INDUCTORES/MODIFICADORES DE

LOS SPCD (comorbilidad, iatrogenia, trato

inadecuado)
Elena Ubis Diez
Geriatra. Hospital Sagrado Corazn de Jess
Huesca


Introduccin

Modelo terico de los factores implicados

Factores neurobiolgicos

Factores psicolgicos

Factores sociales

Factores modificadores/precipitantes de la conducta

Modelo Need- Driven Demencia Compromised (NDB)

Precipitantes y causas algunos de los SPCD


Asociacin Internacional de Psicogeriatra(IPA) 2000

60 expertos, 16 pases

El trmino trastornos conductuales debera ser reemplazado por el

de sntomas psicolgicos y conductuales en las demencias (SCPD)

definido de este modo:
Sntomas de alteracin de la percepcin, del contenido del pensamiento, el
estado de nimo o la conducta, que a menudo se presentan en pacientes con
demencia

Demencias: reas afectadas

SPCD
(Sntomas psicolgicos y
conductuales)

Deterioro cognoscitivo

DEMENCIAS

AVD
(Actividades de la vida diaria)

Sobrecarga del
cuidador

FUNCIONAMIENTO GLOBAL

Clusters neuropsiquitricos en la
demencia

McShane, Int Psychogeriatr, 2000

Formas de inicio de la demencia

Deterioro cognitivo leve

Sndrome depresivo/ Apata

Alteraciones de conducta / Personalidad

Alucinaciones / Delirio

A. Moriigo, 2010

Impacto de los SPCD

Cummings, 2004

Por qu algunos pacientes con

demencia desarrollan sntomas,
mientras que otros no?
Modelo:

Factores neurobiolgicos (neuroqumicos, neuropatolgicos o

genticos)

Factores psicolgicos (personalidad premrbida, respuesta al

estrs)

Factores sociales (entorno y cuidador)

Factores neurobiolgicos

Disfuncin y muerte cerebral

Disminucin de sntesis de NT:

Ach: N. Basal Meyner

NA: Locus Ceruleus

S: N.rafe

Dopa: Sustancia Negra

Disfuncin de sistemas neuronales:

Sistema Lmbico

Circuitos subcorticales frontales
Cummings, 2004

Sntomas
neuropsiquitricos

Neuroqumica

Neuropatologa

Apata

Ach

Disfuncin circuitos
frontosubcorticales

Depresin

NA en cortex
S
Dopamina en prosubiculun
Monoaminas

Lesiones sustancia blanca

Disfuncin sistema lmbico
Prdida neuronal en locus ceruleus,
n. rafe

Agitacin

Ach
S en lbulos frontales

Disfuncin frontal y temporal

Prdida neuronal en locus ceruleus

Psicosis

Ach
S
NA en sustancia negra

Disfuncin sistema lmbico

Disfuncin temporal y parietal dcho
Alteracin vas pticas y TE

Alteracin personalidad

Ach frontal

Disfuncin frontal
N Basal de Meynert

Vagabundeo

Ach y DOPA

Disfuncin parieto-temporal izda

Factores psicolgicos

Personalidad premrbida:

Suspicaces

Agresivos

Controladores

Respuesta al estrs

Clment JP, Darthourt N, Nubukpo P.

Life events, personality and dementia.
Psychol Neuropsychiatr Vieil. 2003;1(2):129-38
Abstract
Etiopathogeny of dementia is presently considered as multidimensional, involving genetic,
biological and psychological factors. This study was aimed to find out if life events and personality
People
suffering
fromanddementia
hadtosignificant
personality
s higher
are risk factors
for dementia
varied according
the type of dementia.
54 subjectstrait
meeting
the
DSMcontrols
IV criteria for
dementia
were includedavoidance,
and compared toobsessive
54 cognitivelyfeatures
controls. 25and
patients
than
such
as passivity,
had dementia of Alzheimer type, 17 frontotemporal dementia and 12 vascular dementia. Data
alexithymia.
However,
no difference
personality
traits
collection was performed
using various
questionnaireswas
filled found
in by the in
patients
and caregivers:
questionnaire
EVVIE forwith
life events,
French version
of the
traits (VKP)
the ults
between
subjects
the the
different
types
ofpersonality
dementia.
Theseforres
assessment of personality, a questionnaire for diagnosing alexithymia (EFEA), the mini-geriatric
suggest
that
stress
and personality
could
depression
scalepsychosocial
for depression, andcumulative
the Neuropsychiatric
Inventory
for behavioural disorders.
Cognitive function
assessedfor
by the
Mini Mental State
Examination,
Global
constitute
a riskwasfactor
dementia,
which
could and
bethe
mediated
by a
Deterioration Scale. Significant differences were found between people suffering from dementia
dysregulation
the HPA
axis.of several life events occurred during childhood, marital
and controls for theinfrequency
and impact
or professional life. Some qualitative but no quantitative differences in life events experienced were
found between patients with different types of dementia. People suffering from dementia had
significant personality traits higher than controls such as passivity, avoidance, obsessive features and
alexithymia. However, no difference was found in personality traits between subjects with the
different types of dementia. These results suggest that psychosocial cumulative stress and
personality could constitute a risk factor for dementia, which could be mediated by a dysregulation
in the HPA axis.

Gould SL, Hyer LA.

Dementia and behavioral disturbance: does premorbid personality really
matter?.
Psychol Rep. 2000;95(3):1072-8.

Specifically,
increased withdrawal and irritability after dementia onset
Abstract
This study
considerswith
the influence
of premorbid
personalitypersonality
on the expression
of behavioral
were
associated
an inhibited
premorbid
style.
In
disturbances among individuals with dementia. A total of 68 outpatients with a diagnosis of
addition,
a premorbidly
independent
personality
stylepersonality
was associ
ated
dementia were
assessed for current
cognitive functioning,
premorbid
traits,
and
with
less withdrawal.
research
needed
clarify
the some
role of
new behavioral
disturbancesFurther
since dementia
onset. is
The
results oftothis
study show
evidence for the
influence of on
personality
on thein
expression
of both irritability and
premorbid
personality
behaviors
this population.
withdrawal. Specifically, increased withdrawal and irritability after dementia onset were
associated with an inhibited premorbid personality style. In addition, a premorbidly
independent personality style was associated with less withdrawal. Further research is
needed to clarify the role of premorbid personality on behaviors in this population.

Carol Magai, Carl I. Cohen, Clayton Culver, David Gomberg, Chris Malatesta
Relation between premorbid personality and patterns of emotion expression
expression in
midmid- to latelate-stage dementia
Int J Geriatr Psychiatry 1997; 12:1092-1099
Abstract
Twenty-seven nursing home patients with mid- to late-stage dementia participated in a
Attachment
style was found to be related to the expression of
study of the relation between preillness personality, as indexed by attachment and
positive
affect, with
securely
attachedbehavior.
individuals
displaying
more
emotion regulation
style, and
current emotional
Preillness
measures were
completedaffect
by family
members
and current
assessments
of emotion were
by on
positive
than
avoidantly
attached
individuals.
Highsupplied
ratings
nursing home aides and family members; in addition, emotion was coded during a
premorbid
hostility were associated with higher rates of negative
family visit using an objective coding system for facial emotion expressions. Attachment
affect
and
lower
positive
affect.
These
findings
indicaattached
te that
style was
found
to be rates
relatedof
to the
expression
of positive
affect,
with securely
individuals displaying
affect than
avoidantly
attachedover
individuals.
premorbid
aspectsmore
of positive
personality
show
continuity
time,Ineven in
addition, high ratings on premorbid hostility were associated with higher rates of
mid
- to late-stage dementia
negative affect and lower rates of positive affect. These findings indicate that premorbid
aspects of personality show continuity over time, even in mid- to late-stage dementia

Archer, Nicola B.A et al.

Premorbid Personality and Behavioral and Psychological Symptoms in Probable
Alzheimer Disease
American Journal of Geriatric Psychiatry 2007;15: 202-213
Objectives: Previous research investigating the influence of premorbid personality on behavioral and psychological
symptoms in dementia (BPSD) has produced mixed findings. Addressing some limitations of previous studies,
the authors aimed to investigate whether some of the common individual symptoms of BPSD (depression, anxiety,
irritability, and aggression) were associated with key aspects of previous personality (neuroticism and
agreeableness); and also to perform an exploratory investigation into the broader influence of personality factors
on behavioral and psychological syndromes.

Conclusion: Lower premorbid agreeableness is associated with agitation

and irritability symptoms in Alzheimer disease and also predicts an
agitation/apathy syndrome. The relationship between premorbid
Methods: Two hundred eight patients with a diagnosis of probable Alzheimer disease were assessed for the presence
neuroticism
BPSD
less straightforward,
and(NPI).premorbid
of BPSD over the and
disease course
using is
the caregiver-rated
Neuropsychiatric Inventory
One or two
knowledgeable informants
rated
patients'
midlifeto
personalities
using a retrospective
version
of the NEO-FFI
neuroticism
does
not
appear
be
associated
with
depression
in
questionnaire.
Alzheimer
orwas
predict
affect
Results:
Premorbiddisease
neuroticism
correlatedan
with
anxietysyndrome.
and total NPI score, although not with depression.
Premorbid agreeableness was negatively correlated with agitation and irritability. Principal components analysis
of the 10 NPI behavioral domains identified three syndromes: agitation/apathy, psychosis, and affect. In
stepwise linear regression analyses, including personality domains from the Five-Factor Model and a range of
potential confounders as independent variables; the only significant personality predictor of a behavioral
syndrome was agitation/apathy, predicted by lower premorbid agreeableness.

Conclusion: Lower premorbid agreeableness is associated with agitation and irritability symptoms in Alzheimer
disease and also predicts an agitation/apathy syndrome. The relationship between premorbid neuroticism and
BPSD is less straightforward, and premorbid neuroticism does not appear to be associated with depression in
Alzheimer disease or predict an affect syndrome.

Jun Ah Song, Donna Algase

Premorbid Characteristics and Wandering Behavior in Persons
with Dementia
Arch Psychiatr Nurs. 2008;22 (6):318-27

This study aimed to explore relationships of premorbid personality and behavioral

responses to stress with wandering behavior of persons with dementia in long-term care
facilities. Ambulatory
residents
(N =
108) with dementia
wereverbalization
selected from 21stre
long-ss
Premorbid
extroversion
and
premorbid
negative
term care facilities. The Mini-Mental State Examination, the NEO Five-Factor
response
were
significant
negative
predictors
the
RAAlgase
WSPersonality
Inventory,
the Behavioral
Responses
to Stress for
Scale,
andoverall
the Revised
ScaleNursing
NHWandering
and some
subscales Home Version (RAWS-NH) were used as data collection
tools. When the MMSE and age were controlled, regression analyses revealed that
premorbid extroversion and premorbid negative verbalization stress response were
significant negative predictors for the overall RAWS-NH and some subscales.

Alow LF, Brodaty H, Draper B.

Study of premorbid personality and behavioural and psychological symptoms
of dementia in nursing home residents.
Int J Geriatr Psychiatry.2002 Aug;17(8):779-83.
Abstract
OBJECTIVE: to investigate the relationship between pre-morbid personality and behavioural and
RESULTS:
higher neuroticism was predictive of delusions; higher
psychological symptoms of dementia (BPSD).
agreeableness
of58hallucinations,
aggressiveness,
affective
disturbance
METHODS:
we studied
subjects with dementia
and depression and/or
psychosis residing
in 11
Sydney
nursing behavioural
homes cross-sectionally.
Informal caregivers
completed
ratings of residents'
preand
overall
disturbance;
and higher
openness
of affective
morbid personality on the NEP Five-Factor Inventory (NEO-FFI). Information on BPSD was
disorder.
obtained using the BEHAVE-AD.
RESULTS: higher neuroticism
was predictive
of delusions;
higher agreeableness
of hallucinations,
CONCLUSION:
our findings
are
inconsistent
with previous
research
aggressiveness, affective disturbance and overall behavioural disturbance; and higher openness of
and
clinical experience. Prospective studies are needed to clarify the
affective disorder.
association our
between
and
behavioural
disturbance
CONCLUSION:
findings arepersonality
inconsistent with
previous
research and clinical
experience.in
Prospective studies are needed to clarify the association between personality and behavioural
dementia.
disturbance in dementia.

Factores sociales:

Factores ambientales:

Cambio en la ubicacin

Factores fsicos: Luz, ruidos, temperatura

Cuidador:

Relaciones interpersonales entre el paciente y cuidador

Sobrecarga del cuidador

Lawlor B, 1996

Donna L. Algase, PhD, Elizabeth R. A. Beattie, PhD, Cathy Antonakos, PhD,

Cynthia A. Beel-Bates, PhD, and Lan Yao, PhD
Wandering and the Physical Environment
American Journal of Alzheimers Disease & Other Dementias, 2012; 25(4) 340346
Abstract
Background: Guided by the need-driven dementia-compromised behavior (NDB) model, this study
examined influences
of the physical
environment
wandering behavior.
Conclusions:
Location,
light,
sound,onproximity
of others, and
Methods: Using a descriptive, cross-sectional design, 122 wanderers from 28 long-term care (LTC)
ambiance
are associated with wandering and may serve to inform
facilities were videotaped 10 to 12 times; data on wandering, light, sound, temperature and
humidity levels, location,
and crowding
were obtained. Associations between
environmental
designsambiance,
and care
practices.
environmental variables and wandering were evaluated with chi-square and t tests; the model was
evaluated using logistic regression.
Results: In all, 80% of wandering occurred in the residents own room, dayrooms, hallways, or dining
rooms. When observed in other residents rooms, hallways, shower/baths, or off-unit locations,
wanderers were likely (60%-92% of observations) to wander. The data were a good fit to the
model overall (LR [logistic regression] w2 (5) 50.38, P < .0001) and by wandering type.
Conclusions: Location, light, sound, proximity of others, and ambiance are associated with wandering
and may serve to inform environmental designs and care practices.

Mansfield C, Thein K, Marx MS, Dakheel Ali M, Murad H, Freedman LS

The relationships of environment and personal characteristics to agitated
behaviors in nursing home residents with dementia.
J Clin Psychiatry 2011
OBJECTIVE: To explore the impact of personal attributes, environmental attributes, and the presentation of 9 categories
of stimuli on agitation in nursing home residents with dementia.
METHOD: Participants in this randomized, controlled, observational cross-sectional study were 193 residents of 7
nursing homes, all with a diagnosis of dementia, for whom we obtained data pertaining to cognitive functioning (via
the Mini-Mental State Examination), performance of activities of daily living (Minimum Data Set), and roleidentity/activities of past interest (Self-Identity Questionnaire). Environmental attributes (eg, noise, lighting) and
direct observations of agitation (primary outcome) were recorded via the Agitation Behavior Mapping Inventory.
Engagement was measured using the Observational Measurement of Engagement. Both agitation and engagement
were assessed for each stimulus (including a control condition).

In the multivariate analyses, higher cognitive function (P < .001), male

gender (P < .05), level of engagement with stimuli (eg, duration of
engagement for 3 minutes or longer, P < .05), and all 9 stimulus
RESULTS: Univariate
findings
(ie,exception
for 1 explanatoryof
variable
at a time)
showedindependently
agitation to be related topredictive
several personal
categories,
with
the
music,
were
attributes-ie, female gender was related to verbal agitation (P < .0001); low cognitive function was related to total,
verbal, andlevels
physical agitation
(P < .001 for
low performance of activities of daily living was significantly related
of lower
of agitation
(Peach);
< .001).
to all types of agitation (P < .01 for total agitation and P < .05 for each type of agitation); and unclear speech was
CONCLUSIONS:
The (Pfinding
type were
of significantly
stimulirelated
andto
significantly related to total agitation
< .01). Eightthat
of the 9both
stimulus categories
decreased levels of agitation, with ORs ranging from 0.37 (live human stimuli, P < .001) to 0.79 (inanimate social
engagement
level with the stimuli were significant predictors of
stimuli, P < .05). Higher levels of engagement were related to lower levels of agitation (P < .001 for total agitation).
In the multivariate
analyses, higher
function (P <of
.001),
male gender (P <as
.05),
of engagement
agitation
underscores
thecognitive
importance
engagement
a level
determin
antwith
of
stimuli (eg, duration of engagement for 3 minutes or longer, P < .05), and all 9 stimulus categories, with the
agitation
exception levels.
of music, were independently predictive of lower levels of agitation (P < .001).
CONCLUSIONS: The finding that both type of stimuli and engagement level with the stimuli were significant predictors
of agitation underscores the importance of engagement as a determinant of agitation levels.

The variance in SCU symptom prevalence (variance between SCUs)

accounted for 3.514.8% of the total variance in neuropsychiatric
symptoms. In SCUs of which the staff spent more time on care activities did
the patients show lower levels of apathy. Other environmental
correlates did not predict neuropsychiatric symptoms.

Int J Geriatr Psychiatry 2010;25:14-22

Conclusions: Ambient bright light is not effective in reducing agitation in

dementia and may exacerbate this behavioral symptom.

Conclusions: Bright light therapy is a potential alternative to drug treatment

in people with dementia who are agitated.

Factores precipitantes:
COMORBILIDAD

Patologa cerebrovascular

Dolor

Depresin/Ansiedad

Deprivacin sensorial

Patologa endocrinometablica

Alteracin hidroelectroltica

Impacto fecal

Infecciones
FARMACOS
NECESIDADES BSICAS

OBrien J, Perry R, Barber R et al.

The Association between White Matter Lesions on Magnetic Resonance
Resonance
Imaging and Noncognitive Symptoms.
Ann NY Acad Sci 2000; 903:482-9
Abstract: A number of studies have suggested that cerebral changes, particularly deep white matter lesions
(WML) visualized on magnetic resonance imaging(MRI), may be involved in the genesis of late life
depression. This has been confirmed in a prospective study which also found a relationship between the
presence of WML and poor 3-year outcome in elderly depressed subjects. Most studies find these lesions to
Frontal
predominate
WML
in frontal
were
lobeassociated
and basal ganglia,
with
supporting
higherthedepression
hypothesis of scores
fronto-striatal
in patdysfunction
ients in
depression. To investigate whether WML are associated with mood disturbance in dementia, proton density
with
dementia, implying a common pathophysiology of depression
and T2-weighted images were obtained in 80 subjects with dementia (dementia with Lewy bodies, n= 27;
Alzheimer's disease,
n= 28; vascular dementia, n= 25) and 26 age-matched normal controls. Periventricular
irrespective
of diagnosis.
lesions (PVL), white matter lesions (WML), and basal ganglia hyperintensities (BG) were visually rated blind
to diagnosis using a semiquantitative scale. Frontal WML were associated with higher depression scores in
patients with dementia, implying a common pathophysiology of depression irrespective of diagnosis. Further
study of the neurobiological basis of WML is needed. This can best be achieved by serial clinical assessment
combined with in vivo and in vitro MRI and neuropathological examination.

Conclusion: The contribution of CVD to the pathogenesis of various NPS is

still debated. Our study, based on patients diagnosed with AD in a memory
clinic setting, suggests that there is no relationship between the extent of
CVD pathology and neuropsychiatric and behavioural measures in AD
patients. Further prospective quantitative studies are needed to assess the
role of CVD, if any, in neuropsychiatric and behavioural symptoms in AD.
It is possible that the relatively small pathological contribution of CVD to
the development of these symptoms is obscured by the effect of the wider
neurodegeneration encountered in AD.

Conclusion:
We suggest that right anterior insular dysfunction may exacerbate
delusions, although it is not responsible for the onset of delusions.

Objective To determine whether

a systematic approach
to the treatment
of pain
canmanagement
reduce agitation in peopleof
withpain
moderate to severe
Conclusion
A
systematic
approach
to
the
dementia living in nursing homes. Design Cluster randomised controlled trial. Setting 60 clusters (single independent nursing home units) in
18 nursing homes within
five municipalities
of western Norway.
Participants 352of
residents
with moderate
to severewith
dementia moderate
and clinically
significantly
reduced
agitation
in
residents
nursing
homes
significant behavioural disturbances randomised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four
after the end
of treatment (33 clusters;
n=175) ormanagement
to usual treatment (control,
clusters; n=177).
Intervention
Participants in the
toweeks
severe
dementia.
Effective
of27pain
can play
an important
intervention group received individual daily treatment of pain for eight weeks according to the stepwise protocol, with paracetamol
(acetaminophen),
buprenorphine
patch, and
or pregabaline.
The control
group received
usual treatment of
and care. Main
part
in themorphine,
treatment
of transdermal
agitation
could
reduce
the number
outcome measures Primary outcome measure was agitation (scores on Cohen-Mansfield agitation inventory). Secondary outcome measures
were aggression (scoresprescriptions
on neuropsychiatric inventory-nursing
home version), pain (scores
on mobilisation-observation-behaviour-intensityunnecessary
for psychotropic
drugs
in this population.
dementia-2), activities of daily living, and cognition (mini-mental state examination). Results Agitation was significantly reduced in the
intervention group compared with control group after eight weeks (repeated measures analysis of covariance adjusting for baseline score,
P<0.001): the average reduction in scores for agitation was 17% (treatment effect estimate 7.0, 95% confidence interval 3.7 to 10.3).
Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms (9.0, 5.5 to 12.6) and pain (1.3,
0.8 to 1.7), but the groups did not differ significantly for activities of daily living or cognition. Conclusion A systematic approach to the
management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Effective management of
pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in
this population.

Conclusion: There is a profound dearth of rigorous studies of the effect of

pain treatment in patients with dementia and agitation. The available
studies do not support the hypothesis that pain management reduces
agitation in nursing-home patients with dementia. Randomized,
controlled parallel-group studies are needed.

There are some cases of vitamin B12 deficiency that can manifest
with the symptoms of frontotemporal dementia and that they are
completely reversible after substitution therapy.

Denis Shub MD, David M, Bass PhD, Robert O et al.

Irritability and Social Isolation in Dementia Patients With and Without
Depression.
J Geriatr Psych and Neur 2011; 24 (4):229-234
Abstract
This study examined the prevalence of irritability and social isolation in veterans
with dementia, with and without depression. Participants were diagnosed with
dementia and enrolled in a dementia care-coordination and support-service
Conclusions:
Depressed
dementiaassessment
are significantly
intervention. Participants
were persons
interviewedwith
and underwent
with the 10more
likelyfortoEpidemiologic
experienceStudies
irritability
andscale,
sociala Patient
isolation
those
item Center
Depression
Strainthan
Measure
and the
Test. In all, of 294 participants completing interviews, 77
who
areShort
not Blessed
depressed.
(26.2%) were depressed and 107 (36.4%) endorsed irritability; mean social isolation
score was 1.59 1.96. Irritability was significantly more likely to be present in
depressed versus nondepressed participants (P < .0001), but this relationship was
moderated by dementia severity. The mean social isolation score was also
significantly more elevated in depressed rather than nondepressed patients (2.82
1.96 vs 1.15 1.76, respectively). Conclusions: Depressed persons with dementia
are significantly more likely to experience irritability and social isolation than those
who are not depressed.

Paul J. Seignourela, Mark E. Kunikb,c,d,e, Lynn Snowd F.G, Nancy Wilson B H,

and Melinda Stanley B E.
Anxiety in dementia: A critical review
Clin Psychol Rev. 2008 October ; 28(7): 10711082.

Movement Disorders, Vol. 26, No. 13, 2011

Regression analysis identified a variety of factors independently predictive

of complex visual hallucinations (e.g., dementia, visual acuity, and
depression), illusions (e.g., excessive daytime somnolence and disease
severity), and presence (e.g., rapid eye movement sleep behavior
disorder and excessive daytime somnolence)

This effect was limited to the period during which the treatment is being
applied. Half of the participants (54%) demonstrated considerable
behavioural improvement during the intervention (50% reduction of
symptoms) and those whose functioning is best preserved showed the best
response to the intervention.
Conclusion: This need-based intervention appears promising for improving
the behaviour of a considerable proportion of patients.

The Need-Driven Dementia-Compromised

Behavior (NDB) model
FACTORES DE FONDO:
Caractersticas sociodemogrficas
Factores neurobiolgicos
Capacidad cognitiva
Estado de salud
Factores psicosociales (personalidad
premrbida)

TRASTORNOS CONDUCTUALES:
Vagabundeo
Agresividad fsica
Agresividad verbal

FACTORES PROXIMALES:
Necesidades fsicas
Necesidades psicolgicas
Entorno fsico
Entorno social

Modificado de Algase DL 1996

Ann L. Whall et al.

Residents
esidents
Factors Associated With Aggressive Behavior Among Nursing Home R
With Dementia
The Gerontologist 2008; 48(6):72148(6):721-31
Purpose: In an attempt to more thoroughly describe aggressive behavior in nursing home residents with
dementia, we examined background and proximal factors as guided by the Need-Driven DementiaCompromised Behavior model. Design and Methods: We used a multivariate cross-sectional survey with
repeated measures; participants resided in nine randomly selected nursing homes within four midwestern
counties. The Minimum Data Set (with verification by caregivers) identified participants. We used a
disproportionate probability sample of 107 participants (51% with a history of aggressive behavior) to ensure
variability. Videotaped care events included four of direct care (shower baths, meals, dressing, and
undressing) and two of nondirect care (two randomly selected 20-minute time periods in the afternoon and
evening). The majority of participants (75%) received three shower baths, for a total of 282 videotaped baths.
Results: Because the shower bath was the only care event significantly related to aggressive behavior (F=6.9,
p , .001), only those data are presented. Multilevel statistical modeling identified background factors (gender,
mental status score, and lifelong history of less agreeableness) and a proximal factor (amount of nighttime
sleep) as significant predictors (p , .05) of aggressive behavior during the shower bath. We found significant
correlations between aggressive behavior and negative subject affect (r=.27) during the bath, and aggressive
behavior and lifetime agreeableness level (r = .192). We also found significant correlations between mental
status and the amount of education (r = .212), and between negative caregiver affect and negative participant
affect (r = .321). Implications: We identified three background and one proximal factor as significant risk
factors for aggressive behavior in dementia. Data identify not only those persons most at risk for aggressive
behavior during care, but also the care event most associated with aggressive behavior. Together these data
inform both caregiving for persons with dementia as well as the design of intervention studies for aggressive
behavior in dementia.

Implications: We identified three background and one proximal factor

as significant risk factors for aggressive behavior in dementia. Data
identify not only those persons most at risk for aggressive behavior during
care, but also the care event most associated with aggressive behavior.
Together these data inform both caregiving for persons with dementia as
well as the design of intervention studies for aggressive behavior in
dementia.

Agresin/agitacin fsica
Alteracin cognitiva

Afasia
Agnosia
Disfuncin ejecutiva

Patologa/Sntomas psiquitricos

Depresin
Alucinaciones
Ideacin delirante

Patologa mdica

Delirium
Dolor
Dficits sensoriales

Frmacos

Esteroides
Agonistas dopaminrgicos

Factores ambientales

Sobre estimulacin
Pobre estimulacin

Cuidador

Hablar fuerte
Acercarse desde atrs
Rapidez en la intervencin

Agresin/agitacin verbal
Alteracin cognitiva

Afasia (palilalia)
Disfuncin ejecutiva
Agnosia

Patologa/Sntomas psiquitricos

Depresin
Alucinaciones
Ideacin delirante

Patologa mdica

Delirium
Dolor
Infecciones
Inmovilidad
Dficit sensoriales

Necesidades insatisfechas

Sed
Hambre
Disconfort

Factores ambientales

Ruido excesivo
Luz brillante
Estimulacin excesiva

Cuidador

Estrs del cuidador

Pobre estimulacin
Excesiva estimulacin

Resistencia al cuidado
Alteracin cognitiva

Amnesia
Afasia
Apraxia
Agnosia
Apata

Patologa/Sntomas psiquitricos

Depresin
Ideacin delirante
Alucinaciones

Patologa mdica

Dolor
Dficits sensoriales
Incontinencia

Frmacos

Empeoran dficit cognitivo y contribuyen

Factores ambientales

Oscuridad
Ruido excesivo

Cuidador

Demandante
Ordenes complejas
Expectativas no realistas

Deambulacin errtica
Alteracin cognitiva

Amnesia
Afasia
Apraxia

Patologa/Sntomas psiquitricos

Depresin
Alucinaciones/Ideacin delirante

Patologa mdica

Dolor
RAO
Hipertiroidismo
Parkinson
Delirium

Necesidades insatisfechas

Hambre, Sed
Soledad
Miccin

Frmacos

Acatisia por psicofrmacos

Teofilina, epinefrina, cafena
Hormona tiroidea
Diurticos

Factores ambientales

Sobre estimulacin (ruido, luz) o pobre

estimulacin

Cuidador

Si se les impide deambular reacciones catastrficas

Depresin/ Ansiedad
Alteracin cognitiva

Amnesia
Agnosia

Patologa/Sntomas psiquitricos

Antecedente de depresin
Delirios congruentes

Patologa mdica

Lesiones frontales izdas (Ictus/tumor)

Tumor pancretico
Dficit de Vit B12, Hipotiroidismo, Cushing
Dolor
Infecciones

Frmacos

Esteroides
Benzodiacepinas
Betabloqueantes
Reserpina

Factores ambientales

Cambio de ubicacin, salir de rutina

Objetos pasados

Cuidador

Tono crtico, amenazante, enojado

Depresin en cuidadores

Apata/Aislamiento
Alteracin cognitiva

Amnesia
Agnosia
Afasia
Apraxia
Disfuncin ejecutiva

Patologa/Sntomas psiquitricos

Depresin
Ideacin delirante
Esquizofrenia
Agorafobia, pnico

Patologa mdica

Hipoxia aguda/crnica (EPOC, SAOS)

Dficits sensoriales
Cancer (pancreas)
Hipotiroidismo, cushing
Encefalopata heptica, insuficiencia renal, anemia
Hidrocefalia, Parkinson/Huntington

Frmacos

Antipsicticos, antidepresivos tricclicos,

Betabloqueantes, antiarrtmicos
Alcohol
Anticolinrgicos

Factores ambientales

Sobre estimlacin ( ruido, luz, actividad ), hacinamiento

Pobre estimulacin

Cuidador

Demandantes, estimulantes
Crticos, desagradables, abusivos

Ideacin delirante
Alteracin cognitiva

Amnesia
Agnosia
Afasia
Disfuncin ejecutiva

Patologa/Sntomas psiquitricos

Delirium
Depresin

Patologa mdica

Ictus
Parkinson
Delirium

Frmacos

Esteroides
Agonistas dopaminrgicos
Antihistamnicos
Betabloqueantes

Factores ambientales

Desorden
Sobreestimlacin/pobreestimulacin

Cuidador

Susurra, irritables, bromear

Alucinaciones
Alteracin cognitiva

Deterioro cognitivo moderado grave

Patologa/Sntomas psiquitricos

Delirium
Esquizofrenia
Depresin mayor

Patologa mdica

Ictus
Deprivacin alcohlica
Alteracin metablica
Infecciones
Dficit sensorial

Frmacos

Benzodiacepina
Anticolinrgicos
Esteroides
Agonistas dopaminrgicos

Factores ambientales

Pobre iluminacin
Exceso de ruido

Cuidador

Genera distrs

Conclusiones

Desconocimiento de la etiopatogenia del sd demencial y de

los SPCD

Modelos tericos basados en trabajos empricos y experiencia
clnicas

Resultados contradictorios en los estudios

Aunque no se pueden modificar los factores intrnsecos del
individuo, si que podemos determinar los pacientes en riesgo
y establecer en ellos estrategias de prevencin o intervencin
de los factores precipitantes