1. Interreg-IPA Cross-border Cooperation Programme Romania-Serbia
10 noiembrie Timșoara, România
Interreg-IPA Cross-border Cooperation Programme Romania-Serbia
Agitation assessment scales
in Dementia
Slavica Nikolic Lalic, MD
November 2017
Employment promotion and basic services strengthening for an inclusive growth

2. Dementia Today Dementia is a global public health concern
The prevalence of dementia increases.
nearly 35.6 million people with dementia worldwide
expected - nearly 115 million by the year 2050
Dementia disease is best known as a memory disorder.
The hallmark of dementia is progressive cognitive and functional decline

3. Dementia Today II
However, behavioral and psychiatric symptoms may also occur
Many individuals with dementia will develop them.
over the course of the illness, nearly 97% of patients develop behavioral or psychiatric symptoms - “Behavioral and Psychological Symptoms of Dementia (BPSD).”

4. Behavioral and Psychological Symptoms
behavioral symptoms are the most challenging and distressing aspects of the disease.
These symptoms are often a determining factor in residential care placement.
They also have an enormous impact on quality of life for individuals in long-term care.

5. Evaluation of Behavioral Symptoms
International Psychogeriatric assotiation (IPA)-formulated a consensus definition about agitation in dementia
Anyone experiencing behavioral symptoms should receive a thorough medical evaluation.
With proper intervention, patients’ symptoms can often be reduced or stabilized.

6. Agitation in Dementia Contributing medical conditions may include:
Infections, uncorrected problems with hearing or vision, pain, medication side effects or drug interactions
Contributing environmental influences may include:
Change in caregiving arrangements
Admission to a hospital Presence of houseguests
Being asked to bathe or change clothes
Moving to a new home
Difficulty with expressing needs and wishes
Travel

7. Rating scales
Essential tools for diagnosis, staging, assessment and careful monitoring of AD symptoms as well as for evaluation of treatment effects.
For decades most AD assessments were predominantly focused on cognition, which is the lead symptom in AD
the symptoms more relevant to a patient's quality of life, caregiver burden and institutionalization - are functional and behavioral symptoms

8. Neuropsychiatric Inventory - NPI
The NPI is the behavior instrument most widely used in clinical trials of antidementia agents.
The NPI/NPI-C can be used to rate the presence of neuropsychiatric symptoms (NPS) across many domains
Measure for specific NPS domains (e.g., dysphoria, agitation), or a combination of both (presence of NPS across domains plus particular focus on one or more specific domains.)

9. Elements of the NPI
NPI assesses 10 (10-item NPI) or 12 (2-item NPI) behavioral domains common in dementia. These include:
Hallucinations
Delusions
Agitation/aggression
Dysphoria/depression
Anxiety
Irritability
Disinhibition
Euphoria
Apathy
Aberrant motor behavior
Sleep and night-time behavior change (12 item version only)
Appetite and eating change (12 item version only)

10. Key Aspects of the NPI track record in clinical trials
adds the behavioral dimension to outcomes in clinical trials
assesses behavioral changes s based on a standardized caregiver interview
integrated caregiver distress scale
training CDs available
outpatient, residential and brief clinical versions available
application across many neurologic and psychiatric disorders with behavioral profiles
translations available in many (more than 40) languages

11. NPI/NPI-C
Unlike the NPI, the NPI-C allows the rater to obtain additional caregiver and patient information to inform the rating for each item within a domain.
completing each of the three NPI-C sections: caregiver interview, patient interview, and clinician rating

12. CMAI-C The Cohen-Mansfiled agitation inventory (1986)
Agitation is operationally defined as: inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to result directly from the needs or confusion of the agitated individual.
Agitated behavior is always socially inappropriate, and can be manifested in three ways:
1. It may be abusive or aggressive toward self or other.
2. It may be appropriate behavior performed with inappropriate frequency, such as constantly asking questions.
3. It may be inappropriate according to social standards for the specific situation, as in taking off clothes in the activity room.

13. SCORING THE CMAI The rating scale for the agitated behaviors follows:
1 – Never
2 - Less than once a week but still occurring
3 - Once or twice a week
4 - Several times a week
5 - Once or twice a day
6 - Several times a day
7 - Several times an hour

14. VERSIONS OF THE COHEN-MANSFIELD AGITATION INVENTORY
Long form - This is the original assessment used with the nursing home population.
Long form with expanded definitions - This form gives additional examples of each behavior.
Short form - Only 14 agitated behavior categories are included, each rated on a 5-point frequency scale instead of a 7-point frequency scale.
Community form (CMAI-C) - this 37-item questionnaire has been used with formal and informal caregivers of community-dwelling elderly persons in a longitudinal study of agitation. This instrument is available in two formats: CMAI-C and the CMAI-Relative Form.
Disruptiveness form - The disruptiveness of each behavior is rated along with frequency.

15. Treatment Options for BPSD
There are two major types of treatment for behavioral symptoms:
Nondrug
strategies
2. Prescription
medications

16. The Non-Pharmacological Interventions
For the treatment of BPSD • Cognitive Interventions • Stimulant Based Interventions • Social Activity/Social Interaction • Physical Activity/Exercise/Dance • Environmental Interventions • Interventions For Caregivers and Stuff of Nursing Homes Psychoeducation Caregiver Support Group Therapy Case Management/ Counselling • Multicomponent Interventions

18. Helpful hints when a person becomes agitated
Things to do:
Use calm, positive statements
"Back off" and ask permission
Reassure
Slow down
Add light
Offer guided choices between two options
Focus on pleasant events
Offer simple exercise options
Try to limit stimulation

19. Helpful hints when a person becomes agitated
Things to say:
May I help you?
Do you have time to help me?
You are safe here.
Everything is under control.
I apologize.
I’m sorry that you are upset.
I know it’s hard.
I will stay with you until you feel better.

20. Helpful hints when a person becomes agitated
Do not:
Raise your voice
Make sudden movements
Show alarm or offense
Corner, crowd or restrain
Demand, force or confront
Rush or criticize
Ignore or argue
Shame or condescend

21. 10 noiembrie 2015 - Timșoara, România
Thank you!