Dementia and agitation in nursing home residents: How are they related?

Aggressive behavior and prognosis in patients with mild cognitive impairment

The diagnosis of mild cognitive impairment (MCI) is associated with an increased risk of developing dementia. When evaluating the further prognosis of MCI, the occurrence of neuropsychiatric symptoms, particularly aggressive and impulsive behavior, may play an important role.

Objective

The aim of this study was to evaluate the relationship between aggressive behavior and cognitive dysfunction in patients diagnosed with MCI.

Methods

The results are based on a 7-year prospective study. At the time of inclusion in the study, participants, recruited from an outpatient clinic, were assessed with Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). A reassessment was performed after 1 year using the MMSE scale in all patients. The time of next MMSE administration was depended on the clinical condition of patients took place at the end of follow-up, that is, at the time of diagnosis of the dementia or after 7 years from inclusion when the criteria for dementia were not met.

Results

Of the 193 patients enrolled in the study, 75 were included in the final analysis. Patients who converted to dementia during the observation period exhibited a greater severity of symptoms in each of the assessed CMAI categories. Moreover, there was a significant correlation between the global result of CMAI and the results of the physical nonaggressive and verbal aggressive subscales with cognitive decline during the first year of observation.

Conclusions

Despite several limitations to the study, aggressive and impulsive behaviors seem to be an unfavorable prognostic factor in the course of MCI.

The Cognitive Daisy (COG-D) for improving care for residents with dementia in care homes: protocol of a feasibility RCT

BACKGROUND

Cognitive problems associated with dementia affect a large proportion of older adults living in residential care. Knowledge of cognitive impairments is important for providing person-centred care (PCC). The impact of specific cognitive impairments on residents' needs is often overlooked in dementia training and information about residents' individual cognitive profiles are frequently underspecified in care-plans, potentially undermining the delivery of PCC. This can lead to reduced resident quality of life and increased distressed behaviours-a major cause of staff stress and burnout. The COG-D package was developed to fill this gap. Daisies provide a visual representation of a resident's individual cognitive strengths and weaknesses in a colourful flower (Daisy) representing five cognitive domains. By viewing a resident's Daisy, care-staff can flexibly adjust in-the-moment care-decisions and can consult Daisies in care-plans for longer-term planning. The primary aim of this study is to assess the feasibility of implementing the COG-D package in residential care homes for older adults.

METHODS/DESIGN

This 24-month feasibility cluster randomized controlled trial involves a 6-month intervention of the use of Cognitive Daisies in 8-10 residential care homes for older adults after training of care staff on the use of Cognitive Daisies in daily care (basic training) and on conducting the COG-D assessments with residents (advanced training). The key feasibility outcomes include % residents recruited, % COG-D assessments completed, and % staff completing the training. Candidate outcome measures for residents and staff will be obtained at baseline, and at 6 and 9 months post-randomization. COG-D assessments of residents will be repeated 6 months after the first assessment. A process evaluation will assess intervention implementation and barriers and facilitators to this through care-plan audits, interviews and focus groups with staff, residents, and relatives. Feasibility outcomes will be analysed against progression criteria to a full trial.

DISCUSSION

The results of this study will provide important information about the feasibility of using COG-D in care homes and will inform the design of a future large-scale cluster RCT to assess the effectiveness and cost-effectiveness of the COG-D intervention in care homes.

TRIAL REGISTRATION

This trial was registered on 28/09/2022 (ISRCTN15208844) and is currently open to recruitment.

[Les effets de l'environnement de soins sur les comportements réactifs des personnes ayant des troubles neurocognitifs vivant en centre d'hébergement : Une revue de la portée]

Les personnes âgées atteintes de troubles neurocognitifs (démences) vivant en centre d'hébergement adoptent fréquemment des comportements réactifs qui limitent leur engagement dans des occupations. La présente étude vise à identifier des moyens d'intervention centrés sur l'engagement des personnes âgées ayant un trouble neurocognitif avec l'environnement humain et non humain en centre d'hébergement afin de diminuer leurs comportements réactifs, en particulier les comportements d'errance, d'apathie et d'agitation. Cette revue de la portée est basée sur la méthode proposée par Levac et ses collaborateurs (2010). Parmi les 21 études retenues, la plupart s'intéressent à des interventions ciblant l'environnement non humain (n=9) ou ciblant simultanément l'environnement humain et non humain (n=9). Plusieurs de ces interventions sont efficaces pour diminuer les comportements réactifs et permettent aux personnes âgées de s'engager avec leur environnement. Le support de l'environnement humain semble toutefois nécessaire à l'utilisation optimale de plusieurs interventions.

The Relationship between Size of Core Network and Frequency of Contacts with Agitation and Positive Affect in Older Adults with Dementia

BACKGROUND

Few studies have explored the associations of agitation symptoms among older adults with core network size and with frequency of contact with core network care providers. The present study aimed to investigate the associations of agitation and affect among older adult people with dementia (PWD) with core network size and frequency of contact with core network care providers.

METHODS

A convenience sample of 98 Omani older adult PWD residing in their homes was recruited. Most of the participants (63.3%) were female, and the mean age of the participants was 80 years (standard deviation = 9.0). A total of 77 participants suffered from severe dementia, while the remaining 21 had mild to moderate dementia levels. Valid and reliable instruments completed by either the participating PWD or their caregivers were used to measure the study variables.

RESULTS

The main hypothesis of the study was not supported, whereby core network size and frequency of contact with the core network were not found to be significantly associated with activities of daily living (ADL) and instrumental ADL (IADL) core networks or agitation and affect. Further, the findings indicated no significant associations between core network size or closeness between PWD and their IADL and ADL caregivers and the amount of ADL and IADL care provided. The level of care provided by the caregivers and the participants' frequency of contact with the core network remained consistent throughout the progress of the dementia patients' conditions.

DISCUSSION/CONCLUSION

The findings of this study are incongruent with the findings of studies conducted in Western countries, which have reported that older adults prefer to have meaningful interactions with small, close social networks as opposed to large networks. Our findings may be explained by the strong cultural values in Oman which place great emphasis on caring for elderly family members. It is essential to understand these relationships in order to develop effective home care interventions for older adult PWD in Oman.

Virtual Reality Experience Intervention May Reduce Responsive Behaviors in Nursing Home Residents with Dementia: A Case Series

BACKGROUND

People with advanced dementia often exhibit responsive behaviors such as apathy, depression, agitation, aggression, and psychosis. Non-pharmacological approaches (e.g., listening to music, watching television, doing arts and crafts) are now considered as a first-line strategy to manage responsive behaviors in clinical practice due to the potential risks associated with the antipsychotic medications. To date, no evaluations of immersive non-head mounted virtual reality (VR) experience as a non-pharmacologic approach for people with advanced dementia living in nursing homes have been reported.

OBJECTIVE

To evaluate the feasibility (acceptance and safety) of VR experience.

METHODS

A single site case series (nonrandomized and unblinded) with a convenience sample (N = 24; age = 85.8±8.6 years; Cognitive Performance Scale score = 3.4±0.6) measuring depression and agitation before and after the intervention. The intervention was a 30-min long research coordinator- facilitated VR experience for two weeks (10 sessions).

RESULTS

The intervention was feasible (attrition rate = 0% ; adverse events = 0). A reduction in depression and in agitation was observed after the intervention. However, we suggest extreme caution in interpreting this result considering the study design and small sample size.

CONCLUSION

This study provides the basis for conducting a randomized controlled trial to evaluate the effect of VR experience on responsive behaviors in nursing homes. Since our intervention uses a smart remote-controlled projector without a headset, infectious exposure can be avoided following the COVID-19 pandemic-induced physical distancing policy in care homes.

Agitation in people with dementia: A concept analysis

AIM

This article aims to clarify the concept of agitation in people with dementia (PWD) by identifying its attributes, antecedents, and consequences to propose an operational definition of the concept.

BACKGROUND

Agitation is a recurrent behavior problem for many people with and without dementia, which results in psychosocial distress. The current literature lacks the conceptual clarity of agitation, which limits its effective nursing management.

DATA SOURCES

Several databases search was utilized that comprise computer searches of PsycINFO, MEDLINE (PubMed), the Cumulative Index of Nursing and Allied Health of data between the years 1970 and 2013.

DESIGN

Concept analysis.

REVIEW METHODS

Rodgers' Evolutionary Method of concept analysis (2000) was employed as a guide for analyzing the agitation concept.

RESULTS

Four main attributes were used to describe and propose a definition of agitation in PWD: disruptive behaviors, repetitiveness, inappropriateness, and aggression.

CONCLUSION

This analysis provides an operational definition that will improve knowledge of investigating relevant issues to agitation, which can be used by nurses and family caregivers when managing and preventing agitation in PWD.

Factors Associated with Home Care Outcomes among Community-Dwelling Older Adult Patients with Dementia

Background

With the increase in the proportion of people with dementia (PWD), it is necessary to address dementia-related issues among older adults who live at home; however, there is no integrative review on this issue.

Objectives

To describe and analyze quantitative and qualitative studies from primary sources in order to identify the factors which impact home care outcomes among PWD.

Methods

A computer search of PsycINFO, MEDLINE (PubMed), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) was performed. This study was guided by Whittemore and Knafl's integrative review method.

Results

This review of the literature identified 3 main factors related to home care outcomes among PWD. These factors are environmental factors, caregiver-related factors, and social network factors.

Conclusions

Further research is required to investigate the impacts of multiple social and environmental factors on home care outcomes among PWD; which can eventually be used by nurses and family caregivers when providing care for older adult PWD.

Bayesian analysis of the association between effective strategies of multimodal nonpharmacological intervention and characteristics of cognitive function in nursing home residents with cognitive impairment: A cross-sectional study

The cognitive function of nursing home (NH) residents with cognitive impairment (CI) tends to decline over time. An effective multimodal non-pharmacological intervention (MNPI) strategy is needed to improve the cognitive function of NH residents with CI.The aim of this study was to clarify the cognitive function characteristics of NH residents with CI in whom a non-pharmacological intervention (NPI) can be implemented, consisting of MNPI using a Bayesian analysis, and to incorporate suggestions to make the MNPI strategy as effective as possible.This study had a cross-sectional design. The 61 subjects were selected from the residents of 5 NHs, of whom 90.16% were female, and the mean (standard deviation) age was 87.20 ± 6.90. Analyses were performed using a hierarchical Bayesian model, and the global and specific cognitive functions as assessed by the Japanese version of the Neurobehavioral Cognitive Status Examination were the response variables. Three types of NPI (cognitive enhancement NPI, physical NPI, psychological and psychosocial NPI), and activities of daily living (ADL), as assessed by the Barthel index, were the explanatory variables.Cognitive enhancement NPI was revealed to have no association with any cognitive function. Physical NPI was negatively associated with orientation [OR 0.31 (95% credible interval (95% CI) -2.33, -0.10)], comprehension [OR 0.16 (95% CI -2.78, -0.95)] and naming [OR 0.49 (95% CI -1.47, -0.02)]. Psychological and psychosocial NPI was positively associated with comprehension [OR 3.67 (95% CI 0.52, 2.13)]. Barthel index was positively associated with total Japanese version of the Neurobehavioral Cognitive Status Examination [OR 1.74 (95% CI 0.08, 2.12)], comprehension [OR 3.49 (95% CI 0.45, 4.67)], repetition [OR 10.07 (95% CI 0.53, 9.01)], naming [OR 2.24 (95% CI 0.07, 3.20)], and calculations [OR 18.82 (95% CI 2.71, 9.40)].The implementation of MNPI should be preceded by cognitive enhancement NPI and physical NPI. Providing ADL enhancing NPI in response to cognitive improvement may be an effective strategy. Providing cognitive enhancement NPI, physical NPI, psychological, and psychosocial NPI, as well as ADL-enhancing NPI at the same time, is also an effective strategy for subjects with mild dementia who are considered to have relatively high cognitive functions.

A Systematic Review of Multimodal Non-Pharmacological Interventions for Cognitive Function in Older People with Dementia in Nursing Homes

INTRODUCTION

Multimodal non-pharmacological interventions (MNPIs) have been reported to be effective in improving the cognitive function. Therefore, it is necessary to study these interventions in older people with dementia (PWD) in nursing homes (NHs).

AIMS

This study aimed to investigate the effects, contents, frequency, duration, length, and form of MNPIs on the global and specific cognitive functions of PWD in NHs through a systematic review, and to consider what kind of intervention design is most effective.

METHODS

A systematic search of peer-reviewed literature published between January 2008 and October 2018 was performed on the PubMed, Cochrane Library, Web of Science and CINAHL databases.

RESULTS

Six randomized controlled trials (RCTs) and one non-RCTs were extracted from electronic databases, and a review was carried out.

CONCLUSION

Our review suggests that MNPIs may improve the global, executive function and memory of PWD in NHs. The combination of exercise, cognitive training and activities of daily living, and intervention at least 3 times a week over at least 8 weeks with, at least 30 min per session using the integrated form is recommended for improving the global and specific cognitive functions of PWD in NHs.

Concept Development of Identification of Discomfort for Nursing Home Patients With Advanced Dementia

PURPOSE

The aim of this study is to clarify the concept of discomfort identification by concept development in the nursing home.

METHODS

The Schwartz-Barcott and Kim's hybrid model was used.

FINDINGS

The identification of discomfort can be explained as an interactive and confirmative process of sympathetically responding to patients with dementia's problem behavior expressions that communicate unmet needs.

CONCLUSIONS

The identification of discomfort has the potential to improve the detection of multidimensional discomfort related to nursing diagnosis as a holistic and patient-centered approach.

IMPLICATION FOR NURSING PRACTICE

The findings could help nursing home nurses have a better understanding of identification of discomfort and can improve nurses and interdisciplinary caregivers' knowledge for developing appropriate comfort caring activities.

Sundown Syndrome, Sleep Quality, and Walking Among Community-Dwelling People With Alzheimer Disease

PURPOSES

Sundown syndrome and sleep disturbances cause people with Alzheimer disease (PAD) and caregivers suffering. Studies have indicated that physical exercise could have a positive impact on sundown syndrome, yet no research has ever explored the relationship between walking and sundown syndrome. The aims of this study were to examine the relationship between sundown syndrome and sleep quality, and determine whether the severity of dementia, sleep quality, and weekly duration of walking influenced sundown syndrome, and to assess differences in sundown syndrome and sleep quality in relation to the accompanying walker and weekly duration of walking among people with Alzheimer disease living in the community.

DESIGN

A cross-sectional observation study was conducted.

METHODS

A total 184 participants were recruited from dementia outpatient clinics of several hospitals and long-term care resource management centers in southern Taiwan. The Chinese version of the Cohen-Mansfield Agitation Inventory, Community form was used to assess sundown syndrome, and the Chinese version of the Pittsburgh Sleep Quality Index was used to measure sleep quality. Pearson correlation, multiple regression, and 1-way analysis of variance were performed for data analysis.

RESULTS

The results indicated that sundown syndrome was significantly correlated with sleep quality (r = 0.374), whereas severity of dementia, sleep quality, and weekly duration of walking were influencing factors of sundown syndrome and accounted for a total of 24.8% of the variance (adjusted R² = 0.222, F_6,177 = 9.709). In addition, PAD who walked with relatives showed less sundown syndrome (F_3,180 = 4.435, P = .005) and better sleep quality (F_3,180 = 3.565, P = .015) compared with those walking with nonrelatives. Also, longer walking time led to less sundown syndrome (F_4,179 = 4.351, P = .002) and better sleep quality (F_4,179 = 3.592, P = .008).

CONCLUSIONS

Advanced dementia, poor sleep quality, and shorter weekly duration of walking were the influencing factors of sundown syndrome. Walking with relatives and regular longer walking time could improve sleep quality and alleviate sundown syndrome. It is suggested that a well-designed walking intervention considering these factors could be an appropriate strategy to manage sundown syndrome and sleep quality for PAD and their caregivers.

The Cognitive Daisy - A novel method for recognising the cognitive status of older adults in residential care: Innovative Practice

The Cognitive Daisy is an innovative assessment system created to provide healthcare staff with an instant snapshot of the cognitive status of older adults in residential care. The Cognitive Daisy comprises a flower head consisting of 15 colour coded petals depicting information about: visual-spatial perception, comprehension, communication, memory and attention. This study confirmed the practicality of the Cognitive Daisy protocol for assessing cognition in a sample of 33 older adults living in residential care and endorsed the use of the Cognitive Daisy as a tool for recognising the cognitive status of care home residents.

Effectiveness of Special Care Unit (SCU) placements in reducing physically aggressive behaviors in recently admitted dementia nursing home residents

Using a sample of new dementia admissions who entered selected nursing facilities December 1992 through June 1994, this paper compares special care dementia units (SCUs) to non-specialized (traditional) nursing home care in their effectiveness in reducing physically aggressive behaviors within six-months of placement. Findings indicate that SCUs admit younger and more highly aggressive residents. Our results indicate that when differences in age and baseline levels of disruptive behaviors are controlled, SCU placement showed no positive or negative effect on the frequency of aggressive behaviors. Rather than SCU placement, it was the increased use of psychotropic medications and the reduction in the use of physical restraints that showed a relationship with lower levels of physically aggressive behaviors. While SCUs do not appear to be the hoped for panacea with regard to reducing physically aggressive behaviors, they still appear to serve a useful function within the broader context of the provision of services for residents with dementia within the nursing home.

Vocally disruptive behaviors in people with cognitive impaitment: Current knowledge and future research directions

This paper is a literature review of vocally disruptive behaviors (VDB) in people with dementia. This area of interest has not caught the full attention of researchers and professionals alike. Thus, the knowledge base being developed is limited. This paper will discuss the prevalence and the severity of the problem. The profiles of persons displaying VDB will be portrayed, as will the context for which VDB frequently occurs. Then, postulations regarding the etiologies for VDB and corresponding interventions will be explicated. Unfortunately, systematic studies are few and the effectiveness of different kinds of intervention strategies has not been supported by empirical data. Finally, issues pertaining to the study of VDB will be examined and directions for future research will be recommended.

Environmental influences on agitation: An integrative summary of an observational study

This paper consolidates empirical findings from an observational study aimed at elucidating the environmental conditions surrounding the manifestation of agitated behaviors. Although great variability was found between and within participants, when environmental conditions were analyzed separately, different behaviors occurred under different environmental conditions and seem to have different meanings. For example, verbally disruptive behaviors seem to be associated with discomfort. Others, such as requests for attention and aggressive behaviors, may be adaptive, and may signal an attempt to communicate needs. Additionally, certain environmental conditions seem to affect agitation regardless of the specific manifestation, such that most agitated behaviors seem to increase when the resident is physically restrained, inactive, or alone.

Aggressive behavior in institutionalized elders: A theoretical framework

This review article explores current research on aggression in institutionc ized elders and proposes a theoretical framework for use by caregivers. The relationships of brain dysfunction, past behaviors, social networks and environmental triggers to the expression of aggression a te discussed. The framework can be used to generate research hypothesis, or as a guide for assessing rise factors associated with these behaviors.

Therapeutic recreation as an intervention for persons with dementia and agitation: An efficacy study

Thirty-six long term care residents with dementia and agitation were selected for participation in this eight week study. During the eight week J period, the participants received two different four week therapeutic recreation interventions in a clinical crossover design. These interventions included a sensorimotor program and a traditional activity program. The effects of these two programs were evaluated in terms of the effect on strength, flexibility, over all functioning, and agitation. The analysis showed that there was a significant improvement of grip strength, flexibility, and a reduction in agitation during the sensorimotor segment of the treatment. The results of this study indicate a new direction for therapeutic recreation specialists working with older adults with dementia and agitation.

Characteristics of dementia admissions to standard nursing homes and to special care units

As a result of using admission criteria, the characteristics of special care unit (SCU) admissions are generally different from dementia admissions. As part of the National Evaluation of Special Care Units Project, all dementia admissions to a nationwide sample of SCUs and comparable non-SCU nursing facilities were screened during a 13-month recruitment window. Results show that SCU admissions are younger, more likely to be male, admitted from home, admitted under private-pay status, have recorded AD diagnoses, are independently mobile, and have fewer physical health problems. Program and policy implications of these findings are discussed.

The Social Network of the Agitated Nursing Home Resident

Syndromes of agitation (aggressive, physically nonaggressive, verbal) were compared to dimensions of the social network (intimacy, size/density) in 408 nursing home residents. Results showed that the social networks of aggressive residents and verbally agitated residents were lacking in intimacy. Social networks of physically nonaggressive residents were neutral, even though these persons were severely cognitively impaired, as were the aggressive residents. The size/density of the social network did not differentiate agitated individuals from other residents.

Characterization of Family-Generated Videotapes for the Management of Verbally Disruptive Behaviors

In this study, the authors examined the characteristics of family-generated videotapes used to manage the manifestation of verbally disruptive behaviors (VDB) in nursing home residents. Videotapes prepared by the relatives of 30 verbally disruptive nursing home residents to be shown to residents were systematically observed and coded for content and mode of presentation. The relationship between the videotapes' characteristics and their impact on the resident was studied. The majority of the time in the videotape was spent talking about the past or present of the family, was characterized by an overall feeling of respect, and did not show great variability in the features examined. Videotapes coded as showing more love and those not talking about current events were associated with higher effectiveness in reducing VDB. This treatment proved to be an appropriate and rewarding avenue to involve family members in the care of their frail institutionalized elderly relatives.

The Hamburg-Hannover Agitation Scale (H2A): Development and validation of a self-assessment tool for symptoms of agitation

BACKGROUND

Agitation has long been underestimated as a symptom occurring across psychiatric disorders. While several instruments exist for highly specific clinical target groups (e.g., dementia, traumatic brain injury), no tool captures agitation in a broader range of psychiatric patients. The Hamburg-Hannover Agitation Scale (H2A) has been designed to satisfy this demand. This study concentrated on the development and validation of the scale in a psychiatric and a healthy control sample.

METHODS

The H2A was developed, tested in an expert sample, and revised. The German version was validated in a study involving two clinical institutions. Patients (n = 180) completed the H2A and several other questionnaires in order to test for congruent and discriminant validity. Healthy subjects (n = 685) completed the H2A only. The H2A was translated into English.

RESULTS

The H2A showed very satisfying quality criteria (reliability, selectivity, item difficulty) and regression analysis demonstrated the H2A's ability to distinguish between subjects with a psychiatric diagnosis and healthy subjects with or without psychiatric record. Factor analysis revealed a three-factorial structure representing a physiological/somatic, a mental and a mixed ('psychophysiological') dimension of agitation.

LIMITATIONS

Although validation showed promising quality criteria and predictive value of the H2A, calibration tests with bigger and more balanced sample sizes are necessary.

CONCLUSIONS

Agitation has become more clinically relevant as a symptom occurring in various affective disorders, yet its assessment is limited. The H2A was developed in order to meet this need. Validation of the H2A revealed very satisfactory item and scale quality criteria promoting its utility.

What carers and family said about music therapy on behaviours of older people with dementia in residential aged care

AIM

This study sought to evaluate the effectiveness of group music therapy (MT) intervention on behaviours of older people with dementia.

METHOD

Reported here are qualitative data from five, semi-structured focus groups; two comprising a total of seven family members and three comprising a total of 23 staff members.

RESULTS

A number of core themes emerged: temporality, effect and policy with a number of subthemes. The MT effect is tempered by the temporality of (i) the older person's dementia state, (ii) the session and (iii) the psychosomatic effect on the older person. Music therapy is perceived to (i) evoke memories and facilitate reminiscence, (ii) act as a diversion (has an instrumental value) and it is contentious to discount the (iii) dichotomy between music and therapist in terms of the overall effect. Finally, policymakers need to know that MT is (i) highly prized and more, not less, MT is recommended.

CONCLUSION

Findings from this study illustrate that the timing of the MT session has consequences for the workflow in the residential aged care facility; MT has a psychosomatic effect and participants here evaluate this as temporal. Care providers and family members acknowledge the instrumental value of MT and its helping with cognition and exercise. They have mixed views about the effects of the music and the effect on the older person by the therapist but most definitely want policymakers to ensure more, not less, planned and better funded MT is part of ongoing care in the residential aged care context. Areas for future research and policy are also highlighted.

IMPLICATIONS FOR PRACTICE

These views on group MT in residential aged care can initiate critical reflection on current practices and systems. Research is needed exploring the timing and scheduling of MT sessions at different times in the day for older person with dementia exhibiting negative behaviours.

Foot massage and physiological stress in people with dementia: a randomized controlled trial

BACKGROUND

The anxiety associated with unfamiliar surroundings, the disorientation and mental confusion, and the social isolation that accompanies dementia can often create increased stress for people living in long-term care settings. Such a response is thought to affect the autonomic nervous system and result in emotional and physical symptoms of distress that may be manifested as agitation. There is the potential for such distress to influence the physiological response and in particular Blood Pressure and Heart Rate. A relaxation intervention such as massage may influence the physiological stress response.

METHODS

This randomized controlled trial aimed to compare the effect of foot massage (FM) versus a control activity (quiet presence, QP) on physiological stress response (i.e., blood pressure [BP] and heart rate [HR]) in people living with moderate-to-severe dementia in long-term-care settings.

RESULTS

Fifty-three residents were randomized to intervention (10-minute FM) or control group (QP). While the FM group experienced a greater reduction in HR than the control group, these reductions were not significantly different between groups (p=0.83; see Table 1 ), or across time (p=0.46). Both groups experienced a reduction in systolic BP and diastolic BP, while the mean reduction in systolic BP was greater for those in the FM group.

CONCLUSIONS

While the findings do not provide strong support for FM, the finding that both conditions allowed the person with dementia to rest in the presence of another human being is of importance in the care of people with dementia. The close presence of another person may in fact promote relaxation and therefore improve BP and HR measures.

Aggressive and impulsive behavior in Alzheimer's disease and progression of dementia

BACKGROUND

The symptoms of Alzheimer's disease (AD) are numerous, including worsening of mood, psychotic symptoms, aggressive and impulsive behaviours, and many others. It is generally assumed that there exists a relationship between the severity of dementia and aggressive symptoms. The aim of this study was to assess the relationship between aggressive and impulsive behaviours and cognitive function disorders in AD patients.

MATERIAL/METHODS

Forty-eight AD patients living in a nursing home were included in the research group on the basis of NINCDS/ADRDA criteria. The subjects underwent two years of naturalistic observation. The intensity of agitation and aggressive behaviours was assessed on the basis of the Cohen-Mansfield Agitation Inventory (CMAI). The Alzheimer's Disease Assessment Scale Cog (ADAS-cog) was used to assess cognitive function. Pharmacotherapy administered during the observation period was also taken into account.

RESULTS

Thirty-one patients completed the two year long observation. Individuals with more severe cognitive deficiencies demonstrated a greater intensity of aggressive and impulsive behaviours, as assessed using the CMAI scale. Aggression escalated together with the development of dementia disorders. The intensity of dementia disorders was most significantly connected with physical agitation and verbal aggression. The use of neuroleptics and mood stabilisers decreased the progression of aggressive and impulsive behaviours.

CONCLUSIONS

There is a relationship between cognitive functioning disorders and the intensification of aggressive and impulsive behaviours. More severe forms of dementia are connected with greater intensification of aggressive and impulsive behaviours as the disease progresses. Periodical administration of pharmacotherapy may reduce the development of aggressive behaviours.

Pain treatment of agitation in patients with dementia: a systematic review

BACKGROUND

Advancing age is associated with high prevalence of both dementia and pain. Dementia is frequently accompanied by distressing behavioral and psychological symptoms, including agitation and aggression, particularly in nursing home patients. The etiology of agitation is multifactorial. It has been suggested that un-diagnosed and untreated pain may contribute to agitation in people with dementia. If this is correct, individual pain treatment could be of benefit in ameliorating agitation and other behavioral changes in people with dementia.

OBJECTIVE

The objective of this paper is to conduct a systematic review of studies of whether pain medication can improve agitation in people with dementia.

METHODS

A systematic search of the PubMed and Cochrane databases for the period 1992-2010 was performed, using dementia, agitation, aggression, depression, behavioral disturbances, behavioral and psychological symptoms (BPSD), pain, pain assessment, pain treatment, pain management, and analgesics as search terms. Inclusion criteria were: prospective studies including patients with dementia, interventions focusing on pain reduction, inclusion of a control condition, and outcome measures including agitation or other related behavioral disturbances.

RESULTS

Only three controlled trials were identified; all were cross-over trials, and two included small sample sizes (<50). Findings were inconsistent, and although some correlations were reported, these did not support the hypothesis that pain management reduced agitation.

CONCLUSION

There is a profound dearth of rigorous studies of the effect of pain treatment in patients with dementia and agitation. The available studies do not support the hypothesis that pain management reduces agitation in nursing-home patients with dementia. Randomized, controlled parallel-group studies are needed.

Differential diagnosis of behavioral variant of fronto-temporal dementia (bvFTD)

Background

The aim of the paper is the differential diagnosis of various types of Fronto-Temporal Dementia (FTD), with the focus on its behavioural variant (bvFTD).

Material/Method

Material and Method. Screening was done in order to assess the depth of dementia with the short version of MMSE, while evaluation of various variants of FTD was performed with the use of such neuropsychological tests as Newcomb and Chicago Fluency Tests, Wechsler Memory Scale - III (WMS-III), Western Aphasia Battery (WAB-R), and the Boston Naming Test (BNT). Behaviour was evaluated with a Polish version of the Frontal Behavioral Inventory (FBInv). The inventory consists of 24 questions which enable an evaluation of social behaviour disorders. The study included 112 patients - 68 men and 46 women treated in the Reintegrative -Training Centre of the Foundation for Persons with Brain Dysfunctions in Kraków and in the Clinic for Developmental Psychiatry, Psychotic Disorders and Old Age Psychiatry, of the Medical University at Gdańsk, who were suffering from various types of dementia.

Results

It was found that FTD patients scored the highest, while the VAD patients scored somewhat lower in the FBInv. At the same time the scores obtained by PPA patients were higher in comparison to the control groups, but not as high as in the case of patients with FTD. In the process of the neurotherapy of FTD patients we found a reduction of the behavioral disturbances, despite the progression of the illness.

Conclusions

The results obtained in the present study confirmed the diagnostic value of FBInv in the differential diagnosis of various types of FTD and in the evaluation of neurotherapy efficacy.

Managing dementia agitation in residential aged care

Agitation is a widespread and challenging problem among aged care residents with dementia. This article draws on empirical and theoretical literature to propose a model for preventing and treating agitation non-pharmacologically. A literature review finds agreed, coherent definition and measurement of agitation to be absent despite numerous agitation remedies having been suggested, yet sufficient material to support evidence-based care planning. Agitation is revealed as resulting from a resident’s interactions with the environment or their internal state, giving rise to unmet needs that attentive care can treat. Agitation treatments are reviewed to find no single effective remedy and a lack of quality evaluation. A higher-order, problem-solving approach is proposed. The described system consists of sequential diagnosis, decision making and treatment options, commencing with individualized and institutional preventative measures removing environmental triggers, followed by individual remediation, with residents’ unmet needs receiving priority consistent with patient-centred care.

Validité et fidélité de l'Inventaire d'agitation de Cohen-Mansfield

Agitation in older persons is a major problem for the agitated individual and those around him/her. French-language measures of agitation with demonstrated validity and reliability are necessary for research and interventions in the French-speaking community. The goal of this study is to verify the reliability and validity of the “Inventaire d'agitation de Cohen-Mansfield” (IACM), a French version of the Cohen-Mansfield Agitation Inventory. The IACM measures the frequency of 29 agitated behaviours during a two-week period. Ninety-nine residents of a long-term care facility participated in this study. Results demonstrate the inter-rater reliability (r = .72), test-retest reliability (r = .72), internal consistency (Cronbach's alpha from .75 to .77), concurrent validity (r = .74) and construct validity (all r are significant, p < .05) of the IACM.

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.

Review: verbal agitation in dementia: the role of discomfort

Verbal agitation (VA) is a disturbing and commonly observed behavioral symptom in people with dementia. Although several different variables contribute to VA, it seems that discomfort plays an important role. The overall objective of this article is to review the relationship between VA and discomfort among people with dementia. Specifically, this article discusses the place of discomfort within the conceptualizations of VA, empirical support for the association between discomfort and VA, and practical implications of this relationship in the assessment and treatment of VA. This article contributes to a better understanding of VA and provides recommendations for prevention and effective intervention.

The reasons for nursing home entry in an adult day care population: caregiver reports versus regression results

This article aims to compare reasons for nursing home entry determined through a regression of baseline predictors to relatives' perceptions of reasons for entry. Participants included 201 community-residing members of 5 senior day care centers in Maryland. Through a prospective design, statistical predictors using Cox regressions were compared to the relatives' reports of reasons for nursing home entry. These reports identified the most common reasons for nursing home entry as deterioration of independence and confusion. Behavior problems were also reported for almost half of the participants. In contrast, strong baseline statistical predictors of institutionalization were depressed affect, number of psychiatric diagnoses, a diagnosis of dementia, and age. Because of its strong significance within the baseline predictors, the meaning of depressed affect and why it was such a potent predictor of nursing home entry, yet still not reported by caregivers, should be studied further.

What environmental factors irritate people with acquired brain injury?

PURPOSE

This study aims to determine the environmental factors nurses identify as being irritating to people with acquired brain injury.

METHOD

This was a qualitative study. An experienced interviewer used the Critical Decision Method to interview 28 nurses working in 10 inpatient brain injury rehabilitation units in Australia on a one to one basis for 1-1.5 h on two consecutive days. Transcripts of interviews were analysed using thematic analysis.

RESULTS

Nurses identified five groups of irritants that acted as triggers for aggression:

CONCLUSION

The nurses in this study identified many environmental factors that irritate people with acquired brain injury. Some irritants appeared unavoidable but others could be addressed by staff expertise.

The efficacy of nurse implemented non-pharmacological strategies for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities: a systematic review

AIM

Agitation is a common symptom of dementia which becomes exacerbated in the advanced stages of the disease. The negative effects of this symptom are numerous and often result in institutionalisation. Given it is the registered nurse, with the cooperation of the enrolled nurse/ assistant in nursing, who provide the majority of face-to-face care in residential aged care facilities, there is a clear need to identify effective management strategies for agitated behaviours which nursing staff can easily access and implement.This review identifies the best available evidence regarding the efficacy of nurse implemented non-pharmacological strategies for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities METHOD: A systematic literature search of MEDLINE, CINAHL, PsycINFO, Cochrane Library, SCOPUS, EMBASE, and AgeLine databases was undertaken. Additionally, the reference lists of relevant papers were examined for additional trials.This review considered any English language randomised trial that investigated strategies implemented by a nurse for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities. Outcomes measured included frequency and severity of agitation.

RESULTS

Seven trials were included in this review. Five of the seven strategies investigated were shown to be effective in the symptom management of agitation when compared to alternate strategies. Effective strategies include: behavioural therapy, balancing arousal states, therapeutic touch, multi-sensory stimulation and person-centred bathing.

CONCLUSIONS

The heterogeneity of the included trials made it difficult to draw definitive conclusion. However, the results of this systematic review reveal that some non-pharmacological strategies are effective when implemented by a nurse for the symptom management of agitation in pesons with advanced dementia living in residential aged care facilities. Despite this finding, there is currently insufficient evidence to develop practice guidelines.

The Mahoney Pain Scale: examining pain and agitation in advanced dementia

Pain and distress are widespread for people with dementia. However, effective pain management is limited by the quality of assessment tools. In this study, the development and trial of the Mahoney Pain Scale, which aims to assess pain in advanced dementia and distinguish it from agitation is described. A total of 112 participants with advanced dementia who experienced either pain, agitation, neither or both were assessed via the Mahoney Pain Scale during a pleasant and aversive activity. The Mahoney Pain Scale demonstrated adequate interrater reliability and internal consistency. As predicted, participants experiencing pain and/or agitation obtained higher Mahoney Pain Scale scores during the aversive activity. Participants also differed with respect to their pattern of scores, and consequently, the Mahoney Pain Scale differentiated pain states from non-pain ones. The clinical impressions of nurses who trialed the tool were favorable; they reported that it seemed accurate and easy to use. Thus, the Mahoney Pain Scale may be useful for assessing pain in dementia.

Resident-to-Resident Aggression in Long-Term Care Facilities: An Understudied Problem

Resident-to-resident aggression (RRA) between long-term care residents includes negative and aggressive physical, sexual, or verbal interactions that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Although this problem potentially has high incidence and prevalence and serious consequences for aggressors and victims, it has received little direct attention from researchers to date. This article reviews the limited available literature on this topic as well as relevant research from related areas including: resident violence toward nursing home staff, aggressive behaviors by elderly persons, and community elder abuse. We present hypothesized risk factors for aggressor, victim, and nursing home environment, including issues surrounding cognitive impairment. We discuss methodological challenges to studying RRA and offer suggestions for future research. Finally, we describe the importance of designing effective interventions, despite the lack currently available, and suggest potential areas of future research.

Discomfort and agitation in older adults with dementia

Background

A majority of patients with dementia present behavioral and psychological symptoms, such as agitation, which may increase their suffering, be difficult to manage by caregivers, and precipitate institutionalization. Although internal factors, such as discomfort, may be associated with agitation in patients with dementia, little research has examined this question. The goal of this study is to document the relationship between discomfort and agitation (including agitation subtypes) in older adults suffering from dementia.

Methods

This correlational study used a cross-sectional design. Registered nurses (RNs) provided data on forty-nine residents from three long-term facilities. Discomfort, agitation, level of disability in performing activities of daily living (ADL), and severity of dementia were measured by RNs who were well acquainted with the residents, using the Discomfort Scale for patients with Dementia of the Alzheimer Type, the Cohen-Mansfield Agitation Inventory, the ADL subscale of the Functional Autonomy Measurement System, and the Functional Assessment Staging, respectively. RNs were given two weeks to complete and return all scales (i.e., the Cohen-Mansfield Agitation Inventory was completed at the end of the two weeks and all other scales were answered during this period). Other descriptive variables were obtained from the residents' medical file or care plan.

Results

Hierarchical multiple regression analyses controlling for residents' characteristics (sex, severity of dementia, and disability) show that discomfort explains a significant share of the variance in overall agitation (28%, p < 0.001), non aggressive physical behavior (18%, p < 0.01) and verbally agitated behavior (30%, p < 0.001). No significant relationship is observed between discomfort and aggressive behavior but the power to detect this specific relationship was low.

Conclusion

Our findings provide further evidence of the association between discomfort and agitation in persons with dementia and reveal that this association is particularly strong for verbally agitated behavior and non aggressive physical behavior.

Nonpharmacological treatment of agitation: a controlled trial of systematic individualized intervention

OBJECTIVE

The objective of this study was to examine the efficacy of a systematic algorithm for providing individualized, nonpharmacological interventions for reducing agitated behaviors in nursing home residents with dementia.

METHODS

This placebo-controlled study combined nomothetic and ideographic methodologies. The study was conducted in 12 nursing home buildings in Maryland; 6 were used as treatment facilities, and 6 as control facilities. Participants were 167 elderly nursing home residents with dementia. Interventions were tailored to the individual profiles of agitated participants using a systematic algorithm that considered type of agitation and unmet needs. Interventions were then designed to fulfill the need in a manner that matched the person's cognitive, physical, and sensory abilities, and their lifelong habits and roles. Interventions were provided for 10 days during the 4 hours of greatest agitation. Direct observations of agitation were recorded by trained research assistants via the Agitated Behavior Mapping Instrument (ABMI). Evaluation of positive and negative affect was also based on direct observation and assessed via Lawton's Modified Behavior Stream. Data analysis was performed via SPSS software.

RESULTS

The implementation of personalized, nonpharmacological interventions resulted in statistically significant decreases in overall agitation in the intervention group relative to the control group from baseline to treatment (F(1,164) = 10.22, p =.002). In addition, implementation of individualized interventions for agitation resulted in statistically significant increases in pleasure and interest (F(1,164) = 24.22, p <.001; F(1,164) = 20.66, p <.001).

CONCLUSIONS

The findings support the use of individualized nonpharmacological interventions to treat agitation in persons with dementia and underscore the importance for clinicians of searching for underlying reasons for agitated behaviors.

Prevalence and correlates of disruptive behavior in patients in Norwegian nursing homes

BACKGROUND

Although Behavioral and Psychological Symptoms of Dementia (BPSD) increase with increasing dementia severity, and institutionalization of an individual with dementia is often caused by behavioral symptoms, relatively few studies have explored the prevalence of BPSD in nursing homes.

OBJECTIVE

To study the prevalence and correlates of agitation in residents with dementia, in Norwegian nursing homes.

METHODS

This study has taken place in dementia wards in four Norwegian nursing homes. To measure agitation in residents with dementia we used the Cohen-Mansfield Agitation Inventory (CMAI), consisting of 29 agitation items. Dementia stage was measured by Functional Assessment Staging (FAST).

RESULTS

Two hundred and eleven patients (71% female) were included in the study: mean (SD) age 85.5 (8.4), FAST 4.7 (2.1), CMAI total sumscore 39.5 (12.6). Dementia was present in 167 (79%) subjects. Among those with dementia, weekly occurrence of at least one CMAI item (i.e. a score of 3 or higher) occurred in 75.4% (95% CI 68.4-81.4). Six of the items occurred at least weekly in 20% of the residents with dementia, and 11 of the items, including physical aggression, occurred in less than 5% of the residents. Agitation was associated with more severe dementia (p = 0.001), but not with age and gender.

CONCLUSION

Symptoms of agitation were common, but may nevertheless be lower compared to findings in other geographical areas. Further studies are warranted to test this hypothesis, and if confirmed, to explore possible causes for such differences.

Light treatment for neuropsychiatric behaviors in Alzheimer's disease

Neuropsychiatric behaviors are common in people with Alzheimer's disease (AD) and make both professional and lay caregiving difficult. Light therapy has been somewhat successful in ameliorating disruptive behaviors. This randomized trial tested the effects of morning or afternoon bright light exposure compared with usual indoor light on the presence, frequency, severity, and occupational disruptiveness of neuropsychiatric behaviors in nursing home residents with AD. Light was administered for 1 hr daily (Monday-Friday) for 10 weeks. The Neuropsychiatric Inventory-Nursing Home was used to assess behavior at baseline and end of the intervention. Analyses revealed statistically significant differences between groups on agitation/aggression, depression/dysphoria, aberrant motor behavior, and appetite/eating disorders. The magnitude of change was small and may not represent clinically significant findings. Agitation/aggression and nighttime behaviors commonly occurred and were highly correlated with occupational disruptiveness. Interventions that decrease the presence and/or severity of neuropsychiatric behaviors have the potential to significantly decrease caregiver burden.

Aggressive Behavior in Patients With Stroke: Association With Psychopathology and Results of Antidepressant Treatment on Aggression

OBJECTIVE

To examine, in a post hoc analysis of an antidepressant treatment trial, correlates of irritability and aggression after stroke and changes in irritability scores associated with antidepressant treatment.

DESIGN

Aggressive patients (n=23) were compared with nonaggressive patients (n=69) on numerous measures of psychopathology, poststroke impairment, and neuroimaging findings.

SETTING

All patients were hospitalized at the time of the initial evaluation for acute stroke or for rehabilitation therapy.

PARTICIPANTS

Ninety-two patients from the Iowa City Stroke Study were classified as aggressive or nonaggressive, based on symptoms elicited by the Present State Examination (PSE) and from family or caretaker reports.

INTERVENTION

All patients were randomized to receive nortriptyline, fluoxetine, or placebo using a double-blind methodology.

MAIN OUTCOME MEASURE

The change in aggression score as elicited by the PSE at the beginning and the end of a 12-week treatment trial.

RESULTS

Twenty-five percent (23/92) of patients reported irritability or aggression. Irritable and aggressive patients had higher total PSE scores, Hamilton Depression Rating Scale scores, Hamilton Anxiety Rating Scale (HAMA) scores, and lower Mini-Mental State Examination scores. They also had lesions that were more proximal to the frontal pole. Stepwise regression analysis showed that HAMA scores and proximity of lesion to the frontal pole were significant independent predictors of irritability. Among irritable and aggressive patients with depression who responded to antidepressants, there was a significantly greater reduction in irritability after treatment, compared with patients whose depression did not lessen with treatment.

CONCLUSIONS

Several factors, such as severity of impairment, other psychopathology, and neurobiologic factors, appear to contribute to irritable and aggressive behavior in stroke patients. If depression accompanies aggression, the results of this small study suggest that successful treatment of depression may reduce aggressive behavior.

Challenging behaviour in the elderly-monitoring violent incidents

OBJECTIVE

To explore the frequency and nature of violent incidents in psychogeriatric wards and nursing homes in terms of type and severity of incidents, what provoked the incidents, and what kind of measure was needed to stop the aggression.

MATERIAL AND METHODS

Aggressive behaviour of the study group was monitored using the Staff Observation Aggression Scale-Revised (SOAS-R( in two Norwegian nursing homes and two geriatric psychiatric wards for a period of three months. Severity of incidents were monitored with the built-in severity scoring system in SOAS-R.

RESULTS

During the study period 32 out of the 82 patients were reported to be violent. The majority of the incidents were generated by a minority of the patients. Physical injury to the staff as a consequence of the aggression was extremely rare. Situations where the client was denied something were the most provocative ones and a substantial number of incidents occurred at bath/shower times. Talking to the patient was the most frequent measure used to stop the aggression, but more intrusive measures were also used.

CONCLUSIONS

A substantial proportion of the incidents were associated with personal care tasks, suggesting a crucial role for communication difficulties and a focus for staff training. We suggest that personal care situations should be added to the variable list in future research.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Components of behavioral pathology in dementia

OBJECTIVE

The purpose of this study was to examine the occurence of the noncognitive behavioral and psychological symptoms and signs of dementia in a geriatric chronic-care hospital and to separate agitated and affective components of behavioral pathology using factor analysis.

METHODS

The frequency and severity of Alzheimer's disease, vascular dementia, mixed dementia and Lewy Body dementia was assessed in 145 consecutive residents of a chronic-care hospital. The presence of noncognitive behavioral symptoms was evaluated with the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) and the Cohen-Mansfield Agitation Inventory (CMAI). A Factor analysis on the BEHAVE-AD subscores was performed to create symptom clusters. Analysis of covariance and post hoc tests were used to compare means of factor variables between different types of dementia.

RESULTS

Statistical analysis showed a significant correlation between severity of dementia and BEHAVE-AD total score and between severity of dementia and CMAI total score. Factor analysis with Varimax rotation revealed the presence of three behavioral subsyndromes: agitation, affectivity and day/night disturbances.

CONCLUSIONS

The finding of three factors of behavioral pathology in demented patients reflects the possibility that different etiological mechanisms could explain the expression of the symptoms and signs of psychosis in demented patients.

Assaultive Behavior in Alzheimer's Disease: IDENTIFYING IMMEDIATE ANTECEDENTS DURING BATHING

To identify immediate antecedents of bathing-related physical assaults against caregivers by nursing home residents with Alzheimer's disease and related disorders, videotapes of nursing home residents who physically assaulted nursing assistants during baths were analyzed. Caregiver behaviors that occurred significantly (p < .01) more often during the 5 seconds preceding an assault included: calling the resident by name, confrontational communication, invalidation of the resident's feelings, failure to prepare the resident for a task, disrespectful speech, any touch, absence of physical restraint, and hurried pace of bath. Assaults were significantly more likely when caregivers sprayed water without a verbal prompt; the resident's feet, axilla, or perineum were touched; residents exhibited signs of temperature discomfort; and multiple caregivers were present. Improved caregiver training and individualized, gentler bathing methods should be investigated as methods of reducing assaults.