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Discomfort and agitation in older adults with dementia
Isabelle Pelletier, Philippe Landreville
BMC Geriatrics , 2007, DOI: 10.1186/1471-2318-7-27
Abstract: 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.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.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.Dementia is not an inevitable consequence of ageing but the risk of dementia increases sharply with advancing age and prevalence is expected to increase dramatically over the coming decades [1]. Dementia features an alteration of memory and at least one other cognitive disorder such as aphasia, agnosia, apraxia or a disturbance in executive functioning [2]. Various etiologies are related to dementia, such as strokes, head t
Effects of Dementia-Care Mapping on Residents and Staff of Care Homes: A Pragmatic Cluster-Randomised Controlled Trial  [PDF]
Geertje van de Ven, Irena Draskovic, Eddy M. M. Adang, Rogier Donders, Sytse U. Zuidema, Raymond T. C. M. Koopmans, Myrra J. F. J. Vernooij-Dassen
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0067325
Abstract: Background The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention. Methods Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents’ neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects. Results 34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI ?2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects. Conclusions Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect. Trial Registration Dutch Trials Registry NTR2314.
Improving person-centred care in nursing homes through dementia-care mapping: design of a cluster-randomised controlled trial
Geertje van de Ven, Irena Draskovic, Eddy MM Adang, Rogier ART Donders, Aukje Post, Sytse U Zuidema, Raymond TCM Koopmans, Myrra JFJ Vernooij-Dassen
BMC Geriatrics , 2012, DOI: 10.1186/1471-2318-12-1
Abstract: The study is a cluster-randomised controlled trial, with nursing homes grouped in clusters. Studywise minimisation is the allocation method. Nursing homes in the intervention group will receive a dementia-care-mapping intervention, while the control group will receive usual care. The primary outcome measure is resident agitation, to be assessed with the Cohen-Mansfield Agitation Inventory. The secondary outcomes are resident neuropsychiatric symptoms, assessed with the Neuropsychiatric Inventory - Nursing Homes and quality of life, assessed with Qualidem and the EQ-5D. The staff outcomes are stress reactions, job satisfaction and job-stress-related absenteeism, and staff turnover rate, assessed with the Questionnaire about Experience and Assessment of Work, the General Health Questionnaire-12, and the Maastricht Job Satisfaction Scale for Health Care, respectively. We will collect the data from the questionnaires and electronic registration systems. We will employ linear mixed-effect models and cost-effectiveness analyses to evaluate the outcomes. We will use structural equation modelling in the secondary analysis to evaluate the plausibility of a theoretical model regarding the effectiveness of the dementia-care mapping intervention. We will set up process analyses, including focus groups with staff, to determine the relevant facilitators of and barriers to implementing dementia-care mapping broadly.A novelty of dementia-care mapping is that it offers an integral person-centred approach to dementia care in nursing homes. The major strengths of the study design are the large sample size, the cluster-randomisation, and the one-year follow-up. The generalisability of the implementation strategies may be questionable because the motivation for person-centred care in both the intervention and control nursing homes is above average. The results of this study may be useful in improving the quality of care and are relevant for policymakers.The trial is registered in the Ne
The effect of individualized music on agitation for home-dwelling persons with dementia  [PDF]
Heeok Park
Open Journal of Nursing (OJN) , 2013, DOI: 10.4236/ojn.2013.36061

Purpose: The purpose of this study was to test the effect of individualized music on agitation for homedwelling patients with dementia. Method: One group pre-post test was used for research design and a total of 26 subjects participated in this study. Individualized music intervention was subjects’ listening to their preferred music for 30 minutes prior to peak agitation time twice a week for a total of four sessions. The subject’s agitation levels were measured for three different points: thirty minutes prior to listening to music, 30 minutes while listening to the music, and after listening to the music throughout the 4 sessions. To measure the agitation level, the modified CohenMansfield Agitation Inventory was used. A Paired ttest was used for data analysis. Results: Most subjects were female (73.1%), Caucasian (92.4%), Protestant (50%), and independent activity (53.8%). The mean of the subjects’ MMSE scores was 8.08 (8.17). The most favorite music types included country/western music (31.0%), religious music (26.9%), and big band (26.9%). Agitation level decreased while listening to the music compared to the baseline (t = 3.70, p < .001). Conclusion: The findings of this study would provide meaningful data to develop an individualized music intervention protocol to control agitation for homedwelling patients with dementia.


Efficacy and safety of risperidone oral solution in agitation associated with dementia in the elderly
Laks, Jerson;Engelhardt, Eliasz;Marinho, Valeska;Rozenthal, Marcia;Souza, Fernando de Castro e;Bacaltchuk, Josué;Stoppe Jr., Alberto;Ferreira, R.C.R.;Bottino, Cassio;Scalco, M?nica;
Arquivos de Neuro-Psiquiatria , 2001, DOI: 10.1590/S0004-282X2001000600005
Abstract: background: behavioral and psychological symptoms in dementia (bpsd) contribute to caregiver burden and institutionalization of elderly. neuroleptics are prescribed to control agitation. side effects of typical neuroleptics are harmful, making atypical neuroleptics an indication. objectives: to evaluate efficacy and tolerability of risperidone oral solution (ros) given once daily to demented elderly outpatients with bpsd (agitation). method: patients (n=26), 76.35±8.63 years, diagnostic and statistical manual of mental disorders 4th ed. (dsm-iv) criteria for dementia. rso was given, starting dose of 0.25 mg and increments of 0.25 mg every week. mini-mental state examination (mmse) assessed cognitive status, behavioral and emotional activities manifested in dementia (beam-d) and clinical global impression (cgi) measured bpsd, extrapiramidal symptom rating scale (esrs) evaluated extrapyramidal symptoms. cardiovascular side effects were evaluated clinically. results: there was a 26% reduction in agitation and no cardiovascular side effects in the range from 1.0 to 1.25 mg. side effects were more prevalent above 2.5 mg. conclusion: risperidone oral solution improved agitation with good tolerability from 0.5 to 1.25 mg. a single dose with increments of 0.25 mg may be more acceptable to patients and caregivers.
Efficacy and safety of risperidone oral solution in agitation associated with dementia in the elderly  [cached]
Laks Jerson,Engelhardt Eliasz,Marinho Valeska,Rozenthal Marcia
Arquivos de Neuro-Psiquiatria , 2001,
Abstract: BACKGROUND: Behavioral and psychological symptoms in dementia (BPSD) contribute to caregiver burden and institutionalization of elderly. Neuroleptics are prescribed to control agitation. Side effects of typical neuroleptics are harmful, making atypical neuroleptics an indication. OBJECTIVES: To evaluate efficacy and tolerability of risperidone oral solution (ROS) given once daily to demented elderly outpatients with BPSD (agitation). METHOD: Patients (n=26), 76.35±8.63 years, Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) criteria for dementia. RSO was given, starting dose of 0.25 mg and increments of 0.25 mg every week. Mini-Mental State Examination (MMSE) assessed cognitive status, Behavioral and Emotional Activities Manifested in Dementia (BEAM-D) and Clinical Global Impression (CGI) measured BPSD, Extrapiramidal Symptom Rating Scale (ESRS) evaluated extrapyramidal symptoms. Cardiovascular side effects were evaluated clinically. RESULTS: There was a 26% reduction in agitation and no cardiovascular side effects in the range from 1.0 to 1.25 mg. Side effects were more prevalent above 2.5 mg. CONCLUSION: Risperidone oral solution improved agitation with good tolerability from 0.5 to 1.25 mg. A single dose with increments of 0.25 mg may be more acceptable to patients and caregivers.
Feasibility of Conducting a Music Therapy Study With Hospice Patients with Dementia & Agitation
Barbara Reuer,Julie Guy,Ann Sturley,Matt Soskins
Voices: A World Forum for Music Therapy , 2011,
Abstract: This study's purpose was to explore non-pharmacological means for decreasing agitation in hospice patients with late stage dementia administered by caregivers. Subjects in the study were patients on service with San Diego Hospice and the Institute for Palliative Medicine, diagnosed with late stage dementia, as determined by a FAST (Functional Assessment Staging) score of 7, and who were known to become agitated while performing certain tasks (e.g., bathing or eating). A music therapist assessed the subjects using an adaptation of the Music Therapy Assessment (Krout, 2000). The Short Portable Mental Status Questionnaire (SPMSQ) and Blessed Dementia Scale were administered pre- and post- intervention to assess cognitive functioning severity of dementia, respectively. Caregivers were trained to administer the Agitated Behavior Scale (ABS) after performing the stressful task without music (baseline). The music therapist created a CD for each subject based on the following: a) music background/preferences of subject (preferred styles of music, favorite selections or artists), obtained from family/caregiver, and b) subject responses observed during the assessment. Caregivers were instructed to complete the agitated task during the music intervention and immediately following the task completed an ABS evaluation. Out of the 51 patients referred for the study, 11 met inclusion criteria and were consented. Eight subjects completed the study. According to demographic information the majority of subjects were female, had previous music experience, and lived in a skilled nursing facility. The most frequent agitated task was bathing, which caused agitation in 75% of subjects. SPMSQ results indicated all patients had severe cognitive impairment and pre-/post-scores were the same. Pre-music intervention ABS scores were a mean of 23.46 (SD=5.8), and a mean of 20.69 (SD=7.1) for post-music intervention. This indicated that subjects became slightly less agitated overall though the effects were not statistically significant (t (7) = 1.41, p=0.2). Further analysis was unwarranted due to the lack of statistical significance and the small sample size. Two subjects demonstrated decreased agitation levels. Study limitations, implications for further research, and feasibility of research with late stage dementia patients receiving hospice care are discussed by the researchers.
Efficacy of Memantine for Agitation in Alzheimer’s Dementia: A Randomised Double-Blind Placebo Controlled Trial  [PDF]
Chris Fox, Monica Crugel, Ian Maidment, Bjorn Henrik Auestad, Simon Coulton, Adrian Treloar, Clive Ballard, Malaz Boustani, Cornelius Katona, Gill Livingston
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0035185
Abstract: Background Agitation in Alzheimer’s disease (AD) is common and associated with poor patient life-quality and carer distress. The best evidence-based pharmacological treatments are antipsychotics which have limited benefits with increased morbidity and mortality. There are no memantine trials in clinically significant agitation but post-hoc analyses in other populations found reduced agitation. We tested the primary hypothesis, memantine is superior to placebo for clinically significant agitation, in patients with moderate-to-severe AD. Methods and Findings We recruited 153 participants with AD and clinically significant agitation from care-homes or hospitals for a double-blind randomised-controlled trial and 149 people started the trial of memantine versus placebo. The primary outcome was 6 weeks mixed model autoregressive analysis of Cohen-Mansfield Agitation Inventory (CMAI). Secondary outcomes were: 12 weeks CMAI; 6 and 12 weeks Neuropsychiatric symptoms (NPI), Clinical Global Impression Change (CGI-C), Standardised Mini Mental State Examination, Severe Impairment Battery. Using a mixed effects model we found no significant differences in the primary outcome, 6 weeks CMAI, between memantine and placebo (memantine lower ?3.0; ?8.3 to 2.2, p = 0.26); or 12 weeks CMAI; or CGI-C or adverse events at 6 or 12 weeks. NPI mean difference favoured memantine at weeks 6 (?6.9; ?12.2 to ?1.6; p = 0.012) and 12 (?9.6; ?15.0 to ?4.3 p = 0.0005). Memantine was significantly better than placebo for cognition. The main study limitation is that it still remains to be determined whether memantine has a role in milder agitation in AD. Conclusions Memantine did not improve significant agitation in people with in moderate-to-severe AD. Future studies are urgently needed to test other pharmacological candidates in this group and memantine for neuropsychiatric symptoms. Trial Registration ClinicalTrials.gov NCT00371059 Trial Registration International Standard Randomised Controlled Trial 24953404
Sedative load of medications prescribed for older people with dementia in care homes
Carole Parsons, Jane Haydock, Elspeth Mathie, Natasha Baron, Ina Machen, Elizabeth Stevenson, Sarah Amador, Claire Goodman
BMC Geriatrics , 2011, DOI: 10.1186/1471-2318-11-56
Abstract: Medication data were collected at baseline and at two further time-points for eligible residents of six care homes participating in the EVIDEM-End Of Life (EOL) study for whom medication administration records were available. Regular medications were classified using the Anatomical Therapeutic Chemical classification system and individual sedative loads were calculated using a previously published model.At baseline, medication administration records were reviewed for 115 residents; medication records were reviewed for 112 and 105 residents at time-points 2 and 3 respectively. Approximately one-third of residents were not taking any medications with sedative properties at each time-point, while a significant proportion of residents had a low sedative load score of 1 or 2 (54.8%, 59.0% and 57.1% at baseline and time-points 2 and 3 respectively). More than 10% of residents had a high sedative load score (≥ 3) at baseline (12.2%), and this increased to 14.3% at time-points 2 and 3. Approximately two-thirds of residents (66.9%) regularly used one or more psychotropic medication(s). Antidepressants, predominantly selective serotonin re-uptake inhibitors (SSRIs), were most frequently used, while antipsychotics, hypnotics and anxiolytics were less routinely administered. The prevalence of antipsychotic use among residents was 19.0%, lower than has been previously reported for nursing home residents. Throughout the duration of the study, administration of medications recognised as having prominent sedative adverse effects and/or containing sedative components outweighed the regular use of primary sedatives.Sedative load scores were similar throughout the study period for residents with dementia in each of the care homes. Scores were lower than previously reported in studies conducted in long-term care wards which have on-site clinical support. Nevertheless, strategies to optimise drug therapy for care home residents with dementia which rely on clinicians external to the care
Prevalence of dementia and Alzheimer's disease in elders of nursing homes and a senior center of Durango City, Mexico
Cosme Alvarado-Esquivel, Ana Hernández-Alvarado, Rosa Tapia-Rodríguez, ángel Guerrero-Iturbe, Karina Rodríguez-Corral, Sergio Martínez
BMC Psychiatry , 2004, DOI: 10.1186/1471-244x-4-3
Abstract: One hundred and fifty-five residents of two nursing homes and 125 attendees of a senior center were examined for dementia and Alzheimer's disease. All subjects were tested by the mini-mental state examination, and those who scored twenty-four or less underwent psychiatric and neurological evaluations. Diagnosis of dementia, AD and vascular dementia (VaD) was based on the DSM-IV criteria. Socio-demographic characteristics from each participant were also obtained.Residents of nursing homes found to suffer from dementia were 25 out of 155 (16.1%). Eighteen of them (11.6%) had AD, and seven (4.5%) had VaD. None of the attendees of the senior center suffered from dementia. Dementia (pooled AD and VaD cases) correlated with white ethnicity (OR = 3.2; 95%CI = 1.28–8.31), and a history of unemployment (OR = 6.46; 95%CI = 1.42–25.97), while AD correlated with journeymen occupations (OR = 4.55; 95%CI = 1.00–19.29).Prevalence of dementia in residents of nursing homes found in this study is much lower than reported from more industrialized countries. AD was more frequent than VaD. Ethnicity and occupation showed effects on the prevalence figures. The prevalence of dementia found has implications for the optimum kind of health care that nursing homes should provide to their residents.Dementia in general and Alzheimer's disease (AD) in particular affect elderly people all around the world [1-4]. Medicare costs for dementia are high and increase with severity of the disease and institutionalization [5]. The frequentness of dementia and AD vary substantially in different countries. In the United States, approximately 10% of the population older than sixty-five years of age suffers from dementia, with AD accounting for about two-thirds of the cases [2]. In a study of European population-based cohorts of persons sixty-five years and older, age-standardized prevalences of 6.4% for dementia and 4.4% for AD were found [6]. In contrast, elderly people of comparable age from an urban comm
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