Aggressive behavior in patients with dementia: Correlates and management

Physical Restraint Use in Hospitalized Patients: A Study of Routinely Collected Health Records Data

BACKGROUND

The use of restraints in hospitalized patients is associated with physical and psychological adversity for patients and staff. The minimization of restraint use is a key goal in the hospital setting. Reaching this goal requires an accurate assessment of existing patterns of use across clinical settings.

OBJECTIVE

This study reports the rate of physical restraints among patients hospitalized within a multi-entity healthcare network along with stratification by care context, diagnostic, and demographic factors, and examines the sensitivity and specificity of ICD-10 code Z78.1 "physical restraint status" for defining physical restraints relative to electronic health record (EHR) documentation.

DESIGN

The EHR was used for a retrospective analysis of all adults hospitalized between 2017 and 2022.

PARTICIPANTS

Hospitalized adults.

MAIN MEASURES

Patient demographics, structured diagnostic information, care area, length of stay, and in-hospital mortality, Z78.1 coding for physical restraints, restraint documentation in orders and flowsheets.

KEY RESULTS

Among 742,607 hospitalizations, 6.3% (n=47,041) involved the use of physical restraint based on coding or EHR documentation. Treatment in the intensive care unit (ICU) included restraint in 39% of encounters whereas treatment outside the ICU included restraint use in 1.3% of encounters. Besides critical illness, demographic factors including increasing age (adjusted odds ratio (aOR)=1.21 [1.19-1.23]), male gender (aOR=1.56, [1.52-1.60]), unknown race (aOR=1.27 [1.19-1.35]), and preferred language other than English (aOR=1.24, [1.18-1.29]) were associated with higher odds of restraint utilization. As compared to EHR orders or documentation of restraint, the ICD-10 code for physical restraint had a sensitivity of 1.5% and a specificity of 99.99%.

CONCLUSION

Among adults admitted to acute care hospitals, clinical, demographic, and operational factors were associated with increased odds of restraint, with care in the ICU associated with greatly increased odds of restraint. Research into restraint utilization using coded administrative claims data is likely limited by the sensitivity of physical restraint coding.

Mind-body practices for people living with dementia and their family carers: a systematic review

INTRODUCTION

People with dementia and their family carers may benefit from non-pharmacological interventions, including mind-body (MB-) practices, which can improve physical and mental health by inducing relaxation. This systematic review provides an overview of availability and effects of MB-practices.

CONTENT

The authors performed a systematic search in PubMed, Embase, Emcare, Web of Science, Cochrane Library, PsycINFO, China National Knowledge Infrastructure and Academic Search Premier on February 1, 2024. Research papers on MB-practices for people with dementia and/or their family carers in English, Chinese, Japanese, German, French and Dutch were included if a full text was available. Selection of included articles, data extraction and methodological quality assessments were conducted by two researchers.

SUMMARY

Of the 130 included studies, 100 (77 %) were of high quality. Traditional Chinese Medicine (TCM) and touch interventions for people with dementia, and meditations for family carers resulted in improvements in respectively cognition and neuropsychiatric symptoms, and mental health. Lack of evidence for other MB-practices is related to small numbers of studies, fragmented use of outcome measures and mixed findings.

OUTLOOK

MB-practices showed promising results. We recommend implementation and further research of TCM- and touch interventions for people with dementia as well as meditations for family carers. We suggest a cross-over of the promising results of one group to be studied in the other group.

Patient-related characteristics or local tradition: what predicts the admission to a locked ward or the use of coercive measures in psychiatric inpatient treatment?

Prior research shows that locked doors and coercive measures are not only applied due to safety concerns, but also due to the specific local tradition of an institution. We examined the association of the use of coercive measures and the admission to a locked ward with person-related characteristics compared to the admission to a specific clinic. In this 15-year, naturalistic observational study, we examined 230,684 admissions to 14 German psychiatric inpatient clinics from Jan 1, 1998, to Dec 31, 2012. To analyze the degree to which admission to a locked ward and coercive measures (received vs. not received) were connected with person- and clinic-specific factors, two-step logistic regression analyses were applied. 27% of the variance of the admission to a locked ward were explained by person-related characteristics (Nagelkerke r2 = 0.269). By adding the clinic the person was admitted to, the explained variance increased by 15% (Nagelkerke r2 = 0.418). 36% of the variance of the use of coercive measures were explained by person-related characteristics (Nagelkerke r2 = 0.364). By adding the clinic the person was admitted to, the explained variance increased by 4% (Nagelkerke r2 = 0.400). The local tradition of a psychiatric clinic seems to play a more prominent role for the decision to admit a person to a locked ward than for the decision to use coercive measures. Clinicians should be made aware of the connection of local traditions with clinical pathways in acute psychiatry to avoid unnecessary admissions to locked wards.

Alcohol use, civilian interference, and other possible risk factors for death during restraint

Physical restraint is usually used when trying to control and terminate a violent episode. Many causes are possible behind aggressive, agitated, and violent behavior. Some of these are such factors that can either be detected in forensic autopsies or can be evident from the person's medical records. Various causes for deaths during physical restraint have been suggested. In this study, we wanted to review all incidents in which physical restraint was employed, ending in death of the restrained person, whether the restraint was applied by police officers, security guards, police custody personnel, health care personnel or ordinary civilians. The main aim was to see if this new kind of study design would increase our knowledge in circumstances and causes leading to death in restraint situations. Data was collected retrospectively from all forensic autopsies performed in the Southern Finland area during 2010-2015. We went through 21,036 forensic autopsy cases and found 12 cases (0.06 %) in which a physical restraint was employed before death. Police officers were involved in the physical restraint in 7/12 of the cases: in two of these cases, police alone; in three cases, police and guards; and in two cases, police and health care personnel. Civilians carried out the restraint in 5/12 cases. With civilians responsible for the restraint, the cause of death was more likely considered to be a result of the restraint itself than in cases where police and other authorities were responsible for the restraint. This could be because civilians aren't educated about safe restraint methods, and they might themselves be intoxicated. Alcohol was the most common psychoactive substance found in this study and could be a risk factor for not only aggressive behavior but also death, since alcohol use can provoke cardiac arrhythmias and even sudden death. Based on this study, and previously published studies, we see restraint deaths as a varying spectrum of deaths, in which the death is often possibly a result of many factors, including the effects of agitation and restraint, intoxication, and cardiac and other illnesses.

Evaluating the Impact of Virtual Reality on the Behavioral and Psychological Symptoms of Dementia and Quality of Life of Inpatients With Dementia in Acute Care: Randomized Controlled Trial (VRCT)

BACKGROUND

Virtual reality (VR) is increasingly considered a valuable therapeutic tool for people with dementia. However, rigorous studies are still needed to evaluate its impact on behavioral and psychological symptoms of dementia (BPSDs) and quality of life (QoL) across care settings.

OBJECTIVE

The primary aim of this study was to evaluate the impact of VR therapy on managing BPSDs, falls, length of stay, and QoL in inpatients with dementia admitted to an acute care hospital. The secondary aim was to evaluate the intervention's feasibility in terms of acceptability, safety, and patient experience.

METHODS

A prospective, open-label, mixed methods, randomized controlled clinical trial was conducted between April 2019 and March 2020. A total of 69 participants (aged ≥65 years with a diagnosis of dementia and who did not meet the exclusion criteria) were randomly assigned to either the control (n=35, 51%) or VR (n=34, 49%) arm. Participants in the experimental (VR) arm were visited by a researcher and watched 360° VR films on a head-mounted display for up to 20 minutes every 1 to 3 days, whereas individuals in the control arm received standard of care. Instances of daily BPSDs and falls were collected from nurses' daily notes. QoL was measured through semistructured interviews and the Quality of Life in Late-Stage Dementia scale. Structured observations and semistructured interviews were used to measure treatment feasibility. The primary outcomes were analyzed at a 95% significance level based on the intention-to-treat method.

RESULTS

VR therapy had a statistically significant effect on reducing aggressiveness (ie, physical aggression and loud vociferation; P=.01). Substantial impact of VR therapy was not found for other BPSDs (eg, apathy), falls, length of stay, or QoL as measured using the Quality of Life in Late-Stage Dementia scale. The average VR therapy session lasted 6.8 (SD 6.6; range 0-20) minutes, and the intervention was overall an acceptable and enjoyable experience for participants. No adverse events occurred as a result of VR therapy.

CONCLUSIONS

Immersive VR therapy appears to have an effect on aggressive behaviors in patients with dementia in acute care. Although the randomized controlled trial was stopped before reaching the intended sample size owing to COVID-19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03941119; https://clinicaltrials.gov/study/NCT03941119.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/22406.

Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis

BACKGROUND

The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA.

OBJECTIVE

This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors.

DESIGN

The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019.

PARTICIPANTS

Hospitalized patients aged 18 and older.

MAIN MEASURES

Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges.

KEY RESULTS

In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race.

CONCLUSIONS

In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

Prevention and management of behavioural and psychological symptoms in patients with dementia in acute care: a best practice implementation project

INTRODUCTION

Behavioural and psychological symptoms of dementia are very common in acute care. Agitation and aggressive behaviours are the most common symptoms and are challenging to manage. Early detection and a nonpharmacological approach are recommended.

OBJECTIVES

To implement evidence-based recommendations for the prevention and management of aggression/agitation in patients with dementia in an acute geriatric care unit.

METHODS

The project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. A baseline audit was conducted with seven audit criteria based on evidence summaries. It was followed by the implementation of an action plan and a follow-up audit.

RESULTS

Results showed moderate improvements in compliance with best practice recommendations. The second audit indicated an improvement up to 46% with the identification of factors/triggers that precipitate aggression/agitation and completion of a risk assessment. The highest improvement was the training of the nursing team (79%). Compliance with the involvement of patients and their families in the care planning improved slightly (14%). The lowest improvement was for the development and implementation of individualized care plans (10%).

CONCLUSION

The project implementation achieved some positive changes. A formalized process for preventing aggression/agitation is in place. The interprofessional collaboration, the support given to the nursing team and the basket of nonpharmacological interventions were strengthened. The electronic documentation and a limited collaboration of the nursing team were challenging. As further strategies were implemented, further audit would be required to assess achievement in change and/or demonstration of improved care provided for this vulnerable population.

A Virtual Reality Intervention to Reduce Dementia-Related Agitation Using Single-Case Design

OBJECTIVES

The primary objective of this study was to use a single-case design to evaluate the utility of a VR intervention to reduce agitation behaviors in two female participants with a diagnosis of dementia.

METHODS

A single-case research design with an ideographic approach was selected given the novelty of this intervention. A blended single case experimental design was used combining the Multiple-baseline design across individuals with a reversal design to examine the effects of VR nature scenes on agitation. Visual analysis was used to determine changes in mean, level, and latency of the behaviors.

RESULTS

For both participants, a significant decrease in their respective agitation behaviors was observed during intervention phases.

CONCLUSIONS

This study provides preliminary evidence of the utility of VR as a brief and effective intervention to decrease agitation in individuals with dementia.

CLINICAL IMPLICATIONS

These initial, promising results may help caregivers improve the quality of life for dementia patients. Further, the brevity of the intervention makes this a practical tool for care providers working in clinical settings. The primary objective of this study was to use a single-case design to evaluate the utility of a VR intervention to reduce agitation behaviors in two female participants with a diagnosis of dementia.

The Effect of Doll Therapy on Agitation and Cognitive State in Institutionalized Patients With Moderate-to-Severe Dementia: A Randomized Controlled Study

ClinicalTrials.gov, ID: NCT04120103 Retrospectively registered on 8 April 2019.

Risk factors for inducing violence in patients with delirium

BACKGROUND

Violence in patients with delirium may occur suddenly and unpredictably in a fluctuating state of consciousness. Although various factors are involved, appropriate assessment and early response to factors related to violence in delirium are expected to prevent dangerous and distressing acts of violence against patients, their families and medical staff, and minimize the use of physical restraint and excessive drug sedation.

METHODS

Subjects were 601 delirium cases referred to the department of psychiatry over the course of 5 years at a general hospital. The demographic, clinical, and pharmacological variables of patients with violence (n = 189) were compared with those of patients without violence (n = 412). Logistic regression analysis was applied to determine whether any specific individual factors were associated with violence.

RESULTS

Current smoker status (p < .0005), older age (p < .0005), male gender (p = .004), and use of intensive care units (p = .043) were identified as factors associated with violence in patients with delirium.

CONCLUSIONS

Screening tools for violence in patients with delirium and adequate management may assist in better outcomes for patients and medical staff. Further research should evaluate the usefulness of nicotine replacement treatment for the prevention of violence during nicotine withdrawal, including whether it is safe for elderly inpatients with a high incidence of delirium in clinical practice.

Blood DNA Methylation Levels in the WNT5A Gene Promoter Region: A Potential Biomarker for Agitation in Subjects with Dementia

Background:

Behavioral and psychological symptoms of dementia (BPSD) cause a heavy burden for both patient and caregivers. These symptoms are diverse, and their mechanism is still unclear. Agitation is the most common and difficult to treat among BPSD. In recent years, while changes in DNA methylation levels have been receiving attention as a biomarker of aging and dementia, associations with BPSD have not been examined.

Objective:

Focusing on agitation, the objective of the present study was to identify a region where changes in DNA methylation levels are associated with agitation.

Methods:

Using genome-wide DNA methylation analysis data for 7 dementia subjects with agitation, 5 dementia subjects without agitation, and 4 normal elderly controls, we determined a signaling pathway in the WNT5A gene promoter region to be associated with agitation. Based on this result, we measured DNA methylation levels in this region for 26 dementia subjects with agitation and 82 dementia subjects without agitation by means of methylation-sensitive high-resolution melting (MS-HRM) analysis.

Results:

The WNT5A DNA methylation level in dementia subjects with agitation was significantly lower than in those without agitation (p = 0.001). Changes in WNT5A DNA methylation levels were not influenced by age, sex, body mass index, APOE ɛ4, medication, or inflammatory cytokines.

Conclusion:

Our results suggested an association of agitation with Wnt signaling, in particular with changes in WNT5A DNA methylation levels, which could be a potentially useful biomarker for predicting the appearance of agitation. It may contribute to the elucidation of the mechanism of BPSD.

Rejection of Care and Aggression among Older Veterans with Dementia: The Influence of Background Factors and Interpersonal Triggers

OBJECTIVES

To test relationships among background factors, interpersonal triggers, rejection of care, and aggression among veterans living with dementia in residential long-term care settings, based on the need-driven dementia-compromised behavior model.

DESIGN

A mixed methods secondary analysis of program evaluation data from the Staff Training in Assisted Living Residences-Veterans Health Administration intervention implemented by the US Department of Veterans Affairs healthcare system.

SETTING AND PARTICIPANTS

In total, 315 older veterans who participated in the 2013‒2016 Staff Training in Assisted Living Residences-Veterans Health Administration program at 76 Community Living Centers (Veterans Affairs-operated nursing homes).

METHODS

Text data that captured the interdisciplinary team observations of distressed behaviors of concern and their circumstances were coded into categorical variables and then combined with existing quantitative data to test hypothesized relationships using structural equation modeling.

RESULTS

Rejection of care was directly affected by interpersonal triggers (β = 0.32, P < .005) and background factors such as depression (β = 0.29, P < .018), anxiety (β = -0.18, P < .023), and cognitive status (β = 0.10, P < .049). Depression also had an indirect effect on rejection of care through interpersonal triggers (α × β = 0.13 × 0.32 = 0.04, P < .012). Aggression was directly affected by both interpersonal triggers (β = 0.19, P < .009) and functional status (β = 0.17, P < .011). Both function (α × β = 0.12 × 0.19 = 0.02, P < .035) and depression (α × β = 0.13 × 0.19 = 0.03, P < .005) had indirect effects on aggression through interpersonal triggers.

CONCLUSIONS AND IMPLICATIONS

Interpersonal triggers influenced rejection of care and aggression in veterans with dementia. Background factors such as depression and severity of functional impairment increased the likelihood of these symptoms. Study findings emphasize the importance of developing and implementing interventions that improve interpersonal relationships and developing targeted interventions for those with depressive symptoms.

Benefits of Dog-Assisted Therapy in Patients with Dementia Residing in Aged Care Centers in Spain

(1) Background: Currently, the scientific evidence on the benefits of assisted therapy with dogs in dementia is not clear. In this study, we want to evaluate such benefits through a randomized controlled clinical trial in multiple centers across the country. (2) Methods: The participants were people over 65 years old with dementia, residing in senior centers in Spain (n = 334). The experimental group underwent assisted therapy with dogs based on the Comprehensive Cognitive Activation Program in Dementia, for 8 months, with weekly sessions of 45 min. Data were collected at the commencement, middle, and end of the program, to evaluate the aspects using the Mini-Examination Cognitive, the modified Bartell Index, the Cornell Scale for Depression in Dementia and the Neuropsychiatric Inventory. (3) Results: The results show significant improvements in the experimental group versus the control group in the affective (T1 = p 0.000; T2 = p 0.000) and behavioral (T1 = p 0.005; T2 = p 0.000) aspects, with the affective aspect displaying greater progress in participants with additional depressive (p = 0.022) or anxiety (p = 0.000) disorders, shorter institutionalization periods (r = −0.222, p = 0.004), and those undergoing complementary psychotherapy (p = 0.033) or alternative therapy (p = 0.011). (4) Conclusions: Dog therapy is effective in improving the affective and behavioral aspects of institutionalized patients with dementia.

Biting the Bullet: Firearm Ownership in Persons with Dementia. A Registry-Based Observational Study

BACKGROUND

In Sweden, 2,296,000 firearms were legally owned by private persons in 2017 and there were 150,000 persons living with a dementia diagnosis. A proportion of these persons owning a firearm may pose safety concerns.

OBJECTIVE

The aim was to describe firearm ownership in persons with dementia in Sweden and examine which characteristics are explaining physicians' decision to report a person to the police as unsuitable to possess a firearm.

METHODS

This was a registry-based observational study. 65,717 persons with dementia registered in the Swedish Dementia Registry were included in the study. Logistic regression was used to evaluate which of the persons' characteristics were most important in predicting the likelihood of being reported as unsuitable to possess a firearm. Relative importance of predictors was quantified using standardized coefficients (SC) and dominance analysis (DA).

RESULTS

Out of 53,384 persons with dementia, 1,823 owned a firearm and 419 were reported to the police as unsuitable owners. Firearm owners were predominantly younger, males, living alone, and without assistance of homecare. The most important predictors of being reported to the police were: living with another person (SC = 0.23), frontotemporal dementia (SC = 0.18), antipsychotics prescription (SC = 0.18), being diagnosed in a memory/cognitive clinic (SC = -0.27), female gender (SC = 0.18), mild (SC = -0.25) and moderate (SC = -0.21) dementia, and hypnotics prescription (SC = 0.17).

CONCLUSION

Firearm owners with dementia were mostly younger males who were still living more independent lives. The decision to remove a weapon was not solely based on a diagnosis of dementia but a combination of factors was considered.

A Measure of Emotional Regulation and Irritability in Children and Adolescents: The Clinical Evaluation of Emotional Regulation-9

Objective: To develop a scale for emotional regulation using item response theory. Method: Eighteen Swanson Nolan and Pelham (SNAP-IV) items that loaded on an emotional dysregulation factor were submitted to Rasch analysis. After eliminating the items that violated Rasch criteria, the remaining items were examined for reliability and validated against the Conners' emotional lability index. Results: A nine-item scale for emotional regulation was developed that satisfies the Rasch model and reliably distinguishes emotionally dysregulated/irritable children and adolescents. A score of 4 or higher in this scale has optimal accuracy for identifying children and adolescents with current significant dysfunction in emotional regulation. Among youth with ADHD inattentive, hyperactive-impulsive, and combined types, 42%, 56%, and 71% met the Clinical Evaluation of Emotional Regulation-9 (CEER-9) threshold for emotional lability, respectively. Conclusion: A nine-item scale whose sum total is a measure of emotional regulation is proposed as a tool for clinical and research purposes.

Exploring the patient perspectives of mobile X-ray in nursing homes - A qualitative explorative pilot study

INTRODUCTION

For patients with dementia, behaviour and reactions to stimuli can change and an X-ray examination in the hospital can have be a frightening experience. The aim of this study was to identify the experiences and perspectives of patients with dementia and their caregivers on receiving a mobile x-ray examination in nursing homes.

METHODS

This study was designed as a qualitative study using patient observation and semi structured interviews, with a phenomenology-hermeneutic approach. In total, 23 patients were observed during X-ray examinations in nursing homes, and six semi structured interviews were conducted with the caregivers who participated in the examination.

RESULTS

The observations and interviews indicated that a known environment, a recognizable framework and calmness were central for a patient with dementia. The patients appeared calm and relaxed during the examination in their usual environment (nursing homes) where there are less stimuli and impressions based of the observations.

CONCLUSION

Mobile X-ray examinations for patients with dementia living in nursing homes had a positive impact on patients' reactions towards the X-ray examination. The examinations were performed in the patients' usual and safe environments, where impressions and stimuli were less disturbing for patients with dementia.

IMPLICATIONS FOR PRACTICE

The mobile x-ray unit can be of benefit for patients suffering from dementia and result in less impact. The patients living in nursing homes have the opportunity to be examined in their familiar environment, because of the mobile x-ray unit.

Inhibitory Mechanism of An Anticancer Drug, Bexarotene Against Amyloid β Peptide Aggregation: Repurposing Via Neuroinformatics Approach

BACKGROUND

Aggregation of Amyloid β (Aβ) peptide is a crucial feature of Alzheimer disease (AD) pathogenesis. In fact, Aβ peptides are misfolded and aggregated to frame Amyloid fibrils, which is considered as one of the major contributing events in the onset of AD. All these observations have prompted the researchers to design therapeutic molecules with robust anti-Aβ aggregation potential. Interestingly, in the last few decades, drug repurposing has turned into a fruitful and savvy approach for the treatment of several diseases. Bexarotene is an anticancer drug that has been under consideration for its ability to suppress Aβ-peptide aggregation. However, the exact mechanistic aspect of suppression of Aβ-peptide accumulation has not yet been completely revealed.

METHODS

In the present study, we have attempted to decipher the mechanistic aspects of the anti-aggregation potential of bexarotene by using the computational biology approach.

RESULTS

We have observed the effect of 'Aβ-bexarotene' interaction on the aggregation ability of the Aβ-peptide and decoded the involvement of receptor for advanced glycation end products (RAGE) and beta-secretase (BACE-1). A deep structural analysis of Aβ upon binding with bexarotene revealed critical binding sites and structural twists involved in Aβ aggregation. It is evident from the present that bexarotene could significantly restrain the process of primary nucleation of Aβ. In addition, bexarotene showed a strong interaction with RAGE and BACE-1, suggesting them as plausible targets for the neuro-therapeutic action of bexarotene.

CONCLUSION

Hence, we could safely suggest that bexarotene is a potent drug candidate that could reduce Aβ- peptide aggregation by applying different mechanistic pathways. These results might boost the portfolio of pharmaceutical companies looking for the development of new chemical entities against AD.

Caregiver Reactions to Aggressive Behaviors in Persons With Dementia in a Diverse, Community-Dwelling Sample

Purpose: To describe caregiver challenges with and confidence managing three aggressive behavior types in persons with dementia: verbal aggression, destroying property, and threatening to hurt others. Design and Method: Secondary analysis of baseline data from the 2001-2004 Resources for Enhancing Alzheimer's Caregiver Health II (REACH II) initiative. Results: One or more aggressive behaviors within 1 week were reported by more than a third of caregivers, with most expressing upset but fewer expressing confidence managing the behaviors. Caregiver distress and confidence differed by race/ethnicity in response to verbal aggression, with more White/Caucasian caregivers expressing upset than Hispanic/Latinos or Black/African Americans. Fewer Hispanic/Latinos expressed confidence managing verbal aggression, compared with White/Caucasians or Black/African Americans. Discussion: Aggressive behaviors challenge caregivers, with reactions varying by behavior type and race/ethnicity. Cultural and contextual factors suggest the need to tailor interventions, especially skill-building interventions that increase confidence managing aggressive behaviors while decreasing upset.

Delirium and Antipsychotic Medications at Hospital Intake: Screening to Decrease Likelihood of Aggression in Inpatient Settings Among Unknown Patients With Dementia

For individuals with dementia, disorientation and both external and internal stimuli may trigger behaviors that are difficult to manage or dangerous to health-care providers. Identification of correlational risk factors to aggressive behavior in patients who are unknown to the hospital can allow providers to adapt patient care quickly. Records for patients aged 60+ who spent at least 24 hours at the hospital other than in the psychiatric unit were used (N = 14 080). The first 4000 records and every 10th person who met criteria (N = 5008) were searched for documentation of dementia (n = 505). Logistic regressions and χ2 tests were used to examine relationships between variables. Recognition of delirium (P = .014, Exp(B) = 2.53), coupled with an existing prescription for antipsychotic medication at intake (P < .001, Exp(B) < 4.37), may be a reliable means of screening for risk and intervening at the earliest possible contact, improving quality of care and safety in acute care for individuals with dementia.

Impact of Multisensory Environments on Behavior for People With Dementia: A Systematic Literature Review

Purpose of the Study

Behavioral and psychological symptoms of dementia (BPSD) affect quality of life for people with dementia. Nonpharmacological interventions are the preferred first line of treatment, and it is theorized that BPSD are directly influenced by sensory imbalance and improved by sensory equilibrium. The purpose of this article is to investigate the evidence regarding the use of multisensory environments (MSEs) as treatment for BPSD.

Design and Methods

A systematic literature review was performed using the PICO framework within PsycINFO, Web of Science, ERIC, PubMED, and Cinahl databases, as well as additional hand-searched documents. Included articles were published during 1990 to 2015 and report empirical studies of MSE BPSD interventions that include furniture, fixtures, and equipment to provide visual, auditory, tactile, and olfactory stimulation. Desired elements include ergonomic vibroacoustic furniture, bubble tubes, color-changing lights, and fiber optics.

Results

Twelve articles met the inclusion criteria for review. Evidence supports the positive impact of sensory stimulation as a nonpharmacological behavioral treatment for dementia. Many studies investigated both behavior and mood, and several investigated biomedical parameters including heart rate and cognition. Significant differences were not found in the between-group studies when MSE was compared with other one-to-one interventions. Results on long-term effects were mixed. Variations can be seen in terms of research methods, types of environmental interventions, duration, and specific characteristics of participants, thus confounding the reliability of findings.

Implications

Key findings and directions for future research are discussed including primary outcomes, study design, environmental intervention types, and relevant assessment tools.

A Contagious Disorder: Folie à Deux and Dementia

BACKGROUND

Folie à deux is a clinical condition that was first described in 19th century. It is a psychotic disorder in which two closely associated individuals share a similar delusional system.

OBJECTIVES

The aim of this article is to review the nosological significance of folie à deux and to explore the disorder among patients with dementia.

METHODS

Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2017. Search terms used included dementia, folie à deux, induced delusional disorder, neurocognitive disorders, shared psychotic disorder. Publications found through this indexed search were reviewed for further relevant references.

RESULTS AND CONCLUSION

Cases of Folie à deux involving patients with dementia are reported quite infrequently. Most of the studies on the topic consist in case reports. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent this psychotic syndrome.

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.

Animal-Assisted Intervention and Dementia: A Systematic Review

This review discusses the relationship between animal-assisted interventions (AAI) and behavioral and psychological symptoms of dementia (BPSD). A systematic search was conducted within CINAHL, Web of Science CAB Abstracts, PubMed, Abstracts in Social Gerontology, Google Scholar, and PsycINFO for primary research articles. A total of 32 studies were included in the final review. Variation was noted in study designs and in study setting. Twenty-seven of 32 studies used dogs as the intervention. Agitation/aggression showed a significant decrease in nine of 15 studies. Eleven of 12 studies demonstrated increased social interaction with AAI. Mood had mixed results in nine studies. Quality of life was increased in three of four studies. Resident activity and nutritional intake were each increased in two studies. Animal assisted activities/interventions showed a strong positive effect on social behaviors, physical activity, and dietary intake in dementia patients and a positive effect on agitation/aggression and quality of life.

The association between cognitive fluctuations and activities of daily living and quality of life among institutionalized patients with dementia

OBJECTIVE

Cognitive fluctuations (CFs) occur commonly in dementia of all types. While it is generally accepted that CFs can affect the clinical rating of dementia severity and neuropsychological performance, little is known about their impact on patients' activities of daily living (ADLs) and quality of life (QOL). Our study aims to explore the impact of CFs on ADLs and QOL among institutionalized patients with dementia.

METHODS

The present study examined the nature and frequency of CFs in 55 institutionalized dementia patients. We used the Dementia Cognitive Fluctuation Scale (DCFS) to assess the presence and severity of CFs. The Alzheimer's Disease Functional Assessment of Change Scale (ADFACS) was used to assess patients' ADLs, and the Quality of Life in Late Stage Dementia scale (QUALID) was used to assess QOL. Linear regression models were used to assess the relationships between CFs, ADLs, and QOL.

RESULTS

The mean age of the patients was 90.41 years (SD = 2.84). Their mean Aggressive Behavior Scale score was 1.13 (SD = 1.59), mean Severe Impairment Battery total score was 86.65 (SD = 13.77), and mean DCFS score was 10.07 (SD = 3.04). The mean ADFACS-ADL score was 10.88 (SD = 6.37), mean ADFACS-IADL score was 16.61 (SD = 9.54), and mean QUALID total score was 18.25 (SD = 5.70). DCFS significantly predicted ADFACS-ADL score (R²  = 0.39, β = 0.30, P = .011) although the relationship between ADFACS-IADL score and DCFS score was not significant (R²  = 0.16, P = .111). DCFS significantly predicted QUALID score (R²  = 0.08, β = 0.29, P = .033).

CONCLUSION

More severe CFs in patients with dementia were significantly associated with impaired ability to engage in ADLs and poorer QOL.

Delirium and mental health history as predictors of aggression in individuals with dementia in inpatient settings

OBJECTIVES

Aggressive behaviors by patients with dementia present risk to health care workers and patients. An information processing model, developed to study aggressive behaviors among children, was applied to study aggression among older hospital patients with dementia. Hypotheses were that delirium and mental health or depression history, would relate to increased risk of aggressive behaviors.

METHOD

Electronic medical records were sampled for one year (n = 5008) and screened using the EMERSE search engine and hand review for dementia (n = 505) and aggressive behavior in individuals with dementia (n = 121). Records were reviewed for mental health history and presence of delirium.

RESULTS

Regression analyses found interaction effects representing delirium and mental health or depression history associated with greater risk of aggressive behavior. Significant main effects were found for both dementia and mental health or depression history. Of the lowest risk group, 12% of patients exhibited aggression compared to 24%-35% of those with delirium, mental health or depression history, or the combination of these risk factors.

CONCLUSION

Delirium is the leading correlate of aggressive behaviors in hospitalized patients with dementia, and delirium or history of mental health diagnosis may lead to increased risk of aggressive behaviors in this setting.

Systematic review of evidence underpinning non-pharmacological therapies in dementia

Objective Dementia is one of the most common illnesses worldwide, and is one of the most important causes of disability in older people. Currently, dementia affects over 35 million people around the globe. It is expected that this number will increase to 65.7 million by 2030. Early detection, diagnosis and treatment to control the principal behaviour symptoms may help reduce these numbers and delay the progression to more advanced and dangerous stages of this disorder with resultant increase quality of life for those affected. The main goal of the present systematic literature review was to examine contemporary evidence relating to non-pharmacological therapy in the treatment of dementia. Methods To achieve the study goal, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used. Results This study identified the five most common behaviours in patients with dementia as aggression, wandering, agitation, apathy and sleep disturbances. Two non-pharmacological therapies were the most studied treatment: music therapy and aromatherapy. Ten other non-pharmacological therapies were also identified, but these lack a sufficient evidence-base. Conclusion Although all the therapies identified could be used as part of the treatment of behavioural symptoms, there is insufficient evidence relating to the indications, appropriate use and effectiveness of these therapies to apply in each behavioural treatment. Thus, the present study has demonstrated a significant research gap. What is known about the topic? Despite the widespread use of many different types of therapies, there is limited evidence regarding the efficacy of non-pharmaceutical therapies deployed in the management of behaviours of concern manifested by some people who suffer with dementia in all its forms. What does this paper add? This systematic review examines contemporary evidence from the literature to determine whether there is an evidence base available that would underpin the use of these therapies. This report on a PRISMA systematic review of the available literature demonstrates that only two therapies have some evidence to underpin the use of these non-pharmaceutical therapies and that a significant research gap is exists. What are the implications for practitioners? The implications for practitioners is that significant research effort is required to determine the efficacy of many of the therapies that are currently deployed, and thus many of the therapies used lack an evidence base at this time.

Armed and Aging: Dementia and Firearms Do Not Mix !

The possibility that persons with dementia possess firearms is cause for concern, but only a limited number of research studies have been conducted on such a topic, usually in the form of case reports. Reducing the occurrence of the firearm-related violence requires effectively identifying dangerous individuals and keeping firearms out of their hands. The health care professionals, i.e. the social workers and the physicians, need to work together and to produce a suitable evaluation of patients with dementia to prevent firearm-related injuries and serious and irreparable damage to persons.

Old and dangerous: Prison and dementia

Older prisoners are the fastest growing group of prisoners in many countries. The purpose of this study is to explore the phenomenon of detention of persons suffering from dementia. Medline searches were conducted for relevant articles, chapters and books published until August 2016. Search terms included dementia, elderly, prison and criminal. Publications found through this indexed search were reviewed for further relevant references. As results, there is a lack of data about elderly with dementia in prisons. Given the rise in the average age, it is reasonable to hypothesize that the number of older prisoners is growing. Moreover, some elderly are imprisoned with a concomitant cognitive impairment or psychiatric disorder while others will develop such diseases once incarcerated. At the present time, legal and social systems seem unprepared to handle the phenomenon of dementia in prison. As proposal, health assessments for older first time offenders should become a practice inside the correctional facilities and include an evaluation for specific health issues, such as psychiatric comorbidity and cognitive impairment.

Eating Behaviors and Dietary Changes in Patients With Dementia

BACKGROUND

Eating problems and dietary changes have been reported in patients with dementia.

OBJECTIVES

The aim of this article is to explore the generalized problems with nutrition, diet, feeding, and eating reported among patients with dementia.

METHODS

Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2016. Search terms used included behavioral and psychological symptoms of dementia, dementia, dietary changes, eating behavior. Publications found through this indexed search were reviewed for further relevant references.

RESULTS

Abnormal eating behaviors, eating problems, and dietary changes are present in most people with dementia, especially in the later stages of the condition.

CONCLUSION

Individuals with dementia frequently develop serious feeding difficulties and changes in eating and dietary habits. The changes may be secondary to cognitive impairment or apraxia, or the result of insufficient caregiving, or the consequence of metabolic or neurochemical abnormalities occurring as part of the dementing process.

"Sundowning" as a biological phenomenon: current understandings and future directions: an update

The clinical phenomenon of early evening disruptive behavior also called "Sundowning" in elderly patients has been largely reported in the medical literature without a consistent diagnosis and criteria to define this phenomenon. The current understandings of sundowning are incomplete and current treatment strategies have relied heavily on use of antipsychotic medications, despite side effects and limited evidence to justify their use. A comprehensive understanding of the biogenesis of this phenomenon and mechanistic changes from oxidative pathways may provide novel information on completing the sundowning puzzle. Future studies could examine the utility of natural factors in reviving neuronal energy loss and altering the oxidative pathways might be safe and additional options in development of treatment models for this behavioral disorder.

Agitation-associated behavioral symptoms in mild cognitive impairment and Alzheimer's dementia

OBJECTIVES

The aim of this study is to determine the prevalence of agitation in mild cognitive impairment (MCI, Petersen's criteria) and patients with Alzheimer's dementia (AD), and to characterize the associated behavioral symptoms.

METHOD

A cross-sectional analysis of baseline data from a prospective, longitudinal study on behavioral symptoms was performed, including 268 MCI and 393 AD patients. Behavioral assessment was performed through Middelheim Frontality Score (MFS), Behavioral Pathology in Alzheimer's Disease Rating Scale (Behave-AD) and Cornell Scale for Depression in Dementia (CSDD). Agitated behavior was considered to be clinically relevant when one or more items of the Cohen-Mansfield Agitation Inventory (CMAI) occurred at least once a week.

RESULTS

The prevalence of agitation in AD (76%) was higher than in MCI (60%; p < 0.001). Patients with agitation showed more severe frontal lobe, behavioral and depressive symptoms (MFS, Behave-AD and CSDD total scores). In agitated AD patients, all behavioral symptoms and types of agitation were more severe compared to non-agitated AD patients, but in agitated MCI patients only for diurnal rhythm disturbances. This resulted in more severe Behave-AD global scores in patients with agitation as compared to patients without agitation. Comparing MCI and AD patients, MCI patients with agitation showed more severe behavioral and depressive symptoms than AD patients without agitation. The structure of agitation in AD consisted of more aggressive and physically non-aggressive behavior than in MCI.

CONCLUSION

Frontal lobe, behavioral and depressive symptoms are more severe in MCI and AD patients with clinically relevant agitation as compared to patients without agitation. However, this association is less pronounced in MCI.

Personality and dementia

Personality describes persistent human behavioral responses to broad classes of environmental stimuli. Change in personality may be an early sign of dementia. Our goal was to review scientific literature on the association between personality and dementia. Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published since 1980. Search terms used included personality, dementia, Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies. People with dementia commonly exhibit changes in personality that sometimes precede the other early clinical manifestations of the condition, such as cognitive impairment. Premorbid personality might be a determining factor so that caricature or exaggeration of original personality emerges as dementia progresses. Although it is generally accepted that these personality changes reflect the impact of progressive brain damage, there are several possible patterns of personality alterations with dementia. Early identification of personality modifications might assist with the timely diagnosis of dementia.

The course of neuropsychiatric symptoms in community-dwelling patients with dementia: a systematic review

BACKGROUND

Neuropsychiatric symptoms (NPS) often occur in patients with dementia. Understanding the course of NPS in dementia is important for healthcare professionals for psycho-educational purposes and adequate and timely interventions to prevent or diminish NPS as much as possible.

METHODS

We conducted a systematic literature search in several electronic databases. We combined search strings for the terms dementia, community-dwelling, cohort studies and NPS. Screening titles and abstracts, assessing the methodological quality and data-extraction were independently conducted by at least two authors.

RESULTS

This literature search revealed 6605 unique records of which 23 studies were included in data synthesis. In total 7184 patients participated in the included studies with a mean number of 312. Sixty percent of the participants were female and the mean age of all participants was 74.8 years. Follow-up varied between 1 and 6 years; in 17 studies loss to follow-up was less than 20% per year. NPS are highly prevalent, incident and persistent although frequency parameters vary considerably across studies. Delusions/delusional misidentification, wandering/agitation, aberrant motor behavior/motor hyperactivity and apathy are the most common NPS. For hallucinations, delusions/delusional misidentification, paranoia, aggression, wandering/agitation, aberrant motor behavior/motor hyperactivity, disinhibition, apathy, and sleep disturbance increasing trends in point prevalence rates have been found.

CONCLUSIONS

NPS in community-dwelling patients are frequent and persistent. The increasing trends of several NPS in the course of dementia require a preventive approach of professional caretakers. For such an approach, a timely diagnosis and adequate professional support to prevent or diminish these problems is necessary.

Uncommon and/or bizarre features of dementia

This study aimed at describing uncommon or bizarre symptoms observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published since 1967. Search terms used included uncommon presentation, behavioural and psychological symptoms, dementia, Alzheimer's disease, and fronto-temporal dementia. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms are described as case-reports and there are no systematic investigations. Bizarre behaviours arising late in life should be thoroughly investigated as symptoms of dementia.

Validation of a causal model of agitation among institutionalized residents with dementia in Taiwan

The aim of this study was to test a causal model of the predictors of agitation among 405 nursing home residents in Taiwan with varying degrees of cognitive impairment. Chart review and behavioral observations were used to assess residents' physical and psychosocial condition. The final version of the model had a good fit. Cognitive function and depression had direct effects on agitation, and pain and functional ability had indirect effects on agitation via depression. Additionally, cognitive function and pain influenced functional ability directly, which in turn influenced depression and ultimately influenced agitation. The results suggest that effective management of agitation in demented residents requires identifying the needs underlying the behavior rather than directly treating the behavior itself.

Managing severe aggression in frontotemporal dementia

OBJECTIVE

The aim of this paper is to present a case and discussion illustrating the limitations in the evidence base to guide practice in relationship to managing severe aggression in people with dementia. It also calls attention to the association between haloperidol use and increased mortality in dementia.

METHOD

Case report and review of the literature.

RESULTS

A 60-year-old man with rapidly progressive frontotemporal dementia complicated by severe aggression was managed in specialised psychogeriatric services and high-dose haloperidol was used. This treatment decision was made following literature review, consultation with experts and a detailed risk-benefit analysis. Unfortunately, his physical condition deteriorated swiftly and he died soon after.

CONCLUSIONS

Haloperidol is associated with increased mortality in patients with dementia. This case exposes the difficulties in managing severe aggression in dementia, with few safe and effective treatment options and a lack of consensus guidance in the area of very severe aggression in dementia.

Delusional misidentification syndromes and dementia: a border zone between neurology and psychiatry

The delusional misidentification syndromes (DMSs) are psychopathologic phenomena in which a patient consistently misidentifies persons, places, objects, or events. Although often described in relation to psychotic states including schzofrenia, it is, nevertheless, widely considered that these syndromes have an anatomical basis because of their frequent association with organic brain disease; studies have pointed to the presence of identifiable lesions, especially in the right frontal lobe and adjacent regions, in a considerable proportion of patients. The purpose of this article is to examine the phenomenon in people with dementia. We searched the electronic databases for original research and review articles on DMS in patients with dementia using the search terms "Delusional Misidentification Syndrome, Capgras syndrome, Fregoli syndrome, reduplicative paramnesia, and dementia." The DMSs are a frequent problem in dementia. The violence and dangerousness in patients with dementia having these syndromes are well documented, and forensic aspects are highlighted. Pathogenetic viewpoint and management are considered.

Understanding delusion in dementia: a review

Alzheimer's disease and other dementia are associated with cognitive and functional impairment, as well as neuropsychiatric sequelae, including psychotic features. Research has largely concentrated on the study of cognitive decline, but the associated behavioral and neuropsychiatric symptoms are of equal importance in the clinical profile of the disease. Delusions are common, disabling and persistent in the course of dementia. The purpose of the present review was to examine the phenomenon of delusion in people with dementia. We searched the electronic databases for original research and review articles using the search terms "delusion, dementia, Alzheimer's disease, frontotemporal dementia, vascular dementia and Lewy body disease". Various types of explanations have been proposed regarding the etiology of delusional belief in dementia, and cerebral correlates are considered. Pharmacological and non-pharmacological treatments are analyzed.

Compliance and Caregiver Satisfaction in Alzheimer's Disease: Results from the AXEPT Study

Background/Aims

According to experimental data, a transdermal application is preferred by caregivers of Alzheimer's disease (AD) patients compared with oral medications. The AXEPT study compared compliance to treatment among community-dwelling patients with mild-to-moderate AD treated with transdermal application compared to oral medications and caregiver satisfaction in a real clinical setting.

Methods

Data from 45 memory clinics in Italy were collected between September 8, 2010 and January 31, 2011. Compliance to treatment and caregiver satisfaction were measured using the Caregiver Medication Interview.

Results

A total of 855 AD patients and their caregivers participated in the study. Nearly 80% of caregivers of patients on patch were not concerned about adherence to treatment compared with 64% of caregivers of patients on oral drugs. Among caregivers of patients on patch, 94% did not report any difficulties in remembering to administer treatment compared with 73% of caregivers of patients on oral medications. The highest level of compliance and satisfaction was reported by caregivers of patients on transdermal application.

Conclusion

Caregivers of patients treated with a transdermal application appeared to be more satisfied and reported a higher level of compliance than caregivers of patients receiving anti-AD oral medications.