviors are frequent and are associated with adverse events.

Neuropsychiatric symptoms in early onset Alzheimer's disease and frontotemporal dementia

AbstractBackgroundHaving in mind a significant percentage of atypical presentations at disease onset (behavioral symptoms, depression, psychotic symptoms or non‐cognitive cognitive deficits), understanding clinical heterogeneity of early onset Alzheimer's disease (EOAD) and frontotemporal dementia (EOFTD) can improve early diagnosis and differentiation between these clinical entities.Our objective was to investigate the heterogeneity of neuropsychiatric symptoms (NPS) in EOAD and EOFTD spectrum.MethodTwo hundred and seven consecutive patients with EOAD and EOFTD spectrum, diagnosed according to the current clinical criteria, were recruited from the Neurology Clinic, Clinical Centre of Serbia. Sociodemographic and clinical characteristics were evaluated using a pre‐designed semi‐structured questionnaire while neuropsychiatric symptoms (NPS) were evaluated using Neuropsychiatric Inventory (NPI).ResultEOAD and EOFTD patients did not differ in age, age at disease onset, duration of the disease, gender and education. In comparison to EOAD, patients in the EOFTD spectrum expressed agitation, euphoria, apathy, disinhibition, irritability, aberrant motor behavior and dietary changes more frequently. EOFTD behavioral variant patients expressed apathy, aberrant motor behavior and disinhibition more often than patients with PPA, while in PPA anxiety was represented. In EOAD group total NPI score correlated with clinical dementia rating scale score. In the advanced stages of dementia, EOAD patients expressed agitation and irritability more frequently than at disease onset, while in advanced EOFTD agitation and aberrant motor behavior were more frequent than in the earlier stages of the disease. Amnestic and non‐amnestic presentation of EOAD did not differ in frequency on NPSConclusionNPS are a hallmark of behavioral variant of EOFTD and later stages of EOAD.

Use of psychotropic agents to treat agitation and aggression in Brazilian patients with Alzheimer's disease: A naturalistic and multicenter study

We assessed psychotropic prescribing patterns in the clinical treatment of agitation and aggressive behavior in patients with Alzheimer's disease (AD) treated at specialist outpatient clinics in the Federal District of Brazil. This was a naturalistic, observational, multicenter study of a convenience sample of patients with AD (according to DSM-5) who had behavioral symptoms of aggression and/or agitation at outpatient visits, as assessed by the Neuropsychiatric Inventory (NPI), and required pharmacologic intervention. Participants were recruited in 2018-2019 from 11 AD treatment centers. Sociodemographic and clinical data were collected during routine visits. The sample consisted of 369 older adults with a mean age of 82.3 (SD, 7.7) years. The medications most commonly used in patients with behavioral disorders were antidepressants (79.1%), antipsychotics (70.2%), benzodiazepines (10.6%), and mood stabilizers (9.5%). Quetiapine was the most frequently prescribed antipsychotic medication (48.5%), at a mean dose of 57.4 (SD, 40.7) mg. Citalopram was the most widely used antidepressant medication (32.0%), at a mean daily dose of 24.1 (SD, 8.1) mg. In this sample, two or more pharmacologic agents were frequently used together to control aggression and agitation. Benzodiazepine was not frequently used.

Distribution of agitation and related symptoms among hospitalized patients using a scalable natural language processing method

BackgroundAgitation is a common feature of many neuropsychiatric disorders. ObjectiveUnderstanding the prevalence, implications, and characteristics of agitation among hospitalized populations can facilitate more precise recognition of disability arising from neuropsychiatric diseases. MethodsWe developed two agitation phenotypes using an expansion of expert curated term lists. These phenotypes were used to characterize five years of psychiatric admissions. The relationship of agitation symptoms and length of stay was examined. ResultsAmong 4548 psychiatric admissions, 1134 (24.9%) included documentation of agitation based on the primary agitation phenotype. These symptoms were greater among individuals with public insurance, and those with mania and psychosis compared to major depressive disorder. Greater symptoms were associated with longer hospital stay, with ~0.9 day increase in stay for every 10% increase in agitation phenotype. ConclusionAgitation was common at hospital admission and associated with diagnosis and longer length of stay. Characterizing agitation-related symptoms through natural language processing may provide new tools for understanding agitated behaviors and their relationship to delirium.

CLINICAL FEATURES OF BEHAVIORAL DISORDERS RELATING TO AMPHETAMINE TYPE SUBSTANCES USE

The symptoms of behavioral disturbances in patients with psychosis caused by the use of amphetamine-type substances (ATS) are diverse, leading to difficulties in diagnosis and treatment. Purposes: To describe the clinical features of behavioral disorders relating to ATS use. Objects and research methods: Study on case clusters of 74 patients with inpatient mental disorders by using ATS at the National Institute of Mental Health, Central Mental Hospital 1, Psychiatric Hospital Ha Noi from September 2019 to August 2020. Results: Common symptoms relating to ATS use are hyperactive behavior (54%), agitated behavior (62%), behavior dominated by delusions, hallucinations (47.3%). There was a relationship between hyperactive behavior, impulsive behavior, aggressive behavior, and property destruction and agitation (p &lt;0.05). There was no relationship between hyperactive behavior, agitated behavior, aggressive behavior, impulsive behavior with delusions, hallucinations (p&gt; 0.05).

Effectiveness of non-pharmacological interventions for managing agitation during post-traumatic amnesia following traumatic brain injury: a systematic review protocol.

To synthesize current evidence on the effects and harms of non-pharmacological interventions for managing agitation during post-traumatic amnesia in adults who have sustained a traumatic brain injury. Agitation is one of the most disruptive and clinically significant sequelae observed during post-traumatic amnesia. Patients who experience agitation during this period demonstrate reduced engagement in rehabilitation and poorer long-term functional outcomes. Agitation also poses a risk to staff and patient safety. Research for the effects of pharmacological intervention for managing agitation during this period is inconclusive. Thus, synthesis of the research for non-pharmacological interventions for reducing agitation during post-traumatic amnesia is essential for improving long-term outcomes for survivors of traumatic brain injury. Studies will be considered if they include participants aged 16 years and older who exhibit agitated behaviors during post-traumatic amnesia after sustaining a traumatic brain injury (irrespective of severity or mechanism). Studies will be considered if they evaluate any non-pharmacological intervention for reducing agitation, with all types of comparators accepted. Primary outcomes of interest include a change in agitation severity and any adverse effects. Key information sources include MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO, and Cochrane CENTRAL. Studies published in English will be included, irrespective of publication year. Two independent reviewers will be involved in study selection and data extraction. Eligible studies will be critically appraised for methodological quality. Studies will be pooled with statistical meta-analysis where possible; otherwise findings will be reported in narrative form. PROSPERO CRD42020186802.

Assisted bathing of older people with dementia: a mixed methods systematic review protocol.

The objective of this review update is to determine the best strategies for assisted bathing or showering of older people with dementia. Bathing is a high-risk activity that can worsen agitated behavior in people with dementia, becoming a source of stress or burden for nurses and caregivers. Since a review was originally published in 2013, new studies have been conducted reporting on various interventions related to assisted bathing and showering. The review will consider people older than 60 years with dementia, their families, nurses, and formal caregivers. The quantitative component will consider studies that examine interventions aiming to reduce agitated behaviors during assisted bathing. The qualitative component will include studies reporting on experiences of assisted bathing of older people with dementia. This review update will follow the JBI mixed methods review approach. Published and unpublished studies will be identified from searches of the major international databases and relevant databases for gray literature. Two independent reviewers will carry out screening, critical appraisal, and data extraction. The extracted data will include details about the study characteristics, quantitative results, and qualitative findings relevant to the review. Where possible, quantitative data will be statistically pooled. Qualitative results will be synthesized using the meta-aggregation approach developed by JBI. Finally, the findings from both quantitative and qualitative components will be organized into a line of argument to produce an overall configured analysis. Where configuration is not possible, the findings will be presented in narrative form. PROSPERO CRD42020208048.

Factors influencing management of agitation in aged care facilities: A qualitative study of staff perceptions.

Agitation in older people is commonly associated with cognitive decline, complex medical diagnoses and polypharmacy. Impaired communication and comprehension within a dementia trajectory adds complexity to assessment and management. Despite high prevalence, agitated behaviours remain challenging to manage in residential aged care settings. To explore staff perceptions of agitation in residents of aged care facilities, including the influence of dementia, when selecting management strategies to reduce agitated behaviour. Qualitative descriptive. Semi-structured interviews with 11 aged care staff were conducted at two aged care sites. Transcripts were examined using content analysis to identify common issues and categories. The study complied with COREQ guidelines (see. Appendix S1). Participants reported managing resident agitation at least once per shift; most frequently manifesting as wandering, restlessness or aggression. Management strategies included distraction, providing space, knowing the resident, identifying causative factors, spending individual time and if necessary medication administration. Agitation management was more challenging for residents with dementia due to impaired communication or comprehension of instruction. While participants strived to deliver individualized person-centred care, this was difficult given time and resource constraints. Contemporary management of agitation therefore remains variable in everyday practice, with resident preference used when causative factors were known. Conversely, for residents with impaired communication and/or comprehension, distraction and chemical restraint were commonly used. Nuanced education for assessment and management is recommended to better address this unmet need for some residents. For optimal care, appropriate allocation of time and resources is necessary to identify causative and contextual factors for individual residents. Recommendations are for additional staff training in communication and attitude, and collaborating with frontline staff to develop a practical guide for management of agitation in aged care. These simple initiatives may help to improve consistency of care delivery and resident outcomes.

Neuropsychiatric Presentations due to Traumatic Brain Injury in Cognitively Normal Older Adults.

Neuropsychiatric symptoms (NPS) are common sequelae of traumatic brain injuries (TBI) among adults. However, little is known about NPS associated with a history of TBI in adults relative to adults without a history of TBI and to what extent NPS may be modulated by sex and other factors. Using the National Alzheimer's Coordinating Center Uniform Data Set, we examined the association between Neuropsychiatric Inventory-Questionnaire (NPI-Q) scores in cognitively normal older adults with and without a history of TBI. A binomial logistic regression model was used to examine NPI-Q domains in adults with a history of TBI (n = 266) versus without a history of TBI (n = 1508). History of TBI, sex, age, and body mass index were used as covariates. Adults with a history of TBI had a greater probability of exhibiting agitation, anxiety, apathy, disinhibition and aberrant motor behavior relative to adults without a history of TBI. In terms of sex differences, males with and without a history of TBI had an increased likelihood of agitation, apathy, disinhibition, and apnea, whereas females had an increased likelihood of anxiety and insomnia relative to males. Our study confirms that history of TBI is associated with an increased prevalence of specific NPS, including agitation, anxiety, apathy, disinhibition, and aberrant motor behavior. Given that the aforementioned NPS are linked through different pathways, damage to any of them may cause an alteration in behavior. As well, NPS appear to be modulated by sex, with symptoms differing between males and females. Our research suggests future studies examining NPS sequelae of TBI should adjust for sex.

Simulation of Mixing Intensity Profile for Bioethanol Production via Two-Step Fermentation in an Unbaffled Agitator Reactor

Bioethanol synthesis techniques have been studied intensively due to the energy crisis and various environmental concerns. A two-step bioethanol production process was carried out multiple times in an unbaffled agitator tank. The parameters varied, including the fermentation temperature, the pH level, the amount of yeast, and the impeller type. Then, a simulation was used to obtain an image of the agitation behavior inside the agitator tank to compare the velocity profile of each type of impeller design. The impeller with eight blades was found to produce the highest flow velocity: 0.28 m/s. The highest concentration of bioethanol generated from the fermentation was 34 g/L, which was produced by using an eight-blade impeller at 30 °C, a pH level of 5, an agitation speed of 70 rpm, and 2 wt % yeast. The two-blade impeller produced the lowest bioethanol concentration, 18 g/L, under the same conditions. Ethanol concentration was found to peak at 40 °C and a pH level of 5. The geometry of the impeller, the fermentation temperature, and the pH level were each found to have a significant effect on the resulting bioethanol concentration according to the results of an ANOVA test. The amount of yeast had no effect on the fermentation reaction. Finally, the results demonstrated the possibility of using computational fluid dynamic modeling to determine the impeller’s behavior for the development of the bioethanol fermentation process. The simulation and experimental results from this research support the scaling up of a bioethanol production facility.

Pain in Dementia: Prevalence and Association With Neuropsychiatric Behaviors

ContextPain is linked to behaviors and psychological symptoms of dementia (BPSD); however, it often remains underrecognized in this population. ObjectivesWe aimed to investigate the prevalence and intensity of pain in people living in aged care homes with BPSD and by dementia subtypes and the association between pain intensity and BPSD. MethodsA 1-year retrospective cross-sectional analysis was conducted on BPSD and the presence of pain in referrals to a national BPSD support service using the Neuropsychiatric Inventory and PainChek®, respectively. Referrals were categorized into two groups: pain group and no pain group. ResultsOf the 479 referrals (81.9 ± 8.3 years old) included in the analysis, two-thirds (65.6%) had pain identified, with almost half (48.4%) of these categorized as experiencing moderate-severe pain. Pain was highly prevalent (range: 54.6-78.6%) in all subtypes of dementia, particularly in mixed dementia and dementia with Lewy bodies. Compared with the no pain group, the pain group had 25.3% more neuropsychiatric behaviors, 33.6% higher total severity of these behaviors, and 31.4% higher total distress caused to caregivers. For all results, effect sizes were small to medium (η²p = 0.04-0.06). Despite a high prevalence of aggressive or agitated behaviors across the entire group, the pain group was 3.8 times more likely to experience these behaviors than referrals not in pain. ConclusionThere is a strong need to consider the possibility of pain as a contributor to behavioral changes in aged care residents living with dementia.

422 - Behavioral Variant Frontotemporal Dementia : an atypical case

Objective: To present an atypical clinical case and to review the literature on frontotemporal dementia (FTD) focusing on the most frequent psychopathological findings.Methods: Case report and a non systematic review using databases Pubmed, UpToDate, Medscape, between 2007 to 2020. Keywords: frontotemporal dementia, psychiatry, psychopathology.Results: FTD is a neurodegenerative syndrome that appears most frequently in the fifth and sixth decades, mostly before the age of 65. Six to seven years before the diagnosis of FTD, psychiatric disorders such as major depression can appear. The behavioral variant DFT is characterized by symptoms such as disinhibition, apathy or inertia, loss of empathy, hyperorality, persevering behaviors, executive dysfunction, and it is also associated with changes in imaging exams, namely frontal and temporal cortical atrophy, which may affect one or both hemispheres. We present the case of a 66-year-old female patient, accompanied for a long time in psychiatry by conversion and dissociative symptoms, associated with histrionic personality traits. She was hospitalized for deteriorating functioning, pauted by great agitation and maladjusted behavior, alteration of thought and speech, and marked perseverance, as well as periods of space-time disorientation. Analytically, there were no changes, as well as in imaging exams such as CT and MRI. It was performed an electroencephalogram (EEG) that demonstrated diffuse cortical dysfunction.Discussion/Conclusion: This case is atypical in the DFT pattern, regarding the age of onset and the absence of imaging findings. However, there was alterations in the EEG, which together with the symptomatic presentation point to DFT. This case exemplifies the difficulty in the management of symptoms, whose therapy is purely symptomatic and psychoeducational strategies for the family and caregivers are fundamental.

201 - Behavioral and Psychological Symptoms of Dementia: a symposium of the IPA BPSD Shared Interest Forum

Section A. Psychotropic drug use (20 minutes)1) Sytse Zuidema: The RID (Reduction of inappropriate psychotropic drugs in dementia) study Nursing home residents with dementia and neuropsychiatric symptoms are prescribed psychotropic drugs too often and also sometimes inappropriate. Multidisciplinary interventions can help to facilitate better care by using psychosocial interventions and help to decrease inappropriate psychotropic drug use. We supported implementation of such interventions through participatory action research, to facilitate nursing homes to design, and implement their own local interventions. The results of the RCT (including a process evaluation) will be presented.2) Tzung-Jeng Hwang: dextromethorphan for treating agitationAgitation is highly prevalent in patients with dementia and associated with significant impairment of quality of life, early institutionalization, and higher mortality. Although no pharmacotherapy has been approved by the US FDA for dementia patients with agitation, off-label use of antipsychotic agents is common. But antipsychotic agents are clearly associated with increased adverse effects, including stroke and death. Dextromethorphan (DXM) is a low-affinity uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist, a high-affinity sigma-1 receptor agonist, a serotonin and norepinephrine reuptake inhibitor, and a nicotinicα3β4 receptor antagonist. The combination of DXM and low dose quinidine (Q) has been approved for the treatment of pseudobulbar affect in 2010. A recent study found that DXM/Q may be effective for the management of agitation in patients with Alzheimer disease (AD). In this talk, a pilot study on using DXM alone to treat agitation in dementia will be reported. Overall, the use of DXM 60-240 mg/day resulted in a high proportion of improvement (CGI-agitation: 69% much improved, 25% minimally improved). No severe adverse events were found. The results support DXM may be efficacious and safe.3) Marie Andree Bruneau: OPUS-APOPUS-AP aims at improving resident care through increased staff’s knowledge and competency, resident-centered approaches, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. OPUS-AP is implemented through integrated knowledge translation and mobilization activities. Antipsychotic, benzodiazepine, antidepressant prescriptions and BPSD were evaluated every 3 months for 9 months. Phase 2 of OPUS-AP was conducted in 129 LTC centres in Quebec, Canada, from April to December 2019. At baseline (April 2019), 10,601 residents were admitted on OPUS-AP participating wards from which 74% had a diagnosis of major neurocognitive disorder (MNCD) and 47% an antipsychotic prescription. The follow-up cohort included 4,087 residents with both MNCD and antipsychotic prescription. Among the 1381 residents in whom antipsychotic deprescribing was attempted between baseline and 9 months and still included at 9 months, successful deprescribing was achieved in 79,2% (cessation 44,8% or dose decrease 34,5%)). No increase in benzodiazepine or antidepressant prescriptions nor worsening of BPSD were observed.Section B. Updates on BPSD (20 minutes)1) Kathrin Schmuedderich: Severe agitation and quality of lifeA secondary data analysis was performed on the relationships between the severity of agitation (NPI-Q) and the single dimensions of quality of life (QUALIDEM) in people with dementia living in German nursing homes. In order to determine the differences between people with severe agitation and the group of people with mild or no agitation, a matching method and regression analyses were used. The findings show that severe agitation is related to lower quality of life in five out of six dimensions of quality of life.2) Wai-chi Chan: BPSD as a predictor of cognitive declineDescription will follow3) Huali Wang: Challenging behavior in ChinaDescription will followSection C. Measurement of BPSD (25 minutes)1) Wendy Moyle: Measurement of agitationThis presentation demonstrates how the use of video observation/coding, standardised measures of agitation (CMAI-SF), and physiological measures (actigraphy) produced different outcome results related to agitated behaviours following the introduction of a social robot. When measuring agitation, we need to consider using different types of measures to ensure data reliability and validity and longitudinal research methods to identify efficacy of psychosocial interventions and effective measurement of agitation when using social robots.2) Discussion on measurement of agitation, discussing and making plans for datasharing based on a template for datastructuresSection D. ECT (15 minutes)1) Rob Kok: short intro on ECT in BPSDThe majority of patients with dementia develop agitation or aggression in the course of their disease. In some severe cases, pharmacological and other interventions are not effective in improving these symptoms. A recent systematic review suggested that electroconvulsive therapy (ECT) could be an effective treatment for severe and treatment-refractory agitation and aggression in dementia, with few adverse consequences. We need to have controlled studies, address the stigma of ECT and develop professional guidelines for the application of ECT for agitation and aggression in dementia, particularly because most patients are not able to provide informed consent.2) Discussion and making plan for international survey on application of ECT in BPSD

Nighttime Agitation and Restless Legs Syndrome in Persons With Alzheimer's Disease: Study Protocol for a Double-Blind, Placebo-Controlled, Randomized Trial (NightRest).

Persons with AD with nighttime agitation potentially caused by RLS. Diagnose RLS and determine the effect of GEn. The frequency of RLS behaviors will mediate the relationship between GEn and nighttime agitation. Determine the effect of GEn on nighttime agitation, sleep, and antipsychotic medications. ClinicalTrials.gov Identifier: NCT03082755 (Date of registration March 6, 2017). [Research in Gerontological Nursing, 13(6), 280-288.].

The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury

This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. Observational prospective study with correlational design. Inpatient rehabilitation hospital for TBI. A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.

The Prevalence and Determinants of Neuropsychiatric Symptoms in People With Acquired Brain Injury in Nursing Homes

ObjectivesEstablishing the prevalence and determinants of neuropsychiatric symptoms (NPS) in patients with acquired brain injury (ABI) in nursing homes. DesignCross-sectional, observational study. Setting and ParticipantsPatients 18-65 years old with ABI in special care units in Dutch nursing homes. MethodsNursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the Internet. Patient characteristics were collected through digital questionnaires. NPS were assessed with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use (PDU) was retrieved from the electronic prescription system. Individual NPS were clustered. Associations between determinants and NPS were examined using multilevel multivariate linear regression models. ResultsIn a population of 118 patients from 12 nursing homes, 73.7% had 1 or more clinically relevant NPS and 81.3% 1 or more agitated behaviors. The most common NPS were agitation, in particular aberrant motor behavior (24.6%), repetitious sentences/questions (35.5%), and constant requests for attention (34.6%), verbal (33.6%) and physical (50.5%) aggression, and irritability (28.0%). Male patients were more likely to display hyperactivity. Being married was associated with less verbally agitated behavior and pain was associated with a higher CMAI total score. PDU increased the likelihood of a higher NPI-NH total score. Conclusions and ImplicationsNPS are common in patients with ABI ≤65 years of age residing in nursing homes. This is a first step to fill in the knowledge gap concerning NPS in this population. An increasing number of patients with severe ABI may survive the acute phase and will reside many years in nursing homes. It is important to shed more light on these NPS, with regard to course, magnitude, and severity, to ultimately develop appropriate care for this vulnerable group of patients.

Why we need to care about the care: A longitudinal study linking the quality of residential dementia care to residents’ quality of life

BackgroundResidential dementia care staff are often the most important people in a resident’s social world. It is a symbiotic relationship and the work can involve highly emotional interactions as well as physical and technical demands. This study focused on narrowing down the most useful targets for intervention in quality of care (QOC) in order to improve quality of life (QOL) for people with dementia in residential care. MethodOver six months we followed: 247 older adults with dementia from 12 residential care facilities, their families/care partners (n = 225), managers (n = 12) and staff (n = 232). Facilities ranged from 10 to 137 beds, located across remote, rural and metropolitan areas. Measures: Staff surveys, family member and resident interviews, resident file audits, live resident and staff observations and organisational audits. ResultsThe QOC provided had an immediate impact on resident’s pain, depression, QOL scale score, Body Mass Index, ease/engagement with staff, and food and fluid intake. This influence was still evident six months later, with baseline QOC leading to improved ease and engagement with staff, QOL scores, and fluid intake. Restraint use featured heavily as a predictor of poor outcomes for residents. QOC did not significantly impact agitated behaviours, frailty, nor physical/verbal expressions of well-being. ConclusionsWhat staff do and the way they do it has a real and lasting impact on the QOL of residents. The most useful targets for improving QOL are: eradicating physical restraint and supporting and upskilling care staff so that they treat and interact empathetically and humanely with residents.

Prevalence and risk factors for seclusion and restraint at Geneva’s adult psychiatric hospital in 2017

Background and objectivesCoercion is frequent in psychiatry, with an overall downward trend. Knowledge on the application of seclusion and restraint in open wards remains limited. We aimed to describe the prevalence of coercion in an open inpatient setting and identify risk factors for it. MethodsWe conducted a retrospective analysis of the use of seclusion and restraint in 2017 in the adult psychiatry division of Geneva University Hospital. To identify risk factors for coercion, we estimated incidence rate ratios using multivariable Poisson regressions. ResultsOf 865 patients, 142 (16.4%) experienced at least one coercive measure (mostly seclusion). The incidence of coercion was higher in men, single patients, patients with psychotic or bipolar disorders, patients receiving disability benefits, patients with a higher number of previous psychiatric hospitalizations, and patients with higher global scores and higher scores on item 1 (overactive, aggressive or agitated behaviour) on Health of the Nation Outcome Scales (HoNOS) at admission. Age and referrals from the emergency department were not associated with a higher risk of coercion. ConclusionRisk factors for coercion were being male, being single, having psychotic or bipolar disorders, having previous psychiatric hospitalizations, having high HoNOS scores at admission, and being referred from outpatient centres or private physicians. Ratings on the first HoNOS item at admission might be sufficient for a pertinent aggression risk evaluation and thus for the prevention of coercion due to violence. This study is the first to analyse the risks of seclusion in open wards and calls for further research.

Teaching caregivers to respond safely during agitated states before aggression using simulation training.

Individuals who engage in aggression often display precursors or agitated behavior first, and it is important for caregivers to learn how to minimize risk of injury in the event that aggression were to occur. In this study, behavioral skills training was used to teach 4 caregivers of children who engage in aggression to position their body safely and prevent access to dangerous items during agitated states. Confederates were used during all baseline, training, and posttraining sessions to maintain consistency and the safety of the caregivers. All caregivers quickly learned to use these safety skills during agitated periods but not during calm periods with minimal between-session feedback regarding correct responding.