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IIR 01-159 – HSR Study

IIR 01-159
Causes and Consequences of Aggressive Behavior in Demented Patients
Mark E. Kunik, MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: July 2003 - June 2007
Aggression has been documented to be highly prevalent in convenience samples of patients with dementia (25% to 50%); however, scant literature exists on the incidence of new aggression in patients with dementia. Without an accurate estimate of incidence, it is not possible to quantify the absolute risk of aggression. Identifiction of modifiable causal factors of aggression as a primary or secondary prevention strategy would fundamentally change the current approach to the treatment of aggression. Such a prevention strategy was the long-term goal of this research.

This was a 4-year prospective cohort study to empirically validate risk factors and consequences in an inception cohort of newly diagnosed, community-dwelling dementia patients. .

Patients and caregivers were assessed at baseline and every 4 months thereafter in their home and called monthly to test for the development of aggression. This 4-month cycle was repeated 6 times over 24 months. Home assessments included assessments to detect the development of aggression and assessments of putative risk factors, including patient factors (e.g., depression, psychosis, pain, and delirium) and factors external to the patient (e.g., social stimulation, caregiver burden, and quality of caregiver-patient relationship). Each month adverse consequences, including nursing home placement, injury to caregiver or self, and use of physical restraints or anxiolytic/antipsychotics, were tracked.

Incidence of Aggression: Forty percent of the cohort of newly diagnosed, non-aggressive dementia patients became aggressive; but a rate of only 25% was anticipated, based on previous literature.
Quality of Care for Aggressive Dementia Patients: Practice guidelines were used as a benchmark to examine standard/quality of care. Aggression was infrequently recognized and assessed, particularly in primary care. Non-pharmacologic interventions were rarely used despite their recommendations as a first- line intervention.
Causes of Aggression: Intensive follow-up of newly diagnosed, previously non-aggressive dementia patients revealed several modifiable causes of aggression, including depression, pain, psychosis, caregiver burden, and caregiver-patient relationship. All have important implications for the assessment and treatment of this special population.
Consequences of Aggression: Aggression among newly diagnosed dementia patients leads to greater use of medication; more nursing home placements; and more injuries to the patient, caregiver, and others.
Antipsychotic Use in Non-Aggressive Dementia Patients: Despite recommended guidelines, few physicians used non-pharmacologic interventions for this group of newly diagnosed, non-aggressive dementia patients; however, physicians prescribed antipsychotics for a sizeable minority of them.

This study resulted in one published, three submitted, and five planned/in preparation manuscripts that make the strongest contribution to date to the literature on the enormous unmet needs of newly diagnosed dementia patients with and without aggression. The longitudinal cohort study helped to determine the extent to which mutable determinants cause aggression and can be used as a foundation to develop strategies and interventions to prevent aggression. Such a preventive approach could fundamentally change the approach to dementia patients with aggression from that of tertiary prevention strategies, primarily using restraints and tranquilizing medications, to an innovative secondary prevention strategy. By reducing aggressive behaviors, such an intervention could potentially reduce institutionalization, injuries, restraint and anxiolytic/antipsychotic use, and utilization of other health services. Such an intervention strategy is currently being developed for a future proposal.

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Journal Articles

  1. Orengo CA, Khan J, Kunik ME, Snow AL, Morgan R, Steele A, Cully JA, Graham DP. Aggression in individuals newly diagnosed with dementia. American journal of Alzheimer's disease and other dementias. 2008 Jun 1; 23(3):227-32. [view]
  2. Kunik ME, Snow AL, Davila JA, Steele AB, Balasubramanyam V, Doody RS, Schulz PE, Kalavar JS, Morgan RO. Causes of aggressive behavior in patients with dementia. The Journal of clinical psychiatry. 2010 Sep 1; 71(9):1145-52. [view]
  3. Shub D, Kunik ME. Comorbidity: Psychiatric Comorbidity in Persons with Dementia. Psychiatric Times. 2009 Apr 16; 26(4):32-36. [view]
  4. Shub D, Hudson S, Kunik ME. Comparison of behavioral and psychological symptoms in persons with vascular dementia and Alzheimer's disease: a review. Minerva Psichiatrica. 2010 May 1; 51(1):27-36. [view]
  5. Kunik ME, Snow AL, Davila JA, McNeese T, Steele AB, Balasubramanyam V, Doody R, Schulz PE, Kalavar JS, Walder A, Morgan RO. Consequences of aggressive behavior in patients with dementia. The Journal of Neuropsychiatry and Clinical Neurosciences. 2010 Jan 1; 22(1):40-7. [view]
  6. Dhawan N, Steele AB, Morgan RO, Snow AL, Davila JA, Kunik ME. Documentation of antipsychotic use and indications for newly diagnosed, nonaggressive dementia patients. Primary care companion to the Journal of clinical psychiatry. 2008 Jan 1; 10(2):97-102. [view]
  7. Kunik ME, Walgama JP, Snow AL, Davila JA, Schulz PE, Steele AB, Morgan RO. Documentation, assessment, and treatment of aggression in patients with newly diagnosed dementia. Alzheimer disease and associated disorders. 2007 Apr 1; 21(2):115-21. [view]
  8. Kalkonde YV, Pinto-Patarroyo GP, Goldman T, Strutt AM, York MK, Kunik ME, Schulz PE. Ethnic disparities in the treatment of dementia in veterans. Dementia and geriatric cognitive disorders. 2009 Nov 17; 28(2):145-52. [view]
  9. Steele AB, Kunik ME, Cully JA, Davila JA, Morgan RO, Snow AL. Feasibility of using standardized patient methodology to develop and assess research assistant competence in dementia research. Dementia (London, England). 2009 May 1; 8(2):317-324. [view]
  10. Morgan RO, Sail KR, Snow AL, Davila JA, Fouladi NN, Kunik ME. Modeling causes of aggressive behavior in patients with dementia. The Gerontologist. 2013 Oct 1; 53(5):738-47. [view]
  11. Ball VL, Hudson S, Davila J, Morgan R, Walder A, Graham DP, Snow AL, Kunik ME. Post-traumatic stress disorder and prediction of aggression in persons with dementia. International journal of geriatric psychiatry. 2009 Nov 1; 24(11):1285-90. [view]
  12. Veazey C, Aki SO, Cook KF, Lai EC, Kunik ME. Prevalence and treatment of depression in Parkinson's disease. The Journal of Neuropsychiatry and Clinical Neurosciences. 2005 Aug 1; 17(3):310-23. [view]
  13. Nguyen VT, Love AR, Kunik ME. Preventing aggression in persons with dementia. Geriatrics. 2008 Nov 1; 63(11):21-6. [view]
  14. Ball V, Snow AL, Steele AB, Morgan RO, Davila JA, Wilson N, Kunik ME. Quality of relationships as a predictor of psychosocial functioning in patients with dementia. Journal of geriatric psychiatry and neurology. 2010 Jun 1; 23(2):109-14. [view]
  15. Simpson SM, Krishnan LL, Kunik ME, Ruiz P. Racial disparities in diagnosis and treatment of depression: a literature review. The Psychiatric quarterly. 2007 Mar 1; 78(1):3-14. [view]
  16. Snow AL, Chandler JF, Kunik ME, Davila JA, Balasubramanyam V, Steele AB, Morgan RO. Self-reported pain in persons with dementia predicts subsequent decreased psychosocial functioning. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2009 Oct 1; 17(10):873-80. [view]
  17. Kunik ME, Cully JA, Snow AL, Souchek J, Sullivan G, Ashton CM. Treatable comorbid conditions and use of VA health care services among patients with dementia. Psychiatric services (Washington, D.C.). 2005 Jan 1; 56(1):70-5. [view]
  18. McNeese TD, Snow AL, Rehm LP, Massman PJ, Davila JA, Walder A, Morgan RO, Kunik ME. Type, frequency, and disruptiveness of aggressive behavior in persons with dementia. Alzheimer's care today. 2009 Oct 1; 10(4):204-211. [view]

  1. Kunik ME, Wilson N. A comprehensive plan for addressing the burden of Alzheimer's disease in Texas. Austin, TX: Texas Department of State Health Services; 2010 Sep 17. 57 p. Report No.: 42-13351. [view]
Conference Presentations

  1. Kunik ME. Advanced Veteran-centric care for Veterans, families, and caregivers. Paper presented at: VA National Research Week; 2010 Apr 22; Washington, DC. [view]
  2. Orengo CA, Khan J, Kunik ME, Snow AL, Morgan RO, Steele A, Cully JA, Graham DP. Aggression in individuals newly diagnosed with dementia. Paper presented at: American Association for Geriatric Psychiatry Annual Meeting; 2006 Mar 10; San Juan, Puerto Rico. [view]
  3. Kunik ME. Aggressive behaviors in geropsychiatric patients: Neurobiology, assessment, and management. Paper presented at: American Psychiatric Association Annual Meeting; 2010 May 22; New Orleans, LA. [view]
  4. Kunik ME. Alzheimer's and Dementia. Paper presented at: VA Houston VAMC Annual Research Week; 2007 Jun 28; Houston, TX. [view]
  5. Montgomery EC, Weiss BJ, Kunik ME, Wilson N, Stanley MA. Can Paraprofessionals Deliver Cognitive-Behavioral Therapy to Treat Anxious and Depressive Symptoms? Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2006 Nov 1; Chicago, IL. [view]
  6. George M, Zimmer M, Walder A, Kunik ME, Naik AD. Collaborative goal-setting behaviors predict hypertension control in older diabetics'. Paper presented at: American Geriatrics Society Annual Meeting; 2006 May 3; Chicago, IL. [view]
  7. Shahar K, Snow AL, Souchek J, Sullivan G, Ashton CM, Kunik ME. Cutpoint definition of agitation. Paper presented at: American Geriatrics Society Annual Meeting; 2003 May 1; Baltimore, MD. [view]
  8. Kunik ME, Veazey C, Cully JA, Souchek, Graham DP, Hopko D, Carter R, Sharafkhaneh A, Goepfert EJ, Wray NP, Stanley MA. Education vs. CBT for depression and anxiety in COPD patients. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2006 Nov 16; Dallas, TX. [view]
  9. Kunik ME. Improving the quality of dementia care. Paper presented at: VA Houston VAMC Management Advisory Council Monthly Meeting; 2006 May 4; Houston, TX. [view]
  10. Kunik ME. Patient empowerment: take control of the aging process. Paper presented at: Texas Medical Association / Texas Geriatrics Society Annual Meeting; 2004 May 13; Austin, TX. [view]
  11. Shrestha S, Kunik ME, Wilson N, Stanley MA. Preventing aggression in Veterans with dementia. Poster session presented at: Gerontological Society of America Annual Scientific Meeting; 2010 Nov 19; New Orleans, LA. [view]
  12. Kunik ME. Preventing development of aggression in dementia: Epidemiological intervention development. Poster session presented at: Gerontological Society of America Annual Scientific Meeting; 2010 Nov 19; New Orleans, LA. [view]
  13. Gloster AT, Senior A, Rhoades H, Kunik ME, Wilson N, Novy D, Stanley MA. Psychometric properties of the depression anxiety stress scale-21 in late life medical patients seeking treatment to stop worry. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2006 Nov 1; Chicago, IL. [view]
  14. Kunik ME. Ten cities that protect you from dementia, disparity, disease, or diagnosis. Paper presented at: University of Arkansas for Medical Sciences Alzheimer's Disease Center Annual Seminar; 2004 Mar 9; Little Rock, AR. [view]
  15. Kunik ME, Uphold CR. Translating caregiving research into clinical reality: Lesson from the VA experience. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA. [view]
  16. Snow AL, Camp CJ, Zeisel J, O'Connor D, VanDerPloeg E, Luszcz M, Kunik ME. Treatment versus care: Effects of labels used for interventions for persons with dementia. Poster session presented at: Gerontological Society of America Annual Scientific Meeting; 2010 Nov 19; New Orleans, LA. [view]

DRA: Aging, Older Veterans' Health and Care
DRE: Epidemiology, Etiology
Keywords: Dementia, Risk factors
MeSH Terms: none

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