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Original Article

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

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

Copyright © 2016 Korean Society of Adult Nursing

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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  • 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.
kjan-28-213f1.jpg
Figure 2.
Forest plots of the effects size of variables related to agitation in patients with dementia.
kjan-28-213f2.jpg
Figure 3.
Regression of moderator variables in cognition.
kjan-28-213f3.jpg
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
Psychosocial environment
Beck et al. (1998)a3) USA Journal 88 Nursing home Age, Cognition, DBS 11
Depression
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
Depression
Chan et al. (2003)a9) USA Journal 150 Community Age, Gender, Cognition, BSRS 9
ADL
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
Psychotic symptom
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
 
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  
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
Severe 7 -.16 -.25 -.07 68.6 (.662)
Cognition measurement Type of score 13 -.17 -.22 -.12 18.3 11.10 80.7
Type of grade 2 -.05 -.10 -.01 0.0 (＜.001)  
Agitation measurement CMAI 6 -.20 -.25 -.14 0.0 2.39
Others 9 -.13 -.19 -.06 52.6 (.122)

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

2=the proportion of true variance; Qb=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.

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

      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
      Psychosocial environment
      Beck et al. (1998)a3) USA Journal 88 Nursing home Age, Cognition, DBS 11
      Depression
      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
      Depression
      Chan et al. (2003)a9) USA Journal 150 Community Age, Gender, Cognition, BSRS 9
      ADL
      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
      Psychotic symptom
      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
       
      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.

      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  
      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
      Severe 7 -.16 -.25 -.07 68.6 (.662)
      Cognition measurement Type of score 13 -.17 -.22 -.12 18.3 11.10 80.7
      Type of grade 2 -.05 -.10 -.01 0.0 (＜.001)  
      Agitation measurement CMAI 6 -.20 -.25 -.14 0.0 2.39
      Others 9 -.13 -.19 -.06 52.6 (.122)

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

      2=the proportion of true variance; Qb=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.
      Table 1. Characteristics of Studies Included in Meta-Analysis

      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

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

      =the proportion of true variance; Qb=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.

      Table 1.

      Table 2.

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