Copyright 1999 by
The Cerontological Society of America
The Cerontologist
Vol. 39, No. 6, 668-676
This study evaluated outcomes of an inpatient program designed to reduce severe agitated
behavior in geriatric patients with dementia who could not be successfully treated on an
outpatient basis. An individualized treatment plan was created for each patient (N = 250)
that involved pharmacological and nonpharmacological interventions with behavioral,
environmental, and psychological components. Assessment of behavioral, cognitive, and
functional status was conducted for each patient on admission to the program and at
discharge. Significant improvements on these assessments were observed. We conclude
that the longitudinal, multidisciplinary approach used in this study was effective in
significantly reducing intrusive and dangerous behaviors while preserving or enhancing
patients' cognitive and functional abilities.
Key Words: Dementia, Geriatric pyschiatry, Disruptive behavior
The Outcomes of an Inpatient Treatment
Program for Geriatric Patients With
Dementia and Dysfunctional Behaviors
Alvin Holm, MD, FACP,1 Matthew Michel, BS,2 Greg A. Stern, BS,3
Tsui-min Hung, MHS,2 Theresa Klein, OTR,4 Linda Flaherty, PhD,4
Sara Michel, LSW,4 and Gabe Maletta, MD, PhD5
During the course of a dementing illness, impairments are realized in cognitive functions as well as
noncognitive or behavioral functions. Cognitive difficulties include impaired memory, visuospatial, language, attention, and executive functions (McKhann,
Drachman, Folstein, Katzman, & Stadlan, 1984). Behavioral disturbances include agitation, irritability, mood
lability, verbally disruptive behavior, and physically aggressive behavior (Drevets & Rubin, 1989). Although
cognitive losses are observed throughout the course
of dementing illness, behavioral disturbances tend to
occur more frequently in the moderate to moderately
severe stages of the illness and can be so disruptive as
to prompt institutionalization and increased restrictions
on patients in institutionalized settings (Lacks, Becker,
Siegal, Miller, & Tinetti, 1992; Reisberg, Ferris, Franssen,
Jenkins, & Wisniewski, 1989). Dysfunctional behaviors are the most common reason that dementia patients are admitted to a skilled nursing facility (Streim,
Rovner, & Katz, 1996).
Pharmacological treatment options for the intellectual impairments seen in dementia include both agents
that bolster cognition through enhanced cholinergic
transmission and agents that slow the degenerative
process by providing some neural protective effect
(Schneider, 1996). Despite advances in the treatment
of intellectual decline in Alzheimer's disease, untreated
behavioral problems pose a considerable challenge.
These so-called "excess disabilities" (Brody, Kleban,
The dementias represent a group of largely progressive conditions that include some of the most devastating illnesses afflicting the elderly population. Dementia
ranks as the fourth leading cause of death in adults
behind heart disease, stroke, and cancer, and results
in billions of dollars in health care expenditures annually (Dresse, Marechal, Scuvee-Moreau, & Seutin, 1994).
Prevalence studies have indicated that as many as 5%
of elderly individuals aged 65 and older suffer from
dementia. Furthermore, the incidence of dementia increases with age; by the age of 85, as many as one in
two elders may be afflicted (Evans et al., 1989; Livingston, 1994).
This study was conducted at HealthEast Bethesda Rehabilitation Hospital's
Geriatric Behavior Program in St. Paul, Minnesota, and was partially funded
by a grant from the HealthEast Foundation. An oral presentation based on
this study was presented at the Eighth Congress of the International Psychogeriatric Association in Jerusalem, Israel, in August 1997.
This research was supported in part by a grant from the HealthEast
Foundation. We thank and acknowledge HealthEast Bethesda Rehabilitation Hospital's Geriatric Behavioral Program nursing staff for their valuable assistance, Karen Brudvig for her library services, and Kari Nordin for
data collection.
'HealthEast Bethesda Rehabilitation Hospital Geriatric Behavioral Program, St. Paul, M N , and University of Minnesota, Minneapolis, MN.
2
HealthEast Office of Research and Medical Education, St. Paul, MN.
'Address correspondence to Greg A. Stern, HealthEast Office of Research & Medical Education, 1700 University Avenue West, St. Paul, MN
55104. E-mail: [email protected]
"HealthEast Bethesda Rehabilitation Hospital Geriatric Behavioral Program, St. Paul, M N .
5
Geriatrics and Extended Care, Verterans Administration Medical Center, Minneapolis, MN.
668
The Gerontologist
Lawton, & Silverman, 1971) resulting from treatable
psychiatric illnesses result in medical illnesses, hospital
admissions, institutionalizations, and increased health
care expenditures (Livingston, 1994). Unfortunately,
many of the problem behaviors seen as a result of
dementia are often viewed as expected and untreatable consequences of the degenerative condition
itself.
Roadblocks to successful treatment of dysfunctional
behaviors in dementia include the sometimes confusing manner in which treatable conditions present in
these patients and the difficulty of effective treatment
plan execution. Patients with dementia and severe
agitated behaviors are difficult to assess in an outpatient setting. Even when a patient is institutionalized,
contact with the treating physician is limited to relatively brief encounters, and treatment decisions become heavily dependent on observations by staff with
varying levels of training and experience.
We established an approach to treat patients with
dementia and severe agitated behaviors that could
not be successfully treated on an outpatient basis. The
approach allows for comprehensive multidisciplinary
assessments in an ongoing fashion, thus enabling the
treatment team to more accurately identify the etiology of problem behaviors. The approach is based on
the assumption that a patient's behavioral, cognitive,
and functional status not only forms the rationale for
intervention, but also validates therapies used and forms
the basis for alterations in therapy over time.
The impact of this program on patients' behavioral,
cognitive, and functional status was measured at admission and discharge. We hypothesized that dysfunctional behaviors seen in dementia patients are
commonly the result of treatable psychiatric illnesses
and that successful treatment of these illnesses will reduce these behaviors while at the same time preserving, if not enhancing, their cognitive and functional
abilities.
Methods
The Impatient Unit
The unit includes 16 beds, with audiovisual equipment in each room. A monitor located in the nurses'
station can be switched from room to room, as needed,
to observe patient behavior. There is a common dining area (also with audiovisual equipment) with a divider for patients with special behavioral needs. The
staffing ratio is one nurse to every three patients.
Program Admission Requirements
Patients referred to the unit are screened by registered nurses before admission to determine if placement in the geriatric behavior program is appropriate.
Patients are admitted if they meet the following admission criteria: (a) a diagnosis of a dementing illness;
(b) unsuccessful prior attempts at nursing home and/
or outpatient behavior management; (c) behavioral
problems such as agitation, poor attention, anxiety, aggressive behavior, delusional behavior, hallucinations,
Vol. 39, No. 6, 1999
669
apathy, and regressed or bizarre behavior that result
in the patient's inability or unwillingness to perform
the activities of her or his expected daily routine; (d)
behavior that threatens harm (to others or to property) and that requires close observation (e.g., 24-h
supervision), a quiet room, and/or medication; (e) considered a high risk for self-destructive behavior; or
(f) behavior that threatens displacement from the current living situation.
The Program Model
The evaluation and treatment of patients is multidisciplinary and longitudinal in nature. Treatment is
provided in a traditional manner using the principles
of geriatric psychiatry when diagnoses related to behavioral dysfunction can be made with an acceptable
degree of certainty, such as in clear cases of depression, delirium, or psychosis (Jenike, 1989). In a situation in which diagnosis is unclear, treatment is more
experimental and based on observation of the patient.
Clinical decision making and treatment planning are
guided by repeated assessments of broad-based behavioral, cognitive, and functional outcomes as various therapies are introduced and evaluated for effectiveness.
The program's care team includes individuals from
all of the disciplines necessary to provide comprehensive assessment and treatment of behavioral dysfunction in geriatric patients. The multidisciplinary care
team consists of a geriatrician, a psychologist, a nurse
manager, unit nurses, an occupational therapist, a recreational therapist, a social worker, a dietitian, a pharmacist, and a chaplain. A psychiatrist and a neurologist are available as needed for consultation.
Initially, assessments are compiled and discussed
with the care team members to determine the most
appropriate therapeutic interventions. The care team
creates an individualized treatment plan to address
each patient's unique needs. Pharmacological therapies are used to treat diagnosable psychiatric conditions or to test appropriate hypotheses about the
physiological basis of patients' behavioral dysfunction.
At the same time, emphasis is placed on maximizing
environmental and structural interventions to prevent
overreliance on pharmacological treatment.
Nondrug interventions often involve the creation
of structure for patients who cannot provide this for
themselves (Birchmore & Clague, 1983; Cornbleth, 1977;
Knopman & Sawyer-DeMaris, 1990; Mintzer et al.,
1994). In an attempt to improve structure, specific tasks
and activities designed to decrease frustration, promote
successful outcomes, and provide security are identified for each patient on the basis of objective assessments of function and intellectual capacity. For lower
functioning patients, these tasks include gross motor
activities. A higher cognitively functioning patient may
be appropriately challenged with a higher level activity involving verbal skills. When appropriate, treatment
also includes individual, one-on-one supportive sessions with the psychologist or occupational therapist,
planned group activities, or both. Once again, the
type of activity, as well as the length of session, is
dependent on the patient's present level of cognitive
functioning.
Environmental management and adaptive equipment
are also used to meet patients' individual needs and
thus also to promote successful outcomes. Often, a
decrease in trie level of visual and auditory stimulation decreases patient agitation and aggressive behavior. For patients who are higher functioning, treatment
programs may include behavioral programming (e.g.,
placing a limit on the number of requests per hour a
patient can make, with a care team member assigned
to monitor requests). Often, higher functioning patients
are given daily schedules with times for daily care,
meals, activities, therapies, recreation, and daytime rest
periods to control the amount of daytime sleep. The
care plans and schedules are kept as brief and simple
as possible to allow for greater consistency in implementation. As patients progress, their environmental
and structural interventions are adjusted and modified in preparation for discharge.
Care team members hold patient care conferences
at least two times per week to discuss the results
of patients' serial assessments and their responses to
treatment. The patients' families are included as an
essential part of the care team and are involved in
the patients' treatment planning, assessment, and discharge preparations. Comprehensive discharge planning, coordinated by the team social worker, is an
important part of the overall treatment plan. The goal
at discharge is to place patients in the least restrictive
environment that ensures behavioral control. Discussions with patients' responsible caregivers regarding discharge disposition begin at admission. Readiness for
discharge is evaluated and is based on many considerations. These considerations include cognitive and
functional status, medical needs, dependency for transfers, medication administration and monitoring requirements, and environmental needs for structure and
supervision of daily schedules. Discharge options include long-term care skilled nursing facilities, board
and care centers, assisted living apartments, or home
with caregivers. For patients discharged to home, varied amounts of in-home care and community-based
services may be recommended (e.g., adult day care,
home health services, meals-on-wheels, chore services).
In summary, the inpatient geriatric behavior program is essentially an assessment and treatment "laboratory" that allows members of the care team to make
informed and rational choices in planning the most
appropriate therapeutic interventions for each patient
over time. The success of treatment is measured in
relation to the patient's global function (i.e., behavioral, cognitive, and functional status) and not simply
in relation to the effects of treatment only on specific
problem behaviors.
types of problem behaviors, cognitive level, functional
status, active medical comorbidities, psychiatric diagnoses, and pharmacological treatment. All patients were
found to be testable despite varying degrees of behavioral dysfunction.
Specific psychiatric diagnoses were assigned to patients by a geriatrician at the time of discharge according to Diagnostic and Statistical Manual of Mental
Disorders (4th ed., or DSM-IV; American Psychiatric
Association, 1994) criteria whenever these criteria
clearly were met. Often, however, because of the patients' dementia and the complexity of their condition, psychiatric diagnoses could not be assigned on
the basis of strict adherence to DSM-IV criteria. In
these cases, the geriatrician's diagnoses relied on the
interpretation of the patient's behavior in the context
of her or his cognitive impairment as well as her or
his response to treatment.
Patients' behavioral, cognitive, and functional status were assessed at admission and discharge. Assessments of aggressive behavior were conducted by a
trained clinical nurse manager, using the Rating Scale
for Aggressive Behavior in the Elderly (RAGE; Patel &
Hope, 1992). Cognitive performance was assessed by
an occupational therapist certified in using the Allen
Cognitive Level Test (ACL; Allen, 1982, 1985; Allen,
Earnart, & Blue, 1992; Velligan, Bow-Thomas, Mahurin,
Dassoric, & Erdely, 1998). Functional status was measured by a certified occupational therapist, using a modified version of the Functional Independence Measure
(FIM), which included the self-cares, social skills, and
leisure skills scales (Granger, 1990; Hamilton, Laughlin,
Fiedler, & Granger, 1994; Pollak, Rheault, & Stoecker,
1996).
The RAGE is a 21-item scale. RAGE scores range
from 0 to 61, with higher scores indicating higher levels of agitated behavior. Nineteen of the items address specific kinds of aggressive behaviors; one item
has to do with the patient's need for sedation or physical restraints to control her or his behavior, and the
final item is a global rating of aggressive behavior. The
item regarding the need for restraint to control aggressive behavior is rated on a 2-point scale where
0 = no and 1 = yes. All other items are rated on a
4-point frequency scale where 0 = not once in the
past three days—never; 1 = at least once in the past
three days—occasionally; 2 = at least once every day
in the past three days—often; and 3 = more than
once every day in the past three days—always.
The ACL is based on a 6-point ordinal scale where
Level 1 = severe cognitive impairment and Level 6 =
normal cognitive functioning. The levels assess how
patients receive and process information in order to
perform activities of daily living (ADLs). The levels also
allow for the assessment of attention, problem-solving
skills, ability to follow directions, capacity for new
learning, and capacity to perform ADLs. In addition,
the levels can be used to monitor patients' status on
a day-to-day basis, serve as a tool to educate caregivers, and suggest recommendations for discharge. The
levels are determined by the patients' completion of
an occupational therapy assessment. This assessment
is a process whereby the patient completes a series of
Evaluation
Data were collected prospectively on 250 patients
admitted to the inpatient geriatric behavior unit between January 1, 1994, and December 31, 1995. Information was collected on patients' demographic
characteristics including admission source, severity and
670
The Gerontologist
three leather lacing stitches that progressively increase
in difficulty. Task analysis (breaking down a task into
steps) is used to assist the patient in completing each
task. The amount of steps, cueing, and expectation of
performance vary with level of impairment.
The three scales of the FIM address basic ADLs
(eating, dressing upper body, dressing lower body,
grooming, and toileting), leisure, and social skills. Each
item was rated on a 7-point ordinal scale of disability
where 1 = total assistance (less than 25% independence), 2 = maximal assistance (at least 25% independence), 3 = moderate assistance (at least 50% independence), 4 = minimal assistance (at least 75%
independence), 5 = supervision, 6 = modified independence, and 7 = complete independence. FIM scores
ranged from 7, representing need for total assistance
in all areas, to 49, representing complete independence in all areas.
Results
Patient Characteristics
Two hundred fifty patients were included in this
study. The mean length of stay was 25.6 days {SD —
19.1) and ranged from 7 to 152 days. The patients'
average age was 81 years {SD = 8). Twenty-three
patients (9%) were admitted from home and 164
patients (67%) were admitted from a skilled nursing facility. Patient demographics are summarized in
Table 1.
Gender
Male
Female
Age
<60
60-69
70-79
80-89
90-99
Marital status
Single
o
Married
Widowed
Divorced
Race
Caucasian
African American
Other
Admission living status
Home
Skilled nursing facility
Acute or transitional care
Other assisted living"3
Na
Pharmacological
Treatment
%
Table 2. Definitions of Problem Behaviors
113
137
45.2
54.8
3
21
84
1.2
8.4
33.6
111
31
44.4
12.4
60
75
102
3
24.0
30.0
40.8
1.2
236
4
4
96.7
1.6
1.6
23
164
50
9
9.3
66.7
20.3
3.6
Behavior Name
a
Numbers of patients do not always total 250 because of missing data. Percentages are based on valid, nonmissing data.
b
"Other assisted living" includes assisted living facilities, board
and care facilities, and group homes.
Vol.39. No. 6. 1999
Patients' behavior problems were classified into five
categories (see Table 2). The three most common problem behaviors identified at admission were physical
aggression (68%), agitation (62%), and verbal disruption (54%). Table 3 lists the definition of the presenting psychiatric illnesses used by the clinical team.
The three most common psychiatric illnesses were
major or minor depressive disorders without psychosis (30%), major or minor depressive disorders with
psychosis (25%), and bipolar disorder or bipolar symptoms (23%). Patients' common admission behaviors,
presentation of psychiatric illnesses, and common active medical comorbidities were identified by a geriatrician (see Table 4). An association between psychiatric illness and admission behaviors was detected. We
found that a higher proportion of patients with bipolar illness were physically aggressive than patients with
depression (79% vs 64%, p = .04). In addition, we
found that a higher proportion of patients with bipolar illness were both physically aggressive and verbally
disruptive as compared with patients with depression
(58% vs 41%, p = .03). The patients were medically
complex, with an average of 2.3 active medical comorbid conditions on admission, including atherosclerotic
cardiovascular disease (37%), hypertension (30%), and
cerebrovascular disease (20%).
A patient's pharmacological treatment regimen at
discharge represents the medication management strategy that was most effective for achieving the goal of
decreasing agitated behaviors and maximizing function. Of the 229 patients (92%) who were discharged
Table 1. Summary Characteristics of Patients Admitted
to an Inpatient Geriatric Behavior Program
Demographic Characteristics
Behavioral Diagnoses
Agitation3
Inappropriate verbal, vocal, or motor
activity not explained by apparent
needs or confusion, per se
Verbally disruptive
A form of agitated behavior whereby
one's utterances, intentionally or
unintentionally, result in a prolonged
disruption of the environment
Physically aggressive
A form of agitated behavior whereby
physical actions potentially resulting in
injury (e.g., hitting, spitting, scratching,
kicking) are directed toward self or
others
Resistive behavior
Behavior, either verbal or physical,
indicating an unwillingness to comply
with requests or directives
InaDDroDriate sexual
behavior
Verbal or Dhvsical behavior indicating
or inappropriately intimating a desire
for sexual contact
a
fi71
Description
Cohen-Mansfield (1995).
Table 3. Definitions of Presenting Psychiatric Illnesses
Presentation of
Psychiatric Illness
Table 4. Clinical Characteristics
Clinical Characteristics
Definition
Major depression
without psychosis
DSM-IV criteria3
Minor depression
without psychosis
Features of depressive illness but
does not meet full DSM-IV
criteria for major depressive
disorder
Major depression with
psychosis
DSM-IV criteria for major
depressive disorder including
the presence of either delusions
or hallucinations
Minor depression with
psychosis
Features of depressive illness,
including the presence of either
delusions or hallucinations, but
does not meet full DSM-IV
criteria for major depressive
disorder
Bipolar disorder
DSM-IV criteria
Features of bipolar illness
Features of bipolar illness, but does
not meet full DSM-IV criteria for
bipolar disorder
Psychotic disorders
DSM-IV criteria
Anxiety disorder
DSM-IV criteria
Common admission behaviors
Physically aggressive
Agitation
Verbally disruptive
Resistive behavior
Inappropriate sexual behavior
Presentation of psychiatric illness"3
Major depression without psychosis
Minor depression without psychosis
Major depression with psychosis
Minor depression with psychosis
Bipolar disorder
Features of bipolar illness
Organic psychosis
Anxiety disorder
Common admission medical comorbidities
Atherosclerotic cardiovascular disease
Hypertension
Cerebrovascular disease
Diabetes mellitus
Hypothyroidism
Ophthalmologic illness
169
155
136
83
12
67.6
62.0
54.4
33.2
4.8
9
66
5
58
13
44
25
4
3.6
26.4
2.0
23.2
5.2
17.6
10.0
1.6
92
74
51
31
25
25
36.8
29.6
20.4
12.4
10.0
10.0
a
Numbers add to greater than 250 because patients often had
more than one admitting behavior, psychiatric illness, or active
medical comorbidity.
b
Psychiatric diagnoses in addition to the patients' dementia diagnoses.
of 21.2 (p < .001). The observed reductions in mean
RAGE scores reflect a clinically significant decrease. A
complete elimination of the problem behaviors was
observed in 38% of patients. The mean discharge ACL
score of 3.5 was significantly higher than the mean
admission ACL score of 3.3 (p < .001). The mean
discharge FIM score of 24.9 was significantly higher
than the mean admission FIM score of 22.4 (p < .001).
These relatively small but significant increases in mean
ACL and FIM scores indicate that behavioral management was achieved while maintaining and, in many
cases, improving patients' cognitive and functional
abilities.
The outcomes in patients with different psychiatric
diagnoses were evaluated. Of particular interest were
*DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994).
on any number of psychotropic agents, 66 patients
(26%) were discharged on one, 103 patients (41%)
received two, 59 patients (24%) received three, and
one patient (0.4%) received four. The most common
combination of psychotropic agents consisted of an
antidepressant and an antipsychotic agent. Twentyone patients (8%) were discharged without any psychotropic agents. It should be noted that on admission, only 20% of patients were being treated with
two or more psychotropic agents as compared with
65% at the time of discharge.
The medications prescribed at preadmission and
discharge are summarized in Table 5. A significantly
higher proportion of antipsychotic agents, antidepressant agents, and mood-stabilizing anticonvulsant agents
were prescribed to patients at discharge from the program (p < .001). A significantly lower proportion of
antianxiety agents were prescribed to patients at discharge from the program (p = .003).
Table 5. Pharmacological Treatment Prescribed
Before Admission and at Discharge
Before
Admission
Medication
Pharmacological
Treatment
Any antipsychotic agents
Any antidepressant agents
Any mood stabilizing
anticonvulsant agents
Any antianxiety agents
Comparison of Patients' Behavioral,
Functional, and Cognitive Status
Average admission, discharge, and improvement
scores for the RACE, ACL, and FIM are presented in
Table 6. The mean discharge RAGE score of 3.6 was
significantly lower than the mean admission RAGE score
Discharge
Medication
N
(%)
N
(%)
107
45
42.8
18.0
170
148
68.0
59.2
<.001
<.001
23
64
9.2
25.6
102
36
40.8
14.4
<.001
.003
a
Two proportion comparisons between medications perscribed
before admission and at discharge.
672
The Gerontologist
Table 6. Admission and Discharge RAGE, ACL, and FIM Scores
Admission
Discharge
Improvement
Improvement Status (%)b
N
M
SD
M
SD
M
SD
Pa
RACE
(Min 0, Max 61)
250
21.2
13.2
3.6
5.7
17.6
13.2
<.001
Better
Same
Worse
90.0
5.6
4.4
ACL
(Min 1, Max 6)
250
3.3
0.6
3.5
0.7
0.2
0.4
<.001
Better
Same
Worse
78.8
9.6
11.6
Modified FIM Total
(Min 7, Max 49)
250
22.4
7.5
24.9
7.7
2.5
4.3
<.001
Better
Same
Worse
91.6
2.0
6.4
Self-care FIM
(Min 5, Max 35)
250
16.7
5.9
17.5
5.8
0.8
3.2
<.001
Better
Same
Worse
54.8
32.0
13.2
Social FIM
(Min 1, Max 7)
250
2.9
1.3
3.6
1.4
0.7
1.0
<.001
Better
Same
Worse
62.4
30.4
7.2
Leisure FIM
(Min 1, Max 7)
250
2.8
1.2
3.6
1.2
0.8
1.1
<.001
Better
Same
Worse
59.6
36.0
4.4
Measure
Notes: RACE = Rating Scale for Aggressive Behavior in the Elderly; ACL = Allen Cognitive Level Test; FIM = Functional Independence Measure; Min = minimum; Max = maximum.
a
Two-tailed, paired comparison f. tests for the difference between the scores at admission and discharge.
b
Better is defined as an improvement from admission to discharge (i.e., lower RAGE score, higher ACL and FIM scores). Same
indicates no change from admission to discharge. Worse is defined as a decline (i.e., higher RAGE score, lower ACL and FIM scores).
For RAGE and FIM scores, Better and Worse were determined by one full point higher or lower. For the ACL, Better and Worse were
determined by any higher or lower point score.
the differences between depressed and bipolar patients (see Table 7). Both groups had similar mean
scores on the ACL and FIM on admission (p > .63).
We noted that bipolar patients had a significantly
higher mean RACE score on admission (p = .04). The
before-and-after comparison shows that the treatment
significantly improved cognition and function in patients with depression while simply preserving cognition and functional status in patients with bipolar illness (ps < .001 and > .10, respectively). The reduction of agitated behavior was significant for both depressed and bipolar patients despite the higher mean
RACE score on admission in the bipolar group (p <
.001).
Admission source was evaluated with respect to clinical characteristics and treatment (Table 8). Patients
admitted from a home environment tended to have
lower RAGE scores and higher total FIM scores than
those admitted from a skilled nursing facility (p < .004).
The before-and-after comparison indicates that dysfunctional behavior was effectively controlled and cognition improved in patients admitted from both a home
environment and a skilled nursing facility (p < .02).
However, functional status was found to significantly
improve in patients admitted from a skilled nursing
facility while simply being preserved in patients admitted from a home environment (ps < .001 and .09,
respectively). Admission source was significantly assoVol. 39, No. 6, 1999
673
ciated with the number of psychotropic medications
eventually required to achieve an optimal outcome
(p = .03). Among the patients admitted from a home
environment, 9% were treated with no psychotropic
medications, 48% were treated with one, 26% were
treated with two, and 17% were treated with three.
Among the patients admitted from skilled nursing facilities, 7% were treated with no psychotropic medications, 19% were treated with one, 48% were treated
with two, and 26% were treated with three or more.
With respect to the entire study group, improvement in RAGE scores was observed in 90% of patients.
Improvement in ACL scores was observed in 79% of
patients and improvement in FIM scores was observed
in 92%. Seventy percent of the patients demonstrated
improvements on all three measures. Eighty-three percent of the total patient population either improved
or remained the same on all three measures. Among
patients demonstrating reduction in RAGE score, 89%
improved or maintained their ACL scores, and 95%
improved or maintained their FIM scores.
Discussion
We herein report on the outcomes of an inpatient
behavior program in addressing the cognitive, as well
as noncognitive, neuropsychiatric sequelae of dementing iNness. Similar to the Mintzer et al. (1993)
Table 7. Global Outcomes for Patients With Depression2 and Bipolar lllnessb
Admission
Measure
RAGE
Depression
Bipolar
ACL
Depression
Bipolar
Modified FIM total
Depression
Bipolar
Discharge
Improvement
N
M
SD
M
SD
M
SD
p3
138
20.6
12.3
3.3
4.2
17.3
11.9
<.001
Better
Same
Worse
92.0
5.8
2.2
57
24.8
13.9
4.3
5.5
20.5
14.0
<.001
Better
Same
Worse
89.5
5.3
5.3
138
3.3
0.6
3.6
0.6
0.3
0.3
<.001
Better
Same
Worse
81.9
8.7
9.4
57
3.3
0.5
3.4
0.6
0.1
0.5
.34
Better
Same
Worse
70.2
8.8
21.1
138
22.2
7.4
25.1
7.3
2.9
3.8
<.001
Better
Same
Worse
94.2
2.2
3.6
57
22.8
6.8
24.0
7.2
1.2
5.7
.10
Better
Same
Worse
84.2
1.8
14.0
Improvement Status (%)
Notes: The depression group consisted of all major depression and all minor depression patients; the bipolar group consisted of
patients with bipolar disorder and patients with features of bipolar illness. RAGE = Rating Scale for Aggressive Behavior in the Elderly;
ACL - Allen Cognitive Level Test; FIM = Functional Independence Measure.
a
Two-tailed, paired-comparison t tests for the difference between the scores at admission and discharge.
Combination psychotherapeutic regimens were found
to be an essential aspect of treatment for a majority
of our patients. At discharge from the program, combination psychotherapeutic regimens were used in 65%
of patients, with the most common combination consisting of an antidepressant and an antipsychotic agent.
Monotherapy was prescribed in only 26% of patients,
with antipsychotics being used most frequently. Patients demonstrating evidence of a mixed mood state
were often treated with three agents, including medications from the antidepressant, antipsychotic, and
mood-stabilizing classes. Although it is clear that elderly people are a disparate group when it comes to
the use of psychotherapeutic medications, we believe
these results underscore the need to individualize treatment programs in these patients. In addition, these
findings demonstrate that, contrary to common belief,
"polypharmacy" can achieve desirable outcomes in
patients who have shown themselves to be refractory
to more conservative interventions.
Improvements in global functioning were realized
during the course of inpatient treatment as determined
by performance on tests of behavioral, cognitive, and
functional parameters. Interestingly, although dramatic
improvements in behavior were seen in most patients,
improvements in cognitive and functional conditions
were more modest. We believe the improvements seen
in the majority of patients in this study resulted from
the effective treatment of comorbid psychiatric illness.
The fact that improvements in behavior were more
program, our unit relies heavily on observation and
treatment in a multidisciplinary environment with the
goal of returning patients to the least restrictive environment that would ensure continuing behavioral control. In addition, we measured global parameters of
function, including the behavioral, cognitive, and functional status of all study participants on both admission and discharge. We also attempted to more clearly
define the nature of the treatable psychiatric dysfunction occurring in these patients as well as the impact
of psychotropic therapies used as part of their treatment program.
In identifying psychiatric diagnoses in this study sample,
we found that 55% of patients had a major depressive illness or significant features of depression, although
only 18% were being treated with antidepressant medications before admission. Features of bipolar illness
were present in 23% of patients, with 5% meeting
DSM-IV criteria for bipolar disorder. Although bipolar
illness is not commonly reported in association with
dementing illness (Shulman, 1997), our results indicate that it is a major contributor to the etiology of
behavioral dysfunction leading to admission to this inpatient treatment program. Few of the patients in our
study were being treated for bipolar illness at admission, evidenced in part by the fact that at the time of
admission only 4 patients were being treated with mood
stabilizing agents. In contrast, at discharge 102 patients
received mood-stabilizing anticonvulsant agents as part
of their treatment program.
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Table 8. Global Outcomes for Patients Admitted From Home and Skilled Nursing Facilities (SNF)
Admission
Discharge
Improvement
Measure
N
M
SD
M
SD
M
SD
pa
RACE
Home
23
16.0
10.4
3.0
3.5
13.0
10.4
<.001
Better
Same
Worse
82.6
8.7
8.7
SNF
167
24.0
12.5
4.0
5.3
20.0
12.9
<.001
Better
Same
Worse
95.8
3.0
1.2
ACL
Home
23
3.5
0.7
3.6
0.6
0.1
0.2
.02
Better
Same
Worse
73.9
8.7
17.4
SNF
167
3.2
0.6
3.4
0.7
0.2
0.5
<.001
Better
Same
Worse
76.6
10.8
12.6
23
26.3
7.5
27.8
7.8
1.5
4.0
.09
Better
Same
Worse
87.0
4.3
8.7
167
20.7
6.6
23.4
6.9
2.7
4.2
<.001
Better
Same
Worse
92.2
1.8
6.0
Modified FIM Total
Home
SNF
Improvement Status (%)
Notes: RAGE = Rating Scale for Aggressive Behavior in the Elderly; ACL = Allen Cognitive Level Test; FIM = Functional Independence Measure.
a
Two-tailed, paired-comparison t tests for the difference between the scores at admission and discharge.
admission compared with depressed patients. These
findings are consistent with reports of elderly bipolar
patients in other studies (Berrios & Bakshi, 1991; Shulman,
1997).
The ACL was used to assess the cognitive level of
the study population despite the less frequent use of
this instrument in the dementia literature. We believe
this test is more appropriate for this population than
other widely known instruments such as the MiniMental State Examination (MMSE; Folstein, Folstein,
& McHueh, 1975) because, unlike the MMSE, which,
in general, measures domains of cognitive performance,
the ACL measures function related to activities of daily
living. Kehrberg, Kuskowski, Mortimer, and Shoberg
(1992) reported that persons unable to respond to the
MMSE were able to be evaluated with the ACL. In
addition, the ACL has been found to correlate significantly with the MMSE in previous studies (Heying, 1985;
Kehrberg et al., 1992; Wilson, Allen, McCormack, &
Burton, 1989).
It is interesting that despite the diverse nature of
this study population, clear improvements in most outcome measurements were found. Differences in individual outcomes for specific patients can be explained
by the fact that patients included in the study had a
variety of dementia diagnoses with a large range of
behavioral, cognitive, and neurologic problems. They
were also medically complex, with an average of 2.3
active comorbid medical conditions noted at the time
of admission. One would expect these factors to influence individual patients' outcomes.
dramatic is consistent with the idea that cognitive and
functional gains were secondarily related to improvements in behavior rather than primary effects of the
prescribed treatments.
In comparing clinical characteristics and outcomes
based on the degree of structure in patients' daily lives
at the time of admission, we chose to compare patients admitted from a home environment to patients
admitted from a skilled nursing facility. Patients admitted from home were found to be more functionally independent and less behaviorally disruptive than
their institutionalized counterparts. Treatment regimens
required to achieve successful outcomes in patients
admitted from home were less complex, often requiring the use of one or no psychotropic medication. Of
interest, statistically significant improvements in functional status were realized only in patients admitted
from a skilled nursing facility. Clearly, although institutionalized patients were found to be more advanced
in their disease and require more complex management, their outcomes were largely comparable to patients with a lesser degree of dysfunction.
In examining outcomes in the bipolar and depressed
groups, we found that although improvements in behavior were comparable, outcomes with respect to
cognitive and functional parameters were different. Depressed patients realized clinically and statistically significant gains in cognitive and functional status with
treatment, whereas bipolar patients remained stable
with respect to these outcomes. Patients with bipolar
illness were also found to have higher RACE scores at
Vol. 39, No. 6, 1999
675
There are several limitations of this study. One is
the lack of a control group. For example, it is wellknown that a significant placebo effect can be noted
when the behavioral effects of psychotropic therapies
are studied in mentally ill patients in a randomized,
controlled fashion. Another limitation is that data collection did not include the patient's severity and type
of dementia, which may be related to the outcomes
of the treatment. For example, bipolar illness in elderly patients has been attributed to focal brain lesions
occurring as the result of such conditions as cerebral
infarcts and tumors (Shulman, 1997). We could not
determine if the bipolar illness seen in this study was
attributable only to focal brain disease or if primary
degenerative conditions, such as Alzheimer's disease,
were also responsible. This study also did not follow
patients after discharge; therefore, we were not able
to determine if the gains realized within the inpatient
program were maintained in the outpatient setting or
whether these improvements resulted in additional tangible
benefits. This study may also be limited by a form of
investigator bias in that the admission and discharge
assessments were conducted by the treatment team.
The results of our study indicate that inpatient geriatric behavioral treatment using a longitudinal, multidisciplinary approach can effectively evaluate and treat
dysfunctional behaviors in dementia patients while at
the same time preserving, if not enhancing, their cognitive and functional abilities. Because of the evolving
and progressive nature of dementing illness, further
research is needed to determine if inpatient geriatric
behavior programs, such as the one described in this
study, can result in long-term benefits in patients following discharge (i.e., reduction in the frequency of
additional medical illness and hospital readmission
rates). Further research is also needed to more clearly
define the nature, course, and optimal treatment of
bipolar illness in dementia patients.
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Received July 7, 1998
Accepted August 31, 1999
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