Non-aggressive Agitation Research Articles

The impact of a hospital-based special care unit on behavioural and psychological symptoms in older people living with dementia.

Hospital patients with behavioural and psychological symptoms of dementia (BPSD) are vulnerable to a range of adverse outcomes. Hospital-based Special Care Units (SCUs) are secure dementia-enabling environments providing specialised gerontological care. Due to a scarcity of research, their value remains unconfirmed. To compare hospital based SCU management of BPSD with standard care. Single-case multiple baseline design. One-hundred admissions to an 8-bed SCU over 2 years in a large Australian public hospital. Repeated measures of BPSD severity were undertaken prospectively by specialist dementia nurses for patients admitted to a general ward (standard care) and transferred to the SCU. Demographic and other clinical data, including diagnoses, medication use, and care-related outcomes were obtained from medical records retrospectively. Analysis used multilevel models to regress BPSD scores onto care-setting outcomes, adjusting for time and other factors. When receiving standard care, patients' BPSD severity was 6.8 (95% CI 6.04-7.64) points higher for aggression, 15.6 (95% CI 13.90-17.42) points higher for the neuropsychiatric inventory, and 5.8 (95% CI 5.14-6.50) points higher for non-aggressive agitation compared to SCU. Patients receiving standard care also experienced increased odds for patient-to-nurse violence (OR 2.61, 95% CI 1.67-4.09), security callouts (OR 5.39 95% CI 3.40-8.52), physical restraint (OR 17.20, 95% CI 7.94-37.25) and antipsychotic administration (OR 3.41, 95% CI 1.60-7.24). Clinically significant reductions in BPSD and psychotropic administration were associated with SCU care relative to standard ward care. These results suggest more robust investigation of hospital SCUs, and dementia-enabling design are warranted.

Geriatric Psychiatry Inpatient Primer for Residents.

The authors describe a novel curricular intervention that enhances first- and second-year psychiatry residents' geriatric psychiatry knowledge while preparing them for overnight call. A brief, four-page document covering evaluation and management of common clinical scenarios in older adults, including agitation, falls, insomnia, chest pain, abnormal vital signs, and review of pharmacologic interventions, was presented to first- and second-year psychiatry residents. The residents completed an anonymous survey including their comfort level in answering pages and knowledge-based questions regarding evidence-based interventions both before and after the intervention. The pre-survey and post-survey were analyzed using the Wilcoxon-signed rank test, paired T test, and Mann-Whitney U test. The residents demonstrated statistically significant changes in first-line medication choices for common clinical scenarios such as non-aggressive agitation and insomnia. They were less likely to choose medications that should be avoided in elderly based on expert panel recommendations. Findings support the need for educational interventions designed to help residents taking call with geriatric patients. The results demonstrated an improvement in clinical knowledge following this brief intervention.

CAREGIVER STRESS THEORY MAY EXPLAIN ELDER ABUSE BUT NOT NEGLECT IN DEMENTIA FAMILY CAREGIVING

The caregiver stress theory is suggested as a causal theory for physical and psychological elder abuse (EA) and neglect within dementia, due to the high rate of behavioral symptoms of dementia (BSD) and caregiver stress. The purpose of this micro-longitudinal study is to evaluate the caregiver stress theory among a sample of dementia family caregivers who co-reside with their care-recipient. Participants completed online diary surveys for 21 days. Using multi-level modeling of diaries (N=681) nested within participants (N=46), BSD behaviors (aggressive and non-aggressive agitation) and perceived stress were examined as predictors of EA and neglect. On days with non-aggressive BSD behaviors compared to no BSD, the odds of self-report EA were 2.5 times greater (CI 1.04–5.89, p = 0.03), while on days with both non-aggressive and aggressive BSD the odds of EA were 26.9 times greater (CI 9.62–75.15, p < 0.001). For neglect, non-aggressive BSD alone did not increase risk but when they co-occurred with aggressive BSD the odds increased by 5.3 (CI 1.7–16.71, p < 0.001). For every point a caregiver scored their perceived stress above their typical stress rating, the odds of EA increased by 1.9 (CI 1.37–2.55, p < 0.001), however the risk of neglect did not. This suggests support for the caregiver stress theory as an explanation for EA, as both BSD and perceived stress increased the risk. However, neglect may be driven by a different causal mechanism, as only certain BSD combinations increase odds of neglect.

Sleep and agitation in nursing home residents with and without dementia.

The prevalence of dementia in Australian nursing homes is high. A large proportion of residents express themselves through agitated behaviors, with substantial interpersonal and day-to-day variance. One factor that may increase agitation is poor sleep. The current study aimed to determine if sleep influences symptoms of agitation in nursing home residents, and whether this effect differed by dementia status. As benzodiazepines are used widely as hypnotic medication, their impact was also considered. Actigraph devices worn on residents' non-dominant wrists for three days were used to obtain objective measures of sleep. Symptoms of agitation were assessed using staff responses to two standardized questionnaires - the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory - nursing home version (NPI-NH). Presence of dementia and benzodiazepine use were obtained from resident medical charts. Forty-nine residents (mean age: 85.57 years) from four nursing homes in Tasmania were included in the study. Results indicated that residents were in bed for an average of 11.04 h and slept for 10.14 h per day. Significant relationships between sleep and verbal as well as non-aggressive agitation were found. No relationships between sleep and aggressive agitation were detected. A significant moderation effect of dementia was found, in which residents without dementia expressed verbal agitation when obtaining less sleep, but not residents with dementia. Benzodiazepine use did not result in significantly more sleep. These results suggest that sleep could play an important role in explaining agitation, but more research is needed to explore the relationship between sleep and benzodiazepines in nursing home residents.

Dimensions of Agitation Based on the Cohen-Mansfield Agitation Inventory in Patients with Dementia

The aim of this study was to investigate the dimensions of agitation in dementia patients using the Turkish version of the Cohen-Mansfield Agitation Inventory (CMAI-T). The study included 100 patients diagnosed as dementia, according to the DSM-IV-TR. The CMAI-T was administered to the patients' caregivers via face-to-face interviews. The Standardized Mini Mental State Examination (SMMSE) was used to assess cognitive functions. The severity of depression and the functional state of the patients were assessed using the Cornell Scale for Depression in Dementia (CSDD) and the Functional Activities Questionnaire (FAQ). Principal component analysis and varimax rotation were used to determine the factor structure of the CMAI-T. Factor analysis of the CMAI-T indicated a 3-factor structure: physically aggressive agitation, verbal agitation, and physically non-aggressive agitation. In 92% of the patients there was ≥1 agitation behavior during the previous 2 weeks. The CMAI-T total and factor scores were negatively correlated with the SMMSE scores, and positively correlated with the CSDD and the FAQ scores. The CMAI-T yielded 3 factors (physically aggressive agitation, verbal agitation, and physically non-aggressive agitation), which indicated the scale had construct validity. Agitation behaviors were associated with cognitive dysfunction, symptoms of depression and general level of functioning. Additional research is necessary to identify the predictors of these dimensions in different dementia samples, and to determine the efficacy of therapeutic interventions.

The role of pain treatment in managing the behavioural and psychological symptoms of dementia (BPSD)

ore than 90% of people with dementia experience at least one behavioural and psychological symptom of dementia (BPSD) over the course of the condition (Steinberg et al, 2008). BPSD include aggression and non-aggressive agitation, which occur in approxi-mately 20% of people with Alzheimer’s disease (AD) who are in contact with clinical services or living in the community, and 40–60% of people with dementia who are in care facilities (Margallo-Lana et al, 2001). Common manifestations of agi-tation include restlessness/pacing, verbal insults, shouting, and physical aggression, and most often occur during personal care. Delusions and halluci-nations are also present in 25% of people with dementia in clinical settings (Steinberg et al, 2008), and depression occurs in 20% of people with AD (Ballard et al, 2009a). The depression symptoms are similar to those seen in people without demen-tia, but are also often associated with an apparent deterioration in function and cognition. In most of these individuals BPSD have a clin-ically significant impact. They are often distress-ing for the patients who experience them, lead to stress and depression in carers, are associated with a reduced quality of life, and are often the trigger for institutional care (Ballard et al, 2009a; 2009b).

Are Wandering and Physically Nonaggressive Agitation Equivalent?

The authors examined equivalence of wandering and physically nonaggressive agitation (PNA) as concepts. A cross-sectional correlational design was used. Participants were recruited from 22 nursing homes and 6 assisted living facilities in two states. Ambulatory residents meeting DSM-IV criteria for dementia (N = 181) were studied. Video-tapes for up to twelve 20-minute observations per participant were coded for wandering using an empirically derived taxonomy of ambulation patterns. Separate raters coded the same tapes for six PNA behaviors on the agitation behavior mapping instrument. Most participants (73.5%) wandered; all showed PNA behaviors. Factor analyses yielded an one-factor solution for wandering (explained variance = 43.66%) and a two-factor solution for PNA (explained variance = 53.45%). Overall wandering correlated significantly with PNA Factor 1 (df =179, r = 0.68, p <0.001) and Factor 2, but at a lower value (df = 179, r = 0.26, p <0.01). Findings depict wandering and PNA as overlapping, but nonequivalent phenomena. Evidence supporting construct validity of wandering was more robust than that for PNA. Results have implications for accuracy in scientific and clinical detection and labeling of wandering and agitation.

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

More than a decade ago, different syndromes of agitation were identified in elderly nursing home residents, and it was found that these syndromes correlate with medical, cognitive, and psychosocial functioning. The present study was conducted to examine the robustness of two major syndromes, verbal agitation and physical non-aggressive agitation, as assessed via direct observations. Study participants were 175 elderly persons with dementia recruited from 11 nursing home facilities in Maryland. Observations of the participants' behavior were conducted using the agitated behaviors mapping instrument. The profiles that emerged for physically agitated residents and for verbally agitated residents were remarkably similar to those originally reported. Specifically, verbally agitated behaviors correlated with female gender, with cognitive decline, poor performance of activities of daily living, impaired social functioning, and signs of depressed affect. Physically non-aggressive agitated behaviors correlated with cognitive impairment and with fewer concurrent medical diagnoses. Examining correlates of different syndromes of agitated behaviors may provide researchers with valuable information that can be used for in-depth analysis of both the characterization and etiology of agitation, thus paving the way for the development of interventions that target particular types of problem behaviors.

Practical geriatrics: possible association of posttraumatic stress disorder with cognitive impairment among older adults.

Practical geriatrics: possible association of posttraumatic stress disorder with cognitive impairment among older adults.

Behavioral and Psychological Symptoms of Dementia: Physical Nonaggressive Agitation

Agitated behaviors occur frequently in patients with dementia. These behaviors affect the quality of life of the dementia sufferers and their caregivers. For example, these behaviors can greatly complicate everyday management in familiar surroundings and in institutional care, and they predict premature nursing home admission.