Behavioral and psychological symptoms of dementia are very common, and a recent study
found that they occur in up to 90% of people living in residential care facilities.
1
These symptoms are often more disturbing than cognitive impairment and are associated
with increased healthcare use, earlier institutionalization,
2
excess morbidity and mortality, and greater caregiver distress and depression.
3
Development of strategies for the effective management of this problem is hindered
by confusing terminology. This confusion is reflected in a number of scales with different
terminologies used to describe behavioral symptoms of dementia (Table 1). The terminology ranged from derogatory (eg, obstreperous behavior) to neutral description
of the activity. The most common terms are agitation and aggression.
Table 1Terminology Used to Describe and Measure Behavioral Symptoms of Dementia
| Year | Agitation | Comprehensive Term | Aggression |
|---|---|---|---|
| 1955 | Motor activity | Agitation (also included feeding, association of thought and speech, sleep, sociability)
4
|
Manageability |
| 1983 | Sandoz Clinical Assessment-Geriatric (SCAG) scale (4 other factors)
5
|
Interpersonal relationships (uncooperativeness, irritability, bothersome, hostility) | |
| 1986 | Repetitious behavior (verbal and Physical) | Agitation (also inappropriate to social standards–strange noises, disrobing)
6
|
Curse, verbal aggression Hit, fight, push, kick, etc. |
| 1987 | Disinhibition, agitation | Neurobehavioral Scale (4 factors: cognition/energy, metacognition, somatic/anxiety,
language)
7
|
Hostility |
| 1987 | Activity disturbance (pacing and wandering, repetitive activities, inappropriate activities) | BEHAVE-AD Rating Scale (5 other domains)
8
|
Aggressivity (verbal outbursts, physical threat, or violence) |
| 1989 | Agitation, wandering | Disruptive Behavior Rating Scales
9
|
Physical aggression, verbal aggression |
| 1989 | Physically nonaggressive behavior, verbally agitated behavior | Cohen-Mansfield Agitation Inventory (CMAI)
10
|
Aggressive behavior |
| 1992 | Rating Scale for Aggressive Behavior in the Elderly (RAGE)
11
|
Aggressive behavior | |
| 1992 | Mechanical/motor | The Caretaker Obstreperous-Behavior Rating Assessment (COBRA) Scale (also ideational/personality
and vegetative)
12
|
Aggressive/assaultive |
| 1992 | Agitated or restless | Columbia University Scale for Psychopathology in Alzheimer's disease (CUSPAD)
13
|
Verbal outbursts, physical threats and/or violence |
| 1992 | Overactivity | Present Behavioral Examination (PBE)
14
|
Aggression |
| 1993 | 6. Tension, 17. Excitement | Brief Psychiatric Rating Scale (BPRS)
15
|
10. Hostility, 14. Uncooperativeness |
| 1994 | Physically Aggressive Behavior (PAB)
16
|
Defensive response | |
| 1994 | Self-absorbed behavior Behavior necessitating watchful protection |
Troublesome Behavior Scale (TBS) outpatient and inpatient (also elaborate behavior
and behavior resulting in missing articles)
17
|
Behavior toward caregivers Behavior interfering with care work |
| 1994 | Aberrant vocalization, motor agitation | Pittsburgh Agitation Scale
18
|
Aggressiveness, resisting care |
| 1994 | Aberrant motor behavior | Neuropsychiatric Inventory (NPI) (9 other subdomains)
19
|
Agitation/aggression |
| 1995 | Agitated or upset, repetitive behavior, restlessness, purposeless behavior | The Behavior Rating Scale for Dementia (CERAD/BRSD)
20
|
Easily irritated or annoyed, uncooperativeness, verbal aggression, physical aggression |
| 1997 | Overactivity | Present Behavioral Evaluation (PBE)
14
3 factors (also psychosis)
21
|
Aggressive behavior |
| 1998 | International Psychogeriatric Association: Behavioral and Psychological Symptoms of
Dementia (BPSD)
22
|
||
| 1999 | Wandering, socially inappropriate/disruptive behavioral symptoms | MDS 2.0
23
|
Verbally abusive behavior Physically abusive behavior Resists care |
| 1999 | Agitation | Measurement of observed agitation in patients with Alzheimer's disease (SOAPD)
24
|
|
| 1999 | Resistiveness to Care – Dementia of the Alzheimer type (RTC-DAT)
25
|
Resistiveness to care | |
| 2001 | Pulling out tubes, restlessness, repetitive behavior, rapid, loud or excessive talking, self-abusiveness | Agitated Behavior Scale (ABS)
26
|
Uncooperative, resistant to care, violence or threatening violence, explosive and/or unpredictable anger |
| 2013 | Other behavioral symptoms not directed toward others | MDS 3.0
27
|
Physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, rejection of care |
| 2014 | International Psychogeriatric Association: Agitation in dementia is characterized
by emotional distress associated with the presence of at least one of the following:
excessive motor activity, verbal aggression, or physical aggression.
28
|
||
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Investigating the current methods of assessing behavioral and psychological symptoms in residential aged care facilities in a metropolitan city.Int Psychogeriatr. 2017; 29: 855-858
- The incremental effect of dementia-related problem behaviors on the time to nursing home placement in poor, frail, demented older people.J Am Geriatr Soc. 2003; 51: 188-193
- Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel.J Am Geriatr Soc. 2014; 62: 762-769
- Treatment of senile agitation with chlorpromazine.Geriatrics. 1955; 10: 520-522
- The Sandoz Clinical Assessment-Geriatric (SCAG) scale. A general-purpose psychogeriatric rating scale.Gerontology. 1983; 29: 185-198
- Agitated behaviors in the elderly; I. A conceptual review.J Am Geriatr Soc. 1986; 34: 711-721
- The neurobehavioural rating scale: Assessment of the behavioural sequelae of head injury by the clinician.J Neurol Neurosurg Psychiatry. 1987; 50: 183-193
- Behavioral symptoms in Alzheimer's disease: Phenomenology and treatment.J Clin Psychiatry. 1987; 48: 15
- Assessment of disruptive behavior associated with dementia: The Disruptive Behavior Rating Scales.J Geriatr Psychiatry Neurol. 1989; 2: 196-202
- A description of agitation in a nursing home.J Gerontol Med Sci. 1989; 44: M77-M84
- A rating scale for aggressive behavior in the elderly—The RAGE.Psychol Med. 1992; 22: 211-221
- The caretaker obstreperous-behavior rating assessment (COBRA) scale.JAGS. 1992; 40: 463-470
- The Columbia University scale for psychopathology in Alzheimer's disease.Arch Neurol. 1992; 49: 371-376
- The Present Behavioural Examination (PBE): The development of an interview to measure current behavioural abnormalities.Psychol Med. 1992; 22: 223-230
- Training and quality assurance with the Brief Psychiatric Rating Scale: “The drift busters”.Int J Methods Psychiatr Res. 1993; 3: 221-244
- A descriptive study of physically aggressive behavior in dementia by direct observation.JAGS. 1994; 42: 192-197
- Development of a troublesome behavior scale (TBS) for elderly patients with dementia.Nihon Koshu Eisei Zasshhi. 1994; 41: 518-527
- The Pittsburgh Agitation Scale: A user-friendly instrument for rating agitation in dementia patients.Am J Geriatr Psychiatry. 1994; 2: 52-59
- The neuropsychiatric inventory: Comprehensive assessment of psychopathology in dementia.Neurology. 1994; 44: 2308-2314
- The Behavior Rating Scale for Dementia of the consortium to establish a registry for Alzheimer's disease.Am J Psychiatry. 1995; 152: 1349-1357
- Behavioral changes in dementia. 2: Are there behavioural syndromes?.Int J Ger Psychiat. 1997; 12: 1074-1078
- Behavioral and psychological symptoms of dementia: A consensus statement on current knowledge and implications for research and treatment.Am J Geriatr Psychiatry. 1998; 6: 97-100
- The Minimum Data Set 2.0: A functional assessment to predict mortality in nursing home residents.Am J Hosp Palliat Care. 1999; 16: 527-532
- Measurement of observed agitation in patients with Alzheimer's disease.J Mental Health Aging. 1999; 5: 117-133
- Development and testing of the resistiveness to care scale.Res Nurs Health. 1999; 22: 27-38
- A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania.Clin Psychopharmacol. 2001; 21: 389-397
- Operationalizing the MDS 3.0 in the nursing home.J Am Med Dir Assoc. 2013; 14: 445-446
- Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition.Int Psychogeriatr. 2015; 27: 7-17
- An observational study of agitation in agitated nursing home residents.Int Psychogeriatr. 1989; 1: 153-165
- Factors related to rejection of care and behaviors directed towards others: A longitudinal study in nursing home residents with dementia.Dement Geriatr Cogn Dis Extra. 2015; 5: 123-134
- Agitation and touch in the nursing home.Psychol Rep. 1989; 64: 1019-1026
- Reactive and proactive aggression: Similarities and difference.Pers Individ Dif. 2006; 41: 1469-1480
- A systematic evaluation of impulsive-aggressive behavior in psychogeriatric inpatients using the staff observation aggression scale revision (SOAR-R).Int Psychogeriatr. 2018; 30: 61-68
- No more fighting and biting during mouth care: Applying the theoretical constructs of threat perception to clinical practice.Nurs Pract. 2011; 25: 175
- Statistical Manual for the Use of Institutions for the Insane.American Medico-Psychological Association, New York1918
- Diagnostic and Statistical Manual of Mental Disorders.1st edition. American Psychiatric Association, Washington DC1952
- Diagnostic and Statistical Manual of Mental Disorders (DSM-II).2nd edition. American Psychiatric Association, Washington DC1968
- Diagnostic and Statistical Manual of Mental Disorders (DSM-III).3rd edition. American Psychiatric Association, Washington DC1980
- Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).3rd edition revised. American Psychiatric Association, Washington DC1987
- Diagnostic and Statistical Manual (DSM-IV).4th edition. American Psychiatric Association, Washington DC1994
- Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).(4th text revision) American Psychiatric Association, Washington DC2000
- Diagnostic and Statistical Manual of Mental Disorders (DSM-5).5th edition. American Psychatric Publishing, Washingotn DC2013
- Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli?.J Am Geriatr Soc. 2010; 58: 1459-‒1464
- Bathing the Alzheimer's patient in long term care. Results and recommendations from three studies.Am J Alzheimer Dis. 1995; 10: 3-11
- Effects of Namaste care: Pilot study.Am J Alzheimer Dis. 2015; 2: 24-37
- Effect of citalopram on agitation in Alzheimer disease: The CitAD randomized clinical trial.JAMA. 2014; 311: 682-691
- ELND005 for Agitation and Aggression in Alzheimer's Disease (HARMONY-AD Study): Phase 2/3 design and clinical outcomes.J Prevent Alzheimer Dis. 2015; 2: OC20
European Medicines Agency. Risperdal. 2018. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Risperdal_30/WC500007979.pdf. Accessed July 15, 2018.
Article info
Publication history
Published online: September 06, 2018
Footnotes
The authors declare no conflicts of interest.
Identification
Copyright
© 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
