Specific agitation behaviours in dementia differentially contribute to aspects of caregiver burden

Agitation in individuals with Alzheimer's disease: An assessment of behaviors using the cohen-mansfield agitation inventory in community-dwellers and impact on caregiver experience

BackgroundAgitation is a common neuropsychiatric symptom of Alzheimer's disease; however, limited information exists on how measurable changes in agitated behaviors relate to overall caregiver experience. We sought to describe agitated behaviors measured by the Cohen-Mansfield Agitation Inventory (CMAI) score among individuals with Alzheimer's disease living in US community-based settings and experience of their caregivers.MethodsAn online survey was conducted (08/26/2021-09/24/2021) among adult caregivers who lived with and provided unpaid care for an individual with Alzheimer's disease. The 3-part survey involved (1) informed consent and screening; (2) CMAI assessment (total and sub-scores for four agitation factors); (3) characteristics and outcomes of caregivers and individuals with Alzheimer's disease. Descriptive statistics are reported. Association between the CMAI total score and caregiver burden (measured using the Zarit Burden Interview), mental health (measured using the Patient Health Questionnaire 4-item), and work/activity impairment (measured using the Work Productivity and Activity Impairment: Caregiver scale) was estimated using regression models.ResultsA total of 250 caregivers (mean age: 44.5 years; 55.2% male; 86.4% White) completed the survey. Based on the CMAI, 99.6% of individuals with Alzheimer's disease (mean age: 68.6 years; 55.2% male; 83.2% White) experienced ≥1 agitated behavior in the past 2 weeks. Caregivers reported providing an average of 39.1 hours of care per week for individuals with Alzheimer's disease (additional non-paid and paid care provided by other caregivers was 58.8% and 38.4%, respectively); 60.8% of caregivers had a high caregiving burden, 35.2% experienced moderate-to-severe distress, and 68.2/64.0% had impairment in work/daily activities. Agitation among individuals with Alzheimer's disease was associated with significantly poorer caregiver outcomes.ConclusionsIndividuals with Alzheimer's disease frequently experience several different agitated behaviors. Effective management of agitated behaviors is important and has the potential to improve the overall caregiver experience.

Individualized Music Playlist Based on Iso-Principle for De-Escalating Agitation of People With Dementia: A Randomized Controlled Feasibility Study

OBJECTIVES

To evaluate the feasibility of the Individualized Music Playlist based on Iso-Principle for de-escalating agitation of people with dementia and provide preliminary evidence about its efficacy.

METHODS

The randomized participants listened to either a 30-min music playlist or a book-reading audio script twice weekly for six weeks, and when agitation occurred. Their agitation level was observed every 5 min from the beginning of an agitation episode for an hour to monitor its trajectory over a 2-week period. Multilevel models with maximum likelihood analysis was conducted. The frequency of agitation and other behavioural symptoms was assessed at baseline and the 6th week and analysed with Generalized Estimating Equations.

RESULTS

Twenty-four participants were recruited, and 10 presented 36 agitation episodes during the first two weeks of observation. The recruitment and retention rates were 85.7% and 83.3%, respectively. A total of 97.2% of the intervention and control conditions were delivered as planned. The intervention was not more effective than the control condition in de-escalating agitation or reducing agitation and other behavioural symptoms. Overall, agitation symptoms were apparently alleviated in the first 10 min, with a decelerated pace observed thereafter.

CONCLUSIONS

The intervention was feasible, and its efficacy in de-escalating agitation is yet to be confirmed.

Weighted Blankets for Agitation in Hospitalized Patients with Dementia: Protocol for a Randomized Controlled Trial

BACKGROUND

There are limited therapies approved for the treatment of aggression and agitation in patients with dementia. While antipsychotics and benzodiazepines are commonly used, these medications have been associated with significant side effects and US Food and Drug Administration (FDA) boxed warnings. Weighted blankets have been associated with decreased anxiety and improved sleep. Weighted blankets are potentially a nonpharmacologic option to reduce agitation in hospitalized patients with dementia.

OBJECTIVE

The aim of this study is to investigate the effect of weighted blankets on aggression and agitation in hospitalized patients with dementia.

METHODS

A pilot study will be conducted on a total of 30 hospitalized patients with a documented clinical diagnosis of dementia and ongoing agitated behaviors admitted to a medicine or psychiatry service. Patients will be randomly allocated to receive either a weighted blanket for 3 nights or continued usual care. The primary outcome is the change in the observational version of the Cohen-Mansfield Agitation Inventory (CMAI-O) over the course of the 3-night study period. The secondary outcomes are changes in Edmonton Symptom Assessment System Revised (ESAS-r) and Clinical Global Impression (CGI) scores, hours of sleep, use of antipsychotics and benzodiazepines, and incidence of delirium. Identical study assessments will be completed for both the usual care and the weighted blanket study groups. At 5 study time points (baseline, postnight 1, postnight 2, postnight 3, and a final assessment 48-72 h after the last use of the weighted blanket), patients will be assessed with the CMAI-O, ESAS-r, and CGI tools. All assessments will be completed by the bedside nurse or patient care assistant caring for the patient each day. Within 2 to 4 weeks post discharge from the hospital, study coordinators will contact the patient's legally authorized representative (LAR) to assess for continued use of the weighted blanket.

RESULTS

Enrollment of participants began on April 23, 2023. As of November 2024, a total of 24 participants have been enrolled in the study. Baseline characteristics of enrolled participants will be analyzed and reported upon completion of enrollment. We anticipate completing data collection by March 2026.

CONCLUSIONS

The study will determine the effect of weighted blankets on agitation in hospitalized patients with dementia. Insights into the effect of weighted blankets on sleep will also be gained. The results of this study will be relevant in the setting of increasing numbers of older adults with dementia exhibiting agitation, leading to increased hospitalizations, caregiver burden, and health care costs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03643991; http://clinicaltrials.gov/ct2/show/NCT03643991.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57264.

Validation of the Zarit Burden Interview in Informal Caregivers of Patients with Severe Visual Impairment and Blindness

INTRODUCTION

The needs of family caregivers providing care to relatives with visual impairment are often dismissed, leading to caregiver burden. The Zarit Burden Interview (ZBI) can measure the caregiver burden of caring for a family member with vision impairment. The purpose of this study is to validate the ZBI in Mexican family caregivers of patients with visual impairment.

METHODS

The ZBI was applied to 137 family caregivers of patients with visual acuity ≤ 20/200 in the best eye for ≥ 6 months. The ZBI's reliability was determined using Cronbach's α and the factor structure using exploratory factor analysis (EFA, principal axis factoring with promax rotation). Items with loadings < 0.400 were eliminated. Retained factors were determined using the scree test and Horn's parallel analysis (95% CI). Associations between burden factors and other variables were evaluated with descriptive and inferential statistics.

RESULTS

Mean ZBI score was 26.2 ± 13.1, and internal consistency was high (α = 0.871). EFA yielded four factors: (1) embarrassment and frustration, (2) self-efficacy expectations, (3) interference in personal relationships, and (4) personal strain. The α values ranged from 0.649 to 0.812. Spousal caregivers had significantly higher scores (factors 1, 2, and 4), whereas adult children had less scores (factor 3). There was a significant positive correlation between hours of daily caregiving and factors 2 (r = 0.350) and 3 (r = 0.388). A worse degree of visual impairment was associated with higher mean factor scores in all factors.

CONCLUSIONS

The ZBI is a valid instrument to detect burden in Mexican caregivers of patients with visual impairment. We identified a four-factor structure that improved our understanding of the ZBI's underlying constructs. Interventions targeting specific types of burden are warranted.

Effects of simulated presence therapy on agitated behavior, cognition, and use of protective constraint among patients with senile dementia

The research was conducted to investigate the improvement of agitated behaviors, cognitive functions, and negative emotions among patients with senile dementia and the burden of caregivers after simulated presence therapy (SPT) intervention. 85 Patients with senile dementia were included as the research subjects and divided into control group (40 cases performed with routine nursing) and observation group (45 cases undergoing routine nursing combined with SPT) via a random number table method. Cohen-Mansfield agitation inventory (CAMI) and protective constraint were used to assess the improvement of agitated behaviors among patients. Besides, apathy evaluation scale-informant (AES-I), functional independence measure (FIM), self-rating depression scale (SDS), self-rating anxiety scale (SAS), clock drawing test, and caregiver burden inventory (CBI) were adopted to evaluate the differences in apathy, daily living and sociability, depression, anxiety, cognitive functions, and caregiver burden between the two groups. It was demonstrated that CAMI score, the duration of protective constraint use, AES-I score, SDS score, SAS score, and CBI score among patients in observation group all apparently decreased compared with those in control group after the intervention. In contrast, FIM and clock drawing test scores both notably increased (p < 0.05). The above findings suggested that SPT could obviously reduce the incidence of agitated behaviors, improve the level of apathy, daily living and sociability, depression, anxiety, and cognitive functions, and relieve caregiver burden among patients with senile dementia during SPT intervention for patients with senile dementia.

Longitudinal effects of ambivalent and guilt feelings on dementia family caregivers' depressive symptoms

BACKGROUND

The world prevalence of people with dementia is increasing. Most of the care received by people with dementia is provided by family caregivers, and this prolonged activity has a significant impact on caregivers' levels of depression. Stressors and frequency of leisure are known predictors of caregivers' depressive levels. The longitudinal impact of caregivers' ambivalent and guilt feelings is unknown.

METHODS

Participants were 177 family caregivers of relatives with dementia who were assessed three times during a 2-year period. In addition to demographic variables, psychological symptoms of the dementias, and frequency of leisure activities, caregivers' ambivalent feelings, guilt, and depressive symptoms were measured. The longitudinal association of changes in these variables with changes in caregivers' depressive symptoms over time was assessed using mixed linear models.

RESULTS

Changes over time in the assessed variables predicted 48.05% of variance of changes over time in depressive symptoms. Even when variables strongly associated with increased depressive symptoms were controlled (lower caregivers' age and educational level, higher reaction to BPSD, and lower leisure activities), increases in ambivalence and guilt contributed to an increase of 9.22% of the variance of changes depressive symptoms over a 2-year period. The effects of ambivalent feelings on depression are indirect, mediated by guilt feelings. Cessation of caregiving do not seem to alter these findings.

CONCLUSIONS

Caregivers' ambivalent and guilt feelings are significant predictors of caregivers' mental health. Caregivers may significantly benefit from early detection of ambivalent and guilt feelings and preventive strategies targeting triggers associated with ambivalent and guilt symptoms.

Carers' experiences and perspectives of the use of anticholinergic medications in people living with dementia: Analysis of an online discussion forum

INTRODUCTION

There is concern about the use of anticholinergic medications in people living with dementia (PLWD). Such medicines may increase cognitive decline and may be associated with higher mortality in PLWD who take these medicines. The aim of this study was to analyse data from an online dementia discussion forum to explore the experiences and perspectives of PLWD and carers about the use of anticholinergic medicines in this population.

METHODS

Following receipt of ethical approval, archived discussions (posts) from Dementia Talking Point, a fully public online forum for anyone affected by dementia, created and maintained by the Alzheimer's Society, were searched from the date of inception to January 2022 using a range of search terms including commonly used anticholinergic medicines. Posts, including any of the search terms, were assessed for relevance and analysed using inductive thematic analysis.

RESULTS

Five hundred and fifty unique posts were analysed, all of which had been provided by carers, with no posts attributed to PLWD. The themes that encompassed carers' experiences were (1) motivators of prescribing, (2) perspectives on the process of prescribing and (3) the outcomes of prescribing. The dominant motivator of prescribing was the management of noncognitive symptoms, pre- and postdiagnosis of dementia. Carers' perspectives on the process of prescribing were informed by an assessment of the risk-benefit of starting a medication and shared decision-making between the carer and healthcare professional to a greater or lesser degree. The outcomes of prescribing were observing the effects of the medicines, which in turn influenced whether prescribing was reviewed and continued unchanged, continued but amended, reinitiated if the medicine had been previously stopped or discontinued (the process of deprescribing).

CONCLUSION

This study has provided unique insights into carers' experiences and perspectives about the use of anticholinergic medications in PLWD, highlighting how commonly these medications are prescribed for PLWD and carers' concerns about their use. There is a clear need for carers and PLWD to receive information about these medicines and healthcare professionals to consider how to optimise the use of these medicines to avoid adverse effects.

PATIENT OR PUBLIC CONTRIBUTION

This work was informed by findings from previous research studies focusing on optimising medicine use for people with dementia in primary care, in which interviews were conducted with PLWD, their carers and primary healthcare professionals. Although not strictly patient and public involvement, we utilised the feedback provided by key stakeholders to inform the research questions and aim/objectives of this study.

Effectiveness of dyadic sensory art therapies for People with dementia and their caregivers:A systematic review and meta-analysis

BACKGROUND

The need for dyadic intervention is enhanced with increasing numbers of older adults with dementia. Studies have shown that sensory art therapies are essential for dementia patients and their caregivers. The effects of dyadic sensory art therapies for people with dementia and their caregivers require further exploration.

OBJECTIVES

This review aimed to assess the efficacy of dyadic sensory art therapies on neuropsychiatric symptoms and mental function for dementia patients, caregiver burden and psychological state for caregivers, dyad relationship quality for dyads, and evaluate the potential effects of dyadic sensory art therapies on quality of life for both dementia patients and caregivers.

METHODS

An electronic literature search of the PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library, PsycINFO and three Chinese databases (CNKI, Wanfang and CBM) was conducted up to November 2022. Two reviewers (SZ and QG) worked independently to identify relevant studies. Risk of bias was assessed by the Cochrane's and Joanna Briggs Institute's tool. Meta-analyses were conducted using RevMan software 5.4.

RESULTS

This systematic review included 15 studies (7 RCTs and 8 quasi-experimental studies). The meta-analysis showed that dyadic sensory art therapies significantly ameliorated neuropsychiatric symptoms (SMD = -0.90, 95% CI -1.61 to -0.20, P = .01), caregiver burden (SMD = -0.75; 95% CI -1.03 to -0.47; P < .001). No significant improvements were found in caregiver depression and quality of life for both patients and caregivers.

CONCLUSIONS

Dyadic sensory art therapies are generally effective at ameliorating neuropsychiatric symptoms, and caregiver burden. Future studies are encouraged to design large-scale randomized controlled trials with high-quality study to examine and confirm the effectiveness of dyadic sensory art therapies for these dyads composed of dementia patients and their caregivers.

TRIAL REGISTRATION

PROSPERO CRD 42023393577; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023393577.

A Confirmatory and an Exploratory Factor Analysis of the Cohen-Mansfield Agitation Inventory (CMAI) in a European Case Series of Patients with Dementia: Results from the RECage Study

BACKGROUND

One of the most widely used instruments for assessing agitation in dementia patients is the Cohen-Mansfield Agitation Inventory (CMAI), nevertheless no global score has been proposed. The aim of this study is: (a) to conduct a confirmatory (CFA) and exploratory factor analysis (EFA) of CMAI on people with dementia and Psychological and Behavioral Symptoms (BPSD), and (b) to propose an alternative structure, based on clinical criteria including all CMAI items.

METHODS

Confirmatory and exploratory factor analyses were carried out on the CMAI 29 items administered at baseline to 505 patients with dementia (PwD) and BPSD enrolled in the international observational RECage study.

RESULTS

The three-factor structure has not been confirmed by the CFA, whilst the EFA was carried out respectively on 25 items disregarding 4 items with a prevalence ≤5% and then on 20 items disregarding 9 items with a prevalence ≤10%. The four-factor structure explaining 56% of the variance comprised Physically Aggressive behavior, Verbally Aggressive behavior, Physically non-aggressive behavior, and Physically and verbally aggressive behavior.

CONCLUSIONS

A new grouping of all items according to a clinical criterion is proposed, allowing for a more sensible evaluation of the symptoms leading to better differentiation.