Modifiable Factors Predict Aggression in Dementia

By Karla Gale

NEW YORK (Reuters Health) Mar 26 - Aggressive behavior in patients with recent-onset dementia is linked with pain, caregiver burden at baseline, and declining quality of the caregiver-patient relationship, prospective study findings suggest.

"Historically, behavioral problems (in patients with dementia), such as aggression, have been treated with tranquilizing medications without regard to what might be causing the behavior," lead author Dr. Mark E. Kunik told Reuters Health. The medications are not particularly effective and often result in side effects, he said.

"By understanding possible causes, we can develop (nonpharmacologic) interventions to prevent the development of aggression or more effectively treat aggression once it develops," he added.

Dr. Kunik, from the Michael E. DeBakey Veterans Affairs Medical Center, Houston, and colleagues studied 215 community-dwelling patients diagnosed in the past year with dementia, and their caregivers. They excluded patients who had shown aggressive behavior since their diagnosis.

All subjects were at least 60 years old; their mean age was 76, and 95% were men.

Every four months for the next two years, the researchers assessed patients for frequency and disruptiveness of aggression (taking into account spitting, cursing and other verbal aggression, physically trying to hurt themselves or others, destroying property, and making inappropriate verbal and/or physical sexual advances).

The research team also analyzed caregiver burden, along with the quality of the patient-caregiver relationship ("mutuality"), including the frequency of communication, positive engaging interactions, attachment, and emotional support.

As they report in a March 9 online article in the Journal of Clinical Psychiatry, 89 patients (41%) developed aggression (0.37 cases per year at risk). Several baseline characteristics were associated with aggression, including dementia severity, lower mutuality score, and higher scores for depression, hallucinations, delusions, and caregiver burden.

On multivariate analysis, higher levels of baseline caregiver burden (p = 0.002), worst pain (p = 0.01), and decline in mutuality over time (p = 0.006) were independently associated with increased risk of aggression.

"Caregivers do play an important role in the onset of aggression, but it is important to not place blame on the caregiver," Dr. Kunik told Reuters Health by email. "Caregiving of patients is extremely stressful and often caregivers feel isolated and have little access to help or resources to help with caregiving."

He advises physicians to carefully screen for and treat pain in dementia patients.

"Pain is difficult to recognize in persons with dementia because of the language problems that are associated with dementia," he said. "Sometimes, the best way to prevent aggression may be the prescription of over-the-counter Tylenol (acetaminophen)." Is hetzelfde als paracetamol

He continued: "Physicians should also evaluate caregiver stress. Providing the number for the Alzheimer's Association can be extremely helpful. The Alzheimer's association has many resources for caregivers that are available online or in person. Some of the resources are educational and others offer direct support such as care consultation and support groups."

The authors note that their study did not differentiate types of dementia, and that it suffered from attrition at all stages of the project and from the large male composition of the population.

Nevertheless, Dr. Kunik concluded, "The identification of causes of aggression and aiming to prevent aggression is a fundamental shift in how aggression is currently managed."

J Clin Psychiatry 2010.