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Correlates of disruptive behavior in cognitively impaired elderly nursing home residents
Correlates of DisruptiveBehaviorin CognitivelyImpaired ElderlyNursing Home Residents Cornelia Beck, Linda Rossby, and Beverly Baldwin
Disruptive behavior, resulting in negative consequences for both residents and caregivers, occurs in a large proportion of the nursing home population. This review of literature surveys studies that describe disruptive behavior and the correlates of this behavior in the cognitively impaired elderly. In the studies reviewed. the average prevalence of reported disruptive behavior among a total of 5,650 subjects was 42.8%. Correlates most frequently linked with disruptive behavior include cognitive status, functional ability, age, and premorbid personality. Suggestions for future research are discussed.
Copyright
B
0 1991 by W.B. Saunders
EHAVIORAL problems in long-term care facilities for the elderly are pervasive. Behavior categorized as disruptive, aggressive, or agitated is often compounded by coexisting cognitive impairment. Management of residents exhibiting these types of behavior is an escalating problem as the elderly population continues to grow (CohenMansfield, Marx, & Rosenthal, 1990; Cospito & Gift, 1982; Jackson, Drugovich, Fretwell, Spector, Stemberg, & Rosenstein, 1989; Ryden, Bossenmaier, & McLachlan, 1989; Winger, Schirm, & Stewart, 1987, 1989). The critical nature of this problem is addressed in a recent study in which both the severity of dementia and the presence of behavioral problems were found to be significantly related to shorter survival time in 126 subjects diagnosed with Alzheimer’s-type dementia (Walsh, Welch, & Larson, 1990). Behavioral problems among cognitively impaired nursing home residents have not been clearly defined or adequately studied, and knowledge about the distribution of these problems is limited (Ebersole, 1989). Expansion and clarification of existing knowledge is a prerequisite for understanding disruptive behavior in the cognitively impaired elderly. Empirically based nursing interventions directed toward the prediction, prevention, and control of this behavior are needed. The following review of literature describes
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studies on disruptive behavior of the institutionalized elderly. Most studies report incidence and describe two or more correlates. However, the correlates and definitions of disruptive behavior vary widely. Some studies limit the definition to types of aggressive behavior; others broadly define disruptive behavior and include incontinence. In addition, the studies use a variety of instruments to measure both disruptive behavior and its correlates. Therefore, an accurate comparison of these studies is difficult. The studies reviewed will be described individually; Table 1 summarizes correlates of types of disruptive behavior and findings presented in the studies. DESCRIPTION OF STUDIES
In a random sample of 1,139 subjects from 42 skilled nursing facilities, Zimmer, Watson, and
From the College of Nursing and Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock; the Baptist Rehabilitation Institute, Little Rock, AR; and the School of Nursing, University of Ma yland Baltimore. Address reprint requests to Comelia Beck, Ph.D., R.N., Professor and Associate Dean for Research and Evaluation, College of Nursing, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 529, Little Rock, AR 72205. Copyright 0 1991 by W.B. Saunders Company 0883-9417l91/0505-0006$3.00oal0
Archives of Psychiatric Nursing, Vol. V, No. 5 (October), 1991: pp. 281-291
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Treat (1984) gathered data from the most recent routine utilization review forms. They found that 64.2% had significant behavioral problems (behavior that required constant or active consideration in care planning or that occurred more often than once a week). These types of behavior included confusion, agitation, hallucinations, depression, assaultiveness, abusiveness, regression, and wandering. Significant behavioral problems were divided into moderate (41.6%) and serious (22.6%) behavioral problems. Moderate problems consisted of impaired judgment or physical restraint orders, or both. Serious problems included aggressiveness, physical resistance to care, and uncontrolled wandering. These types of behavior endangered others or self, disturbed others, or concerned staff (i.e., refusing to socialize, hoarding, etc.). Cognitive impairment existed in 81.4% of subjects with behavioral problems. Restraints were used for 46.2% of these subjects. Psychoactive drugs were used regularly to treat 58% of subjects with serious behavioral problems and depression was diagnosed in 9% of these subjects. No report of psychoactive drug use or depression was given for subjects in the moderate behavioral problem group. Winger, Schirm, and Stewart (1987) studied 101 residents of a Veterans Administration Medical Center (43 subjects from a nursing home unit and 58 subjects from an intermediate, long-term care unit). Investigators obtained data through interview and observation. A behavioral inventory was constructed to determine the presence of aggressive behavior. The Katz Index of Activities of Daily Living (ADL) (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963) evaluated functional status. Chang’s Situational Control of Daily Activities (Chang, 1978) measured perceived control. Significantly more aggressive behavior was reported for the nursing home group than for the intermediate care group. Aggressive subjects had longer lengths of stay and perceived that they had less control over situational activities than did nonaggressive subjects, though this relationship did not reach significance. In both intermediate and nursing home subjects, the more serious the type of behavior, the lower the score on the Mental Status Questionnaire (Kahn, Goldfarb, Pollock, & Peck, 1960). Furthermore, most of the types of behavior that were dangerous to self (refusal of directions, food, medication, or treatment) or oth-
BECK, ROSSBY, AND BALDWIN
ers (harming or attempting to harm others or breaking objects) occurred in combination with disturbing behavior (shouting, sarcasm, anger, irritation, and impatience), indicating that disturbing behavior may signal endangering behavior. Meddaugh (1987) reviewed chart and incident reports to investigate aggressive behavior in a skilled nursing facility (n = 72). Twenty-six staff members (26.8%) were abused one to two times in a 3-month period. More incidents of aggression occurred during the day and evening shifts. All aggressors (1 l%, women; 30%) men) had cognitive impairment and needed assistance in ADLs. This retrospective study included no observation of caregiver-resident interaction and no information providing the context within which these incidents occurred. Missing data from incident reports and residents’ charts further limited the study. Nilsson, Palmstiema, and Wistedt (1988) observed 40 psychogeriatric patients in two longterm wards of a Swedish hospital. This descriptive study documented characteristics and frequencies of aggressive behavior within a 6-week period. The sample consisted of nine men (mean age, 80.6 years) and 3 1 women (mean age, 8 1.7 years). Admission length ranged from 1 to 46 months (mean, 24.1 months). Diagnoses, according to the Znternational Classification of Diseases (1969), showed marked cognitive impairment in 38 subjects (34 with dementia, four with chronic schizophrenia) and unspecified chronic psychosis in two subjects. The Staff Observation Aggression Scale developed by Palmstiema and Wistedt (1987), measured frequency and severity of behaviors. Results of this investigation indicated that aggression was primarily aimed at staff (88%). Most incidents (75%) occurred during assistance with ADLs. Correlates of age, length of hospitalization, and gender were examined in relation to frequency and degree of aggression. Multiple regression indicated that age was significantly related to frequency of aggression (0.36; coefficient of determination = 0.14, df = 38, P < .05) while length of hospitalization was significantly related to degree of aggression (0.43; coefficient of determination = 0.20, df = 25, P < .05). Ryden , Bossenmaier , and McLachlan ( 1989) studied 124 residents in four nursing homes, on units for the cognitively impaired, during a 7-day period. Data collection included observation and documentation of behavior as well as medical rec-
DISRUPTIVE
BEHAVIOR
IN ELDERLY
ord reviews for diagnosis, drug usage, social, and health history data. ADL dependency was determined from quality-assurance assessments completed by nursing home staff. The Ryden Aggression Scale ([RAS] Ryden, 1988) was used to measure incidents of aggression. Fifty-one percent of observed aggression was physical, 48% was verbal, and 4% was sexual. No significant difference was found between men and women in incidents of aggression. Residents receiving psychotropic drugs had significantly higher aggression scores than those not receiving drugs. Most aggressive behaviors occurred during the day. No significant relationship was found between aggression scores and Short Portable Mental Status Questionnaire ([SPMSQ] Duke University, 1978) scores. This may have been due to the limited range of scores (79% of all subjects were categorized as severely impaired, according to the SPMSQ). ADL dependency scores and aggression scores showed no significant relationship. Limitations of this study included missing data in medical records and staff inexperience in using the Ryden Aggression Scale (1988a). A study to determine whether use of restraints in nursing home residents decreases or increases agitation was conducted by Werner, CohenMansfield, Braun, and Marx (1989). Twenty-four residents from three units of a 550-bed, long-term care facility were observed during this study. Participants were chosen on the basis of a high level of agitation and cognitive impairment. The CohenMansfield Agitation Instrument (CohenMansfield, 1986) assessed agitation and the Brief Cognitive Rating Scale (Reisberg, Schneck, Ferris, Schwartz, & de Leon, 1983) assessed cognitive impairment. During a 3-month period, 1,000 3-minute observations of each resident were obtained during all 24 hours of the day. During each observation, the number of times each resident manifested each of 20 identified agitated behaviors was recorded. Presence or absence of restraints during each observation was also recorded. To determine the relationship between agitation and use of restraints, the frequency of each agitated behavior and the total number of agitated behaviors exhibited by each resident were examined during the following four conditions: (1) unrestrained (excluding the hour preceding the application of restraints); (2) unrestrained during the hour preceding the use of restraints; (3) restrained during the
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hour immediately following restraint use; and (4) restrained (excluding the aforementioned hour). An analysis of variance (ANOVA) indicated that significantly more strange movements (F = 2.78, P < .05), strange noises (F = 5.40, P < .Ol), and total agitated behaviors (F = 4.89, P < .Ol) were manifested when residents were restrained as compared with when they were not restrained. Higher rates of agitated behaviors were observed immediately after application of restraints but not immediately before application. This study suggests that use of restraints may contribute to agitated behavior rather than decrease agitated behavior. Haller, Binder, and McNiel (1989) investigated the prevalence of violence in 52 geriatric subjects during acute psychiatric hospitalization. All subjects had a primary diagnosis of senile dementia according to the international Classification of Diseases (1984). A retrospective chart review showed that 44% of the subjects were involved in violent behavior 2 weeks before admission and 29% exhibited violent behavior within 72 hours of admission. Violent behavior was described as attacks on person, attacks on objects, threats to attack persons, and verbal attacks on persons. Two weeks before admission, 23.1% (n = 12) physically attacked others and 21.3% (n = 11) manifested fear-inducing behavior (verbal attacks, threats to attack, or attacks on objects). Within the first 72 hours of admission, 9.6% (n = 5) of subjects physically attacked others and 19.2% (n = 10) exhibited fear-inducing behavior. Subjects who had lived with their family before admission were more likely to be violent. No significant correlation was found between violence and sex, social class, or ethnic group. Jackson, Drugovich, Fretwell, Spector, Stemberg, and Rosenstein (1989) examined disruptive behavior in 3,35 1 randomly selected nursing home residents from 103 facilities in Rhode Island. Data were collected through interviews, chart reviews, reports from staff, and observation by interviewers. Disruptive behavior recorded was noisiness, abusiveness, wandering, and other (disrobing, stealing, resistance to care, inability to avoid simple dangers). The length-of-observation periods were not reported. Correlates of disruptive behavior studied included age, sex, ADLs, mobility, communication, continence, cognitive impairment, and disruptive behavior. The Katz and Akporn Index of ADLs (Katz & Akpom, 1976) mea-
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sured the ADLs. Mobility was defined as the ability to walk 20 yards or more. Communication referred to ability to communicate coherently with or without difficulty. Cognitive impairment was determined by the SPMSQ (Pfeiffer, 1975). A x2 indicated significantly more disruptive behavior (P < .05) among residents who were older, more dependent in ADLs, nonambulatory, impaired in communication, incontinent, and more severely cognitively impaired. No significant differences were detected by sex when total disruptive behaviors were examined. However, a separate analysis of behaviors indicated a prevalence of noisiness in women (10.7% v 8.0%) and abusiveness in men (16.8% v 10.1%). Highest rates of disruptive behavior were associated with moderate-to-severe cognitive impairment. Cohen-Mansfield, Marx, and Rosenthal (1989) examined the agitated behaviors of 408 residents of a long-term facility. The Cohen-Mansfield Agitation Inventory ([CMAI] Cohen-Mansfield, 1986) measured agitated behaviors. The charge nurse of day, evening, and night shifts rated each resident independently to provide a measurement of agitated behaviors across a 24-hour period. Factor analysis showed three factors of agitation: aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. Frequency of agitated behaviors decreased significantly from day to evening to night (P < ,lO). Most manifestations of particular types of agitated behaviors correlated significantly across shifts as determined by Pearson correlation (77 of 87 correlations reached statistical significance at or above the .05 level). This suggests that participants were likely to manifest the same behaviors across shifts. Using the same subjects mentioned above, Cohen-Mansfield and Marx (1989) used observation and interview to examine the three syndromes of agitation (aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior) for their relationship to three aspects of past personality (previous mental disorders, exposure to stress, and leisure habits). The relationship between manifestation of agitated behaviors before nursing home entry and occurrence of agitation within the nursing home was also examined. Stress was measured using an adaptation of the Holmes and Rahe’s Social Readjustment Scale (Muhlenkamp, Gress, & Flood, 1975), Rahe’s Recent Life
BECK, ROSSBY, AND BALDWIN
Changes Questionnaire (Holmes & Rahe, 1967), the Life Crises History (Rahe, 1975), and the Life Events Questionnaire (Center for the Study of Neuroses, 1980). Preference for leisure habits was measured using a modification of Gordon, Gaitz, and Scott’s Intensity of Expressive Social and Leisure Activity Scale (1976). Past mental disorders were determined by interviewing significant others who were asked to respond to items based on the classifications of the Diagnostic and Statistical Manual of Mental Disorders, Revised ([DSM-IIIR] American Psychiatric Association, 1988). Family and friends were interviewed to determine the resident’s agitated behaviors before entry into the nursing home. Results showed no significant correlation between categories of leisure habits and measures of agitation. No significant correlation was found between history of mental disorder and agitation. A greater total number of agitated behaviors were manifested by residents who had experienced the stressors of (1) separation from a spouse (t = 3.05, P < .Ol), (2) life-threatening situations (t = 2.16, P < .05), (3) retirement (t = 2.10, P < .Ol), (4) financial problems (t = 3.56, P < .Ol) or (5) immigration (t = 2.66, P < .Ol) than residents without these experiences. However, residents who had experienced the stress of relocation at least once before nursing home entry exhibited fewer total agitated behaviors than did residents who had not relocated (t = - 2.80, P < .Ol). More aggressive behavior was shown by those residents who had never relocated (t = - 2.97, P < .Ol). More aggressive behavior was also displayed by those who had experienced financial problems (t = 2.43, P < .05). Those who had relocated manifested fewer physically nonaggressive behavior (t = - 1.99, P < .05). Results also indicated that agitation before nursing home entry is highly related to agitated behavior within the nursing home. Marx, Cohen-Mansfield, and Werner ( 1990) used observation to examine the three dimensions of agitation (aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior) in relation to the occurrence of falls in the same 408 residents. Residents who fell exhibited a greater total number of agitated behavior than those who did not fall (r = 15.01 v. r = 8.07, F score = 42.81, P < .Ol). They also exhibited significantly more behaviors from each dimension
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of agitated behaviors than residents who did not fall. The relationship between agitation and sleep disturbances was also studied through observation by Cohen-Mansfield and Marx (1990) with the same sample group. The CMAI (CohenMansfield, 1986) measured agitation. Total hours of sleep, length of time needed to fall asleep, frequency of awakenings, length of average wakeful period, the hour that each resident woke up in the morning, and external disruptions of night sleep were recorded by a nurse. Agitation and sleep ratings were completed within a 2-week period to provide a consistent view of each resident. Pearson correlation coefficients indicated that an overall lack of sleep and interruptions of sleep are related to the amount and type of agitation manifested during the day. Physically nonaggressive behavior and aggressive behavior were linked with increasing time needed to fall asleep and external disruptions. Physically nonaggressive behavior was associated with frequent awakenings by the resident. Verbally agitated residents awoke frequently on their own at night, had fewer hours of sleep, and were awake very early in the morning. External disruptions of sleep and length of awake periods (r = .64, .19, respectively; P < .Ol) were significantly correlated to cognitive impairment. Multiple regressions indicated that sleep disturbances were independently and modestly related to agitation. Cohen-Mansfield, Marx, and Rosenthal ( 1990) conducted additional research on this same population to determine the relationships between agitated behaviors and the independent variables of dementia, cognitive impairment, and impaired ADL functioning. For each subject, a hypothetical diagnosis of dementia was determined by a review of medical records, then presented for confirmation by a physician. Nursing staff and social workers rated agitation using the CMAI (CohenMansfield, 1986). Cognitive impairment was measured using a modified version of the Brief Cognitive Rating Scale ([BCRS] Reisberg, Scheneck, Ferris, Schwartz, & de Leon, 1983). Six items (eating, walking, bathing, dressing, toileting, and grooming) from the Rapid Disability Rating Scale-2 ([RDRS-21 Linn & Linn, 1983) were used to measure impaired ADL functioning. Cognitive impairment was significantly corre-
lated with ratings both by nursing staff (N) and social workers (SWs) for the total number of agitated behaviors (r = .37 for N; r = .40 for SWs), aggressive behaviors (r = .22 for N; r = .26 for SWs), physically nonaggressive behaviors (r = .37, .40 respectively), and verbally aggressive behaviors (r = - .09, - .13 respectively, all P < .Ol). No significant correlation was found between cognitive impairment and hiding/hoarding behaviors. Stepwise regressions were estimated for each measure of agitation on the independent variables of cognitive impairment, ADL impairment, and dementia. Cognitive impairment and ADL impairment explained 37% of the variance in physically nonaggressive behaviors (e.g., pacing). Cognitive impairment and ADL impairment also explained 7% of the variance in verbally agitated behavior. Cognitive impairment was the only variable to explain the variance of aggressive behaviors (positive quadratic term; R2 = .07), whereas ADL impairment provided the best explanation of hiding and hoarding behavior (negative quadratic term; R2 = .Ol). This study indicates that aggressive and physically nonaggressive manifestations of agitation are strongly related to cognitive impairment, while verbal agitation and hiding/hoarding are not. A sample of 213 community-based, demented elderly and their 213 caregivers were studied by Hamel, Gold, Andres, Reis, Dastoor, Grauer, and Bergman (1990). Observation, interviews, and questionnaires were used to obtain data. Subjects had a diagnosis of a progressive dementia disorder for at least 1 year, and had no additional lifethreatening or immobilizing illnesses. The Hierarchic Dementia Scale (Dastoor & Cole, 1983) indicated that the majority of subjects were moderately impaired. The RAS forms 1 and 2 (Ryden, 1988a, 1988b) were used to determine the nature, frequency, and context of aggressive behavior. The General Health Questionnaire (Goldberg, 1978) determined physical and psychological health of the caregiver. The Burden Interview (Zarit, Orr, & Zarit, 1985) measured the degree of burden perceived by the caregiver. The Memory and Behavior Problem Checklist (Zarit, Grr, & Zarit, 1985) assessed frequency of problems reported in demented patients, as well as caregiver reactions. The Social Interaction Questionnaire (Gilleard, Belford, Gilleard, Whittick, & Gledhill, 1984)
BECK, ROSSBY, AND BALDWIN
286
Table 1. Summary
Author/Date Zimmer, Watson,
of Literature Review on Correlates of Disruptive Behavior
Sample
Method of
Type of
Characteristics.1
Data
Behavior
Size
Collection
Studied
Nursing home
and Treat
residents
(1984)
(n = 1,139)
Review of
Correlates of Disruptive Behavior Studied
Behavioral
Cognitive status
Findings Cognitive impairment
in
utilization
problems
psychotropic drug
81.4% of behavioral
review
(behavior that
use, physical
problem residents;
forms
required active
restraint use,
psychotropic drug use
or constant
depression
consideration
in 58% of serious behavior residents;
in care
restraint use in 46.2%
planning)
of behavior problem residents; depression in 9% of residents with serious behavioral problems
Winger, Schirm,
Nursing home
Interviews
Aggression
Cognitive status,
Aggressive residents did
and Stewart
residents, R age
and
(endangering
functional ability,
less well on MSQ;
(1987)
= 69 fn = 43),
observations
others,
age, length of stay,
nursing home resi-
and interme-
endangering
perceived control
diate care
self, and
residents, X age
disturbing)
dents with decreased functional ability demonstrated
more
serious behavioral
= 64 (n = 58)
problems; older nursing home residents exhibited more aggressive behavior; aggressive residents had longer lengths of stay; no significant correlation between perceived control and aggression Meddaugh
(1987)
Unclear sensorium in all
Chart and
Aggression
residents, X age
incident
(abusive)
= 85 (n = 72)
report
social support
impaired functional
review
network, gender,
ability in all abusive
age
residents; abusive
Nursing home
Cognitive status, functional ability,
abuse incidents;
incidents occurred in 30% of residents who received less than weekly visits; 11% receiving at least weekly visits; women abusers, 11%; men abusers, 30%; abusers < 85, 15.8%; abusers 1 85, 11.8% Nilsson,
Psychogeriatric,
Observations
Age, length of
Aggression (no
Age significantly related
Palmstierna,
long-term in-
definition
hospitalization,
to aggression fre-
and Wistedt
patients, 38
provided)
gender
quency; length of stay
(1988)
with marked
significantly related to
cognitive
degree of aggression;
impairment
no significant
(n = 40)
correlation between gender and frequency or degree of aggression (Continued
on following
page)
287
DISRUPTIVE BEHAVIOR IN ELDERLY
Table 1. (continuedd)
Author/Date Ryden,
Sample
Method of
Type of
Characteristics/
Data
Behavior
Size
Collection
Studied
Cognitively
Observations
Aggression
Correlates of Disruptive Behavior Findings
Studied Cognitive status,
No significant corre-
Bossenmaier,
impaired
(physical,
functional ability,
lation between
and McLachlan
nursing home
verbal, sexual)
psychotropic drug
aggression and mental
(1989)
residents
(physical,
use, physical
status or between
(n = 124)
50.8%; verbal,
restraint use
aggression and
47.6%; sexual,
functional ability;
4.0%)
significantly higher aggression scores in residents receiving psychotropic drugs; physical restraints used in 60.5% of residents studied; no significant correlation between aggression and restraint use
Werner, Cohen-
Long-term care
Observation
Agitation
Physical restraint
Significantly more total
Mansfield,
residents with
(aggressive,
Braun, and
high levels of
physically
manifested when
Marx (1989)
cognitive im-
nonaggressive
residents were
pairment
and verbally
restrained as
(n = 24)
nonaggressive)
compared with when
use
agitation was
they were not restrained Haller, Binder,
Psychiatric in-
Chart review
Violent (attacks
Gender, social class,
No significant corre-
and McNeil
patients with
person or
ethnic group, living
lation between
(1989)
senile dementia
objects,
with family
violence and sex,
fn = 52)
threatens to
social class and ethnic
attack, verbal
group; significant
attack)
correlation between living with family and violence
Jackson et al. (1989)
Nursing home
Interviews,
Disruptive
Cognitive status,
Disruptive behavior was
residents
chart
behavior
functional ability,
more prevalent in
fn = 3,351)
reviews,
(noisiness,
continence,
residents who were
staff
abusiveness,
communication,
more severely
reports,
wandering)
age, sex
cognitively impaired,
observations
were more functionally impaired, nonambulatory, incontinent, and had impaired communication: disruptive behavior increased with age; significantly higher prevalence of noisiness in women and abusiveness in men
(Continued on following pagel
288
BECK, ROSSBY, AND BALDWIN
Table 1. (continuedl
Author/Date Cohen-Mansfield,
Sample
Method of
Type of
Characteristics/
Data
Behavior
Size
Collection
Studied
Nursing home
Observations
Agitation
Correlates of Disruptive Behavior Studied Time of day
Findings Agitation frequency
Marx, and
residents
and
(aggressive
significantly decreased
Rosenthal
In = 408)
interviews
physically
from day to night;
(1989)
nonaggressive,
particular types of
and verbally
agitation correlated
agitated)
significantly across shifts
Cohen-Mansfield
Nursing home
Observations
Agitation
Premorbid
Premorbid agitation was
and Marx
residents
and
(aggressive,
(1989)
In = 408)
interviews
physically
with agitation in the
nonaggressive,
nursing home
personality
positively correlated
and verbally agitated) Marx, Cohen-
Nursing home
Observations
Agitation
Falls
Residents who fell had
Mansfield, and
residents
(aggressive,
greater total number
Werner (1990)
(n = 408)
physically
of agitated behaviors
nonaggressive, and verbally agitated) Cohen-Mansfield,
Nursing home
Observations
Agitation
Sleep patterns
Overall lack of sleep and
and Marx
residents
and
(aggressive,
(1990)
(n = 408)
interviews
physically
related to the amount
nonaggressive,
and type of agitation
interruptions of sleep
and verbally agitated) Cohen-Mansfield,
Nursing home
Observations
Agitation
Cognitive status
Residents with severe
Marx, and
residents
(aggressive.
Rosenthal
(n = 408)
physically
and moderate-to-
nonaggressive,
severe functional
verbally
impairment
agitated,
a greater total number
hiding, and
of agitated behaviors
hoarding)
and physically
(1990)
functional ability
cognitive impairment
exhibited
nonaggressive agitation Hamel et al. (1990)
Community-
Observations,
Aggression
Social support
A more troubled
based
interviews
(physical,
network,
premorbid
dementia
and ques-
verbal, sexual)
permorbid
caregiverisubject
subjects
tionnaires
(physical,
personality
(n = 213)
relationship and
34.1%) (verbal,
premorbid aggression
51 .O%) (sexual,
significantly predicted
7.2%)
current subject aggression
measured the quality of the relationship between caregiver and subject before onset of illness. The NE0 Personality Inventory (Costa & McCrae, 1985) measured caregiver neuroticism (defined as emotional overreactivity and lability). Subjects reacted with aggression most often when given instructions to do something. Premorbid aggression was reported for 9.6% of the subjects. Feeling angry but not responding in an ag-
gressive manner was reported by 10.11% of the caregivers. Caregiver aggressive reactions were reported at 10.6%. A multiple regression analysis determined that the predictors of aggressive behavior in dementia subjects, accounting for 25.42% of the variance in total aggression scores (F = 5.35, P < .OOOl), were premorbid aggression, greater frequency in behavior and memory problems, and a more troubled premorbid relationship between
DISRWTIVE
BEHAVIOR
IN ELDERLY
caregiver and subject. Level of cognitive impairment did not predict aggression. No caregiver demographic or personality characteristics predicted aggression scores. SUMMARY
This review of literature shows that the elderly in long-term care facilities demonstrate behavior considered to be disruptive. In the studies reviewed, average prevalence of reported disruptive behavior among a total of 5,650 subjects was 42.8%. Precise comparative analysis of studies is not possible due to the variety of instruments used and lack of uniformity of terms. Furthermore, a limited number of correlates is investigated in each study. Several studies have linked disruptive behavior with cognitive impairment (Cohen-Mansfield, Marx, & Rosenthal, 1990; Jackson et al., 1989; Winger, Schirm, 8z Stewart, 1987; Zimmer, Watson, & Treat, 1984) and functional dependency (Cohen-Mansfield, Marx, & Rosenthal, 1990; Jackson et al., 1989; Meddaugh, 1987). However, one study (Ryden, Bossenmaier, & McLachlan, 1989) did not support the relationship of functional dependency to aggression. Sex was associated with disruptive behavior in one study (Jackson et al., 1989), though two studies found no significant relationship between sex and disruptive behavior (Haller, Binder, & McNeil, 1989; Nilsson, Palmstiema, & Wistedt, 1988). Premorbid personality, (Cohen-Mansfield & Marx, 1989; Hamel et al., 1990) and age (Jackson et al., 1989; Nilsson, Palmstiema, & Wistedt, 1988) are additional factors with reported relationships to disruptive behaviors. Physical restraint use was significantly related to disruptive behavior by Werner, CohenMansfield, Braun, and Marx (1989), though Ryden, Bossenmaier, and McLachlan (1989) found no significant relationship. An individual’s social support network has been associated with disruptive behaviors (Hamel et al., 1990; Meddaugh, 1987), as have length of hospitalization (Nilsson, Palmstiema, & Wistedt, 1988), psychotropic drug use (Ryden, Bossenmaier, & McLachlan, 1989), falls (Marx, Cohen-Mansfield, & Werner, 1990), sleep pattern (Cohen-Mansfield & Marx, 1990), living with family (Haller, Binder, & McNeil, 1989), time of day (Cohen-Mansfield, Marx, & Rosenthal, 1989), and communication and
289
incontinence (Jackson et al., 1989). Perceived control (Winger, Schirm, & Stewart, 1987), as well as social class and ethnic group (Haller, Binder, & McNeil, 1989) have not been found to be associated with disruptive behavior. A summary of the relationship of these biopsychosocial correlates to disruptive behavior is presented in Table 2. The finding that most disruptive behaviors seem to occur during the day and during assistance with ADLs (Cohen-Mansfield, Marx, & Rosenthal, 1989; Nilsson, Palmstiema, & Wistedt, 1988; Ryden, Bossenmaier, & McLachlan, 1989) has important implications for development of nursing interventions. These findings were not contradicted by other studies. In light of findings correlating increased agitation/aggression with drug and restraint use (Ryden, Bossenmaier, & McLachlan, 1989; Werner, Cohen-Mansfield, Braun, & Marx, 1989), experimental research that focuses on (1) nurse/resident relationship and (2) effectiveness of nursing interventions other than administration of drugs and restraints seems a plausible recommendation. Increased disruption during the day and during assistance with ADLs (Cohen-Mansfield, Marx, & Rosenthal, 1989; Nilsson, Palmstiema, & Wistedt, 1988; Ryden, Bossenmaier & McLachlan, 1989) suggests that further investigation is needed. Research that examines (1) interventions designed to decrease anxiety/frustration during ADL activities (2) effect of low versus high daytime staff/resident ratio on disruptive behaviors, and (3) staff perception of disruptive behavior in relation to frequency of occurrence is recommended. Studies that rely on chart reviews and/or reports from staff for data related to disruptive behavior leave many questions about the nature, context, and accuracy of reported events. More observation-based, qualitative studies in which observed behaviors are fully described within the context of occurrence are recommended. These studies could include: (1) a consistent definition of disruptive behavior, (2) use of the same instruments for measures of behavior and its correlates, and (3) description of precedent and/or antecedent nursing interactions as integral elements of the occurrence. Such research would contribute a more specific understanding of types of disruptive behavior in the cognitively impaired elderly resident and would also contribute to the development of meaningful interventions for management of the disturbed demented resident.
290
BECK, ROSSBY, AND BALDWIN
Table 2. Correlates and Their Ralationship to Disruptive Behavior Related to Disruptive Behavior?
Correlate Studied Cognitive status
Functional ability
Sex
Premorbid personality
Age Restraint use
Author/Date
Yes
Jackson et al. (1989)
Yes
Cohen-Mansfield,
No
Ryden, Bossenmaier, and McLachlan (1989)
Marx, and Rosenthal (1990)
Yes
Meddaugh
Yes
Jackson et al. (1989)
Yes
Cohen-Mansfield.
No
Ryden, Bossenmaier,
Yes
Jackson et al. (1989)
(1987) Marx, and Rosenthal (1990) and McLachlan (1989)
No
Nilsson, Palmstierna, and Wistedt (1988)
No
Hailer, Binder, and McNeil (1989)
Yes
Cohen-Mansfield
Yes
Hamel et al. (1990)
Yes
Jackson et al. (1989)
and Marx (1989)
Yes
Nilsson, Palmstierna, and Wistedt (1988)
Yes
Werner, Cohen-Mansfield,
No
Ryden, Bossenmaier,
Braun, and Marx (1989)
and McLachlan (1989)
Social support network
Yes
Hamel et al. (1990)
Length of hospitalization
Yes
Nilsson, Palmstierna, and Wistedt (1988)
Psychotropic drug use
Yes
Ryden, Bossenmaier, and McLachlen (1989)
Falls
Yes
Marx, Cohen-Mansfield,
Sleep pattern
Yes
Cohen-Mansfield
Communication
Yes
Jackson et al. (1989)
Incontinence
Yes
Jackson et al. (1989)
Living with family
Yes
Haller, Binder, and McNeil (1989)
Time of day
Yes
Cohen-Mansfield,
Perceived control
No
Winger, Schirm, and Stewart (1987)
Social class
No
Haller, Binder, and McNeil (1989)
Ethnic group
No
Haller, Binder, and McNeil (1989)
REFERENCES American Psychiatric Association. 1988. D&gnostic and stntistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Center for the Study of Neuroses, University of California, San Francisco. (1980). Life Events Questionnaire--Short Form. Cohen-Mansfield, J. (1986). Agitated behaviors in the elderly II. Preliminary results in the cognitively deteriorated. Journal of the American Geriatrics Society, 34, 122121.
Cohen-Mansfield, J., & Marx, M. (1989). Do past experiences predict agitation in nursing home residents? Intertartional Journal of Aging and Human Development, 28(4), 285-294.
Cohen-Mansfield, J., between sleep home. Journal Cohen-Mansfield, J., description of
& Marx, M. (1990). The relationship disturbances and agitation in a nursing of Aging and Health, 2(l), 42-57.
Marx, M., & Rosenthal, A. (1989). A agitation in a nursing home. Journal of
Gerontology, 44(3), Mll-84.
Cohen-Mansfield, J., Marx, MS., & Rosenthal, A.S. (1990). Dementia and agitation in nursing home residents: How are they related? Psychology and Aging, 5(l), 3-8. Cospito, E., & Gift, T. (1982). Assaultive patients in a chronic
and Werner (1990)
and Marx (1990)
Marx, and Rosenthal (1989)
care medical facility. Journal of Psychiatric Treatment and Evaluation, 4(5), 433-436.
Costa, P.T., & McCrae, R.R. (1985). The NE0 Personality Inventory. Odessa, FL: Psychosocial Assessment Resources. Dastoor, D.P., & Cole, M.G. (1983). Hierarchic Dementia Scale. Journal of Clinical and Experimental Gerontology, 5(3), 219-234.
Ebcrsole, P. (1989). Caringfor thepsychogeriutric client. New York, NY: Springer. Gilleard, C.J., Belford, H., Gilleard, E., Whittick, J.E., & Gledhill, K. (1984). Emotional distress among the supporters of the elderly mentally infirm. British Journul of Psychiatty, 145. 12-177.
Goldberg, D.P. (1978). Manual of the general health questionnaire. Windsor, Ontario, Canada: Nelson. Gordon, C., Gaits, C.M., & Scott, J. (1976). Leisure and lives: Personal expressivity across the life span. In R.H. Binstock & E. Shanas @is.), The handbook of aging and sociul sciences. New York, NY: Van Nostrand Reinhold. Haller, E., Binder, R., & McNiel, D.E. (1989). Violence in geriatric patients with dementia. Bulletin of American Academy of Psychiatry and the Law, 17(2), 183-188. Hamel, M., Gold, D.P., Andre% D., Reis, M., Dastoor, D., Grauer, H., &Bergman, H. (1990). Predictors and con-
291
DISRUPTIVE BEHAVIOR IN ELDERLY
sequences of aggressive behavior by community-based dementia patients. The Geronrologisr, 30(2), 206-211. Holmes, T.H., & Rahe, R.H. (1967). The Social Readjustment Scale. Journal of Psychosomatic Research, 11 I 213-
Rahe, R.H. (1975). Epidemiological studies of life changes and illness. International Journal of Psychiatry Medicine. 6, 133-146.
218. International
patients. Journal of the American Geriatrics Society, 23, 433-441.
Classification
of Diseases,
(9th ed., Rev.)
(1984). New York, NY: Revisionist. Jackson, M.E., Drugovich, M.L., Fretwell, M.D., Spector, W.D., Stemberg, J., & Rosenstein, R.B. (1989). Prevalence and correlates of disruptive behavior in the nursing home. Journal of Aging and Health, l(3), 349-369. Katz, S., & Akpom, C.A. (1976). A measure of sociobiological function. International Journal of Health Services, 6, 493408.
Linn. M.W., & Limr, B.S. (1983). Assessing activities of daily living. In T. Crook, S. Ferris, & R. Bartus (Eds.), Geriatric psychopharmacology (pp. 97-109). New Canaan, CT: Powley. Marx, M., Cohen-Mansfield, J., & Werner, P. (1990). Agitation and falls in institutionalized elderly persons. The Journal of Applied Gerontology, 9(l), 106-l 17. Meddaugh, D.I. (1987). Staff abuse by the nursing home patient. The Clinical Gerontologist, 6. 45-47. Muhlenkamp, A., Gress, L.D., & Flood, M.A. (1975). Perception of life change events by the elderly. Nursing Research, 2, 109-l 13.
Nilsson, K., Palmstiema, T., & Wistedt, B. (1988). Aggressive behavior in hospitalized psychogeriatric patients. Acta Psychiatrica Scandinavia, 78(2), 172-175.
Palmstiema, T., & Wistedt, B. (1987). Staff observation aggression scale (SOAS), presentation and evaluation. Acta Psychiatrica Scandinavia, 76. 657-663.
Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly
Reisberg, B., S&neck, M.K., Ferris, S.H., Schwartz, G.E., & de Leon, M.J. (1983). The Brief Cognitive Rating Scale (BCRS): Findings in primary degenerative dementia (PDD). Psychopharmacology Bulletin, 19, 47-50. Ryden, M. (1988a). Aggressive behavior in persons with dementia who live in the community. Alzheimer’s Disease and Associated Disorders, 2. 342-355.
Ryden, M. (1988b, November). Aggressive behavior in cognitively impaired nursing home residents. Paper presented at the Annual Scientific Meeting of the Gerontological Society of America, San Francisco, CA. Ryden, M., Bossenmaier, M., & McLachlan, C. (1989). Aggressive behavior in cognitively impaired nursing home residents. Manuscript submitted for publication. Walsh, J.S., Welch, H.G., & Larson, E.B. (1990). Survival of outpatients with Alzheimer-type dementia. Annals of Internal Medicine, 113, 429-434.
Werner, P., Cohen-Mansfield, J., Braun, J., & Marx. M. (1989). Physical restraints and agitation in nursing home residents. Journal of the American Geriatrics Society, 37. 1122-1126. Winger, J., Schirm, V., L Stewart, D. (1987). Aggressive behavior in long-term care. Journal of Psychosocial Nursing, 25, 28-33.
Zarit, S.H., Orr, N.K.. & Zarit, J.M. (1985). The hidden victims of Alzheimer’s disease. New York, NY: New York
University. Zimmer, J., Watson, N., &Treat, A. (1984). Behavioral problems among patients in skilled nursing facilities. American Journal of Public Health, 74, 1118-l 121.
Disruptive behavior, resulting in negative consequences for both residents and caregivers, occurs in a large proportion of the nursing home population. This review of literature surveys studies that describe disruptive behavior and the correlates of this behavior in the cognitively impaired elderly. In the studies reviewed. the average prevalence of reported disruptive behavior among a total of 5,650 subjects was 42.8%. Correlates most frequently linked with disruptive behavior include cognitive status, functional ability, age, and premorbid personality. Suggestions for future research are discussed.
Copyright
B
0 1991 by W.B. Saunders
EHAVIORAL problems in long-term care facilities for the elderly are pervasive. Behavior categorized as disruptive, aggressive, or agitated is often compounded by coexisting cognitive impairment. Management of residents exhibiting these types of behavior is an escalating problem as the elderly population continues to grow (CohenMansfield, Marx, & Rosenthal, 1990; Cospito & Gift, 1982; Jackson, Drugovich, Fretwell, Spector, Stemberg, & Rosenstein, 1989; Ryden, Bossenmaier, & McLachlan, 1989; Winger, Schirm, & Stewart, 1987, 1989). The critical nature of this problem is addressed in a recent study in which both the severity of dementia and the presence of behavioral problems were found to be significantly related to shorter survival time in 126 subjects diagnosed with Alzheimer’s-type dementia (Walsh, Welch, & Larson, 1990). Behavioral problems among cognitively impaired nursing home residents have not been clearly defined or adequately studied, and knowledge about the distribution of these problems is limited (Ebersole, 1989). Expansion and clarification of existing knowledge is a prerequisite for understanding disruptive behavior in the cognitively impaired elderly. Empirically based nursing interventions directed toward the prediction, prevention, and control of this behavior are needed. The following review of literature describes
Company
studies on disruptive behavior of the institutionalized elderly. Most studies report incidence and describe two or more correlates. However, the correlates and definitions of disruptive behavior vary widely. Some studies limit the definition to types of aggressive behavior; others broadly define disruptive behavior and include incontinence. In addition, the studies use a variety of instruments to measure both disruptive behavior and its correlates. Therefore, an accurate comparison of these studies is difficult. The studies reviewed will be described individually; Table 1 summarizes correlates of types of disruptive behavior and findings presented in the studies. DESCRIPTION OF STUDIES
In a random sample of 1,139 subjects from 42 skilled nursing facilities, Zimmer, Watson, and
From the College of Nursing and Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock; the Baptist Rehabilitation Institute, Little Rock, AR; and the School of Nursing, University of Ma yland Baltimore. Address reprint requests to Comelia Beck, Ph.D., R.N., Professor and Associate Dean for Research and Evaluation, College of Nursing, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 529, Little Rock, AR 72205. Copyright 0 1991 by W.B. Saunders Company 0883-9417l91/0505-0006$3.00oal0
Archives of Psychiatric Nursing, Vol. V, No. 5 (October), 1991: pp. 281-291
281
282
Treat (1984) gathered data from the most recent routine utilization review forms. They found that 64.2% had significant behavioral problems (behavior that required constant or active consideration in care planning or that occurred more often than once a week). These types of behavior included confusion, agitation, hallucinations, depression, assaultiveness, abusiveness, regression, and wandering. Significant behavioral problems were divided into moderate (41.6%) and serious (22.6%) behavioral problems. Moderate problems consisted of impaired judgment or physical restraint orders, or both. Serious problems included aggressiveness, physical resistance to care, and uncontrolled wandering. These types of behavior endangered others or self, disturbed others, or concerned staff (i.e., refusing to socialize, hoarding, etc.). Cognitive impairment existed in 81.4% of subjects with behavioral problems. Restraints were used for 46.2% of these subjects. Psychoactive drugs were used regularly to treat 58% of subjects with serious behavioral problems and depression was diagnosed in 9% of these subjects. No report of psychoactive drug use or depression was given for subjects in the moderate behavioral problem group. Winger, Schirm, and Stewart (1987) studied 101 residents of a Veterans Administration Medical Center (43 subjects from a nursing home unit and 58 subjects from an intermediate, long-term care unit). Investigators obtained data through interview and observation. A behavioral inventory was constructed to determine the presence of aggressive behavior. The Katz Index of Activities of Daily Living (ADL) (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963) evaluated functional status. Chang’s Situational Control of Daily Activities (Chang, 1978) measured perceived control. Significantly more aggressive behavior was reported for the nursing home group than for the intermediate care group. Aggressive subjects had longer lengths of stay and perceived that they had less control over situational activities than did nonaggressive subjects, though this relationship did not reach significance. In both intermediate and nursing home subjects, the more serious the type of behavior, the lower the score on the Mental Status Questionnaire (Kahn, Goldfarb, Pollock, & Peck, 1960). Furthermore, most of the types of behavior that were dangerous to self (refusal of directions, food, medication, or treatment) or oth-
BECK, ROSSBY, AND BALDWIN
ers (harming or attempting to harm others or breaking objects) occurred in combination with disturbing behavior (shouting, sarcasm, anger, irritation, and impatience), indicating that disturbing behavior may signal endangering behavior. Meddaugh (1987) reviewed chart and incident reports to investigate aggressive behavior in a skilled nursing facility (n = 72). Twenty-six staff members (26.8%) were abused one to two times in a 3-month period. More incidents of aggression occurred during the day and evening shifts. All aggressors (1 l%, women; 30%) men) had cognitive impairment and needed assistance in ADLs. This retrospective study included no observation of caregiver-resident interaction and no information providing the context within which these incidents occurred. Missing data from incident reports and residents’ charts further limited the study. Nilsson, Palmstiema, and Wistedt (1988) observed 40 psychogeriatric patients in two longterm wards of a Swedish hospital. This descriptive study documented characteristics and frequencies of aggressive behavior within a 6-week period. The sample consisted of nine men (mean age, 80.6 years) and 3 1 women (mean age, 8 1.7 years). Admission length ranged from 1 to 46 months (mean, 24.1 months). Diagnoses, according to the Znternational Classification of Diseases (1969), showed marked cognitive impairment in 38 subjects (34 with dementia, four with chronic schizophrenia) and unspecified chronic psychosis in two subjects. The Staff Observation Aggression Scale developed by Palmstiema and Wistedt (1987), measured frequency and severity of behaviors. Results of this investigation indicated that aggression was primarily aimed at staff (88%). Most incidents (75%) occurred during assistance with ADLs. Correlates of age, length of hospitalization, and gender were examined in relation to frequency and degree of aggression. Multiple regression indicated that age was significantly related to frequency of aggression (0.36; coefficient of determination = 0.14, df = 38, P < .05) while length of hospitalization was significantly related to degree of aggression (0.43; coefficient of determination = 0.20, df = 25, P < .05). Ryden , Bossenmaier , and McLachlan ( 1989) studied 124 residents in four nursing homes, on units for the cognitively impaired, during a 7-day period. Data collection included observation and documentation of behavior as well as medical rec-
DISRUPTIVE
BEHAVIOR
IN ELDERLY
ord reviews for diagnosis, drug usage, social, and health history data. ADL dependency was determined from quality-assurance assessments completed by nursing home staff. The Ryden Aggression Scale ([RAS] Ryden, 1988) was used to measure incidents of aggression. Fifty-one percent of observed aggression was physical, 48% was verbal, and 4% was sexual. No significant difference was found between men and women in incidents of aggression. Residents receiving psychotropic drugs had significantly higher aggression scores than those not receiving drugs. Most aggressive behaviors occurred during the day. No significant relationship was found between aggression scores and Short Portable Mental Status Questionnaire ([SPMSQ] Duke University, 1978) scores. This may have been due to the limited range of scores (79% of all subjects were categorized as severely impaired, according to the SPMSQ). ADL dependency scores and aggression scores showed no significant relationship. Limitations of this study included missing data in medical records and staff inexperience in using the Ryden Aggression Scale (1988a). A study to determine whether use of restraints in nursing home residents decreases or increases agitation was conducted by Werner, CohenMansfield, Braun, and Marx (1989). Twenty-four residents from three units of a 550-bed, long-term care facility were observed during this study. Participants were chosen on the basis of a high level of agitation and cognitive impairment. The CohenMansfield Agitation Instrument (CohenMansfield, 1986) assessed agitation and the Brief Cognitive Rating Scale (Reisberg, Schneck, Ferris, Schwartz, & de Leon, 1983) assessed cognitive impairment. During a 3-month period, 1,000 3-minute observations of each resident were obtained during all 24 hours of the day. During each observation, the number of times each resident manifested each of 20 identified agitated behaviors was recorded. Presence or absence of restraints during each observation was also recorded. To determine the relationship between agitation and use of restraints, the frequency of each agitated behavior and the total number of agitated behaviors exhibited by each resident were examined during the following four conditions: (1) unrestrained (excluding the hour preceding the application of restraints); (2) unrestrained during the hour preceding the use of restraints; (3) restrained during the
283
hour immediately following restraint use; and (4) restrained (excluding the aforementioned hour). An analysis of variance (ANOVA) indicated that significantly more strange movements (F = 2.78, P < .05), strange noises (F = 5.40, P < .Ol), and total agitated behaviors (F = 4.89, P < .Ol) were manifested when residents were restrained as compared with when they were not restrained. Higher rates of agitated behaviors were observed immediately after application of restraints but not immediately before application. This study suggests that use of restraints may contribute to agitated behavior rather than decrease agitated behavior. Haller, Binder, and McNiel (1989) investigated the prevalence of violence in 52 geriatric subjects during acute psychiatric hospitalization. All subjects had a primary diagnosis of senile dementia according to the international Classification of Diseases (1984). A retrospective chart review showed that 44% of the subjects were involved in violent behavior 2 weeks before admission and 29% exhibited violent behavior within 72 hours of admission. Violent behavior was described as attacks on person, attacks on objects, threats to attack persons, and verbal attacks on persons. Two weeks before admission, 23.1% (n = 12) physically attacked others and 21.3% (n = 11) manifested fear-inducing behavior (verbal attacks, threats to attack, or attacks on objects). Within the first 72 hours of admission, 9.6% (n = 5) of subjects physically attacked others and 19.2% (n = 10) exhibited fear-inducing behavior. Subjects who had lived with their family before admission were more likely to be violent. No significant correlation was found between violence and sex, social class, or ethnic group. Jackson, Drugovich, Fretwell, Spector, Stemberg, and Rosenstein (1989) examined disruptive behavior in 3,35 1 randomly selected nursing home residents from 103 facilities in Rhode Island. Data were collected through interviews, chart reviews, reports from staff, and observation by interviewers. Disruptive behavior recorded was noisiness, abusiveness, wandering, and other (disrobing, stealing, resistance to care, inability to avoid simple dangers). The length-of-observation periods were not reported. Correlates of disruptive behavior studied included age, sex, ADLs, mobility, communication, continence, cognitive impairment, and disruptive behavior. The Katz and Akporn Index of ADLs (Katz & Akpom, 1976) mea-
284
sured the ADLs. Mobility was defined as the ability to walk 20 yards or more. Communication referred to ability to communicate coherently with or without difficulty. Cognitive impairment was determined by the SPMSQ (Pfeiffer, 1975). A x2 indicated significantly more disruptive behavior (P < .05) among residents who were older, more dependent in ADLs, nonambulatory, impaired in communication, incontinent, and more severely cognitively impaired. No significant differences were detected by sex when total disruptive behaviors were examined. However, a separate analysis of behaviors indicated a prevalence of noisiness in women (10.7% v 8.0%) and abusiveness in men (16.8% v 10.1%). Highest rates of disruptive behavior were associated with moderate-to-severe cognitive impairment. Cohen-Mansfield, Marx, and Rosenthal (1989) examined the agitated behaviors of 408 residents of a long-term facility. The Cohen-Mansfield Agitation Inventory ([CMAI] Cohen-Mansfield, 1986) measured agitated behaviors. The charge nurse of day, evening, and night shifts rated each resident independently to provide a measurement of agitated behaviors across a 24-hour period. Factor analysis showed three factors of agitation: aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. Frequency of agitated behaviors decreased significantly from day to evening to night (P < ,lO). Most manifestations of particular types of agitated behaviors correlated significantly across shifts as determined by Pearson correlation (77 of 87 correlations reached statistical significance at or above the .05 level). This suggests that participants were likely to manifest the same behaviors across shifts. Using the same subjects mentioned above, Cohen-Mansfield and Marx (1989) used observation and interview to examine the three syndromes of agitation (aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior) for their relationship to three aspects of past personality (previous mental disorders, exposure to stress, and leisure habits). The relationship between manifestation of agitated behaviors before nursing home entry and occurrence of agitation within the nursing home was also examined. Stress was measured using an adaptation of the Holmes and Rahe’s Social Readjustment Scale (Muhlenkamp, Gress, & Flood, 1975), Rahe’s Recent Life
BECK, ROSSBY, AND BALDWIN
Changes Questionnaire (Holmes & Rahe, 1967), the Life Crises History (Rahe, 1975), and the Life Events Questionnaire (Center for the Study of Neuroses, 1980). Preference for leisure habits was measured using a modification of Gordon, Gaitz, and Scott’s Intensity of Expressive Social and Leisure Activity Scale (1976). Past mental disorders were determined by interviewing significant others who were asked to respond to items based on the classifications of the Diagnostic and Statistical Manual of Mental Disorders, Revised ([DSM-IIIR] American Psychiatric Association, 1988). Family and friends were interviewed to determine the resident’s agitated behaviors before entry into the nursing home. Results showed no significant correlation between categories of leisure habits and measures of agitation. No significant correlation was found between history of mental disorder and agitation. A greater total number of agitated behaviors were manifested by residents who had experienced the stressors of (1) separation from a spouse (t = 3.05, P < .Ol), (2) life-threatening situations (t = 2.16, P < .05), (3) retirement (t = 2.10, P < .Ol), (4) financial problems (t = 3.56, P < .Ol) or (5) immigration (t = 2.66, P < .Ol) than residents without these experiences. However, residents who had experienced the stress of relocation at least once before nursing home entry exhibited fewer total agitated behaviors than did residents who had not relocated (t = - 2.80, P < .Ol). More aggressive behavior was shown by those residents who had never relocated (t = - 2.97, P < .Ol). More aggressive behavior was also displayed by those who had experienced financial problems (t = 2.43, P < .05). Those who had relocated manifested fewer physically nonaggressive behavior (t = - 1.99, P < .05). Results also indicated that agitation before nursing home entry is highly related to agitated behavior within the nursing home. Marx, Cohen-Mansfield, and Werner ( 1990) used observation to examine the three dimensions of agitation (aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior) in relation to the occurrence of falls in the same 408 residents. Residents who fell exhibited a greater total number of agitated behavior than those who did not fall (r = 15.01 v. r = 8.07, F score = 42.81, P < .Ol). They also exhibited significantly more behaviors from each dimension
285
of agitated behaviors than residents who did not fall. The relationship between agitation and sleep disturbances was also studied through observation by Cohen-Mansfield and Marx (1990) with the same sample group. The CMAI (CohenMansfield, 1986) measured agitation. Total hours of sleep, length of time needed to fall asleep, frequency of awakenings, length of average wakeful period, the hour that each resident woke up in the morning, and external disruptions of night sleep were recorded by a nurse. Agitation and sleep ratings were completed within a 2-week period to provide a consistent view of each resident. Pearson correlation coefficients indicated that an overall lack of sleep and interruptions of sleep are related to the amount and type of agitation manifested during the day. Physically nonaggressive behavior and aggressive behavior were linked with increasing time needed to fall asleep and external disruptions. Physically nonaggressive behavior was associated with frequent awakenings by the resident. Verbally agitated residents awoke frequently on their own at night, had fewer hours of sleep, and were awake very early in the morning. External disruptions of sleep and length of awake periods (r = .64, .19, respectively; P < .Ol) were significantly correlated to cognitive impairment. Multiple regressions indicated that sleep disturbances were independently and modestly related to agitation. Cohen-Mansfield, Marx, and Rosenthal ( 1990) conducted additional research on this same population to determine the relationships between agitated behaviors and the independent variables of dementia, cognitive impairment, and impaired ADL functioning. For each subject, a hypothetical diagnosis of dementia was determined by a review of medical records, then presented for confirmation by a physician. Nursing staff and social workers rated agitation using the CMAI (CohenMansfield, 1986). Cognitive impairment was measured using a modified version of the Brief Cognitive Rating Scale ([BCRS] Reisberg, Scheneck, Ferris, Schwartz, & de Leon, 1983). Six items (eating, walking, bathing, dressing, toileting, and grooming) from the Rapid Disability Rating Scale-2 ([RDRS-21 Linn & Linn, 1983) were used to measure impaired ADL functioning. Cognitive impairment was significantly corre-
lated with ratings both by nursing staff (N) and social workers (SWs) for the total number of agitated behaviors (r = .37 for N; r = .40 for SWs), aggressive behaviors (r = .22 for N; r = .26 for SWs), physically nonaggressive behaviors (r = .37, .40 respectively), and verbally aggressive behaviors (r = - .09, - .13 respectively, all P < .Ol). No significant correlation was found between cognitive impairment and hiding/hoarding behaviors. Stepwise regressions were estimated for each measure of agitation on the independent variables of cognitive impairment, ADL impairment, and dementia. Cognitive impairment and ADL impairment explained 37% of the variance in physically nonaggressive behaviors (e.g., pacing). Cognitive impairment and ADL impairment also explained 7% of the variance in verbally agitated behavior. Cognitive impairment was the only variable to explain the variance of aggressive behaviors (positive quadratic term; R2 = .07), whereas ADL impairment provided the best explanation of hiding and hoarding behavior (negative quadratic term; R2 = .Ol). This study indicates that aggressive and physically nonaggressive manifestations of agitation are strongly related to cognitive impairment, while verbal agitation and hiding/hoarding are not. A sample of 213 community-based, demented elderly and their 213 caregivers were studied by Hamel, Gold, Andres, Reis, Dastoor, Grauer, and Bergman (1990). Observation, interviews, and questionnaires were used to obtain data. Subjects had a diagnosis of a progressive dementia disorder for at least 1 year, and had no additional lifethreatening or immobilizing illnesses. The Hierarchic Dementia Scale (Dastoor & Cole, 1983) indicated that the majority of subjects were moderately impaired. The RAS forms 1 and 2 (Ryden, 1988a, 1988b) were used to determine the nature, frequency, and context of aggressive behavior. The General Health Questionnaire (Goldberg, 1978) determined physical and psychological health of the caregiver. The Burden Interview (Zarit, Orr, & Zarit, 1985) measured the degree of burden perceived by the caregiver. The Memory and Behavior Problem Checklist (Zarit, Grr, & Zarit, 1985) assessed frequency of problems reported in demented patients, as well as caregiver reactions. The Social Interaction Questionnaire (Gilleard, Belford, Gilleard, Whittick, & Gledhill, 1984)
BECK, ROSSBY, AND BALDWIN
286
Table 1. Summary
Author/Date Zimmer, Watson,
of Literature Review on Correlates of Disruptive Behavior
Sample
Method of
Type of
Characteristics.1
Data
Behavior
Size
Collection
Studied
Nursing home
and Treat
residents
(1984)
(n = 1,139)
Review of
Correlates of Disruptive Behavior Studied
Behavioral
Cognitive status
Findings Cognitive impairment
in
utilization
problems
psychotropic drug
81.4% of behavioral
review
(behavior that
use, physical
problem residents;
forms
required active
restraint use,
psychotropic drug use
or constant
depression
consideration
in 58% of serious behavior residents;
in care
restraint use in 46.2%
planning)
of behavior problem residents; depression in 9% of residents with serious behavioral problems
Winger, Schirm,
Nursing home
Interviews
Aggression
Cognitive status,
Aggressive residents did
and Stewart
residents, R age
and
(endangering
functional ability,
less well on MSQ;
(1987)
= 69 fn = 43),
observations
others,
age, length of stay,
nursing home resi-
and interme-
endangering
perceived control
diate care
self, and
residents, X age
disturbing)
dents with decreased functional ability demonstrated
more
serious behavioral
= 64 (n = 58)
problems; older nursing home residents exhibited more aggressive behavior; aggressive residents had longer lengths of stay; no significant correlation between perceived control and aggression Meddaugh
(1987)
Unclear sensorium in all
Chart and
Aggression
residents, X age
incident
(abusive)
= 85 (n = 72)
report
social support
impaired functional
review
network, gender,
ability in all abusive
age
residents; abusive
Nursing home
Cognitive status, functional ability,
abuse incidents;
incidents occurred in 30% of residents who received less than weekly visits; 11% receiving at least weekly visits; women abusers, 11%; men abusers, 30%; abusers < 85, 15.8%; abusers 1 85, 11.8% Nilsson,
Psychogeriatric,
Observations
Age, length of
Aggression (no
Age significantly related
Palmstierna,
long-term in-
definition
hospitalization,
to aggression fre-
and Wistedt
patients, 38
provided)
gender
quency; length of stay
(1988)
with marked
significantly related to
cognitive
degree of aggression;
impairment
no significant
(n = 40)
correlation between gender and frequency or degree of aggression (Continued
on following
page)
287
DISRUPTIVE BEHAVIOR IN ELDERLY
Table 1. (continuedd)
Author/Date Ryden,
Sample
Method of
Type of
Characteristics/
Data
Behavior
Size
Collection
Studied
Cognitively
Observations
Aggression
Correlates of Disruptive Behavior Findings
Studied Cognitive status,
No significant corre-
Bossenmaier,
impaired
(physical,
functional ability,
lation between
and McLachlan
nursing home
verbal, sexual)
psychotropic drug
aggression and mental
(1989)
residents
(physical,
use, physical
status or between
(n = 124)
50.8%; verbal,
restraint use
aggression and
47.6%; sexual,
functional ability;
4.0%)
significantly higher aggression scores in residents receiving psychotropic drugs; physical restraints used in 60.5% of residents studied; no significant correlation between aggression and restraint use
Werner, Cohen-
Long-term care
Observation
Agitation
Physical restraint
Significantly more total
Mansfield,
residents with
(aggressive,
Braun, and
high levels of
physically
manifested when
Marx (1989)
cognitive im-
nonaggressive
residents were
pairment
and verbally
restrained as
(n = 24)
nonaggressive)
compared with when
use
agitation was
they were not restrained Haller, Binder,
Psychiatric in-
Chart review
Violent (attacks
Gender, social class,
No significant corre-
and McNeil
patients with
person or
ethnic group, living
lation between
(1989)
senile dementia
objects,
with family
violence and sex,
fn = 52)
threatens to
social class and ethnic
attack, verbal
group; significant
attack)
correlation between living with family and violence
Jackson et al. (1989)
Nursing home
Interviews,
Disruptive
Cognitive status,
Disruptive behavior was
residents
chart
behavior
functional ability,
more prevalent in
fn = 3,351)
reviews,
(noisiness,
continence,
residents who were
staff
abusiveness,
communication,
more severely
reports,
wandering)
age, sex
cognitively impaired,
observations
were more functionally impaired, nonambulatory, incontinent, and had impaired communication: disruptive behavior increased with age; significantly higher prevalence of noisiness in women and abusiveness in men
(Continued on following pagel
288
BECK, ROSSBY, AND BALDWIN
Table 1. (continuedl
Author/Date Cohen-Mansfield,
Sample
Method of
Type of
Characteristics/
Data
Behavior
Size
Collection
Studied
Nursing home
Observations
Agitation
Correlates of Disruptive Behavior Studied Time of day
Findings Agitation frequency
Marx, and
residents
and
(aggressive
significantly decreased
Rosenthal
In = 408)
interviews
physically
from day to night;
(1989)
nonaggressive,
particular types of
and verbally
agitation correlated
agitated)
significantly across shifts
Cohen-Mansfield
Nursing home
Observations
Agitation
Premorbid
Premorbid agitation was
and Marx
residents
and
(aggressive,
(1989)
In = 408)
interviews
physically
with agitation in the
nonaggressive,
nursing home
personality
positively correlated
and verbally agitated) Marx, Cohen-
Nursing home
Observations
Agitation
Falls
Residents who fell had
Mansfield, and
residents
(aggressive,
greater total number
Werner (1990)
(n = 408)
physically
of agitated behaviors
nonaggressive, and verbally agitated) Cohen-Mansfield,
Nursing home
Observations
Agitation
Sleep patterns
Overall lack of sleep and
and Marx
residents
and
(aggressive,
(1990)
(n = 408)
interviews
physically
related to the amount
nonaggressive,
and type of agitation
interruptions of sleep
and verbally agitated) Cohen-Mansfield,
Nursing home
Observations
Agitation
Cognitive status
Residents with severe
Marx, and
residents
(aggressive.
Rosenthal
(n = 408)
physically
and moderate-to-
nonaggressive,
severe functional
verbally
impairment
agitated,
a greater total number
hiding, and
of agitated behaviors
hoarding)
and physically
(1990)
functional ability
cognitive impairment
exhibited
nonaggressive agitation Hamel et al. (1990)
Community-
Observations,
Aggression
Social support
A more troubled
based
interviews
(physical,
network,
premorbid
dementia
and ques-
verbal, sexual)
permorbid
caregiverisubject
subjects
tionnaires
(physical,
personality
(n = 213)
relationship and
34.1%) (verbal,
premorbid aggression
51 .O%) (sexual,
significantly predicted
7.2%)
current subject aggression
measured the quality of the relationship between caregiver and subject before onset of illness. The NE0 Personality Inventory (Costa & McCrae, 1985) measured caregiver neuroticism (defined as emotional overreactivity and lability). Subjects reacted with aggression most often when given instructions to do something. Premorbid aggression was reported for 9.6% of the subjects. Feeling angry but not responding in an ag-
gressive manner was reported by 10.11% of the caregivers. Caregiver aggressive reactions were reported at 10.6%. A multiple regression analysis determined that the predictors of aggressive behavior in dementia subjects, accounting for 25.42% of the variance in total aggression scores (F = 5.35, P < .OOOl), were premorbid aggression, greater frequency in behavior and memory problems, and a more troubled premorbid relationship between
DISRWTIVE
BEHAVIOR
IN ELDERLY
caregiver and subject. Level of cognitive impairment did not predict aggression. No caregiver demographic or personality characteristics predicted aggression scores. SUMMARY
This review of literature shows that the elderly in long-term care facilities demonstrate behavior considered to be disruptive. In the studies reviewed, average prevalence of reported disruptive behavior among a total of 5,650 subjects was 42.8%. Precise comparative analysis of studies is not possible due to the variety of instruments used and lack of uniformity of terms. Furthermore, a limited number of correlates is investigated in each study. Several studies have linked disruptive behavior with cognitive impairment (Cohen-Mansfield, Marx, & Rosenthal, 1990; Jackson et al., 1989; Winger, Schirm, 8z Stewart, 1987; Zimmer, Watson, & Treat, 1984) and functional dependency (Cohen-Mansfield, Marx, & Rosenthal, 1990; Jackson et al., 1989; Meddaugh, 1987). However, one study (Ryden, Bossenmaier, & McLachlan, 1989) did not support the relationship of functional dependency to aggression. Sex was associated with disruptive behavior in one study (Jackson et al., 1989), though two studies found no significant relationship between sex and disruptive behavior (Haller, Binder, & McNeil, 1989; Nilsson, Palmstiema, & Wistedt, 1988). Premorbid personality, (Cohen-Mansfield & Marx, 1989; Hamel et al., 1990) and age (Jackson et al., 1989; Nilsson, Palmstiema, & Wistedt, 1988) are additional factors with reported relationships to disruptive behaviors. Physical restraint use was significantly related to disruptive behavior by Werner, CohenMansfield, Braun, and Marx (1989), though Ryden, Bossenmaier, and McLachlan (1989) found no significant relationship. An individual’s social support network has been associated with disruptive behaviors (Hamel et al., 1990; Meddaugh, 1987), as have length of hospitalization (Nilsson, Palmstiema, & Wistedt, 1988), psychotropic drug use (Ryden, Bossenmaier, & McLachlan, 1989), falls (Marx, Cohen-Mansfield, & Werner, 1990), sleep pattern (Cohen-Mansfield & Marx, 1990), living with family (Haller, Binder, & McNeil, 1989), time of day (Cohen-Mansfield, Marx, & Rosenthal, 1989), and communication and
289
incontinence (Jackson et al., 1989). Perceived control (Winger, Schirm, & Stewart, 1987), as well as social class and ethnic group (Haller, Binder, & McNeil, 1989) have not been found to be associated with disruptive behavior. A summary of the relationship of these biopsychosocial correlates to disruptive behavior is presented in Table 2. The finding that most disruptive behaviors seem to occur during the day and during assistance with ADLs (Cohen-Mansfield, Marx, & Rosenthal, 1989; Nilsson, Palmstiema, & Wistedt, 1988; Ryden, Bossenmaier, & McLachlan, 1989) has important implications for development of nursing interventions. These findings were not contradicted by other studies. In light of findings correlating increased agitation/aggression with drug and restraint use (Ryden, Bossenmaier, & McLachlan, 1989; Werner, Cohen-Mansfield, Braun, & Marx, 1989), experimental research that focuses on (1) nurse/resident relationship and (2) effectiveness of nursing interventions other than administration of drugs and restraints seems a plausible recommendation. Increased disruption during the day and during assistance with ADLs (Cohen-Mansfield, Marx, & Rosenthal, 1989; Nilsson, Palmstiema, & Wistedt, 1988; Ryden, Bossenmaier & McLachlan, 1989) suggests that further investigation is needed. Research that examines (1) interventions designed to decrease anxiety/frustration during ADL activities (2) effect of low versus high daytime staff/resident ratio on disruptive behaviors, and (3) staff perception of disruptive behavior in relation to frequency of occurrence is recommended. Studies that rely on chart reviews and/or reports from staff for data related to disruptive behavior leave many questions about the nature, context, and accuracy of reported events. More observation-based, qualitative studies in which observed behaviors are fully described within the context of occurrence are recommended. These studies could include: (1) a consistent definition of disruptive behavior, (2) use of the same instruments for measures of behavior and its correlates, and (3) description of precedent and/or antecedent nursing interactions as integral elements of the occurrence. Such research would contribute a more specific understanding of types of disruptive behavior in the cognitively impaired elderly resident and would also contribute to the development of meaningful interventions for management of the disturbed demented resident.
290
BECK, ROSSBY, AND BALDWIN
Table 2. Correlates and Their Ralationship to Disruptive Behavior Related to Disruptive Behavior?
Correlate Studied Cognitive status
Functional ability
Sex
Premorbid personality
Age Restraint use
Author/Date
Yes
Jackson et al. (1989)
Yes
Cohen-Mansfield,
No
Ryden, Bossenmaier, and McLachlan (1989)
Marx, and Rosenthal (1990)
Yes
Meddaugh
Yes
Jackson et al. (1989)
Yes
Cohen-Mansfield.
No
Ryden, Bossenmaier,
Yes
Jackson et al. (1989)
(1987) Marx, and Rosenthal (1990) and McLachlan (1989)
No
Nilsson, Palmstierna, and Wistedt (1988)
No
Hailer, Binder, and McNeil (1989)
Yes
Cohen-Mansfield
Yes
Hamel et al. (1990)
Yes
Jackson et al. (1989)
and Marx (1989)
Yes
Nilsson, Palmstierna, and Wistedt (1988)
Yes
Werner, Cohen-Mansfield,
No
Ryden, Bossenmaier,
Braun, and Marx (1989)
and McLachlan (1989)
Social support network
Yes
Hamel et al. (1990)
Length of hospitalization
Yes
Nilsson, Palmstierna, and Wistedt (1988)
Psychotropic drug use
Yes
Ryden, Bossenmaier, and McLachlen (1989)
Falls
Yes
Marx, Cohen-Mansfield,
Sleep pattern
Yes
Cohen-Mansfield
Communication
Yes
Jackson et al. (1989)
Incontinence
Yes
Jackson et al. (1989)
Living with family
Yes
Haller, Binder, and McNeil (1989)
Time of day
Yes
Cohen-Mansfield,
Perceived control
No
Winger, Schirm, and Stewart (1987)
Social class
No
Haller, Binder, and McNeil (1989)
Ethnic group
No
Haller, Binder, and McNeil (1989)
REFERENCES American Psychiatric Association. 1988. D&gnostic and stntistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Center for the Study of Neuroses, University of California, San Francisco. (1980). Life Events Questionnaire--Short Form. Cohen-Mansfield, J. (1986). Agitated behaviors in the elderly II. Preliminary results in the cognitively deteriorated. Journal of the American Geriatrics Society, 34, 122121.
Cohen-Mansfield, J., & Marx, M. (1989). Do past experiences predict agitation in nursing home residents? Intertartional Journal of Aging and Human Development, 28(4), 285-294.
Cohen-Mansfield, J., between sleep home. Journal Cohen-Mansfield, J., description of
& Marx, M. (1990). The relationship disturbances and agitation in a nursing of Aging and Health, 2(l), 42-57.
Marx, M., & Rosenthal, A. (1989). A agitation in a nursing home. Journal of
Gerontology, 44(3), Mll-84.
Cohen-Mansfield, J., Marx, MS., & Rosenthal, A.S. (1990). Dementia and agitation in nursing home residents: How are they related? Psychology and Aging, 5(l), 3-8. Cospito, E., & Gift, T. (1982). Assaultive patients in a chronic
and Werner (1990)
and Marx (1990)
Marx, and Rosenthal (1989)
care medical facility. Journal of Psychiatric Treatment and Evaluation, 4(5), 433-436.
Costa, P.T., & McCrae, R.R. (1985). The NE0 Personality Inventory. Odessa, FL: Psychosocial Assessment Resources. Dastoor, D.P., & Cole, M.G. (1983). Hierarchic Dementia Scale. Journal of Clinical and Experimental Gerontology, 5(3), 219-234.
Ebcrsole, P. (1989). Caringfor thepsychogeriutric client. New York, NY: Springer. Gilleard, C.J., Belford, H., Gilleard, E., Whittick, J.E., & Gledhill, K. (1984). Emotional distress among the supporters of the elderly mentally infirm. British Journul of Psychiatty, 145. 12-177.
Goldberg, D.P. (1978). Manual of the general health questionnaire. Windsor, Ontario, Canada: Nelson. Gordon, C., Gaits, C.M., & Scott, J. (1976). Leisure and lives: Personal expressivity across the life span. In R.H. Binstock & E. Shanas @is.), The handbook of aging and sociul sciences. New York, NY: Van Nostrand Reinhold. Haller, E., Binder, R., & McNiel, D.E. (1989). Violence in geriatric patients with dementia. Bulletin of American Academy of Psychiatry and the Law, 17(2), 183-188. Hamel, M., Gold, D.P., Andre% D., Reis, M., Dastoor, D., Grauer, H., &Bergman, H. (1990). Predictors and con-
291
DISRUPTIVE BEHAVIOR IN ELDERLY
sequences of aggressive behavior by community-based dementia patients. The Geronrologisr, 30(2), 206-211. Holmes, T.H., & Rahe, R.H. (1967). The Social Readjustment Scale. Journal of Psychosomatic Research, 11 I 213-
Rahe, R.H. (1975). Epidemiological studies of life changes and illness. International Journal of Psychiatry Medicine. 6, 133-146.
218. International
patients. Journal of the American Geriatrics Society, 23, 433-441.
Classification
of Diseases,
(9th ed., Rev.)
(1984). New York, NY: Revisionist. Jackson, M.E., Drugovich, M.L., Fretwell, M.D., Spector, W.D., Stemberg, J., & Rosenstein, R.B. (1989). Prevalence and correlates of disruptive behavior in the nursing home. Journal of Aging and Health, l(3), 349-369. Katz, S., & Akpom, C.A. (1976). A measure of sociobiological function. International Journal of Health Services, 6, 493408.
Linn. M.W., & Limr, B.S. (1983). Assessing activities of daily living. In T. Crook, S. Ferris, & R. Bartus (Eds.), Geriatric psychopharmacology (pp. 97-109). New Canaan, CT: Powley. Marx, M., Cohen-Mansfield, J., & Werner, P. (1990). Agitation and falls in institutionalized elderly persons. The Journal of Applied Gerontology, 9(l), 106-l 17. Meddaugh, D.I. (1987). Staff abuse by the nursing home patient. The Clinical Gerontologist, 6. 45-47. Muhlenkamp, A., Gress, L.D., & Flood, M.A. (1975). Perception of life change events by the elderly. Nursing Research, 2, 109-l 13.
Nilsson, K., Palmstiema, T., & Wistedt, B. (1988). Aggressive behavior in hospitalized psychogeriatric patients. Acta Psychiatrica Scandinavia, 78(2), 172-175.
Palmstiema, T., & Wistedt, B. (1987). Staff observation aggression scale (SOAS), presentation and evaluation. Acta Psychiatrica Scandinavia, 76. 657-663.
Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly
Reisberg, B., S&neck, M.K., Ferris, S.H., Schwartz, G.E., & de Leon, M.J. (1983). The Brief Cognitive Rating Scale (BCRS): Findings in primary degenerative dementia (PDD). Psychopharmacology Bulletin, 19, 47-50. Ryden, M. (1988a). Aggressive behavior in persons with dementia who live in the community. Alzheimer’s Disease and Associated Disorders, 2. 342-355.
Ryden, M. (1988b, November). Aggressive behavior in cognitively impaired nursing home residents. Paper presented at the Annual Scientific Meeting of the Gerontological Society of America, San Francisco, CA. Ryden, M., Bossenmaier, M., & McLachlan, C. (1989). Aggressive behavior in cognitively impaired nursing home residents. Manuscript submitted for publication. Walsh, J.S., Welch, H.G., & Larson, E.B. (1990). Survival of outpatients with Alzheimer-type dementia. Annals of Internal Medicine, 113, 429-434.
Werner, P., Cohen-Mansfield, J., Braun, J., & Marx. M. (1989). Physical restraints and agitation in nursing home residents. Journal of the American Geriatrics Society, 37. 1122-1126. Winger, J., Schirm, V., L Stewart, D. (1987). Aggressive behavior in long-term care. Journal of Psychosocial Nursing, 25, 28-33.
Zarit, S.H., Orr, N.K.. & Zarit, J.M. (1985). The hidden victims of Alzheimer’s disease. New York, NY: New York
University. Zimmer, J., Watson, N., &Treat, A. (1984). Behavioral problems among patients in skilled nursing facilities. American Journal of Public Health, 74, 1118-l 121.