Modifiable Factors Related to Abusive Behaviors in Nursing Home Residents With Dementia

ORIGINAL STUDIES

Modifiable Factors Related to Abusive Behaviors in Nursing Home Residents With Dementia Ladislav Volicer, MD, PhD, Jenny T. Van der Steen, PhD, and Dinnus H. M. Frijters, PhD

Objectives: To determine modifiable factors related to abusive behaviors in nursing home residents with dementia.

of depression, presence of delusions, hallucinations, pain frequency and constipation, and number of days receiving medications).

Design: Analysis of Minimum Data Set (MDS) of the Resident Assessment Instrument (RAI) information.

Results: Resistiveness to care, related to lack of understanding, depression, hallucinations and delusions, was strongly related to abusive behaviors. Presence of depressive symptoms and delusions was also related to abusive behaviors independent of resistiveness to care. Only very few residents who understood others and were not depressed were abusive.

Setting: We used MDS-RAI data from 8 Dutch nursing homes and 10 residential homes that volunteered to collect data for care planning. We included the data of residents within a 12-month time window for each facility separately, resulting in a range from April 4, 2007, to December 1, 2008. Participants: We selected 929 residents older than 65 with Alzheimer’s disease or other dementia who were dependent in decision making and not comatose. Measurements: Cognitive Performance Scale, MDS Depression Scale and several individual items from the MDS-RAI (ability to understand others, verbally and physically abusive behavioral symptoms, resist care, diagnosis of Alzheimer’s disease and of dementia other than Alzheimer’s disease, diagnosis

Behavioral symptoms of dementia are often more difficult to manage than cognitive and functional impairments. Especially difficult to manage are behaviors that are labeled as violent, aggressive, or assaultive. Assaultive behaviors occur almost School of Aging Studies, University of South Florida, Tampa, FL, and Charles University 3rd Medical Faculty, Prague, Czech Republic (L.V.); EMGO Institute, Department of Nursing Home Medicine, Amsterdam, The Netherlands (J.T.V.d.S., D.H.M.F.); EMGO Institute, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands (J.T.V.d.S.). The authors have no conflicts of interest relating to this article. Address correspondence to Ladislav Volicer, MD, PhD, University of South Florida, School of Aging Studies, 2337 Dekan Lane, Land O’Lakes, FL 34639. E-mail: [email protected]

Copyright Ó2009 American Medical Directors Association DOI:10.1016/j.jamda.2009.06.004 ORIGINAL STUDIES

Conclusion: Abusive behaviors may develop from lack of understanding leading to resistiveness to care. Behavioral interventions preventing escalation of resistiveness to care into combative behavior and the treatment of depression can be expected to decrease or prevent abusive behavior of most nursing home residents with dementia. (J Am Med Dir Assoc 2009; 10: 617–622) Keywords: Dementia; depression; abusive behavior; resistiveness to care; nursing home

always during caregiving activities. Caregivers who are not able to effectively cope with these behaviors are prone to respond with abusive behavior toward the resident.1 Actually, caregivers who exhibit state and trait anger are more likely to report being assaulted by a resident. Violence on the ward may cause need for medical and psychological care and leads to increased absenteeism and staff turnover, property damage, decreased productivity, and increased worker’s compensation.1 Development of management strategies for these symptoms is complicated by confusing terminology and sometimes by an erroneous presumption that individuals with dementia may be inherently dangerous because of potential aggression toward caregivers. Aggressive behavior is considered to be a type of agitation when the term agitation is used to describe all behavioral symptoms of dementia.2 This terminology prevents development of specific strategies for different behaviors. Behavior Volicer et al 617

that is labeled ‘‘aggressive’’ may occur because the residents do not understand the need for care and resist caregiving activities. If the caregivers persist in trying to provide care, resistiveness to care escalates into combative behavior by which the residents defend themselves from unwanted attention.3 The Minimum Data Set (MDS) completed by the nursing home provides an opportunity for studying behaviors that are labeled in MDS forms as verbal and physical abuse. Recently, we have presented evidence based on MDS data analysis indicating that abusive behavior occurs more frequently in residents who are resisting care. However, not all residents who were labeled as abusive were resisting care.4 Therefore, in this study we investigated other modifiable factors that may lead to abusive behavior in residents with dementia including the presence of depression, delusions, hallucinations, constipation, and pain. METHODS AND PATIENT POPULATION Data Elements All variables were derived from the Minimum Data Set (MDS) 2.0 items for nursing home care.5 The MDS assessment is based on a combination of physical examination, patient history, observation, consultation of other caregivers, and information found in medical records. Full MDS assessments are performed within 7 days of admission to the facility, after 30 days, and quarterly thereafter. The MDS has been mandated for all nursing homes in the United States, and several European countries have since introduced it. In the Netherlands, there are at the moment 18 long-term care facilities that voluntarily use the MDS 2.0 as a structural assessment instrument for care planning. We used MDS–Resident Assessment Instrument (RAI) data collected by 8 Dutch nursing homes and 10 residential homes. We included the data of residents within a 12-month time window for each facility separately, resulting in a range from April 4, 2007, to December 1, 2008. Of records of 2705 residents available from the 18 facilities, we selected the last records of 929 residents older than 65 with Alzheimer’s disease or other dementia (I1q or u), who were dependent in decision making (B4 not equal 0) and who were not comatose (B1 equal 0). Cognitive Performance Scale ratings were calculated from 4 variables: short-term memory (B2a), cognitive skills for daily decision making (B4), making oneself understood (C4), and dependence in eating (G1hA).6 Scores ranged from 1 (borderline intact) to 6 (very severe impairment). There were no values of 0 because we excluded patients who were independent in decision making. MDS Depression Rating Scale scores were calculated from 7 MDS items: negative statements (E1a), anger (E1d), unrealistic fears (E1f), repetitive health complaints (E1 h), repetitive anxious complaints (E1i), sad expression (E1l), and crying (E1 m).7 The scores ranged from 0 to 14 and the score of 3 or higher was used to indicate presence of depression. The Cronbach alpha for this scale in this study was 0.785. Other data elements used in this study were ability to understand others (C6), verbally abusive behavioral symptoms 618 Volicer et al

(E4bA/B), physically abusive behavioral symptoms (E4cA/ B), resist care (E4eA/B), diagnosis of Alzheimer’s disease (I1q), diagnosis of dementia other than Alzheimer’s disease (I1u), diagnosis of depression (I1ee), delusions (J1e), hallucinations (J1i), pain frequency (J2a), constipation (H2b), and number of days receiving medications (O4a-d). Statistical Analysis We analyzed correlations between frequencies of abusive behaviors and postulated modifiable factors related to these behaviors: resistiveness to care, frequency of pain, ability to understand, and presence of delusions and MDS depression by bivariate and partial correlations using 3-step analysis. Because we found previously that abusive behavior is more common in residents who resist care, we first correlated postulated related factors with resistiveness to care (step 1) and resistiveness to care with abusive behaviors (step 2). If a factor was not correlated with resistiveness to care we explored its correlation with abusive behaviors. To find out if postulated factors related to resistiveness to care also have an independent relationship with abusive behavior, we performed partial correlations controlled for resistiveness to care (step 3). In addition, we used multivariable binary logistic regression with the dichotomous variables for abusive behaviors and resist care (behavior not present or easily altered versus behavior was not easily altered), MDS diagnosis of depression (score .3) and constipation (present versus absent), and nominal variables for ability to understand others (0–3) and frequency of pain (0–2). In the first analysis that explored relationships between postulated factors and dependent variables, we used resistiveness to care as the dependent variable. In the second 2 analyses we used abusive behaviors as dependent variables and resistiveness to care as the independent variable. We also described the use of antidepressants and antipsychotics and analyzed correlations between the number of days patients received medications and frequency of abusive behaviors. All analyses were performed using SPSS 17.0 for Windows (SPSS Inc., Chicago, IL). RESULTS Demographic characteristics of the subject population are shown in Table 1. The subjects were mostly female and most of them had either moderate or severe cognitive impairment. They were almost evenly divided between residents with a diagnosis of Alzheimer’s disease and residents with a diagnosis of dementia other than Alzheimer’s disease. Based on our previous results4 we postulated that lack of understanding others would be a factor related to resistive behavior that is related to abusive behaviors. Therefore we performed a 3-step analysis, using first a bivariate correlation to analyze relationships between resistiveness to care and the following factors possibly related to it: lack of understanding, MDS depression diagnosis, presence of delusions and hallucinations, constipation, and frequency of pain. Figure 1 (left part) shows that we found that lack of understanding, MDS depression diagnosis, and presence of delusions and hallucinations were significantly correlated with resistiveness to care, whereas pain frequency (r 5 0.04, P 5 .178) and JAMDA – November 2009

Table 1.

Characteristics of the Study Populations (n5929)

Characteristic Age Gender, % of women Dementia diagnosis Cognitive Performance Scale

Ability to understand others

Delusions Hallucinations Pain (n5923) Constipation Resist care Verbally abusive Physically abusive

MeanSD (range) or N 84.57.0 (65–102) Alzheimer’s disease Other dementia Both 1 2 3 4 5 6 Always Usually Sometimes Rarely/never

74.5 44.8 51.1 4.1 2.6 7.4 34.6 7.1 36.2 12.2 15.6 40.3 30.9 13.2 7.6 8.7 51.2 19.2 29.0 13.9 34.7 28.7 30.2 25.4 14.7 11.5

416 475 38 24 69 321 66 336 113 145 374 287 123 71 81 476 178 269 129 322 267 281 236 137 107

No Less than daily Daily At least 1–3 d/wk Not easily altered At least 1–3 d/wk Not easily altered At least 1–3 d/wk Not easily altered

constipation (r 5 0.05, P 5 .123) were not (not in Figure 1). However, pain frequency was directly correlated with frequency of verbal abuse (r 5 0.07, P 5 .028). In the second step, we used bivariate correlation to analyze relationships between frequency of resistiveness to care and frequencies of verbally and physically abusive behaviors and found them to be highly significant (right part of Figure 1). To determine if some of the factors related to resistiveness to care were also independently related to abusive behaviors, we performed partial correlations that kept resistiveness to care constant (Step 3). In that analysis, MDS depression diagnosis was significantly related to both verbally and physically abusive behavior, whereas the presence of delusions was significantly related only to verbally abusive behavior (dotted lines in Figure 1). Lack of understanding was no longer related to abusive behaviors (r 5 0.014, P 5 .705 for verbal and r 5 0.002, P 5 .996 for physical) when controlled for resistiveness to care. In this analysis, pain frequency was no longer correlated to frequency of verbal abuse (r 5 0.04, P 5 .363) To further analyze predictors of abusive behaviors, we performed 2 analyses using binary logistic regression. In the first analysis, we included possible factors related to resistiveness to care: lack of understanding, MDS depression diagnosis, presence of delusions and hallucinations, pain frequency, and constipation. Lack of understanding and MDS depression diagnosis were significantly independently related to resistiveness to care (Table 2). In the second analysis we included possible factors related to abusive behaviors including resistiveness to care. In this analysis (Table 3), lack of understanding was no longer significant. ORIGINAL STUDIES

Percent

We thus identified 2 main risk factors when the resistiveness to care was not considered: lack of understanding and MDS depression diagnosis. To demonstrate the impact of these 2 risk factors for development of abusive behaviors, we plotted numbers of subjects exhibiting these behaviors according to presence or absence of lack of understanding and MDS depression diagnosis (Table 4). We found that verbally abusive behavior was present in 50.8% of residents who lacked understanding and were depressed; it was present in only 8.8% of residents who did not have these 2 risk factors. Similarly, physically abusive behavior was present in 23.8% of residents with both risk factors but in only 5.3% of residents without these risk factors.

Understanding .38** Hallucinations

Delusions

.13** .10*

Resistiveness to care

.41**

.13** .31** Depression

.33** .11*

.44**

Verbal abuse Physical abuse

Fig. 1. Model of risk factors for abusive behavior based on statistically significant relationships of antecedent factors to resistiveness to care and verbal and physical abuse. The full lines show bivariate correlation coefficients and dotted lines show partial correlation coefficients when resistiveness to care is controlled for. **P \ .001, *P \.005. Volicer et al 619

Table 2. Multivariable Binary Logistic Regression of Factors Related To Resistiveness To Care Parameter Lack of understanding MDS depression Delusions Hallucinations Pain Constipation Constant

B

SE

0.82 1.12 0.04 0.26 0.06 0.01 2.79

0.10 0.17 0.29 0.27 0.09 0.10 0.21

Exp(B)* P Value 2.26 3.08 1.04 1.29 0.94 0.99 0.06

\.001 \.001 .886 .345 .533 .965 \.001

* Standardized coefficient beta.

Considering all residents who were abusive, the results indicate that the abusive behaviors were rare in individuals who had neither of these risk factors. Only 10 residents (3.5%) who did not have these risk factors exhibited verbally abusive behavior and of these 10, only 8 (2.8%) were labeled as having this behavior that was not easily altered. Physically abusive behavior in residents without these risk factors was present in 6 residents (4.4%) and in only 3 (2.2%) of them it was not easily altered (Table 4). Addition of ‘‘presence of delusions’’ did not change the numbers of residents exhibiting abusive behaviors. Presence of pain did not explain abusive behavior in residents without risk factors. Although pain was listed as present in 48.1% of the residents, it was present in only 1 resident without risk factors exhibiting verbally abusive behavior and was not present in any resident without risk factors exhibiting physically abusive behavior. Because depression was one of the main risk factors for abusive behaviors identified in this study, we examined the number of subjects who had depression diagnosis listed in their MDS and number of subjects treated with antidepressants. A clinical diagnosis of depression was present in 9.0% of residents, whereas 48.8% of residents were depressed according to the MDS depression scale. Antidepressants were administered to 18.6% of residents and the prevalence of antidepressant administration was more than twice as high in residents who did not have a clinical diagnosis of depression. However, in 21 residents the antidepressants were administered only 1 or 2 days a week and may not represent effective treatment of depression. There was no relationship between antidepressant use and frequency of resistiveness to care (r 5 0.023, P 5 .481) or physically abusive behavior Table 3.

(r 5 0.032, P 5 .329) but there was a significant correlation between antidepressant use and frequency of verbally abusive behavior (r 5 0.120, P \ .001). Delusions were listed as present in 7.6% of the residents (Table 1) and 53.5% of them were treated with antipsychotics. Hallucinations were listed as present in 8.7% of the residents (Table 1) and 61.7% of them were treated with antipsychotics. Either delusions or hallucinations were listed as present in 13.1% of residents (n 5 122) and 60.1% of them were treated with antipsychotics. However, antipsychotics were administered also to 32.8% of residents (n 5 265) who were listed as having neither delusions nor hallucinations (n 5 807). Use of antipsychotics was correlated significantly with frequency of resistiveness to care (r 5 0.085, P 5 .009), verbally abusive behavior (r 5 0.216, P \ .001), and physically abusive behavior (r 5 0.090, P 5 .006). DISCUSSION Results of this study indicate that lack of understanding combined with resistiveness to care and depression are 2 main factors leading to development of abusive behaviors. These factors were strongly related to abusive behaviors and lack of understanding was no longer related to abusive behaviors when controlled for resistiveness to care. This result indicates that lack of understanding was affecting abusive behaviors through increased resistiveness to care. Presence of delusions and hallucinations played a lesser role in the development of abusive behaviors, both by affecting resistiveness to care and by a direct effect on verbally abusive behavior. Further, there was a weak association of verbal abuse with pain in bivariate analysis only, and we found no evidence of a relationship between abusive behaviors with constipation. Our study has several limitations. Our data are cross sectional and show only an association of factors with abusive behaviors. However, it is possible to postulate a temporal causative relationship because it is difficult to imagine that abusive behavior would precede resistiveness to care or depression, or that resistiveness to care would cause lack of understanding. The strong connection between depressive symptoms and physically aggressive behavior was already documented by Lyketsos et al7 and by Leonard et al.8 Another limitation is that we did not include other factors that may be related to

Multivariable Binary Logistic Regression of Factors Related To Abusive Behaviors Verbally Abusive

Parameter Resist care Lack of understanding MDS depression Delusions Hallucinations Pain Constipation Constant

B

SE

Exp(B)*

1.49 0.05 2.21 0.57 0.32 0.32 0.20 2.45

0.27 0.15 0.35 0.42 0.38 0.20 0.34 0.49

4.44 0.95 9.13 1.77 1.38 0.73 0.82 0.085

Physically Abusive P Value \.001 .75 \.001 .175 .392 .116 .551 \.001

B

SE

Exp(B)*

P Value

1.55 0.12 1.75 0.09 0.16 0.38 0.09 3.75

0.36 0.20 0.55 0.55 0.47 0.27 0.44 0.73

4.71 1.13 5.77 1.10 1.18 0.69 1.10 0.024

\.001 .551 .001 .869 .731 .161 .833 \.001

MDS, Minimum Data Set. * Standardized coefficient beta.

620 Volicer et al

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Table 4.

Number of Residents Having and Lacking Risk Factors for Abusive Behaviors Divided by Frequency of These Behaviors in Past 7 Days

Abusive Behavior

Frequency

Verbal

Never 1–3 days 4–6 days Every day Total abusive % of total % of abusive Total Never 1–3 days 4–6 days Every day Total abusive % of total % of abusive Total

Physical

Both Risk Factors Present 207 87 68 59 214 50.8% 76.1% 421 320 54 25 21 100 23.8% 73.0% 420

Risk Factors Absent Lack of Understanding 18 8 4 2 14 43.7% 5.0% 32 29 1 2 0 4 12.1% 2.9% 33

Total MDS Depression 320 29 9 5 43 11.8% 15.3% 363 336 21 3 3 27 7.4% 19.7% 363

Both Absent 103 4 5 1 10 8.8% 3.5% 113 107 4 2 0 6 5.3% 4.4% 113

648 128 86 67 281 30.2% 100% 929 792 80 32 25 137 14.7% 100% 929

MDS, Minimum Data Set.

abusive behaviors, eg, gender, age, severity of dementia, and premorbid personality. However, we were mainly interested in factors that are modifiable in a clinical situation, eg, resistiveness to care, depression, delusions, and hallucinations. Information about factors related to abusive behavior suggests strategies for prevention of these behaviors. Lack of understanding may be partially alleviated by better communication strategies, eg, facing the resident, speaking slowly in simple sentences, but may not be eliminated completely in advanced dementia. Therefore, it may not be possible to completely eliminate resistiveness to care. However, it is possible to prevent escalation of resistiveness to care to combative behavior that is labeled as abusive and that results in psychological or physical damage to the resident or caregiver. This escalation may be prevented by delaying the intervention, distraction of the resident, or by changing caregiving strategies.9 Depression was identified as the second most important factor related to abusive behaviors. We identified depression using the MDS depression scale,10 which uses 7 MDS items and assigns diagnosis of depression when the score is 3 or higher. This scale correlated well with the Cornell and Hamilton depression scales using ‘‘at least mild depression’’ as a cut-off point, and with psychiatric diagnosis. It was also more sensitive and specific than the 15-item Geriatric Depression Scale in detecting depression in the nursing home population.10 Other studies found poor validity when the MDS depression scale was compared with standard screening tools11 and this was ascribed to the usual practice of MDS being completed by nondirect caregivers.12 The MDS depression scale did not correlate well with other depression scales13 but had acceptable specificity14 and it was validated in the Netherlands.15 Strong relationship between depressive symptoms and physical aggression was also documented using the Cornell Scale for Depression in Dementia.8 Presence of 3 or more symptoms was recently suggested as a criterion for detection of depression in individuals with dementia.16 ORIGINAL STUDIES

The MDS depression scale detected depression in 48.3% of the subject population. This is comparable to 47.4% detected in a large study of a long-term care facility17 and to the estimate that up to 40% of medically ill older adult nursing facility residents have underdiagnosed depression.18 High prevalence of depression in individuals with Alzheimer’s disease can be expected because Alzheimer’s disease causes serotoninergic deficit19 and some data indicate that this deficit may be related to aggressive behaviors. Density of 5-HT1A receptors determined on autopsy was lower in patients exhibiting aggression before death20 and aggressive subjects exhibited supersensitivity of 5-HT receptors indicating less serotoninergic acitivity.21 Polymorphism of 5-HT2A receptors was correlated with aggressive behavior in 2 studies,22,23 whereas in another the same polymorphism was related just to hallucinations and delusions.24 Similarly, 2 studies found a relationship between polymorphism of 5-HT transporter that may result in increased reuptake of 5-HT and aggressive behavior,25,26 whereas 1 study found a relationship only with psychosis.27 The relationship between serotoninergic function and aggressive behavior may not be unique for Alzheimer’s disease because decreased serotoninergic activity is present also in frontotemporal dementia.28 Serotoninergic deficit may be the mechanism by which depression increases abusive behavior and, therefore, treatment with antidepressants could prevent these behaviors. In our study, use of antidepressants was positively correlated with frequency of verbally abusive behavior whereas there was no significant correlation with resistiveness to care or physically abusive behavior. The positive correlation may indicate that subjects who were verbally abusive were more likely to be treated with antidepressants but it is possible that such treatment was not effective because of a low dose of an antidepressant or short duration of the treatment. Further studies are needed to investigate the effect of antidepressant treatment on abusive behaviors. Treatment with antipsychotics seems to be even less effective because there Volicer et al 621

was a positive correlation between their use and frequencies of resistiveness to care and both abusive behaviors. A strong relationship between depression and abusive behaviors was also found in a study using MDS data from 5 US states.8 The other modifiable risk factors detected by that study were delusions, hallucinations, and constipation. Resistiveness to care was not included in this analysis and that may explain why the effects of delusions and hallucinations were considered stronger than the effects shown in our study. Constipation was not significantly related to abusive behavior in our study. Both the Leonard et al8 study and our study did not find a significant relationship between the occurrence of pain and abusive behaviors. Our results suggest that depression and lack of understanding contribute to abusive behaviors and that antidepressants should be the first line of medication for individuals exhibiting abusive behavior if nonpharmacological strategies are ineffective. This suggestion is supported by results of the Depression in Alzheimer Disease Study, which found that treatment with sertraline decreased behavioral disturbance and caregiver distress in patients whose depression responded to antidepressant treatment.29 Although antidepressant treatment may cause side effects,11 it is likely safer than treatment with antipsychotics, which may cause cerebrovascular incidents and increased mortality rate.30 Of course, prevention of escalation of resistiveness to care into combative behavior by nonpharmacological strategies would avoid all side effects of psychoactive medications. REFERENCES 1. Gates D, Fitzwater E, Succop P. Relationship of stressors, strain, and anger to caregiver assaults. Issues Ment Health Nurs 2003;24:775–793. 2. Cohen-Mansfield J, Marx MS, Werner P, Freedman L. Temporal patterns of agitated nursing home residents. Int Psychogeriatr 1992;4:197–206. 3. Mahoney EK, Hurley AC, Volicer L, et al. Development and testing of the resistiveness to care scale. Res Nurs Health 1999;22:27–38. 4. Volicer L, Bass EA, Luther SL. Agitation and resistiveness to care are two separate behavioral syndromes of dementia. J Am Med Dir Assoc 2007;8: 527–532. 5. Morris JN, Hawes C, Fries BE, et al. Designing the national resident assessment instrument for nursing homes. Gerontologist 1990;30:293–307. 6. Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive Performance Scale. J Gerontol 1994;49:M174–M182. 7. Lyketsos CG, Steele C, Galik E, et al. Physical aggression in dementia patients and its relationship to depression. Am J Psychiatry 1999;156: 66–71. 8. Leonard R, Tinetti ME, Allore HG, Drickamer MA. Potentially modifiable resident characteristics that are associated with physical or verbal aggression among nursing home residents with dementia. Arch Intern Med 2006;166:1295–1300. 9. Sloane PD, Honn VJ, Dwyer SAR, et al. Bathing the Alzheimer’s patient in long term care. Results and recommendations from three studies. Am J Alzheim Dis 1995;10:3–11. 10. Burrows AB, Morris JN, Simon SE, et al. Development of a Minimum Data Set–based depression rating scale for use in nursing homes. Age Ageing 2000;29:165–172.

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