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

Behavioral and Psychological Symptoms (BPSD) in Alzheimer's Disease (AD): Development and Treatment

Behavioral and psychological symptoms of dementia (BPSD), such as agitation, apathy, and psychosis, are highly prevalent and have a significant impact on patients and their care partners. The neurobiology of BPSD involves a complex interplay of structural brain changes and alterations in the neurotransmitter system. Various genetic and plasma biomarkers have also been studied. Research in BPSD has been limited by heterogeneity in the diagnostic criteria and assessment tools. As such, there have been ongoing efforts to develop a gold-standard assessment tool and diagnostic criteria. Current practice guidelines recommend nonpharmacological therapies as first-line treatments. Pharmacological options are often used when there is an insufficient response to nonpharmacological strategies, but there can be serious adverse effects with existing pharmacological agents. This has resulted in growing efforts to develop novel therapeutics with more favorable tolerability profiles, with some showing promising results. Other biological therapies, such as neurostimulation, have also demonstrated positive results. As our understanding of BPSD evolves, ongoing research efforts in treatment of BPSD are warranted in order to enhance the quality of life for patients and their care partners.

Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy

OBJECTIVE

40-60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD.

METHODS

Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools.

RESULTS

6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI).

CONCLUSIONS

The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.

Effects of dance intervention on agitation and cognitive functioning of people living with dementia in institutional care facilities: Systematic review

INTRODUCTION

Agitation and impaired cognitive functioning are common symptoms of dementia, which require costly medication regimens that are associated with adverse effects. This study investigates the effects of dance interventions on agitation and cognitive function in people living with dementia in institutional care facilities.

METHODS

Five electronic databases were searched for eligible studies on dance interventions for people living with dementia published between 2002 and 2021. Standard deviation and post mean values were extracted. Within-group Hedges' g was computed for individual studies.

RESULTS

Six randomised controlled trials and three non-randomised studies of satisfactory quality, with a total of 610 participants, were included. Statistical analysis found significant improvements in agitation and cognitive functioning with dance interventions.

DISCUSSION

This review provided favourable evidence on the effects of dance interventions on agitation and cognitive functions in people with dementia. However, given the limited evidence, more studies are needed to confirm the effects.

Benefits of Affordable Robotic Pet Ownership in Older Adults With Dementia

The current study investigated the impact of affordable robotic pet ownership on agitation, quality of life, and depression in older adults with dementia. Data are reported for five adults with dementia receiving day services at an all-inclusive care center for older adults (one male; mean age = 82.8 years). Data were collected three times to obtain baseline (Time 1 to Time 2) and post-intervention (Time 2 to Time 3) scores. Self-reported quality of life and depression symptoms improved post-intervention, but not during baseline. Caregiver-reported agitation did not change consistently across participants during baseline or post-intervention. Simple ownership of affordable robotic pets may be a feasible option to improve quality of life and affective experiences in individuals with dementia. Further work with larger samples should examine whether a combination of ownership and structured activity would produce changes more perceptible to caregivers. [Journal of Gerontological Nursing, 47(3), 18-22.].

Resident-to-Resident Aggression in Long-Term Care: Analysis of Structured and Unstructured Data From the National Violent Death Reporting System, 2003-2016

Aging adults are at risk for multiple types of abuse including emotional, sexual, or physical abuse. Adults in skilled nursing or assisted living facilities might be particularly vulnerable to injury, including fatal injury resulting from incidents of resident-to-resident aggression (RRA). The purpose of this research is to report findings from the multistate National Violent Death Reporting System (NVDRS) related to fatal RRA incidents between years 2003 and 2016. We analyzed structured categorical data and unstructured narrative data on 101 identified fatal RRA incidents among individuals aged 65+. Findings included that victims average 16 years older than exhibitors and dementia diagnoses are present in most cases. Qualitative analysis revealed that events are described as both unexpected and preventable. Training to improve long-term care staff recognition and reporting of RRA events may potentially improve prevention and provide more accurate trend data. NVDRS data provide a useful source to follow trends in fatal RRA going forward.

Familial caregivers' experiences with home-visit nursing for persons with dementia who live alone

AIM

The Japanese Comprehensive Strategy to Accelerate Dementia Measures, known as the New Orange Plan, aims to support people with dementia living in their communities. Home-visit nurses (HVN) are expected to play an important role in this comprehensive support system. In this preliminary study, we explored caregivers' experiences before and after implementation of HVN care for persons with dementia who lived alone.

METHODS

This study was a qualitative descriptive design using in-depth interviews with five family caregivers of persons with dementia who lived alone while receiving HVN. Thematic content analysis was undertaken.

RESULTS

Before receiving HVN, caregivers experienced anxiety and embarrassment due to the occurrence of dementia symptoms, and they also experienced considerable isolation and anguish after hearing the diagnosis. After initiating HVN, caregivers gained a feeling of security and an alleviation of psychological stress. They also gained a deeper understanding of the disease and appropriate care for dementia patients. Notably, caregivers perceived not only positive changes in themselves, but also in the recipients, such as improvements in symptoms and quality of life. Finally, caregivers realized that people with dementia can live alone if appropriate services are provided.

CONCLUSION

HVN can have a positive impact on family caregivers involved in dementia care, as well as on the recipients' psychological status. Overall, the experience of HVN made the family caregivers more positive about home care for their family member with dementia. Although further case studies are needed to make definitive conclusions, we believe that HVN could play a key role in the forthcoming New Orange Plan.

Correlates of nursing care burden among institutionalized patients with dementia

ABSTRACTBackground:The stress associated with care of patients with dementia has led to high nursing staff turnover. This study aims to explore patient factors that are related to nursing burden.

METHODS

The present study examined nursing care burden related to 55 institutionalized dementia patients using the Modified Nursing Care Assessment Scale (M-NCAS). Cognition was assessed with the Severe Impairment Battery (SIB), activities of daily living (ADLs) were measured with the Alzheimer's Disease Functional Assessment of Change Scale (ADFACS), aggression was measured with the Aggressive Behavior Scale (ABS), and the Charlson Comorbidity Index (CCI) was used to assess medical comorbidity. Finally, the Dementia Cognitive Fluctuation Scale (DCFS) was used to assess the presence and severity of cognitive fluctuations (CFs). Linear regression models were used to assess their relationships with nursing care burden.

RESULTS

The mean age of the patients was 90.41 years (SD=2.84) and 89.10% were males. ADFACS total score (B = 0.36, β = 0.42, p = 0.002) and ABS score (B = 2.933, β = 0.37, p = 0.002) significantly predicted the M-NCAS Attitude score. ABS score was the only significant predictor of M-NCAS Strain score (B = 2.57, β = 0.35, p = 0.009).

CONCLUSIONS

In the long-term care setting, aggressive behavior plays an important role in both subjective and objective nursing burden, while impaired ADLs increase the objective burden for nursing staff.

Person-Centered Primary Care Strategies for Assessment of and Intervention for Aggressive Behaviors in Dementia

With an increase in the number of individuals affected by dementia, it is imperative for health care providers to be well versed in the most effective ways to manage neuropsychiatric symptoms, such as aggression. Aggression can be particularly hard to manage because it creates risk of harm for formal and informal caregivers, and options for medical intervention are complex and situation dependent. Although multiple guidelines for management of aggression in dementia are available in the literature, their scope is widespread and suggested treatments often vary, making decision making difficult to navigate for busy clinicians. Using a composite case as a model, the current article provides guidelines that take outpatient providers through the steps needed to provide effective treatment for aggression in individuals with dementia. Shifting the current focal point of health care for aggressive dementia patients toward a more person-centered approach will have a positive impact on patient care. [Journal of Gerontological Nursing, 43(2), 9-17.].

African-American caregivers' perspectives on aggressive behaviors in dementia

Purpose

Although African-American dementia caregivers report less upset and more confidence managing aggressive behaviors when compared to whites, their contextual experience remains unclear and this study explores that context.

Methods

Semi-structured interviews with 13 African-American family caregivers were analyzed using content analysis.

Results

Two themes emerged, “It’s the disease…not the person” and “You got to pick your battles.” “It’s the disease…not the person,” reframing aggressive behavior, included three sub-themes. Sometimes the person with dementia seemed like a stranger but caregivers remembered “In there somewhere is that person.” Aggressive behavior made this perspective difficult as they reported, “Sometimes it’s hard not to take it personal.” Premorbid dyadic conflict made caregiving difficult but caregivers remembered they were “Not who they were then.” “You got to pick your battles,” reflecting cognitive and behavioral strategies, also included three sub-themes. Participants prioritized caregiving over other commitments by reminding themselves “I got to do what I gotta do.” Preventing aggressive behaviors was most successful when “We didn’t argue…we didn’t insist” and caregivers remembered “Don’t put her in a position to fail” when involving the person with dementia in activities.

Implications

African-American caregivers described substantial challenges when confronted by aggressive behaviors. Strategies employed by caregivers enabled them to maintain a caring perspective and the person with dementia to maintain calm. Interventions that help caregivers manage aggressive behaviors may benefit by considering the challenges, cultural values, and effective strategies used by African-Americans.

Patient and Caregiver Interplay in Behavioral and Psychological Symptoms of Dementia: Family Caregiver's Experience

The purpose of this study was to identify family caregivers' experiences in managing the behavioral and psychological symptoms of dementia (BPSD) with particular focus on their interpersonal interactions with patient with dementia. Data were collected through focus-group interviews with 15 family caregivers from three local dementia-support centers located in Seoul. Data were analyzed using content analysis. Three main themes were identified through data analysis: triggers of BPSD, family caregiver's actions in response to BPSD and patient's reactions, and the effect of BPSD on family caregivers. Findings demonstrated that BPSD depended on the complex interplay of family caregivers and patients, including their interaction style. This information could help nurses when counseling and educating family caregivers to improve or modify their attitudes and approaches to behavioral symptoms of patients.

Resident-to-resident violence triggers in nursing homes

Certified nurses' assistants (CNAs) employed by a rural nursing home in Northeast Arkansas described their perceptions of resident-to-resident violence in order to provide insight on factors, including unmet needs, that may trigger the phenomenon. Semistructured interviews were conducted with 11 CNAs. Data were analyzed using content analysis and constant comparison. Two categories of triggers emerged from the data-active and passive. Active triggers involved the actions of other residents that were intrusive in nature, such as wandering into a residents' personal space, taking a resident's belongings, and so forth. Passive triggers did not involve the actions of residents but related to the internal and external environment of the residents. Examples were factors such as boredom, competition for attention and communication difficulties. Results indicate that there are factors, including unmet needs within the nursing home environment that may be identified and altered to prevent violence between residents.

Verbal and physical aggression directed at nursing home staff by residents

CONTEXT

Little research has been conducted on aggression directed at staff by nursing home residents.

OBJECTIVE

To estimate the prevalence of resident-to-staff aggression (RSA) over a 2-week period.

DESIGN

Prevalent cohort study.

SETTING

Large urban nursing homes.

PARTICIPANTS

Population-based sample of 1,552 residents (80 % of eligible residents) and 282 certified nursing assistants.

MAIN OUTCOME MEASURES

Measures of resident characteristics and staff reports of physical, verbal, or sexual behaviors directed at staff by residents.

RESULTS

The staff response rate was 89 %. Staff reported that 15.6 % of residents directed aggressive behaviors toward them (2.8 % physical, 7.5 % verbal, 0.5 % sexual, and 4.8 % both verbal and physical). The most commonly reported type was verbal (12.4 %), particularly screaming at the certified nursing assistant (9.0 % of residents). Overall, physical aggression toward staff was reported for 7.6 % of residents, the most common being hitting (3.9 % of residents). Aggressive behaviors occurred most commonly in resident rooms (77.2 %) and in the morning (84.3 %), typically during the provision of morning care. In a logistic regression model, three clinical factors were significantly associated with resident-to-staff aggression: greater disordered behavior (OR = 6.48, 95 % CI: 4.55, 9.21), affective disturbance (OR = 2.29, 95 % CI: 1.68, 3.13), and need for activities of daily living morning assistance (OR = 2.16, 95 % CI: 1.53, 3.05). Hispanic (as contrasted with White) residents were less likely to be identified as aggressors toward staff (OR = 0.57, 95 % CI: 0.36, 0.91).

CONCLUSION

Resident-to-staff aggression in nursing homes is common, particularly during morning care. A variety of demographic and clinical factors was associated with resident-to-staff aggression; this could serve as the basis for evidence-based interventions. Because RSA may negatively affect the quality of care, resident and staff safety, and staff job satisfaction and turnover, further research is needed to understand its causes and consequences and to develop interventions to mitigate its potential impact.

How do family carers respond to behavioral and psychological symptoms of dementia?

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) have been associated with increased carer burden and early institutionalization. BPSD are more responsive to treatment than are cognitive and functional decline. Little is known about how family carers understand and try to reduce these symptoms. This study aimed to explore the strategies used by carers looking after someone with high levels of BPSD.

METHODS

Twenty-five carers were interviewed using a semi-structured interview with the Neuropsychiatric Inventory (NPI). They were all caring for someone eligible for an Extended Aged Care at Home Dementia Package, which targets people with BPSD.

RESULTS

Participants reported high levels of BPSD with a mean score of 8.2 for symptoms (range 2-12, SD = 2.38) and a mean NPI score of 51.4 (range 14-111, SD = 28.74). Distress scores were also high with a mean of 18.5 (range 2-42, SD = 11.33). Carers described on average, fewer than four strategies for managing BPSD. Encouraging activity, utilizing psychotropic medications, identifying triggers, restraining or treating in a paternalistic manner, and meeting physiological needs were the most commonly used strategies.

CONCLUSION

While family carers are often at the forefront of identifying triggers and addressing unmet needs, findings from this study suggest that some carers have a limited repertoire of strategies despite experiencing a large number of symptoms. There is a clear need for ensuring evidence-based programs to educate and support carers in identifying triggers, understanding symptoms and learning to cope with these symptoms.

Nurse care manager contribution to quality of care in a dual-eligible special needs plan

We evaluated the quality of care provided to older patients with complex needs in a dual-eligible, community-based Medicare Special Needs Plan that used a nurse care manager model. Care provided by physicians was substantially supplemented by nurse care managers, as measured by Assessing Care of Vulnerable Elders quality indicators. We describe selected nurse care manager activities for six geriatric conditions (falls, dementia, depression, nutrition, urinary incontinence, and end-of-life care) during provision of patient care coordination and management for patients in the highest decile of clinical complexity. We identify areas of high nurse performance (i.e., falls screening, functional assessment, behavioral interventions for dementia problems, advance care planning) and areas of potential missed opportunities (i.e., follow up for new memory problems, targeted dementia counseling, nutrition, and behavioral approaches to urinary incontinence). Increasing the collaborative interaction between nurses providing care in this model and physicians has the potential to enhance nurses' contributions to primary care for vulnerable older adults.

Factors associated with resident aggression toward caregivers in nursing homes

PURPOSE

Caregivers in nursing homes often experience aggressive behavior of residents. The aim of this study was to explore the caregivers' experiences with aggressive behavior from residents and to identify environmental factors as well as caregiver and resident characteristics related to aggressive behavior in Swiss nursing homes.

DESIGN

A retrospective cross-sectional survey was conducted between November 2010 and April 2011 with a sample of caregivers working in various nursing homes in the German-speaking part of Switzerland. In total, 814 caregivers (response rate 51.8%) of 21 nursing homes participated in the study.

METHODS

Data were collected using the German version of the Survey of Violence Experienced by Staff (SOVES-G-R). Standard descriptive statistics were used to describe and summarize the date. To identify risk factors related to the experience of aggression by residents, multilevel logistic regression analysis was applied.

FINDINGS

The prevalence of participants reporting an aggressive incident during the 12-month period prior to data collection was 81.6%. Of these, 76.5% had experienced verbal aggression, 27.6% threats, and 54.0% physical aggression. The predictive variables in the multiple regression model for physical aggression were: staff education level (odds ratio [OR]= 1.82), gender (OR = 1.82), age (< 30 years vs. 30-45 years: OR = 1.46; < 30 years vs. > 45 years: OR = 2.13), and confidence in managing physical aggression (OR = 1.49). The predictive variables for threatening behavior were staff education level (registered nurses vs. non-registered nurses: OR = 1.70; nonstudent vs. student: OR = 1.89) and age (< 30 years vs. 30-45 years: OR = 2.00; < 30 years vs. > 45 years: OR = 2.04).

CONCLUSIONS

Caregivers in nursing homes are at high risk for experiencing aggressive behavior. The identified risk factors are in line with earlier investigations, but some contradictory results also were observed.

CLINICAL RELEVANCE

The high risk for registered nurses exposed to aggressive behavior and the increased risk for caregivers who feel confident in managing aggressive behavior cast a critical light on the content and aim on present programs for management of aggressive behavior. Caregivers in nursing homes should be qualified in understanding resident aggression in a comprehensive way. A critical point in this topic seems to be the interaction between caregiver and resident during basic care activities. This topic should be investigated in further research projects.

Individualized guidelines for the management of aggression in dementia - Part 2: appraisal of current guidelines

BACKGROUND

Individualized guidelines have the potential to offer clinicians assistance in decision-making at the point of consultation to improve health outcomes for patients. This project aims to develop individualized guidelines for the management of aggression in dementia. At an earlier stage, we developed a map of concepts to consider when managing aggression. The purpose of the current study is to appraise paper-based guidelines for their representation of these concepts.

METHODS

Two reviewers used a four-point scale (absent, weak, moderate, strong) to rate the guidelines on their representation of concepts relating to the patient, the aggression and dementia disorder, the treatment, and the guidelines themselves. Consensus was reached on inconsistent scores.

RESULTS

Sixteen guidelines published since 2005 were evaluated for their representation of 13 key concepts. Pharmacological and non-pharmacological interventions were strongly represented overall in the guidelines, in conjunction with a consideration of the individual characteristics of the patients and their environment. Recommendations based on the presentation of the aggressive symptoms, goals of treatment, and theory of the cause of the aggression were moderately represented in the guidelines. Recommendations for the principles of restraint use and emergency treatment, as well as a consideration of the personal history of the patient, were poorly represented. Only 6 of 16 guidelines gave details of the expected review.

CONCLUSION

Concepts important to the management of aggression in dementia are missing in the majority of published guidelines on dementia. This limits the ability of these tools to guide clinical practice effectively.

Individualized guidelines for the management of aggression in dementia - Part 1: key concepts

BACKGROUND

Clinical guidelines have the potential to assist in the management of aggression in dementia. This study aims to develop a conceptual framework for the construction of individualized guidelines for this group.

METHODS

A concept map of the topic "How to manage aggression in dementia" was developed by reviewing research papers, clinical guidelines, and gray literature. Titles and abstracts of papers that met search criteria were manually scanned in an iterative process for the extraction of key ideas and terminology commonly used to describe the field. Essential ideas and concepts were recorded on a concept map and hierarchically arranged. The concept map was converted into an interactive PDF document for easy distribution and sharing.

RESULTS

Ten key concepts were found to be important when managing aggression in dementia clustered along three major dimensions: Patient, Disorder and Treatment. The dimension Patient was defined by the "Patient's individual characteristics," the "Personal life story," and the "Patient's environment." Disorder was defined by the "Presentation of symptoms" and "Theory of causation." Treatment was defined by "Goals and expectations," "Non-pharmacological interventions," "Pharmacological interventions," "Ethics and Restraint Use," and "Emergency treatment." Concepts relating to clinical guidelines themselves were also included in the interactive map, including "Support from evidence-based medicine," "Regular updates," "Disclosures," and "Usability."

CONCLUSION

Managing aggression in dementia requires consideration of a wide range of factors relating to the patient, the dementia and behavioral disturbance, and possible treatment options. An interactive and hierarchical concept map provides a framework to develop individualized clinical guidelines.

Victim or initiator? Certified nursing assistants' perceptions of resident characteristics that contribute to resident-to-resident violence in nursing homes

The purpose of this portion of a larger qualitative study was to explore certified nursing assistants' (CNAs) perceptions of the characteristics of both the victims and initiators of resident-to-resident violence (RRV) to identify resident characteristics that influence development of RRV. Findings gained from semi-structured interviews revealed that CNAs perceive initiators of RRV to be "more with it" and to have "strong personalities," a "short fuse," and "life history" that make them prone to inflict harm on other residents. CNAs described victims of RRV using phrases such as, "they don't know," "can't communicate," and "gets around good." The results also revealed that, in some situations, residents who were usually even tempered might strike out with violence if exposed to triggers over time. This study provides the first detailed description of nursing home residents who initiate violence against other residents. Knowledge gained from this study may be useful in generating models of RRV-a precursor to developing interventions for its prevention.

A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.

[Premorbid personality and aggressive behavior: a study with residents of psychogeriatric nursing homes]

From experimental research it appears that personality plays a role in causes and onset of aggressive behavior in adults. However, studies about the influence of premorbid personality on aggressive behavior of older persons with dementia show contradictory results. In this study we gathered data on personality and behavior of 166 residents of psychogeriatric nursing homes. Nursing staff filled out the Cohen-Mansfield Agitation Inventory (Dutch version, CMAI-D). Proxy family members completed the Hetero Anamnestic Personality questionnaire (HAP). Results showed that on the CMAI-D aggression could be distinguished from other forms of agitation. Four subscales of the HAP showed significant positive correlations with aggression as measured with the CMAI-D. These subscales were: Antagonism, Whimsical and impulsive behavior, Rigid behavior, and Being vulnerable in social interactions. Although the influence of personality decreased with increasing cognitive impairment, it was still present in stage 6 of the Reisberg Global Deterioration Scale. In depth analysis items of the HAP revealed a first profile of the aggression prone personality.

Formal caregiver burden in dementia: impact of behavioral and psychological symptoms of dementia and activities of daily living

The purpose of this study was to identify the impact of the behavioral, psychological, and functional symptoms of dementia on the burden of formal caregivers. A cross-sectional study was conducted among formal caregivers caring for residents with dementia in Japan. The Zarit Caregiver Burden Interview (ZBI) personal strain items, the Personal Self-Maintenance Scale (PSMS), and the Troublesome Behavior Scale (TBS) were used to assess the level of formal caregiver burden, activities of daily living (ADL), and behavioral and psychological symptoms of dementia (BPSD), respectively. The data from 445 respondents were analyzed using multiple linear regression analyses to predict the burden on formal caregivers. Disruptive behaviors, such as aggression, screaming, and a low ADL levels among residents with dementia were significantly correlated with higher formal caregiver burden. The results of this study support a positive relationship between BPSD, low ADL levels, and formal caregiver burden in caring for residents with dementia. These results illustrate the various characteristics of the burdens on staff members compared with those faced by individuals who provide informal care.