Discomfort and agitation in older adults with dementia

<p>Abstract</p> <p>Background</p> <p>A majority of patients with dementia present behavioral and psychological symptoms, such as agitation, which may increase their suffering, be difficult to manage by caregivers, and precipitate institutionalization. Although internal factors, such as discomfort, may be associated with agitation in patients with dementia, little research has examined this question. The goal of this study is to document the relationship between discomfort and agitation (including agitation subtypes) in older adults suffering from dementia.</p> <p>Methods</p> <p>This correlational study used a cross-sectional design. Registered nurses (RNs) provided data on forty-nine residents from three long-term facilities. Discomfort, agitation, level of disability in performing activities of daily living (ADL), and severity of dementia were measured by RNs who were well acquainted with the residents, using the Discomfort Scale for patients with Dementia of the Alzheimer Type, the Cohen-Mansfield Agitation Inventory, the ADL subscale of the Functional Autonomy Measurement System, and the Functional Assessment Staging, respectively. RNs were given two weeks to complete and return all scales (i.e., the Cohen-Mansfield Agitation Inventory was completed at the end of the two weeks and all other scales were answered during this period). Other descriptive variables were obtained from the residents' medical file or care plan.</p> <p>Results</p> <p>Hierarchical multiple regression analyses controlling for residents' characteristics (sex, severity of dementia, and disability) show that discomfort explains a significant share of the variance in overall agitation (28%, <it>p </it>< 0.001), non aggressive physical behavior (18%, <it>p </it>< 0.01) and verbally agitated behavior (30%, <it>p </it>< 0.001). No significant relationship is observed between discomfort and aggressive behavior but the power to detect this specific relationship was low.</p> <p>Conclusion</p> <p>Our findings provide further evidence of the association between discomfort and agitation in persons with dementia and reveal that this association is particularly strong for verbally agitated behavior and non aggressive physical behavior.</p

Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities

BACKGROUND: Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism. METHODS: The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332). RESULTS: The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia. CONCLUSION: Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints

Spatial Language Processing in the Blind: Evidence for a Supramodal Representation and Cortical Reorganization

Neuropsychological and imaging studies have shown that the left supramarginal gyrus (SMG) is specifically involved in processing spatial terms (e.g. above, left of), which locate places and objects in the world. The current fMRI study focused on the nature and specificity of representing spatial language in the left SMG by combining behavioral and neuronal activation data in blind and sighted individuals. Data from the blind provide an elegant way to test the supramodal representation hypothesis, i.e. abstract codes representing spatial relations yielding no activation differences between blind and sighted. Indeed, the left SMG was activated during spatial language processing in both blind and sighted individuals implying a supramodal representation of spatial and other dimensional relations which does not require visual experience to develop. However, in the absence of vision functional reorganization of the visual cortex is known to take place. An important consideration with respect to our finding is the amount of functional reorganization during language processing in our blind participants. Therefore, the participants also performed a verb generation task. We observed that only in the blind occipital areas were activated during covert language generation. Additionally, in the first task there was functional reorganization observed for processing language with a high linguistic load. As the visual cortex was not specifically active for spatial contents in the first task, and no reorganization was observed in the SMG, the latter finding further supports the notion that the left SMG is the main node for a supramodal representation of verbal spatial relations

Visual area V5/hMT+ contributes to perception of tactile motion direction: a TMS study

Human imaging studies have reported activations associated with tactile motion perception in visual motion area V5/hMT+, primary somatosensory cortex (SI) and posterior parietal cortex (PPC; Brodmann areas 7/40). However, such studies cannot establish whether these areas are causally involved in tactile motion perception. We delivered double-pulse transcranial magnetic stimulation (TMS) while moving a single tactile point across the fingertip, and used signal detection theory to quantify perceptual sensitivity to motion direction. TMS over both SI and V5/hMT+, but not the PPC site, significantly reduced tactile direction discrimination. Our results show that V5/hMT+ plays a causal role in tactile direction processing, and strengthen the case for V5/hMT+ serving multimodal motion perception. Further, our findings are consistent with a serial model of cortical tactile processing, in which higher-order perceptual processing depends upon information received from SI. By contrast, our results do not provide clear evidence that the PPC site we targeted (Brodmann areas 7/40) contributes to tactile direction perception

Beyond visual, aural and haptic movement perception: hMT+ is activated by electrotactile motion stimulation of the tongue in sighted and in congenitally blind individuals

The motion-sensitive middle temporal cortex (hMT+ complex) responds also to non-visual motion stimulation conveyed through the tactile and auditory modalities, both in sighted and in congenitally blind individuals. This indicates that hMT+ is truly responsive to motion-related information regardless of visual experience and the sensory modality through which such information is carried to the brain. Here we determined whether the hMT+ complex responds to motion perception per se, that is, motion not perceived through the visual, haptic or aural modalities. Using functional magnetic resonance imaging (fMRI), we investigated brain responses in eight congenitally blind and nine sighted volunteers who had been trained to use the tongue display unit (TDU), a sensory substitution device which converts visual information into electrotactile pulses delivered to the tongue, to resolve a tactile motion discrimination task. Stimuli consisted of either static dots, dots moving coherently or dots moving in random directions. Both groups learned the task at the same rate and activated the hMT+ complex during tactile motion discrimination, although at different anatomical locations. Furthermore, the congenitally blind subjects showed additional activations within the dorsal extrastriate cortical pathway.These results extend previous data in support of the supramodal functional organization of hMT+ complex by showing that this cortical area processes motion-related information per se, that is, motion stimuli that are not visual in nature and that are administered to body structures that, in humans, are not primarily devoted to movement perception or spatial location, such as the tongue. In line with previous studies, the differential activations between sighted and congenitally blind individuals indicate that lack of vision leads to functional rearrangements of these supramodal cortical areas