BACKGROUND/RATIONALE:
Aggression has been documented to be highly prevalent in convenience samples of patients with dementia (25% to 50%); however, scant literature exists on the incidence of new aggression in patients with dementia. Without an accurate estimate of incidence, it is not possible to quantify the absolute risk of aggression. Identifiction of modifiable causal factors of aggression as a primary or secondary prevention strategy would fundamentally change the current approach to the treatment of aggression. Such a prevention strategy was the long-term goal of this research.
OBJECTIVE(S):
This was a 4-year prospective cohort study to empirically validate risk factors and consequences in an inception cohort of newly diagnosed, community-dwelling dementia patients. .
METHODS:
Patients and caregivers were assessed at baseline and every 4 months thereafter in their home and called monthly to test for the development of aggression. This 4-month cycle was repeated 6 times over 24 months. Home assessments included assessments to detect the development of aggression and assessments of putative risk factors, including patient factors (e.g., depression, psychosis, pain, and delirium) and factors external to the patient (e.g., social stimulation, caregiver burden, and quality of caregiver-patient relationship). Each month adverse consequences, including nursing home placement, injury to caregiver or self, and use of physical restraints or anxiolytic/antipsychotics, were tracked.
FINDINGS/RESULTS:
Incidence of Aggression: Forty percent of the cohort of newly diagnosed, non-aggressive dementia patients became aggressive; but a rate of only 25% was anticipated, based on previous literature.
Quality of Care for Aggressive Dementia Patients: Practice guidelines were used as a benchmark to examine standard/quality of care. Aggression was infrequently recognized and assessed, particularly in primary care. Non-pharmacologic interventions were rarely used despite their recommendations as a first- line intervention.
Causes of Aggression: Intensive follow-up of newly diagnosed, previously non-aggressive dementia patients revealed several modifiable causes of aggression, including depression, pain, psychosis, caregiver burden, and caregiver-patient relationship. All have important implications for the assessment and treatment of this special population.
Consequences of Aggression: Aggression among newly diagnosed dementia patients leads to greater use of medication; more nursing home placements; and more injuries to the patient, caregiver, and others.
Antipsychotic Use in Non-Aggressive Dementia Patients: Despite recommended guidelines, few physicians used non-pharmacologic interventions for this group of newly diagnosed, non-aggressive dementia patients; however, physicians prescribed antipsychotics for a sizeable minority of them.
IMPACT:
This study resulted in one published, three submitted, and five planned/in preparation manuscripts that make the strongest contribution to date to the literature on the enormous unmet needs of newly diagnosed dementia patients with and without aggression. The longitudinal cohort study helped to determine the extent to which mutable determinants cause aggression and can be used as a foundation to develop strategies and interventions to prevent aggression. Such a preventive approach could fundamentally change the approach to dementia patients with aggression from that of tertiary prevention strategies, primarily using restraints and tranquilizing medications, to an innovative secondary prevention strategy. By reducing aggressive behaviors, such an intervention could potentially reduce institutionalization, injuries, restraint and anxiolytic/antipsychotic use, and utilization of other health services. Such an intervention strategy is currently being developed for a future proposal.
PUBLICATIONS:
Journal Articles
- Kunik ME, Walgama JP, Snow AL, Davila JA, Schulz PE, Steele AB, Morgan RO. Documentation, assessment, and treatment of aggression in patients with newly diagnosed dementia. Alzheimer Disease and Associated Disorders. 2007; 21(2): 115-21.
- Simpson SM, Krishnan LL, Kunik ME, Ruiz P. Racial disparities in diagnosis and treatment of depression: a literature review. Psychiatric Quarterly. 2007; 78(1): 3-14.
- Veazey C, Aki SO, Cook KF, Lai EC, Kunik ME. Prevalence and treatment of depression in Parkinson's disease. The Journal of Neuropsychiatry and Clinical Neurosciences. 2005; 17(3): 310-23.
- Kunik ME, Cully JA, Snow AL, Souchek J, Sullivan G, Ashton CM. Treatable comorbid conditions and use of VA health care services among patients with dementia. Psychiatric Services. 2005; 56(1): 70-5.
