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P10. Behavioural and psychological symptoms of dementia

Detailed programme and abstracts

P10.1. Using iPad loaded with family videos with patients with dementia 

HELMER Corrina, IP Alice,  AU YEUNG Andy,  ELIJAH, Levi, HUNG Lillian

Staying in the hospital can be a very stressful experience for patients with dementia. A familiar face and reassuring voice of a trusted loved one can offer a sense safety and comfort. This innovative project examines whether using an iPad to play a video purposively created for the patient by his or her family may contribute to enhancing safety and quality of care. We used a mixed method approach. The intervention involved inviting patient participants in two hospital wards to watch a one-minute video of their family. The recorded video made by family included a reassuring, comforting and supportive message to help the patient feel safe and allow staff to help with a specific care task. The process was examined by structural observations (Dementia Observation System) and with video recording. We conducted statistical analysis of the quantitative ratings of behavioural and mood changes in patient participants to compare mean differences between baseline phase (A1) and intervention phase (B1). Also, we conducted staff interviews and video analysis to investigate contextual factors and staff experiences. Our findings lend support to the positive effects of the intervention. When the intervention of iPad was introduced during B1 phase, our results showed a significant change in mood, engagement and participation. Staff described key factors that influenced the effect of the intervention included: (a) knowledge and skills of staff in applying person-centred care approach, (b) the nature of the videos, and (c) environmental factors. Other lessons learned that enabled the success of the intervention will be discussed in this presentation. This study is among the first to examine the effects of using an iPad loaded with family videos to reassure patients with dementia and promote safety and quality of care in the setting of hospital.  


P10.3. Severe agitation in NH residents with dementia – prevalence and associated factors in German nursing homes

Palm Rebecca, SCHWAB Christian, GERRITSEN Debby, HOLLE Bernhard

Background: Neuropsychiatric symptoms are core features of dementia and prevalent in up to 80% of nursing home residents. Symptoms of agitation are the most straining for carers which may increase drug prescription. Hardly any knowledge exists about the prevalence and associated factors of severe agitation although it is important to develop interventions based on known risk factors.

Methods: We conducted a secondary data analysis using a sample of 1,967 residents from 66 German nursing homes who participated in the DemenzMonitor study between 2012 and 2014. The residents who were selected for analysis had a medical diagnosis of dementia in their records and were screened positive for at least mild cognitive impairment. For every resident, neuropsychiatric symptoms were assessed with the NPI-Q. Following the definition of the International Psychogeriatric Association for agitation and a Mokken analysis of the data, we constructed a dichotomous dependent variable based on the NPI-Q-items agitation, disinhibition and irritability: it was positive in residents who scored ‘severe’ on at least one of these symptoms and negative in residents who did not show the symptoms at all. We performed descriptive statistics and a generalized linear mixed model.

Results: Of the 1,967 participants, 124 (6.3%) showed symptoms of severe agitation, disinhibition or irritability. 1,008 (51.2%) did not show any of these symptoms and 835 (42.5%) showed mild or moderate symptoms. Significant associations of severe agitation, disinhibition or irritability were found for the variables male sex (OR 2.7, p=.001), euphoria (OR 7.6, p≤.001), delusions (OR 7.4, p≤.001) and anxiety (OR 1.9, p=.034).

Conclusions: Delusions and euphoria may be considered as risk factors for severe agitation, especially in male residents. Carers of residents with these symptoms could benefit from getting support on how to avoid severe agitation by managing delusions and euphoria appropriately

P10.4. Nursing staff distress associated with neuropsychiatric symptoms in young-onset dementia and late-onset dementia


Background: Neuropsychiatric symptoms (NPS) are common in nursing home residents with dementia in general and residents with young-onset dementia (YOD) in particular. For late-onset dementia (LOD), NPS are associated with increased burden and diminished nursing staff well-being. Little is known about the impact of NPS on nurses caring for residents with YOD. Knowledge about the impact of NPS on nursing staff can provide insight in supporting YOD nursing staff in the management of NPS.

Objective: Aim of this study was (1) to investigate the relationship between different neuropsychiatric symptoms (NPS) and the level of distress experienced by nurses caring for residents with young-onset dementia (YOD) and (2) to compare these findings with those for nurses caring for residents with late-onset dementia (LOD).

Methods: This is a retrospective study in Dutch long-term care facilities. Data were used from the Behavior and Evolution of Young-ONset Dementia studies (BEYOND) Parts 1 and 2 resulting in a study-population of 382 residents with YOD. A LOD comparison group (n=261) was selected from the WAAL Behavior in Dementia-II (Waalbed-II) study. The Neuropsychiatric Inventory, nursing home version, was used to assess nursing staff distress and the frequency (F) and severity (S) of NPS. Multilevel logistic regression analysis was used to investigate the relationships among nursing staff distress related to NPS and YOD and LOD care units, the F x S score per symptom, gender, dementia subtype and dementia severity.

Results: Nurses working in YOD care units rated sleep and nighttime behavior disorders, delusions and agitation/aggression most often as highly distressing and euphoria most often as not distressing. Multivariate analyses indicated that the frequency and severity of NPS were significantly associated with staff distress in all symptoms, except for apathy. Comparing the two groups of nurses demonstrated that the odds for distress related to sleep and nighttime behavior disorders were higher for nurses in YOD care units than for nurses in LOD units. For both the YOD and LOD nurses, the irritability of male residents had a greater effect than similar behavior in female residents.

Conclusion: This study provides important insight into distress related to individual NPS and the interaction with residents’ characteristics. All NPS result in distress. The frequency and severity of the behavior is an important predictor. Sleep and nighttime behavior disorders are more likely to result in distress in YOD nurses than in LOD nurses. The amount of distress related to NPS emphasizes the urgent need for adequate management of NPS and the support of professional caregivers.

P10.5. Is there a place for “expressed emotion” in our understanding of BPSD?


Family issues are at the heart of bio-psycho-social approaches to the way we manage dementia. Clinical experience and a growing amount of evidence suggest circularities involving part of the behavioural and psychological symptoms of dementia (BPSD) and the family.

Both negative and positive consequences of caregiving influence the expression of depression, agitation, withdrawal or other behaviours in people with dementia. Families are often capable of managing many challenges. However, some family-related issues may also impact BPSD negatively. Expressed emotion (EE), sometimes confused with ability to express own feelings, is amongst them. EE, a triad of overinvolvement, criticism and hostility, was described in relatives of people with schizophrenia, and is now recognised as a robust predictor of psychotic relapse. Thereafter, it was reported in chronic disorders such as depression, diabetes and back pain. Despite the ongoing “trait versus state” debate, EE is mostly viewed as an ‘emotional thermometer’, reflecting a heavy family atmosphere and challenging health problems in care receivers. Its actual meaning in BPSD, as e.g. cause, consequence/burden correlate, remains partly undefined.

Discussing EE must not overshadow the family’s role as the most powerful positive resource throughout dementia. Although further research is needed, the systemic principle of circularity (integrating both directions of causality) may be a heuristic assumption regarding part of the BPSD picture. Mediator or modulator variables, such as person with dementia/caregivers’ personality, and their past and present relationship quality, also deserve exploration. Scarcity of evidence of a predictive relationship between EE and BPSD may be accounted for by different reasons, including lack of longitudinal studies and methodological issues.

In this presentation, evidence and clinical illustrations will be discussed. Family issues must be assessed in order to judge their importance in the BPSD context. This is a necessary step towards whatever intervention is both indicated and possible.

Acknowledgment: this presentation is widely based on Gonçalves-Pereira M, Marques MJ, Grácio J. Family Issues in Behavioral and Psychological Symptoms of Dementia: Unraveling Circular Pathways? and Gonçalves-Pereira M. Toward a Family-Sensitive Practice in Dementia. In: Verdelho A, Gonçalves-Pereira M. (Eds.): Neuropsychiatric symptoms in cognitive impairment and dementia. Springer, 2017. (pp: 331-348, and 349-368) DOI: 10.1007/978-3-319-39138-0.

P10.6. Designing enabling buildings for people with dementia: How can this reduce distressed behaviour?


Designing buildings which enable people with dementia rather than disable them has multiple benefits: as well as reducing falls, it can give people more independence, confidence and self-esteem. Importantly, there is also evidence that it can reduce distressed behaviour. This term is preferred to ones like BPSD or 'challenging' behaviour which tend then to describe the behaviour in pejorative terms such as aggression and violence, wandering, resistance, shouting and so on. Some distressed behaviour may need to be seen as a reaction to a ‘hostile’ environment.

This paper synthesises the results of secondary analysis of data on critical incidents gathered from acute hospital, residential care and mental health unit settings. It also draws on a critical review of systematically gathered research evidence on impact of aspects of design on distressed behaviour by people with dementia and some research on prisons and schools. Our analysis demonstrates that some aspects of design have a substantial impact on behaviour. The review sheds light on the extent to which the existing evidence base helps to explain why some designs work better than others at reducing distressed behaviour.

Synthesis of these two sets of results advances knowledge, and stimulates interest and debate on how to design such units so that this source of unnecessary disability is as far as possible prevented. It suggests ways that design can reduce distressed behaviour. The paper contributes to greater understanding of how to improve the design of dementia care settings and will inform designers, commissioners and managers alike. We hope it will encourage more commissioners to insist on dementia enabling design in both new buildings and refurbishments.



Last Updated: Monday 23 October 2017


  • Acknowledgements

    The 27th AE Conference in Berlin received funding under an operating grant from the European Union’s Health Programme (2014-2020). Alzheimer Europe and Deutsche Alzheimer Gesellschaft e.V. gratefully acknowledge the support of all conference sponsors.
  • European Union
  • Roche