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Health and Quality of Life Outcomes

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Open Access 01-12-2023 | Agitation | Research

Agitation and aggression in people living with dementia and mild cognitive impairment in shared-housing arrangements – validation of a German version of the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF)

Authors: André Kratzer, Jennifer Scheel-Barteit, Janissa Altona, Karin Wolf-Ostermann, Elmar Graessel, Carolin Donath

Published in: Health and Quality of Life Outcomes | Issue 1/2023

Abstract

Background

The Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF) is a 14-item scale for assessing agitation and aggression, derived from the original 29-item CMAI, and completed by a proxy. Because the CMAI-SF has not yet been validated in German language, the aim of this study is to explore its construct validity.

Methods

Baseline data from a cluster-randomized trial to evaluate a non-pharmacological complex intervention for people living with dementia (PlwD) and mild cognitive impairment (MCI) were analyzed. The study sample consisted of 97 shared-housing arrangements (SHAs) in Germany, comprising N = 341 residents with mild to severe dementia and MCI. Trained nursing staff collected data by proxy-rating the CMAI-SF, Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), and QUALIDEM. They also conducted the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA).

Results

In an exploratory factor analysis, three factors emerged: “aggressive behavior”, “verbally agitated behavior”, and “physically non-aggressive behavior”. The CMAI-SF total score showed good internal consistency (α = .85), and the factors themselves showed adequate internal consistency (α = .75/.76/.73). The CMAI-SF showed convergent validity with the NPI-NH agitation item (r = .66) and the NPI-NH “agitation & restless behavior” factor (r = .82). Discriminant validity was confirmed by a low (r = .28) correlation with the NPI-NH apathy item. Quality of life decreased significantly with agitation, as the CMAI-SF showed a moderate negative correlation with the QUALIDEM total score (r = -.35).

Conclusions

The 14-item CMAI-SF is a time-efficient, reliable, and valid assessment instrument. Three factors emerged that were similar to those already found in nursing home samples for the original CMAI and the CMAI-SF and in day care samples for the CMAI-SF. The findings provide preliminary evidence that the CMAI-SF can be used instead of the CMAI to reduce time, costs, and burden in future trials.

Trial registration

The DemWG study from which data were used to draft this manuscript was prospectively registered on 16 July 2019 at ISRCTN registry (ISRCTN89825211).

Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350: h369. https://doi.org/10.1136/bmj.h369.CrossRefPubMedPubMedCentral

Livingston G, Barber J, Marston L, Rapaport P, Livingston D, Cousins S, Robertson S, La Frenais F, Cooper C. Prevalence of and associations with agitation in residents with dementia living in care homes: MARQUE cross-sectional study. BJPsych Open.https://doi.org/10.1192/bjpo.bp.117.0051812017;3:171–8.

Zuidema SU, Derksen E, Verhey FRJ, Koopmans RTCM. Prevalence of neuropsychiatric symptoms in a large sample of Dutch nursing home patients with dementia. Int J Geriatr Psychiatry. 2007;22:632–8. https://doi.org/10.1002/gps.1722.CrossRefPubMed

Cloak N, Al Khalili Y. Behavioral And Psychological Symptoms In Dementia. Treasure Island (FL): StatPearls Publishing; 2021.

Baharudin AD, Din NC, Subramaniam P, Razali R. The associations between behavioral-psychological symptoms of dementia (BPSD) and coping strategy, burden of care and personality style among low-income caregivers of patients with dementia. BMC Public Health. 2019;19:447. https://doi.org/10.1186/s12889-019-6868-0.CrossRefPubMedPubMedCentral

Watt JA, Goodarzi Z, Veroniki AA, Nincic V, Khan PA, Ghassemi M, Thompson Y, Tricco AC, Straus SE. Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis. Ann Intern Med. 2019;171:633–42. https://doi.org/10.7326/M19-0993.CrossRefPubMed

Pinkert C, Holle B. [People with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admission]. Z Gerontol Geriatr. 2012;45:728–34. https://doi.org/10.1007/s00391-012-0319-1.CrossRefPubMed

Andrieu S, Reynish E, Nourhashemi F, Shakespeare A, Moulias S, Ousset PJ, Sagnier P, Richard A, Albarede JL, Vellas B. Predictive factors of acute hospitalization in 134 patients with Alzheimer’s disease: a one year prospective study. Int J Geriatr Psychiatry. 2002;17:422–6. https://doi.org/10.1002/gps.624.CrossRefPubMed

Fogg C, Griffiths P, Meredith P, Bridges J. Hospital outcomes of older people with cognitive impairment: an integrative review. Int J Geriatr Psychiatry. 2018;33:1177–97. https://doi.org/10.1002/gps.4919.CrossRefPubMedPubMedCentral

10.

Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of agitation in a nursing home. J Gerontol. 1989;44:M77-84. https://doi.org/10.1093/geronj/44.3.m77.CrossRefPubMed

11.

Cohen-Mansfield J. Instruction manual for the Cohen-Mansfield Agitation Inventory (CMAI). Rockville, Maryland, USA: The Research Institute of the Hebrew Home of Greater Washington; 1991.

12.

de Jonghe JF, Kat MG. Factor structure and validity of the Dutch version of the Cohen-Mansfield Agitation Inventory (CMAI-D). J Am Geriatr Soc. 1996;44:888–9. https://doi.org/10.1111/j.1532-5415.1996.tb03762.x.CrossRefPubMed

13.

Choy CNP, Lam LCW, Chan WC, Li SW, Chiu HFK. Agitation in Chinese elderly: validation of the Chinese version of the Cohen-Mansfield Agitation Inventory. Int Psychogeriatr. 2001;13:325–35. https://doi.org/10.1017/s1041610201007712.CrossRefPubMed

14.

Rabinowitz J, Davidson M, De Deyn PP, Katz I, Brodaty H, Cohen-Mansfield J. Factor analysis of the Cohen-Mansfield Agitation Inventory in three large samples of nursing home patients with dementia and behavioral disturbance. Am J Geriatr Psychiatry. 2005;13:991–8. https://doi.org/10.1176/appi.ajgp.13.11.991.CrossRefPubMed

15.

Schreiner A, Yamamoto E, Shiotani H. Agitated behavior in elderly nursing home residents with dementia in Japan. J Gerontol. 2000;55:P180-186. https://doi.org/10.1093/geronb/55.3.p180.CrossRef

16.

Suh GH. Agitated behaviours among the institutionalized elderly with dementia: validation of the Korean version of the Cohen-Mansfield Agitation Inventory. Int J Geriatr Psychiatry. 2004;19:378–85. https://doi.org/10.1002/gps.1097.CrossRefPubMed

17.

Cohen-Mansfield J, Werner P, Watson V, Pasis S. Agitation among elderly persons at adult day-care centers: the experiences of relatives and staff members. Int Psychogeriatr. 1995;7:447–58. https://doi.org/10.1017/s1041610295002195.CrossRefPubMed

18.

Weiner M, Tractenberg R, Jin S, Gamst A, Thomas RG, Koss E, Thal LJ. Assessing Alzheimer’s disease patients with the Cohen-Mansfield Agitation Inventory: scoring and clinical implications. J Psychiatr Res. 2002;36:19–25. https://doi.org/10.1016/s0022-3956(01)00047-4.CrossRefPubMed

19.

Koss E, Weiner M, Ernesto C, Cohen-Mansfield J, Ferris SH, Grundman M, Schafer K, Sano M, Thal LJ, Thomas R, Whitehouse PJ. Assessing patterns of agitation in Alzheimer’s disease patients with the Cohen-Mansfield Agitation Inventory. The Alzheimer’s Disease Cooperative Study. Alzheimer Dis Assoc Disord. 1997;11(Suppl 2):S45-50. https://doi.org/10.1097/00002093-199700112-00007.CrossRefPubMed

20.

Paudel A, Resnick B, Galik E. Factor Analysis of the Short-Form Cohen-Mansfield Agitation Inventory and the Measurement Invariance by Gender. J Nurs Meas. 2021;29:523–40. https://doi.org/10.1891/JNM-D-20-00031.CrossRefPubMed

21.

Sun FC, Lin LC, Chang SC, Li HC, Cheng CH, Huang LY. Reliability and Validity of a Chinese Version of the Cohen-Mansfield Agitation Inventory-Short Form in Assessing Agitated Behavior. Int J Environ Res Public Health 2022;19:9410. https://doi.org/10.3390/ijerph19159410.

22.

Werner P, Cohen-Mansfield J, Koroknay V, Braun J. The impact of a restraint-reduction program on nursing home residents. Geriatr Nurs. 1994;15:142–6. https://doi.org/10.1016/s0197-4572(09)90040-4.CrossRefPubMed

23.

Griffiths AW, Albertyn CP, Burnley NL, Creese B, Walwyn R, Holloway I, Safarikova J, Surr CA. Validation of the Cohen-Mansfield Agitation Inventory Observational (CMAI-O) tool. Int Psychogeriatr. 2020;32:75–85. https://doi.org/10.1017/s1041610219000279.CrossRefPubMed

24.

Barrick AL, Sloane PD, Williams CS, Mitchell CM, Connell BR, Wood W, Hickman SE, Preisser JS, Zimmerman S. Impact of ambient bright light on agitation in dementia. Int J Geriatr Psychiatry. 2010;25:1013–21. https://doi.org/10.1002/gps.2453.CrossRefPubMedPubMedCentral

25.

Moyle W, Johnston AN, O’Dwyer ST. Exploring the effect of foot massage on agitated behaviours in older people with dementia: a pilot study. Australas J Ageing. 2011;30:159–61. https://doi.org/10.1111/j.1741-6612.2010.00504.x.CrossRefPubMed

26.

Cooke ML, Moyle W, Shum DH, Harrison SD, Murfield JE. A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia. Aging Ment Health. 2010;14:905–16. https://doi.org/10.1080/13607861003713190.CrossRefPubMed

27.

Lee HB, Hanner JA, Yokley JL, Appleby B, Hurowitz L, Lyketsos CG. Clozapine for treatment-resistant agitation in dementia. J Geriatr Psychiatry Neurol. 2007;20:178–82. https://doi.org/10.1177/0891988707303335.CrossRefPubMed

28.

Detweiler MB, Murphy PF, Myers LC, Kim KY. Does a wander garden influence inappropriate behaviors in dementia residents? Am J Alzheimers Dis Other Demen. 2008;23:31–45. https://doi.org/10.1177/1533317507309799.CrossRefPubMed

29.

Ballard CG, Coate B, Abler V, Stankovic S, Foff E. Evaluation of the efficacy of pimavanserin in the treatment of agitation and aggression in patients with Alzheimer’s disease psychosis: A post hoc analysis. Int J Geriatr Psychiatry. 2020;35:1402–8. https://doi.org/10.1002/gps.5381.CrossRefPubMed

30.

Cakir S, Kulaksizoglu IB. The efficacy of mirtazapine in agitated patients with Alzheimer’s disease: A 12-week open-label pilot study. Neuropsychiatr Dis Treat. 2008;4:963–6. https://doi.org/10.2147/ndt.s3201.CrossRefPubMedPubMedCentral

31.

Gräske J, Worch A, Meyer S, Wolf-Ostermann K. Ambulant betreute Wohngemeinschaften für pflegebedürftige Menschen in Deutschland. Eine Literaturübersicht zu Strukturen, Versorgungsoutcomes und Qualitätsmanagement [Shared-housing arrangements for care-dependent people in Germany. A literature overview of structures, outcomes and quality management]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2013;56:1410–7. https://doi.org/10.1007/s00103-013-1825-z.CrossRefPubMed

32.

Kratzer A, Scheel J, Wolf-Ostermann K, Schmidt A, Ratz K, Donath C, Graessel E. The DemWG study: reducing the risk of hospitalisation through a complex intervention for people with dementia and mild cognitive impairment (MCI) in German shared-housing arrangements: study protocol of a prospective, mixed-methods, multicentre, cluster-randomised controlled trial. BMJ Open. 2020;10:e041891. https://doi.org/10.1136/bmjopen-2020-041891.CrossRefPubMedPubMedCentral

33.

Reuther S, Dichter MN, Bartholomeyczik S, Nordheim J, Halek M. Construct validity and internal consistency of the neuropsychiatric inventory - nursing home (NPI-NH) in German nursing homes. Int Psychogeriatr. 2016;28:1017–27. https://doi.org/10.1017/S1041610215002343.CrossRefPubMed

34.

Wood S, Cummings JL, Hsu MA, Barclay T, Wheatley MV, Yarema KT, Schnelle JF. The use of the neuropsychiatric inventory in nursing home residents. Characterization and measurement. Am J Geriatr Psychiatry. 2000;8:75–83. https://doi.org/10.1097/00019442-200002000-00010.CrossRefPubMed

35.

Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994;44:2308–14. https://doi.org/10.1212/wnl.44.12.2308.CrossRefPubMed

36.

Ettema TP, Droes RM, de Lange J, Mellenbergh GJ, Ribbe MW. QUALIDEM: development and evaluation of a dementia specific quality of life instrument. Scalability, reliability and internal structure. Int J Geriatr Psychiatry. 2007;22:549–56. https://doi.org/10.1002/gps.1713.CrossRefPubMed

37.

Dichter MN, Schwab CG, Meyer G, Bartholomeyczik S, Halek M. Item distribution, internal consistency and inter-rater reliability of the German version of the QUALIDEM for people with mild to severe and very severe dementia. BMC Geriatr. 2016;16:126. https://doi.org/10.1186/s12877-016-0296-0.CrossRefPubMedPubMedCentral

38.

Dichter MN, Quasdorf T, Schwab CG, Trutschel D, Haastert B, Riesner C, Bartholomeyczik S, Halek M. Dementia care mapping: effects on residents’ quality of life and challenging behavior in German nursing homes. A quasi-experimental trial. Int Psychogeriatr. 2015;27:1875–92. https://doi.org/10.1017/S1041610215000927.CrossRefPubMed

39.

Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98. https://doi.org/10.1016/0022-3956(75)90026-6.CrossRefPubMed

40.

Creavin ST, Wisniewski S, Noel-Storr AH, Trevelyan CM, Hampton T, Rayment D, Thom VM, Nash KJ, Elhamoui H, Milligan R, et al: Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations. Cochrane Database Syst Rev 2016;2016:CD011145. https://doi.org/10.1002/14651858.CD011145.pub2.

41.

Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40:922–35. https://doi.org/10.1111/j.1532-5415.1992.tb01992.x.CrossRefPubMed

42.

Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA Intern Med. 2015;175:1450–8. https://doi.org/10.1001/jamainternmed.2015.2152.CrossRefPubMed

43.

Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–9. https://doi.org/10.1111/j.1532-5415.2005.53221.x.CrossRefPubMed

44.

O’Caoimh R, Timmons S, Molloy DW. Screening for mild cognitive impairment: comparison of “MCI specific” screening instruments. J Alzheimers Dis. 2016;51:619–29. https://doi.org/10.3233/JAD-150881.CrossRefPubMedPubMedCentral

45.

Freitas S, Simoes MR, Alves L, Santana I. Montreal Cognitive Assessment: validation study for mild cognitive impairment and Alzheimer disease. Alzheimer Dis Assoc Disord. 2013;27:37–43. https://doi.org/10.1097/WAD.0b013e3182420bfe.CrossRefPubMed

46.

Stekhoven DJ, Bühlmann P. MissForest—non-parametric missing value imputation for mixed-type data. Bioinformatics. 2011;28:112–8. https://doi.org/10.1093/bioinformatics/btr597.CrossRefPubMed

47.

Tabachnick B, Fidell L: Principal Components and Factor Analysis. In Using Multivariate Statistics. 6 edition. Edited by Tabachnick B, Fidell L. Harlow: Pearson 2014. p. 660-730

48.

Döring N, Bortz J. Forschungsmethoden und Evaluation in den Sozial- und Humanwissenschaften [Research methods and evaluation in the social and human sciences]. 5th ed. Berlin, Heidelberg: Springer; 2016.CrossRef

49.

Moosbrugger H, Kelava A. Testtheorie und Fragebogenkonstruktion. Berlin: Springer; 2020.CrossRef

50.

Fischer T, Worch A, Nordheim J, Wulff IM, Gräske J, Meye S, Wolf-Ostermann K. Ambulant betreute Wohngemeinschaften für alte, pflegebedürftige Menschen - Merkmale, Entwicklung und Einflussfaktoren [Shared-housing arrangements for care-dependent older persons - characteristics, development and drivers]. Pflege. 2011;24:97–109. https://doi.org/10.1024/1012-5302/a000105.CrossRefPubMed

51.

Wolf-Ostermann K, Worch A, Meyer S, Gräske J. Ambulant betreute Wohngemeinschaften für Menschen mit Pflegebedarf Versorgungsangebote und gesetzliche Rahmenbedingungen in Deutschland [Shared-housing arrangements for care-dependent persons. Legal frameworks and numbers in Germany]. Z Gerontol Geriatr. 2014;47:583–9. https://doi.org/10.1007/s00391-013-0524-6.CrossRefPubMed

Title: Agitation and aggression in people living with dementia and mild cognitive impairment in shared-housing arrangements – validation of a German version of the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF)
Authors: André Kratzer
Jennifer Scheel-Barteit
Janissa Altona
Karin Wolf-Ostermann
Elmar Graessel
Carolin Donath
Publication date: 01-12-2023
Publisher: BioMed Central
Keywords: Agitation
Dementia
Dementia
Mild Neurocognitive Disorder
Published in: Health and Quality of Life Outcomes / Issue 1/2023
Electronic ISSN: 1477-7525
DOI: https://doi.org/10.1186/s12955-023-02132-y

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Agitation and aggression in people living with dementia and mild cognitive impairment in shared-housing arrangements – validation of a German version of the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF)

Abstract

Background

Methods

Results

Conclusions

Trial registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Trial registration

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