Causes of aggressive behavior in patients with dementia.

OBJECTIVE: To examine factors predicting development of aggression. METHOD: Community-dwelling patients over 60 years of age in a Veterans Affairs Medical Center who had a documented ICD-9-CM code for dementia within 12 months of screening and no other dementia codes recorded for 2 preceding years but no aggressive behavior during the 12 months preceding study initiation were assessed every 4 months for 24 months for aggression, depression, pain, patient/caregiver relationship quality (mutuality), involvement in pleasant events, and caregiver burden. The study was conducted from September 5, 2003, to June 10, 2005. RESULTS: Of 215 patients, 89 (41%) developed aggression. In individual models, high baseline mutuality decreased risk of aggression; high burden and pain increased risk. Increases in depression and pain and declines in total mutuality also increased risk. In a full model and step-wise model, high levels of baseline caregiver burden, worst pain, and decline in mutuality over time increased risk of aggression. CONCLUSIONS: Many dementia patients become aggressive. Higher levels of worst pain, caregiver burden, and declining mutuality over time increase risk of aggression.

Consequences of aggressive behavior in patients with dementia.

This study examined aggression as a predictor of nursing-home placement, injuries, use of restraints, and use of health services in community-dwelling patients with newly diagnosed dementia. Participants were identified from 2001-2004 Veterans Administration databases; all had a new diagnosis of dementia and no aggression. Patients and caregivers were evaluated for aggression, using the Cohen-Mansfield Agitation Inventory-aggression subscale, and other outcomes for 2 years, with outcome rates compared between patients who did or did not develop aggression and between pre- and postaggressive periods. Of 215 patients, 88 became aggressive, associated with significantly increased use of psychotropic medication (p< or =0.04), injuries (p< or =0.0001), and nursing-home placement (p< or =0.004).

Self-reported pain in persons with dementia predicts subsequent decreased psychosocial functioning.

OBJECTIVES: Pain self-report is the assessment gold standard in cognitively intact populations but has been discouraged in persons with dementia because of significant evidence that pain intensity is often underreported by persons with dementia. However, most community-dwelling persons with dementia are cared for in primary care settings where a more in depth pain assessment is unlikely. Therefore, it is vital to know the clinical predictive value of self-report pain assessment in this population. Psychosocial functioning is a meaningful focus for clinical prediction, because psychosocial constructs are integrally related to quality of life, physical functioning, and one's ability to function in the presence of pain. The purpose of this study was to investigate the degree to which answers to simple self-report pain questions can predict changes in psychosocial functioning 4 months later in community-dwelling older adults with dementia. DESIGN: Longitudinal. Patients and caregivers were assessed every 4 months for 24 months. SETTING: Veterans Affairs Medical Center, Houston, TX. PARTICIPANTS: One hundred seventy-one patients over age 60 years diagnosed with dementia in the previous year and with no previous aggression were recruited from Veterans Administration clinics. MEASUREMENTS: Pain, agitation, depression, involvement in pleasant events, caregiver burden, psychosis, and patient/caregiver relationship quality (mutuality). RESULTS: Pain scores at each time period were predictive of increased agitation and depression and decreased pleasant event frequency 4 months later. CONCLUSIONS: Our results suggest that persons with dementia who affirmatively respond to pain questions are at higher risk for developing negative psychosocial states.

Cognitive-behavioral treatment for anxiety in patients with dementia: two case studies.

Anxiety is common in dementia and is associated with decreased independence and increased risk of nursing home placement. However, little is known about the treatment of anxiety in dementia. This article reports results from two patients who were treated with a modified version of cognitive-behavioral therapy for anxiety in dementia (CBT-AD). Modifications were made in the content, structure, and learning strategies of CBT to adapt skills to the cognitive limitations of these patients and include collaterals (i.e., family members, friends, or other caregivers) in the treatment process. The patients received education and awareness training and were taught the skills of diaphragmatic breathing, coping self-statements, exposure, and behavioral activation. The Clinical Dementia Rating (CDR) Scale was used to characterize dementia severity and determine eligibility for treatment (a CDR score of 0.5 to 2.0 was required for participation). Other measures included the Rating Anxiety in Dementia scale, the Neuropsychiatric Inventory Anxiety subscale, and the Mini International Neuropsychiatric Interview. Outcome data showed improvement in anxiety as measured by standardized rating scales. We conclude that CBT-AD is potentially useful in treating anxiety in dementia patients and that this technique merits further study.