Cohen-Mansfield Agitation Inventory-Short Form Research Articles

ASSESSMENT OF OLDER ADULTS’ BEHAVIORAL SYMPTOMS AND THEIR SOCIAL BEHAVIORS USING SURVEYS AND A TECHNOLOGY PLATFORM

Abstract Behavioral symptoms are highly prevalent during the course of cognitive decline associated with dementia. Studies have shown that the social environment may affect these symptoms. Data sources examining the effect of environment come from two ongoing studies: 1) MOnitoring DEmentia-Related Agitation Using Technology Evaluations (MODERATE), focusing on agitation in individuals with later-stage dementia, and 2) Monitoring Apathy, Depression and Anxiety Using Technology Evaluations (ADA), focusing on apathy, depression and anxiety in older adults with or without cognitive decline. To date, a total of 9 dyads have enrolled in MODERATE while a total of 9 participants have enrolled in ADA. Caregivers (MODERATE) and participants with cognitive impairment (ADA) report symptoms via weekly online surveys. MODERATE integrates a modified Cohen-Mansfield Agitation Inventory-Short Form series of questions regarding weekly agitation-related levels/events. The ADA weekly online survey consists of Withdrawal-Apathy-Vigor, a subscale from Geriatric Depression Scale-30, a 4-item depression subscale from Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29), and a 4-item anxiety subscale from PROMIS-29. A multi-sensor array (bed pressure mats, motion sensors, and wearables) is deployed in homes to objectively measure participants’ behaviors. With this array, duration of time-out of home, duration of simultaneous activities detected in more than one room, and the total number of occupants and pets within the home are extracted. Additionally, weekly online surveys inquire as to whether participants have been out of town or have overnight visitors. Associations between social activity and behavioral symptoms are obtained combining digital behavioral-activity biomarkers with frequently reported online behavioral data.

Agitation and aggression in people living with dementia and mild cognitive impairment in shared-housing arrangements – validation of a German version of the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF)

BackgroundThe Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF) is a 14-item scale for assessing agitation and aggression, derived from the original 29-item CMAI, and completed by a proxy. Because the CMAI-SF has not yet been validated in German language, the aim of this study is to explore its construct validity.MethodsBaseline data from a cluster-randomized trial to evaluate a non-pharmacological complex intervention for people living with dementia (PlwD) and mild cognitive impairment (MCI) were analyzed. The study sample consisted of 97 shared-housing arrangements (SHAs) in Germany, comprising N = 341 residents with mild to severe dementia and MCI. Trained nursing staff collected data by proxy-rating the CMAI-SF, Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), and QUALIDEM. They also conducted the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA).ResultsIn an exploratory factor analysis, three factors emerged: “aggressive behavior”, “verbally agitated behavior”, and “physically non-aggressive behavior”. The CMAI-SF total score showed good internal consistency (α = .85), and the factors themselves showed adequate internal consistency (α = .75/.76/.73). The CMAI-SF showed convergent validity with the NPI-NH agitation item (r = .66) and the NPI-NH “agitation & restless behavior” factor (r = .82). Discriminant validity was confirmed by a low (r = .28) correlation with the NPI-NH apathy item. Quality of life decreased significantly with agitation, as the CMAI-SF showed a moderate negative correlation with the QUALIDEM total score (r = -.35).ConclusionsThe 14-item CMAI-SF is a time-efficient, reliable, and valid assessment instrument. Three factors emerged that were similar to those already found in nursing home samples for the original CMAI and the CMAI-SF and in day care samples for the CMAI-SF. The findings provide preliminary evidence that the CMAI-SF can be used instead of the CMAI to reduce time, costs, and burden in future trials.Trial registrationThe DemWG study from which data were used to draft this manuscript was prospectively registered on 16 July 2019 at ISRCTN registry (ISRCTN89825211).

Reliability and Validity of a Chinese Version of the Cohen-Mansfield Agitation Inventory-Short Form in Assessing Agitated Behavior.

Background: Patients with dementia often present agitated behaviors. The Cohen–Mansfield Agitation Inventory-short form (CMAI-SF) is one of the most widely used instruments to evaluate agitated behaviors that affect patients’ quality of life and impose burden on caregivers. However, there is no simplified Chinese version of the CMAI-SF (C-CMAI-SF) in clinical settings. Purpose: This study aimed to develop a Chinese version of the C-CMAI-SF and examine its validity and reliability. Methods: This cross-sectional study included three phases. In Phase I, the original CMAI-SF was translated to Chinese. In Phase II, experts were invited to examine the content validity index (CVI). Phase III was conducted to test the validity and reliability of the C-CMAI-SF. Results: The scale showed good validity and reliability with a scale-level CVI of 0.89, Cronbach’s alpha (measure of internal consistency) of 0.874, and test–retest correlation coefficient of 0.902 (for 257 individuals). Using factor analysis, three factors were identified. Regarding concurrent validity, the C-CMAI-SF score was correlated with the Neuropsychiatric Inventory (agitation aggression subscale) and the Cornell Scale for Depression in Dementia (agitation subscale). Conclusions: The study demonstrated that the C-CMAI-SF is a valid and reliable instrument for evaluating agitated behaviors in people with dementia. Relevance to clinical practice: The C-CMAI-SF is an easy and quick tool used to identify and evaluate agitated behaviors in busy clinical settings.

Group Music Intervention for Persons With Dementia in Assisted Living: A Pilot Study

Dementia is the third leading diagnosis among US residents in assisted living communities (ALCs), and agitation is a major challenge for residents, families, and staff. While music interventions in nursing homes and the community have generated promising findings, little evidence of acceptability or efficacy data are available in ALCs. This pilot study tested the acceptability and preliminary efficacy of a staff-led group music intervention among ALC residents with dementia (n=19). We used a mixed-methods pre-post study design. The primary outcome measure was the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF), and facilitator focus group interviews were conducted to gain additional insight into intervention acceptability and facilitators/barriers to implementation among activity staff. Seventeen (89.5%) participants completed the intervention with a 77% overall session attendance rate. Results suggest that the intervention is well-received by management, family, and activity staff, Implications for intervention design, efficacy testing, and contextual factors related to implementation will be discussed.

Evaluation of the efficacy of pimavanserin in the treatment of agitation and aggression in patients with Alzheimer's disease psychosis: A post hoc analysis.

Patients with Alzheimer's disease psychosis (ADP) commonly experience concomitant agitation and aggression. We investigated whether a reduction in ADP following pimavanserin treatment conferred a reduction in associated agitation and aggression. ACP-103-019 was a 12-week, randomized, double-blind, placebo-controlled study that evaluated the efficacy of pimavanserin (34 mg) in reducing psychotic symptoms in patients with ADP. The primary endpoint was change from baseline in Neuropsychiatric Inventory-Nursing Home Version-Psychosis Score (NPI-NH-PS) at week six. A post hoc analysis examined whether there was a greater reduction in agitation and aggression (NPI-NH domain C [agitation/aggression] and Cohen-Mansfield Agitation Inventory-Short Form [CMAI-SF]) in pimavanserin-treated patients who experienced a reduction of hallucinations and delusions (psychosis responders defined as ≥50% reduction from baseline in NPI-NH-PS, week six) when compared with those who did not (nonresponders). Pimavanserin-treated patients with ≥50% response in psychotic symptoms (n = 44) showed a greater improvement in agitation and aggression symptoms on the NPI-NH domain C (week six, least squares mean [LSM] difference = -3.64, t = -4.69, P < .0001) and the CMAI-SF (week six, LSM difference = -3.71, t = -2.01, P = .0483) than nonresponders (n = 32). Differences between psychosis responders and nonresponders were also observed in patients with more severe agitation and aggression at baseline on the NPI-NH domain C (responders, n = 26; nonresponders, n = 13; week six, LSM difference = -3.03, t = -2.44, P = .019). Patients with ADP, who show improvement in psychotic symptoms after pimavanserin treatment, also experience an improvement in concomitant agitation and aggression.

A POST HOC ANALYSIS OF STUDY ACP-103-019 EVALUATING THE IMPACT OF A REDUCTION IN PSYCHOSIS ON THE SEVERITY OF AGITATION AND AGGRESSION IN PATIENTS WITH ALZHEIMER'S DISEASE

Introduction The objective of this post hoc analysis was to evaluate whether Alzheimer's disease (AD) patients with psychosis who experience an improvement in their hallucinations and delusions with pimavanserin treatment also experience an improvement in agitation and aggression. Methods ACP-103-019 was a 12 week, randomized, double-blind, placebo-controlled study that evaluated the efficacy of pimavanserin (PIM) 34mg once-daily in reducing the frequency and/or severity of hallucinations and delusions in patients with AD psychosis. The primary endpoint was change from baseline in the Neuropsychiatric Inventory Nursing Home Version Psychosis Score (NPI-NH PS) [domain A (delusions) + domain B (hallucinations)] at Week 6. A post hoc analysis was conducted to determine if there was a greater reduction in agitation and aggression, as measured by NPI-NH Domain C (agitation/aggression) and Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF), in patients who experienced a reduction in the frequency and/or severity of their hallucinations and delusions when compared with those who did not experience a reduction in hallucinations and delusions. Results Overall in ACP-103-019, there were only minor differences between the placebo (n=91) and PIM (n=87) treatment arms when evaluating changes from baseline to Week 6 in Agitation/Aggression based on CMAI SF total score or NPI-NH Domain C score (0.30 [p=0.8031] and -0.66 [p=0.254], respectively). However, when subjects treated with PIM who responded to the treatment (n=48), defined as a 30% reduction in NPI-NH PS at Week 6, were compared with those who did not respond to PIM treatment (n=28), there was a greater reduction in both CMAI-SF and NPI-NH Domain C scores: -3.74 (p=0.0550) and -2.75 (p=0.0021), respectively. When response was defined as a 50% reduction in NPI-NH PS at Week 6, the greater improvement of agitation/aggression in responders (n=44) vs non-responders (n=32) was also observed for both CMAI-SF and NPI-NH Domain C: -3.714 (p=0.0483) and -3.64 (p Conclusions In this post-hoc analysis, some AD patients whose hallucinations and delusions responded to pimavanserin also experienced improvement in their symptoms of agitation and aggression. These results suggest a correlation between a reduction in hallucinations and delusions and a reduction in agitation/aggression in AD patients with psychosis. This research was funded by Sponsored by ACADIA Pharmaceuticals Inc. (San Diego, CA, USA).

Does Cognitive Impairment and Agitation in Dementia Influence Intervention Effectiveness? Findings From a Cluster-Randomized-Controlled Trial With the Therapeutic Robot, PARO

ObjectivesTo explore whether severity of cognitive impairment and agitation of older people with dementia predict outcomes in engagement, mood states, and agitation after a 10-week intervention with the robotic seal, PARO. DesignData from the PARO intervention-arm of a cluster-randomized controlled trial was used, which involved individual, nonfacilitated, 15-minute sessions with PARO 3 afternoons per week for 10 weeks. Sample and participantsOne hundred thirty-eight residents—aged ≥60 years, with dementia—from 9 long-term care facilities. MeasuresA series of stepwise multiple linear regressions were conducted. Dependent variables were participants’ levels of engagement, mood states, and agitation at week 10 [assessed by video observation and Cohen Mansfield Agitation Inventory-Short Form (CMAI-SF)]. Predictor variables were baseline levels of cognitive impairment [assessed by Rowland Universal Dementia Assessment Scale (RUDAS)] and agitation (CMAI-SF). ResultsFive models were produced. The strongest finding was that participants with more severe agitation at baseline had higher levels of agitation at week 10 (R2 = .82, P < .001). Predictors of positive response were less significant. Low levels of agitation at baseline predicted greater positive behavioral engagement with PARO (R2 = .054, P = .009) and fewer observed instances of agitation (R2 = .033, P = .045) at week 10, whereas greater visual engagement was predicted by both lower levels of agitation and cognitive impairment (R2 = .082, P = .006). Less severe cognitive impairment predicted greater pleasure at week 10 (R2 = .067, P = .004). Conclusions/ImplicationsParticipants with severe agitation had poor response to PARO. Lower levels of agitation and higher cognitive functioning were associated with better responses. In clinical practice, we recommend PARO should be restricted to people with low-moderate severity of agitation. Further research is needed to determine the optimal participant characteristics for response to PARO.

The Cost-Effectiveness of Using PARO, a Therapeutic Robotic Seal, to Reduce Agitation and Medication Use in Dementia: Findings from a Cluster–Randomized Controlled Trial

ObjectivesTo examine the within-trial costs and cost-effectiveness of using PARO, compared with a plush toy and usual care, for reducing agitation and medication use in people with dementia in long-term care. DesignAn economic evaluation, nested within a cluster–randomized controlled trial. SettingTwenty-eight facilities in South-East Queensland, Australia. ParticipantsA total of 415 residents, all aged 60 years or older, with documented diagnoses of dementia. InterventionFacilities were randomized to 1 of 3 groups: PARO (individual, nonfacilitated 15-minute sessions, 3 afternoons per week for 10 weeks); plush toy (as per PARO but with artificial intelligence disabled); and usual care. MeasurementsThe incremental cost per Cohen-Mansfield Agitation Inventory–Short Form (CMAI-SF) point averted from a provider's perspective. Australian New Zealand Clinical Trials Registry (BLINDED FOR REVIEW). ResultsFor the within-trial costs, the PARO group was $50.47 more expensive per resident compared with usual care, whereas the plush toy group was $37.26 more expensive than usual care. There were no statistically significant between-group differences in agitation levels after the 10-week intervention. The point estimates of the incremental cost-effectiveness ratios were $13.01 for PARO and $12.85 for plush toy per CMAI-SF point averted relative to usual care. ConclusionThe plush toy used in this study offered marginally greater value for money than PARO in improving agitation. However, these costs are much lower than values estimated for psychosocial group activities and sensory interventions, suggesting that both a plush toy and the PARO are cost-effective psychosocial treatment options for agitation.

Use of a Robotic Seal as a Therapeutic Tool to Improve Dementia Symptoms: A Cluster-Randomized Controlled Trial

ObjectivesTo test the effects of individual, nonfacilitated sessions with PARO (version 9), when compared against a look-alike plush toy and usual care, on the emotional and behavioral symptoms of dementia for people living in long-term care facilities. DesignParallel, 3-group, cluster-randomized controlled trial conducted between June 14, 2014, and May 16, 2015. SettingTwenty-eight long-term care facilities operated by 20 care organizations located in South-East Queensland, Australia. ParticipantsFour hundred fifteen participants aged ≥60 years, with a documented diagnosis of dementia. InterventionStratified by private/not-for-profit status and randomized using a computer-generated sequence, 9 facilities were randomized to the PARO group (individual, nonfacilitated, 15-minute sessions 3 times per week for 10 weeks); 10 to plush toy (same, but given PARO with robotic features disabled); and 9 to usual care. Treatment allocation was masked to assessors. MeasurementsPrimary outcomes were changes in levels of engagement, mood states, and agitation after a 10-week intervention, assessed by coded video observations (baseline, weeks 1, 5, 10, and 15) and Cohen-Mansfield Agitation Inventory–Short Form (baseline, weeks 10 and 15). Analyses followed intention-to-treat, using repeated measures mixed effects models. Australian New Zealand Clinical Trials Registry (ACTRN12614000508673). ResultsVideo data showed that participants in the PARO group were more verbally [3.61, 95% confidence interval (CI): 6.40–0.81, P = .011] and visually engaged (13.06, 95% CI: 17.05–9.06, P < .0001) than participants in plush toy. Both PARO (−3.09, 95% CI: −0.45 to −5.72, P = .022) and plush toy (−3.58, 95% CI: −1.26 to −5.91, P = .002) had significantly greater reduced neutral affect compared with usual care, whilst PARO was more effective than usual care in improving pleasure (1.12, 95% CI: 1.94–0.29, P = .008). Videos showed that PARO was more effective than usual care in improving agitation (3.33, 95% CI: 5.79–0.86, P = .008). When measured using the CMAI-SF, there was no difference between groups. ConclusionsAlthough more effective than usual care in improving mood states and agitation, PARO was only more effective than a plush toy in encouraging engagement.

Levels of physical activity and sleep patterns among older people with dementia living in long-term care facilities: A 24-h snapshot

ObjectivesTo objectively measure over a 24-h period the daytime and nighttime levels of physical activity and sleep patterns of older people with dementia living in long-term care facilities. Study designNested within a larger research program, this cross-sectional study involved 415 residents, aged ≥60 years, with a documented diagnosis of dementia, from 28 long-term care facilities in south-east Queensland, Australia. Main outcome measuresResidents wore SenseWear® activity armbands continuously for 24h, with data recorded for: step count; total energy expenditure; metabolic equivalent of task (MET); and the amount of time spent physically active, lying down, awake, and asleep. Residents’ levels of cognitive impairment (assessed using the Rowland Universal Dementia Assessment Scale) and agitation (assessed using the Cohen-Mansfield Agitation Inventory-Short Form), and demographic data were also collected. ResultsFrom a total of 415 residents monitored with the SenseWear® activity armbands, 192 met the valid wear-time of 21h or more, and had activity and sleep data recorded. These residents were largely inactive during the daytime (engaged in an average of 1.8h of light physical activity), but achieved recommended amounts of sleep at night (average of 6.8h). There was considerable variation within the sample, and activity and sleep differed by sex (p<0.001), age (p=0.010), mobility (p<0.001), and antipsychotic usage (p=0.030). ConclusionsThese data can be used by long-term care clinicians to assist in planning interventions and care approaches which promote physical activity and good sleep practices, and are individualized to physical and cognitive capabilities.Australian New Zealand Clinical Trials Registry (ACTRN12614000508673).

Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia.

Agitation and aggression are among the most frequent and disruptive behavioral complications of dementia that contribute to increased cost of care, hospitalization, caregiver burden, and risk of premature institutionalization. This current study examined the safety and efficacy of electroconvulsive therapy (ECT) as a treatment for behavioral disturbances in dementia. We hypothesized that ECT would result in reduced agitated and aggressive behaviors between baseline and discharge. Twenty-three participants admitted to McLean Hospital (Belmont, MA, USA) and Pine Rest Christian Mental Health Services (Grand Rapids, MI, USA), with a diagnosis of dementia who were referred for ECT to treat agitation and/or aggression, were enrolled in the study. We administered the Cohen-Mansfield Agitation Inventory-Short Form, Neuropsychiatric Inventory-Nursing Home Version, Cornell Scale for Depression in Dementia, and the Clinical Global Impression Scale at baseline, during, and after the ECT course. Regression analyses revealed a significant decrease from baseline to discharge on the Cohen-Mansfield Agitation Inventory (F(4,8) = 13.3; p = 0.006) and Neuropsychiatric Inventory (F(4,31) = 14.6; p < 0.001). There was no statistically significant change in scores on the Cornell Scale for Depression in Dementia. The Clinical Global Impression scores on average changed from a rating of "markedly agitated/aggressive" at baseline to "borderline agitated/aggressive" at discharge. Treatment with ECT was well tolerated by most participants; discontinuation of ECT occurred for two participants because of recurrence of agitation and for three participants because of adverse events. Electroconvulsive therapy may be a safe treatment option to reduce symptoms of agitation and aggression in patients with dementia whose behaviors are refractory to medication management.

A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia

Objectives: This study, as part of a larger programme of research, sought to investigate the effect that participation in a 40-min live group music programme, involving facilitated engagement with song-singing and listening, three times a week for eight weeks, had on agitation and anxiety in older people with dementia. Methods: A randomized cross-over design, with music and reading control groups, was employed. Forty-seven participants with mild – moderate dementia, from two aged care facilities in Queensland, Australia, were recruited. Participants were assessed three times on the Cohen-Mansfield Agitation Inventory – Short Form (CMAI-SF) and the Rating Anxiety in Dementia Scale (RAID). Results: A sub-analysis of 24 participants attending ≥50% of music sessions found a significant increase in the frequency of verbal aggression over time, regardless of group (F(2,46) = 3.534, p < 0.05). A series of multiple regressions found cognitive impairment, length of time living in the facility and gender to be predictors of agitation overall and by subtype. Conclusion: Participation in the music programme did not significantly affect agitation and anxiety in older people with dementia. Both the music and reading group activities, however, gave some participants a ‘voice’ and increased their verbalization behaviour. Agitation was found to be predicted by a number of background factors (namely level of cognitive impairment, length of time in the facility and gender). Future studies would benefit more from in-depth participant assessment prior to study commencement, helping to moderate the influence of low scores, and by undertaking interventions at times when assessed symptoms are most prevalent.

The efficacy of mirtazapine in agitated patients with Alzheimer&amp;rsquo;s disease: A 12-week open-label pilot study

Agitation is one of the most devastating behavioral symptoms in demented patients but there is little evidence about effective and safe pharmacotherapy. We aimed to determine the effectiveness and safety of mirtazapine in treatment of agitated patients with Alzheimer's disease (AD). The consecutive patients with AD who have significant agitation were assigned to a 12-week open-label, prospective study. Patients received mirtazapine 15-30 mg/day. The changes in Cohen-Mansfield Agitation Inventory-Short form (CMAI-SF) scores were primary outcome measurement. The change in Clinical Global Impression-Severity scale (CGI-S) scores and tolerability-safety profile were the secondary efficacy variables. Thirteen of 16 (81.25%) patients completed the study. There was a significant reduction in CMAI-SF and CGI-S between the pre- and post-treatment with mirtzapaine (p < 0.001). The mean baseline score was 26.54 ( +/- 5.4) and mean reduction was 10.6 ( +/- 7.5) in CMAI-SF. There was no significant side effect and cognitive deterioration. The results of this open-label pilot study suggest that mirtazapine may be an effective choice for treatment of agitated patients with AD.

Does a wander garden influence inappropriate behaviors in dementia residents?

The effect on resident behaviors of adding a wander garden to an existing dementia facility was investigated. 34 male residents were observed for 12 months before and after opening the garden. Behaviors were assessed using the Cohen-Mansfield Agitation Inventory Short Form (CMAI), incident reports, as needed medications (pro re nata [PRN]), and surveys of staff and residents' family members as indices of affect. Final CMAI scores and total PRNs employed were lower than baseline values with a trend for residents who used the garden more often to have less agitated behavior. Verbal inappropriate behaviors did not change significantly whereas physical incidents increased. Staff and family members felt that the wander garden decreased inappropriate behaviors and improved mood and quality of life of the dementia residents. Study design characteristics and garden management may have affected behaviors both positively and negatively. Additional studies are needed to explore the benefits of wander gardens for dementia residents.

Clozapine for Treatment-Resistant Agitation in Dementia

Few studies have examined the potential role of clozapine in treatment of agitation in dementia patients who have previously failed to respond to standard pharmacotherapy. We conducted a systematic chart review of all elderly patients admitted to our inpatient unit between 2001 and 2004. Of them, 16 dementia patients were treated with clozapine for treatment-resistant agitation, and their charts were blindly rated by 3 clinicians on the Clinical Global Impression (CGI) Scale, Brief Agitation Rating Scale (BARS), and the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF). Overall, clozapine therapy seemed beneficial in treatment-resistant agitation in dementia patients.