Association Between Agitated Behaviors and Hospitalizations in Community-Dwelling Individuals with Alzheimer's Dementia: an Assessment Based on the Cohen-Mansfield Agitation Inventory

Introduction Alzheimer's dementia (AD) is characterized by loss of cognitive functioning and a wide range of neuropsychiatric symptoms that may contribute to poor patient outcomes. Agitation is among the most common neuropsychiatric symptoms and includes physically and verbally aggressive behaviors, pacing, wandering, and sexual disinhibition. The frequency of agitated behaviors can be measured using the Cohen-Mansfield Agitation Inventory (CMAI), a validated caregiver-rated questionnaire. Information on the impact of measurable changes in agitated behaviors on healthcare resource utilization (HRU) among patients with AD is limited. Thus, an analysis of a caregiver survey study was conducted to examine the association between hospitalizations and agitated behaviors, as measured by the CMAI, among individuals with AD living in US community-based settings. Methods An online caregiver survey was conducted (26/08/2021-24/09/2021). Adult caregivers who lived with and provided unpaid care for an individual with AD (care recipient) were recruited through email invitation from Dynata's US panel. Participants were asked to complete a 3-part online questionnaire involving: 1) informed consent and screening; 2) CMAI assessment; 3) caregiver and care recipient characteristics and outcomes, including care recipient HRU during the year prior to data collection. The frequency of each of the 29 CMAI agitated behaviors exhibited in the preceding 2 weeks was scored using a 7-point scale from “never” (1 point) to “several times an hour” (7 points). The CMAI total score was derived by summing the frequency responses for all CMAI agitated behaviors. The CMAI sub scores for 4 factors of agitation (i.e., aggressive behavior, physically non-aggressive behavior, verbally agitated behavior, hiding and hoarding behavior) were derived by summing the frequency responses for the CMAI agitated behaviors included in the corresponding factors. The association between the CMAI total score and care recipient's hospitalization was estimated using logistic regression. A separate logistic regression was conducted using the CMAI sub scores for 4 factors of agitation as independent variables. All regressions were adjusted for care recipient's and caregiver's age and gender, AD severity, and time since AD diagnosis. Results A total of 250 caregivers from all US regions completed the survey. The caregivers had a mean age of 44.5 years; 55.2% were male and 86.4% were Caucasian. For their care recipients, mean age was 68.6 years, 55.2% were male, and 83.2% were Caucasian. Most care recipients had moderate or severe dementia (86.8%) and were diagnosed for ≥3 years (54.8%) at the time of survey completion. The most common comorbidities reported for care recipients were depression (48.4%), high blood pressure (37.6%), and balance issues (37.6%). The median CMAI total score was 97.5 (aggressive behavior: 38, physically non-aggressive behavior: 23, verbally agitated behavior: 18, hiding and hoarding behavior: 7, other behavior: 12). Nearly all (99.6%) care recipients experienced ≥1 agitated behavior in the two weeks prior to data collection as measured by the CMAI. The most prevalent agitated behaviors included repetitive sentences or questions (94.8%), complaining (90.8%), negativism (88.4%), general restlessness (88.4%), and pacing or aimless wandering (86.8%). While the frequency of the agitated behaviors varied significantly, each of the behaviors was experienced at least once a day by more than 1 in 3 care recipients (Figure). In the year prior to data collection, 65.6% of care recipients had ≥1 hospital admission and 11.2% had ≥4 admissions, as reported by the caregivers. Most care recipients also had ≥1 other HRU such as dementia-related specialist visits (93.6%), emergency room visits (71.2%), physical, speech, and/or occupational therapy visits (74.0%), and temporary rehabilitation stay in a skilled nursing home (60.0%). More than 3 in 4 (77.6%) care recipients had ≥1 fall in the prior year, among which 54.1% had a fall that led to hospitalization. The CMAI total score was significantly associated with increased odds of hospitalization in the prior year for care recipients (Table). Specifically, a 5-point increase in CMAI total score was associated with 19% increased odds of hospitalization in the prior year. Among CMAI sub scores, a 5-point increase in aggressive behaviors sub score was associated with 42% increased odds of hospitalization in the prior year; the association was not statistically significant for other CMAI sub scores. Conclusions Individuals with AD commonly experience frequent and multiple agitated behaviors, which were associated with increased risk of hospitalization. These findings suggest that improved management of agitation is needed, and the development of treatments for agitated behaviors has the potential to alleviate the burden of care for individuals with AD and reduce hospitalizations. This research was funded by Otsuka Pharmaceutical Development & Commercialization, Inc. and Lundbeck LLC