A Meta-Analysis of the Variables related to Agitation in Patients with Dementia

Heeok Park; Minsuk Gang; Eunsil Park

doi:10.7469/kjan.2016.28.2.213

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A Meta-Analysis of the Variables related to Agitation in Patients with Dementia

Heeok Park¹, Minsuk Gang², Eunsil Park³

Korean Journal of Adult Nursing 2016;28(2):213-225.
Published online: April 30, 2016

DOI: https://doi.org/10.7469/kjan.2016.28.2.213

¹College of Nursing, Keimyung University ․ Research Institute of Nursing Science, Keimyung University, Daegu

²Graduate School, Keimyung University, Daegu

³Department of Nursing, Hosan University, Gyeongsan, Korea

Corresponding author: Gang, Minsuk Graduate School, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 704-701, Korea. Tel: +82-53-580-3961, Fax: +82-53-580-3963, E-mail: kms4790@kmu.ac.kr

• Received: February 29, 2016 • Accepted: April 22, 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
REFERENCES

Abstract

Purpose
The purpose of this study was to provide basic data about agitation in patients with dementia by surveying the literature.
Method
Key words used for search through hand-search and electronic database (CINHAL, Pubmed, Google scholar, Riss, Kiss, DBpia) included 'dementia', 'Alzheimer disease', ‘agitation’, ‘aggression or aggressive behavior’, ‘problem or disruptive behavior’, and ‘abnormal behavior.’ Seventeen studies met the inclusion criteria for the Meta-analysis and ‘R’ version 3.2.2 was used to analyze the correlated effect size.
Results
Study results showed that variables related to agitation were identified as the demographic (age, gender), dementia-related (cognition, medication uses), physical (Activity of Daily Living [ADL], pain), psychological (depression, psychotic symptom, caregiver burden) and environmental (psychosocial environment) factors. The effect size between the correlated variables and agitation were low to moderate (caregiver burden .36; ADL -.24; psychotic symptom and depression .21; pain .19; cognition -.15; medication uses .12; and psychosocial environment -.12).
Conclusion
Based on the findings of this study, strategies to improve patients’ depressive and psychotic symptoms and ADL and to reduce caregivers’ burden are needed for prevention and management of agitation in patients with dementia.
Key Words: Psychomotor agitation; Dementia; Meta-analysis

Figure 1.

Flowchart of study selection.

Figure 2.

Forest plots of the effects size of variables related to agitation in patients with dementia.

Figure 3.

Regression of moderator variables in cognition.

Table 1.

Characteristics of Studies Included in Meta-Analysis

Researchers (year)	Country	Publication	Sample size	e Setting	Related variables	Agitation measurement	Quality assessment
Teri et al. (1989)^a1)	USA	Journal	56	Community	Cognition, ADL	BPC	10
Hamel et al. (1990)^a2)	Canada	Journal	175	Community	Caregiver burden,	Ryden aggression scale	10
Hamel et al. (1990)^a2)	Canada	Journal	175	Community	Psychosocial environment	Ryden aggression scale	10
Beck et al. (1998)^a3)	USA	Journal	88	Nursing home	Age, Cognition,	DBS	11
Beck et al. (1998)^a3)	USA	Journal	88	Nursing home	Depression	DBS	11
Lyketsos et al. (1999)^a4)	USA	Journal	541	Community	Age, Gender, Cognition,	CMAI	10
					ADL, Depression,
					Psychotic symptom
Harwood et al. (2000)^a5)	USA	Journal	114	Outpatient clinic	Cognition, ADL	RMBPC, BEHAVE-AD	9
Buffum et al. (2001)^a6)	USA	Journal	33	Nursing home	Cognition, Pain	CMAI	10
Rapoport et al. (2001)^a7)	Canada	Journal	60	Outpatient clinic	Psychotic symptom	NPI-agitation	9
Talerico et al. (2002)^a8)	USA	Journal	405	Nursing home	Cognition, Medication use,	PGDRS	10
Talerico et al. (2002)^a8)	USA	Journal	405	Nursing home	Depression	PGDRS	10
Chan et al. (2003)^a9)	USA	Journal	150	Community	Age, Gender, Cognition,	BSRS	9
Chan et al. (2003)^a9)	USA	Journal	150	Community	ADL	BSRS	9
Pelletier et al. (2007)^a10)	Canada	Journal	49	Long-term facility	Cognition, ADL, Pain	CMAI	11
Testad et al. (2007)^a11)	Norway	Journal	211	Nursing home	Medication use	CMAI	9
Zuidema et al. (2010)^a12)	Netherlands	s Journal	1019	Nursing home	Cognition, Medication use,	NPI-NH agitation disinhibition irritability	11
					Psychosocial environment

Kunik et al. (2010)^a13)	USA	Journal	215	Community	Age, Gender, Cognition,	CMAI	11
					Pain, Depression,
					Psychotic symptom,
					Caregiver burden,
					Psychosocial environment
Volicer et al. (2012)^a14)	Netherlands	s Journal	1101	Nursing home	Pain, Depression,	MDS	10
Volicer et al. (2012)^a14)	Netherlands	s Journal	1101	Nursing home	Psychotic symptom	MDS	10
Cohen-Mansfield et al. (2012)^a15)	d USA	Journal	193	Nursing home	Age, Cognition,	Agitation Behavior Mapping Inventory	10
					Medication use, ADL

Kwan (2013)^a16)	Korea	Thesis	180	Nursing home	Cognition, Depression	Ryden aggression scale	10
Kwan (2013)^a16)	Korea	Thesis	180	Nursing home		Ryden aggression scale	10
Morgan et al. (2013)^a17)	USA	Journal	171	Community	Cognition, Pain, Depression	, CMAI	11
					Caregiver burden,
					Psychosocial environment

ADL=activity of daily living; BPC=behavioral problems checklist; DBS=disruptive behavior scale; CMAI=cohen-mansfield agitation inventory; RMBPC=revised memory and behavior problem checklist; BEHAVE-AD=behavioral pathology in Alzheimer's disease scale; NPI=neuropsychiatric inventory; PGDRS=psychogeriatric dependency rating scale; BSRS=behavior symptom rating scale; NPI-NH=neuropsychiatric inventory nursing home version; MDS=minimum data set.

Table 2.

Subgroup Analysis of Moderator Variables in Cognition

Variables	Categories	k	ES	-95% CI	+95% CI	I² (%)	Qb (p)	R² (%)
Setting	Community & outpatient clinic	7	-.17	-.22	-.11	0.0	0.07
Setting	Nursing home & long-term facility	8	-.15	-.24	-.07	61.4	(.789)
Severity of dementia	Below & moderate	8	-.14	-.20	-.09	5.4	0.19
Severity of dementia	Severe	7	-.16	-.25	-.07	68.6	(.662)
Cognition measurement	Type of score	13	-.17	-.22	-.12	18.3	11.10	80.7
Cognition measurement	Type of grade	2	-.05	-.10	-.01	0.0	(＜.001)
Agitation measurement	CMAI	6	-.20	-.25	-.14	0.0	2.39
Agitation measurement	Others	9	-.13	-.19	-.06	52.6	(.122)

k=number of studies; CI=confidence interval; I

²=the proportion of true variance; Q_b=value between subgroup; R

²=the proportion of explained between study variance; MMSE=mini-mental state examination; DRS=dementia rating scale; FAST=functional assessment staging; GDS=global deterioration scale; CMAI=cohen-mansfield agitation inventory.

REFERENCES

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2.Oh BH. Diagnosis and treatment for behavioral and psychological symptoms of dementia. Journal of the Korean Medical Association. 2009;52(11):1048-54.
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3.Cohen-Mansfield J, Billig N. Agitated behaviors in the elderly: I. a conceptual review. Journal of the American Geriatrics Society. 1986;34(10):711-21. http://dx.doi.org/10.1111/j.1532-5415.1986.tb04302.x.
4.Cerejeira J, Lagarto L, Mukaetova-Ladinska EB. Behavioral and psychological symptoms of dementia. Frontiers in Neurology. 2012;3(73):1-21. http://dx.doi.org/10.3389/fneur.2012.00073.
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6.Brodaty H, Draper B, Low LF. Nursing home staff attitudes towards residents with dementia: strain and satisfaction with work. Journal of Advanced Nursing. 2003;44(6):583-90. http://dx.doi.org/10.1046/j.0309-2402.2003.02848.x.
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7.Pitkala KH, Laurila JV, Strandberg TE, Tilvis RS. Behavioral symptoms and the administration of psychotropic drugs to aged patients with dementia in nursing homes and in acute geriatric wards. International Psychogeriatrics. 2004;16(01):61-74. http://dx.doi.org/10.1017/s1041610204000079.
8.Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. The Journal of the American Medical Association. 2012;308(19):2020-9. http://dx.doi.org/10.1001/jama.2012.36918.
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12.Estabrooks CA, Floyd JA, Scott Findlay S, O'Leary KA, Gushta M. Individual determinants of research utilization: a systematic review. Journal of advanced nursing. 2003;43(5):506-20. http://dx.doi.org/10.1046/j.1365-2648.2003.02748.x.
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A Meta-Analysis of the Variables related to Agitation in Patients with Dementia

Korean J Adult Nurs. 2016;28(2):213-225. Published online April 30, 2016

DOI: https://doi.org/10.7475/kjan.2016.28.2.213

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A Meta-Analysis of the Variables related to Agitation in Patients with Dementia

Korean J Adult Nurs. 2016;28(2):213-225. Published online April 30, 2016

DOI: https://doi.org/10.7475/kjan.2016.28.2.213

Figure

A Meta-Analysis of the Variables related to Agitation in Patients with Dementia

Figure 1. Flowchart of study selection.

Figure 2. Forest plots of the effects size of variables related to agitation in patients with dementia.

Figure 3. Regression of moderator variables in cognition.

Figure 1.

Figure 2.

Figure 3.

A Meta-Analysis of the Variables related to Agitation in Patients with Dementia

Table 1.

Characteristics of Studies Included in Meta-Analysis

Researchers (year)	Country	Publication	Sample size	e Setting	Related variables	Agitation measurement	Quality assessment
Teri et al. (1989)^a1)	USA	Journal	56	Community	Cognition, ADL	BPC	10
Hamel et al. (1990)^a2)	Canada	Journal	175	Community	Caregiver burden,	Ryden aggression scale	10
Hamel et al. (1990)^a2)	Canada	Journal	175	Community	Psychosocial environment	Ryden aggression scale	10
Beck et al. (1998)^a3)	USA	Journal	88	Nursing home	Age, Cognition,	DBS	11
Beck et al. (1998)^a3)	USA	Journal	88	Nursing home	Depression	DBS	11
Lyketsos et al. (1999)^a4)	USA	Journal	541	Community	Age, Gender, Cognition,	CMAI	10
					ADL, Depression,
					Psychotic symptom
Harwood et al. (2000)^a5)	USA	Journal	114	Outpatient clinic	Cognition, ADL	RMBPC, BEHAVE-AD	9
Buffum et al. (2001)^a6)	USA	Journal	33	Nursing home	Cognition, Pain	CMAI	10
Rapoport et al. (2001)^a7)	Canada	Journal	60	Outpatient clinic	Psychotic symptom	NPI-agitation	9
Talerico et al. (2002)^a8)	USA	Journal	405	Nursing home	Cognition, Medication use,	PGDRS	10
Talerico et al. (2002)^a8)	USA	Journal	405	Nursing home	Depression	PGDRS	10
Chan et al. (2003)^a9)	USA	Journal	150	Community	Age, Gender, Cognition,	BSRS	9
Chan et al. (2003)^a9)	USA	Journal	150	Community	ADL	BSRS	9
Pelletier et al. (2007)^a10)	Canada	Journal	49	Long-term facility	Cognition, ADL, Pain	CMAI	11
Testad et al. (2007)^a11)	Norway	Journal	211	Nursing home	Medication use	CMAI	9
Zuidema et al. (2010)^a12)	Netherlands	s Journal	1019	Nursing home	Cognition, Medication use,	NPI-NH agitation disinhibition irritability	11
					Psychosocial environment

Kunik et al. (2010)^a13)	USA	Journal	215	Community	Age, Gender, Cognition,	CMAI	11
					Pain, Depression,
					Psychotic symptom,
					Caregiver burden,
					Psychosocial environment
Volicer et al. (2012)^a14)	Netherlands	s Journal	1101	Nursing home	Pain, Depression,	MDS	10
Volicer et al. (2012)^a14)	Netherlands	s Journal	1101	Nursing home	Psychotic symptom	MDS	10
Cohen-Mansfield et al. (2012)^a15)	d USA	Journal	193	Nursing home	Age, Cognition,	Agitation Behavior Mapping Inventory	10
					Medication use, ADL

Kwan (2013)^a16)	Korea	Thesis	180	Nursing home	Cognition, Depression	Ryden aggression scale	10
Kwan (2013)^a16)	Korea	Thesis	180	Nursing home		Ryden aggression scale	10
Morgan et al. (2013)^a17)	USA	Journal	171	Community	Cognition, Pain, Depression	, CMAI	11
					Caregiver burden,
					Psychosocial environment

Table 2.

Subgroup Analysis of Moderator Variables in Cognition

Variables	Categories	k	ES	-95% CI	+95% CI	I² (%)	Qb (p)	R² (%)
Setting	Community & outpatient clinic	7	-.17	-.22	-.11	0.0	0.07
Setting	Nursing home & long-term facility	8	-.15	-.24	-.07	61.4	(.789)
Severity of dementia	Below & moderate	8	-.14	-.20	-.09	5.4	0.19
Severity of dementia	Severe	7	-.16	-.25	-.07	68.6	(.662)
Cognition measurement	Type of score	13	-.17	-.22	-.12	18.3	11.10	80.7
Cognition measurement	Type of grade	2	-.05	-.10	-.01	0.0	(＜.001)
Agitation measurement	CMAI	6	-.20	-.25	-.14	0.0	2.39
Agitation measurement	Others	9	-.13	-.19	-.06	52.6	(.122)

k=number of studies; CI=confidence interval; I

²=the proportion of true variance; Q_b=value between subgroup; R

Table 1. Characteristics of Studies Included in Meta-Analysis

Table 2. Subgroup Analysis of Moderator Variables in Cognition

k=number of studies; CI=confidence interval; I

=the proportion of true variance; Q_b=value between subgroup; R

=the proportion of explained between study variance; MMSE=mini-mental state examination; DRS=dementia rating scale; FAST=functional assessment staging; GDS=global deterioration scale; CMAI=cohen-mansfield agitation inventory.

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