Agitated behaviors among elderly people with dementia living in their home in Taiwan
Clinical Interventions in Aging
Agitated behaviors among elderly people with dementia living in their home in Taiwan
Yea-Ing l shyu 0 2
0 s chool of n ursing, College of Medicine & healthy Aging research Center, Chang gung University , Taoyuan , Taiwan
1 n ursing Department, Taoyuan Chang g ung Memorial hospital , Taoyuan , Taiwan
2 Department of gerontological Care and Management, Chang g ung University of s cience and Technology , Taoyuan , Taiwan
3 Chang gung Dementia Center, Department of n eurology, Chang g ung University and Memorial hospital , Taoyuan , Taiwan
4 Department of n ursing, Kaohsiung Chang g ung Memorial hospital , Kaohsiung , Taiwan
5 Department of Orthopedic s urgery, l inkou Chang gung Memorial hospital , Taoyuan , Taiwan
PowerdbyTCPDF(ww.tcpdf.org) Wen-Chuin hsu 6 Background/aims: Limited research has been conducted on agitated behavior in Taiwan and dementia among community-dwelling elderly. Therefore, this study focused on community elderly with dementia and a factor analysis of an inventory of their agitated behaviors was conducted. Patients and methods: Participants (N=221) completed the Chinese Cohen-Mansfield Agitation Inventory, community form. Item analysis and exploratory factor analysis assessed reliability, validity, and the underlying factor structure. Results: Five factors were extracted and accounted for 44.53% of the total variance. This study classified agitated behaviors into 5 main subtypes: physically agitated behaviors, destructive behaviors, verbally agitated behaviors, handling things behavior, and aggressive behaviors. Conclusion: The results indicate that differences in the agitated behavior of elderly with dementia exist with respect to cultural background and setting. This novel research and its findings serve as a reference for assessing the agitated behaviors of elderly with dementia living in their homes. Applications may exist for other countries with Chinese/Taiwanese populations.
agitation; aggressive behavior; behavioral problem; caregiver; factor analysis
open access to scientific and medical research
The prevalence distribution of agitated behavior among elderly with dementia living
in communities has risen from 22% to 88%.1–3 Due to differences in the definition
of agitated behavior and in the evaluation instruments used among various studies, a
rather significant differentiation exists in this prevalence range. Agitated behavior is
the main source of distress for caregivers of elderly with dementia; therefore, provision
of a valid and reliable evaluation instrument can help caregivers to assess the agitated
behavior, understand the stage of progression, and evaluate the results of treatment
intervention.4,5 The agitation inventory that was developed by Cohen-Mansfield6 with
creditability is commonly used for the assessment of agitated behavior in elderly
people with dementia.
Previous studies have indicated that various classified behavioral problems may
stem from a common cause, and a universal treatment can be applied according to the
subtype of each behavioral problem.7–10 Verbally aggressive behavior (VAB), such as
complaining, screaming, and repetitive sentences or questions, may stem from a need
for assistance with physiological or emotional discomfort. Physically nonaggressive
behavior (PNAB), such as pacing, is found to be linked to healthier individuals. Thus, it
can be inferred that PNAB may possibly be beneficial to elderly with severe dementia.
It is therefore recommended that caregivers permit or even promote such behaviors.
Physically aggressive behavior (PAGB) may be caused by nerve damage from severe
dementia, the feeling of abandonment, or prolonged
negative personal relationships.7 These abovementioned results
illustrate that in order to understand agitation in elderly with
dementia, not only do their individual behaviors need to be
monitored, but investigations specifically focusing on
different types of agitated behavior must also be conducted.
A small number of studies have investigated the
classification of agitated behavior. The most common
subtypes include 1) PNAB, such as restlessness and pacing;
2) PAGB, such as hitting, grabbing onto people, pushing,
and kicking; 3) verbally nonaggressive behavior (VNAB),
such as complaining and constant requests for attention;
and 4) verbally aggressive behavior (VAGB), such as
cursing, verbal aggression, and temper outbursts.11–14
The Cohen-Mansfield11,13 Agitation Inventory,
community form (CMAI-C), was used in the assessment of agitated
behavior of elderly in day care centers, and 3 types of agitated
behaviors were extracted from the factor analysis: VNAB,
.vdoepww l.syeonu fPoNr AfaBct,oarnedxtVraActGioBn. fDorurPiAngGtBhiwsastsundoyt, rtehaocuhgehd tbheecacuristeeroiaf
/sw laon the impact it has on the patient’s family, Cohen-Mansfield
h ep still divided the community agitated behavior scale into four
from roF subtypes. First, “physically nonaggressive behavior,” which
ed includes restlessness, pacing, or wandering, trying to get
ldao to a different place, inappropriate dressing or undressing,
now repetitious mannerisms, and handling things inappropriately.
ignd Second, “physically aggressive behavior,” which includes
gA hitting people, themselves, or objects, kicking people or
isnn objects, grabbing onto or clinging to people, pushing other
itno people, biting people or objects, and scratching people,
trvee themselves, or objects. Third, “verbally nonaggressive
lIan behavior,” which includes repetitive sentences or questions,
iilcn relevant (or irrelevant) verbal interruptions, complaining
C or whining, constant requests for attention, negativism,
uncooperativeness, or unwillingness, and being verbally
bossy or pushy. Fourth, “verbally aggressive behavior,”
which includes making strange noises, screaming/shouting
or howling, cursing or verbally threatening behavior, and
The abovementioned 3 or 4 subtypes of classification of
agitated behavior are currently the most common
classification methods. However, as there are differences in agitated
behavior between institutionalized elderly with dementia
and elderly with dementia staying at home, and their cultural
backgrounds, researchers from different countries continue
to investigate different methods of classification.12,14,15 In
Taiwan, limited studies have been conducted on the agitated
behavior of institutionalized dementia patients. In regard to
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the assessment of agitated behaviors, only Lin et al15 has
tested the reliability and validity of the Chinese
CohenMansfield Agitation Inventory, community form (CCMAI-C)
with institutionalized dementia patients, but its subtype has
yet to be investigated, likewise for the studies pertaining to
the agitated behavior assessment of community elderly with
dementia and the investigation on the assessment’s subtype.
Therefore, this study will focus on elderly with dementia
living in their own homes and conduct a factor analysis of
their agitated behaviors.
Patients and methods
study setting and participants
Participants were recruited from neurological clinics within
3 hospitals and a community care management center in
northern Taiwan. Patients were included in the study if they
met the following criteria: 1) diagnosed with dementia by a
psychiatrist or neurologist, 2) .65 years old, 3) living in a
home setting in northern Taiwan, and 4) scored .50 on the
CCMAI-C. Inclusion criteria for caregivers were 1) living
with a dementia patient, 2) spending the majority of time on
the patient’s care, and 3) 18 years or older. Participants were
assessed for study outcomes in their homes.
Design and procedure
A cross-sectional, exploratory design was used to investigate
the behavioral problems of elderly individuals with dementia.
This research was approved by the Human Subjects
Protection Committee of Chang Gung Memorial Hospital in
A research nurse contacted eligible subjects at the
outpatient clinics of 3 hospitals and cases referred by the local
care management center to explain the purpose and method
of the study, subjects’ right to withdraw participation at
any time, and to obtain written consent. All participants
provided written informed consent. Data were collected by
caregivers’ self-report regarding to care receivers’ behavioral
Measurement of agitation
Agitation was measured by the CCMAI-C;6,16–18 the
CCMAI-C has been shown to be valid and reliable for a
Taiwanese sample.19 There are 37 items in the English
version of CMAI for Community and 44 items in the Chinese
version. The additional 7 items in the CCMAI-C are “Unable
to sleep,” “Complaining of being hurt or stolen by someone,”
“Claiming to kill him/herself,” “Picking things up
incessantly,” “Searching for things incessantly,” “Requesting
food incessantly,” and “Going to the toilet incessantly.”18
From the results of original factor analysis of CCMAI, that
the additional 7 items were not classified into subtypes of the
original CCMAI. However, all the items were still included
in the measurement of overall agitation according to the
original author’s suggestion.
Family caregivers were asked to report the frequency of
the agitation in the preceding 2 weeks; each item is rated on a
7-point scale, ranging from 1 (never happened) to 7 (several
times in an hour). In our previous study, Cronbach’s alpha (α)
for the overall scale was 0.88. Cronbach’s α for the PNAB,
PAGB, VAGB, and VNAB subscales were 0.79, 0.75, 0.87,
and 0.78, respectively.19
Data were analyzed using SPSS version 20.0 (IBM
Corporation, Armonk, NY, USA) and AMOS version 20.0 (IBM
Corporation). First, the interitem consistency and
discriminability for each item of the CCMAI-C was carried out by
item analysis according to the critical ratio (CR) and
itemtotal correlation (ITC) value. Second, the construct validity of
the CCMAI-C was performed using exploratory factor
analysis with principal axis factoring and direct oblimin rotation.
Third, the internal consistencies of the CCMAI-C overall
scale and subscales were estimated by Cronbach’s α.
Of the 630 dementia patients screened, 251 patients and
their caregivers met the inclusion criteria, and 221 agreed
to participate in the study. The majority were female (56%)
with an average age of 78.4 years (SD =6.74).
Furthermore, 47% had no formal education and 42% were mildly
dependent on caregivers to perform activities of daily living
(ADLs), as indicated by an average Chinese Barthel Index
score of 77.70 (SD =27.15). All patients had an average
Mini-Mental State Examination score of 12 (SD =7). As
regards dementia severity, 48% had mild dementia, 33%
had moderate dementia, and 19% had severe dementia as
determined by the Clinical Dementia Rating Scale. The
majority were diagnosed with Alzheimer’s disease (55%),
38% with vascular dementia, and on average participants
had dementia for 38 months (SD =28). The patients’
characteristics are listed in Table 1.
Item analysis was performed using the CR test and ITC. The
intention was to determine the CR value in order to assess
internal consistency as measured through item correlation
with the total score. Interitem correlation will also examine
the similarity among test items. ITC obtained the correlation
coefficient ranging from 0.3 to 0.8. Significant items with a
CR value of 0.01 were extracted with a CR test. Items that
failed to reach the standard of both the ITC and CR were
excluded. As a result, 5 items from the CCMAI-C were
deleted including verbal sexual advances, physical sexual
advances, grabs onto or clings to people, pushes other people,
and hurts self with harmful object, with 37 items remaining.
A summary of the item analysis is given in Table 2.
Factor extraction was based on the following criteria: 1)
eigenvalues .1, 2) factor loadings $0.3, and 3) 3 or more
items loading on any given factor. Of the remaining 37 items
5 factors were extracted, which accounted for 44.53% of the
total variance. Each factor accounted for 21.90%, 7.14%,
5.68%, 5.25%, and 4.56% of the variance, respectively.
The first factor, labeled physically agitated behavior
(PAB), contained 10 items. The second factor was labeled
destructive behavior (DB) and contained 4 items. The third
factor, labeled VAB, contained 9 items. The fourth factor
was labeled handling things behavior (HTB) and contained
5 items while the fifth factor, labeled AGB, contained nine
items. Details of the factor structure and item loadings are
presented in Table 3.
The internal consistency for the overall scale was 0.88.
For each subtype of agitation, internal consistency was
as follows: PAB, α =0.75; DB, α =0.69; VAB, α =0.75;
HTB, α =0.76; and AGB, α =0.71. All values indicated
Test for homogeneity
Item-total Corrected itemcorrelation total correlation
if item deleted
Factor 2 DB
Factor 3 VAB
Factor 4 HTB
Factor 5 AGB Item
Through exploratory factor analysis, this study has
classified agitated behaviors into 5 subtypes: PAB, DB, VAB,
HTB, and AGB. These differ from the 4 subtypes of agitated
behavior derived by Cohen-Mansfield.13
In this study, negative/uncooperative behaviors appeared
in the subtype PAB, while in the CMAI-C, it appears within
VNAB. This may have been caused by the refusal to cooperate
with or reluctance to participate in the activities of this study.
Activities such as eating, bathing, or going out involve a physical
elements and are therefore classified as PAB. Regardless of this
study or the findings of the CMAI-C, negative/uncooperative
behaviors are all classified under nonaggressive behaviors.
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There is only 1 verbal subtype, VAB, in the factor
structure identified in this study, and it is similar to the results
of Cohen-Mansfield’s investigation of agitated behavior for
elderly in day care centers. The results of Cohen-Mansfield
et al’s11 study identified 3 types of agitated behaviors:
1) PNAB, 2) VAB, and 3) AGB. Items “making strange
noises” and “screaming/shouting or howling” appear in
AGB in this study, while they appear in VAGB in CMAI-C.
Irrespective of this, the abovementioned behaviors are both
classified under aggressive behaviors.
A notable finding from the current research is that the
second factor and the fourth factor, which are “DB” and “HTB”,
respectively, are not included in Cohen-Mansfield’s CMAI-C.
While in the Dutch and Korean version of their studies as well
as the study by Rabinowitz et al20 a subtype similar to HTB
was found. Labeled as “hiding/hoarding,” this factor consisted
entirely of hiding and hoarding behaviors. In this study, the HTB
subtype contained 5 varying items (handling things
inappropri.vdoepw l.syeon autpeliyn,cheossaarndtslyo,r acnodllescetasrcohbijnegctsfo,rhitdhiinnggsthiinncgess,spainctklyin).gStuhcinhgas
/sw laon difference may arise from the sample of the current research,
tthp rsep elderly with dementia living at home, as other studies assessed
from roF those residing in nursing homes. The difference in setting
ed may produce differences in the agitated behaviors exhibited.
loda Furthermore, this subtype is not represented in other researches,
onw an outcome that may be influenced by limiting the
numignd ber factors extracted to 3 or the low rate of occurrences.5,20
gA Both subtypes DB and HTB are classified under “things”
isnn related to agitated behavior. During the process of gathering
iton data, the interviews with family caregivers conducted in the
trvee current research reveal that elderly with dementia living in
lIan their homes demonstrate the behavior of collecting, hoarding,
iilcn and/or destroying items. Examples of such behavior include
C hoarding or destroying tissues, papers, slippers, foods, and
other items. This phenomenon is especially apparent in
female patients with dementia. As elderly in Taiwan tend
to exhibit the characteristics of saving and collecting, the
question of whether this phenomenon is related to the life of
the elderly and/or the difference in cultures in the East and
West needs further investigation.
The results of this study also identified that being “unable
to sleep” and “going to the toilet incessantly” are 2
common behaviors of the elderly with dementia who live in
their homes in Taiwan. However, the community form of
Cohen-Mansfield’s CMAI does not contain these 2 behaviors;
furthermore, the result classification also differs from country
to country. With the consideration of differences between
cultures, it is recommended that local measuring scales or
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classification methods be used in the future when monitoring
of agitated behavior in elderly with dementia is needed.
The results indicate that differences in the agitated
behavior of elderly with dementia exist with respect to
cultural background and setting. Additionally, participants
were mostly elderly with mild or moderate dementia (81%),
and those with severe dementia formed the minority (19%).
As a result, occurrences of the AGB in severe dementia in
this study were rare. In Taiwan, as severe dementia patients
increase the difficulty of care for family caregivers, most of
these patients have been institutionalized, thereby making
the majority of community cases mild and moderate19,21 and
resulting a limitation to this study, as it is difficult to detect
the behavior characteristics of severe dementia patients.
However, this study does show the characteristics of care
for dementia patients living at home in Taiwan.
To our knowledge, the vast majority of current research
on the classification of agitation focuses on patients living
in nursing homes and rarely specifies patients cared for by
family caregivers. Therefore, these results not only can
serve as a source of reference for the assessment of agitated
behaviors in elderly with dementia living at home in Taiwan
but also may be applicable to other countries with Chinese
populations and those where health care providers support
Chinese/Taiwanese immigrants. Future studies exploring
how patients should be treated differently according to the
subtype of agitated behavior and/or specific interventions for
different subtypes of behavioral problems are suggested.
This research was supported by the National Science Council,
Taiwan (NSC 99-2314-B-255-009-MY2), and Healthy Aging
Research Center, Chang Gung University (EMRPD1H0361,
EMRPD1H0551). We would like to thank the nurses and
doctors working in the neurological clinics of Chang Gung
Memorial Hospital for their participation in this study. We would also
like to express our special thanks to the people with dementia
and their family caregivers who participated in this study.
The abstract of this paper was presented at the Alzheimer’s
Association International Conference 2014 under the name
“Agitated behaviors among elderly people with dementia
living in their home in Taiwan” as a poster presentation
with interim findings. The poster’s abstract was published in
“Poster Abstracts” in Alzheimer’s & Dementia, Volume 10,
Issue 4, Supplement: http://www.alzheimersanddementia.
All authors contributed toward data analysis, drafting and
revising the paper and agree to be accountable for all aspects
of the work.
The authors report no conflicts of interest in this work.
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