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. Author manuscript; available in PMC: 2024 Mar 13.
Published in final edited form as: Alzheimer Dis Assoc Disord. 2023 Mar 13;37(2):120–127. doi: 10.1097/WAD.0000000000000552

Delirium and Behavioral Symptoms in Persons with Dementia at Hospital Admission: Mediating Factors

Marie Boltz 1, Ashley Kuzmik 2, Barbara Resnick 3, Rhonda BeLue 4, Ying-Ling Jao 5, Anju Paudel 6, Liza Behrens 7, Doug Leslie 8, Liron Sinvani 9, James E Galvin 10
PMCID: PMC10238610  NIHMSID: NIHMS1871309  PMID: 36897056

Abstract

Background

Hospitalized persons with dementia are at risk of delirium with behavioral symptoms, predisposing them to a higher rate of complications and caregiver distress. The purpose of this study was to examine the relationship between delirium severity in patients with dementia upon admission to the hospital and the manifestation of behavioral symptoms, and to evaluate the mediating effects of cognitive and physical function, pain, medications, and restraints.

Methods

This descriptive study used baseline data from 455 older adults with dementia enrolled in a cluster randomized clinical trial that tested the efficacy of family centered function-focused care. Mediation analyses were conducted to determine the indirect effect of cognitive and physical function, pain, medications (antipsychotics, anxiolytics, sedative/hypnotics, narcotics, and number of medications), and restraints on behavioral symptoms, controlling for age, sex, race, and educational level.

Results

The majority of the 455 participants were female (59.1%), had an average age of 81.5 (SD=8.4), were either white (63.7%) or black (36.3%), and demonstrated one or more behavioral symptoms (93%) and delirium (60%). Hypotheses were partially supported in that physical function, cognitive function, and antipsychotic medication partially mediated the relationship between delirium severity and behavioral symptoms.

Conclusion

This study provides preliminary evidence identifying antipsychotic use, low physical function, and significant cognitive impairment as specific targets for clinical intervention and quality improvement in patients with delirium superimposed on dementia at hospital admission.

Keywords: behavioral symptoms, hospitalization, delirium, dementia

Introduction

Hospitalization is a “determining event” for the person with dementia, associated with increased risk for functional decline, delirium, increased morbidity, and mortality.1–5 Additionally, approximately three-quarters of hospitalized persons with dementia display a heterogeneous group of non-cognitive disturbances and behaviors, designated by the International Psychogeriatrics Association as behavioral and psychological symptoms of dementia (BPSD).6–8 BPSD include agitation, aggression, depression, anxiety, apathy, hallucinations, and sleep disturbance, and are associated with accelerated functional and cognitive impairment, falls, increased resource consumption, and mortality.6–10 Although the clinical term is BPSD, these behavioral symptoms are now more commonly termed “changes in behavior” or “behavioral manifestations of distress,” underscoring the suffering of the person demonstrating these behaviors.11,12 Behavioral symptoms also cause worry, anxiety, and frustration in family and professional caregivers.10, 13, 14

Behavioral symptoms are thought to be caused by the interaction between intrinsic characteristics, including health, prior experiences, and the environment.15 Biologic changes include volume reduction and decreased metabolism in areas of the brain that mediate emotional regulation, self-awareness, and perception; small vessel white matter disease; and dysregulation in neurotransmission.16,17 Personality factors, including pre-morbid neuroticism and post-traumatic stress disorder, are believed to be predisposing factors to behavioral symptoms. Physical surroundings (e.g., temperature, over/under-stimulation), social environment (e.g., interactions with staff and family), and the presence of unmet needs (e.g., pain, hunger, companionship, activity) also contribute to distress and behavioral symptoms in persons with dementia.18

Behavioral Symptoms in Delirium Superimposed on Dementia

During hospitalization emergence of behavioral symptoms are common in persons with delirium, an acute confusional state (“acute brain failure”) with incidence ranging from 11% to 42% in medical patients.7,9,19, 20 Other intrinsic risk factors for delirium include advanced age, being male, higher comorbidity, impaired physical function, and lower education.19–24 Older adults with dementia have five times the risk of developing delirium when hospitalized.20 Delirium superimposed upon dementia (DSD) disrupts cognition and is associated with worse outcomes, including higher mortality and protracted cognitive and functional decline, and higher caregiver stress as compared to delirium alone.25–29 Hyperactive delirium is characterized by psychomotor agitation and anxiety whereas hypoactive delirium is characterized by psychomotor retardation, lethargy, and decreased level of responsiveness and is often missed or misdiagnosed as depression or dementia- related apathy.20 Delirium may also cause hallucinations or delusions that are distressing to the patient but tied only to the delirium and not to the larger presentation of dementia.21 Individuals who have experienced DSD have described persistent emotional suffering associated with behavioral symptoms. Memories of symptoms such as apathy, delusions, hallucinations, and anxiety have been reported to be distressing even after the resolution of delirium.30

Factors Contributing to Behavioral Symptoms

Intrinsic factors

Baseline physical and cognitive function are significant intrinsic factors that affect hospital outcomes. The discrete contribution of physical function and severity of cognitive impairment to the risk of behavioral symptoms in DSD is not clear, although it has been assumed that persons with high care dependency and severe cognitive impairment are more likely to demonstrate behavioral symptoms.31–33 pain in persons with dementia is often manifested as a behavioral symptom. Pain-related behavioral signs are difficult to differentiate from non-pain behaviors of distress, such as agitation, aggression, sleep disturbances, and apathy in persons with DSD due to dementia-related communication challenges.34–36 There is some evidence demonstrating an association between pain at rest and delirium, suggesting pain may be a risk factor for delirium, and that pain and delirium co-exist and persist throughout the hospital stay.37 Effective pain management has been shown to reduce the risk of delirium, but little research has been conducted to explore the impact of pain management on behavior in DSD.37, 38 An examination of the relationship between pain and behavioral symptoms in persons with DSD could potentially inform strategies to identify and manage pain and minimize behavioral symptoms in persons with DSD, including at the time of admission.

Care practices

Medication use, including polypharmacy, has been cited as a risk factor for delirium and worsened cognition.39 Antipsychotic and other psychotropic medications continue to be frequently used to treat behavioral symptoms in patients with dementia, despite evidence for increased adverse effects such as delirium, falls, and functional decline.40 Thus the majority of persons with dementia who present to the hospital are likely to be receiving psychotropic medications. Additionally, despite evidence of the lack of utility, antipsychotic medication often continues to be the first line of treatment for DSD.41–42 Recent evidence has shown that an existing prescription for antipsychotic medication upon admission to the hospital is associated with a higher likelihood of developing aggressive behavior. 43

Evidence-based approaches to prevent behavioral symptoms include avoiding physical and chemical restraints, staff education to promote positive care interactions, adapting the physical environment to lower stressors, and systematic assessment and care planning to address unmet needs. 43–45 Experts agree that the best management of behavioral symptoms is prevention, which requires the early recognition of risk factors, signs, and trigger events. 44 An efficient assessment of underlying pathways that link the risk for behavioral symptoms in persons with DSD early on in hospital admission will facilitate prompt interventions to prevent avoidable distress and complications.

Therefore, we examined the relationship between delirium severity in hospitalized medical patients with dementia, upon admission to the hospital, and the manifestation of behavioral symptoms. We hypothesized that DSD severity upon admission is associated with behavioral symptoms after adjusting for age, race, sex, and educational level. We also hypothesized that pain, physical function, cognitive function, physical restraint use, and admission medications (total number of medications administered within the first 48 h of admission, and use of sedative hypnotics, anxiolytics, antipsychotics, and narcotics) significantly mediated the association between DSD and behavioral symptoms.

Methods

This study used baseline data from an ongoing cluster randomized clinical trial (ClinicalTrials.gov identifier: NCT03046121). The purpose of the parent study was to examine the efficacy of family centered function-focused care (am-Fam-FFC), a nurse-family caregiver partnership model that aims to improve:1) the physical and cognitive recovery of hospitalized persons living with dementia during hospitalization and the 60-day post-acute period; and 2) the preparedness and experiences of their family care partners. The protocol was approved by the institutional review board and was published. 46

Sample

Baseline data for 455 patients from six medical units in three hospitals (two units per hospital) located in Pennsylvania were included. Family care partners were also enrolled in the study. Patients were eligible to participate if they were aged ≥ 65 years, lived in the community prior to admission to the hospital, screened positive for dementia with a score ≥ 2 47 on the eight-item, informant-based AD8; and a Montreal Cognitive Assessment (MoCA) score ≥25 48 with demonstrated functional impairment evaluated with the Pfeffer Functional Activities Questionnaire (FAQ) to discriminate MCI from dementia.49 Eligible patients also had very mild to moderate stage dementia, as confirmed by a score of 0.5 to 2.0 on the Clinical Dementia Rating Scale (CDR),50 and had a family caregiver as the designated study partner. Patients were excluded from the study if they had a major acute psychiatric disorder, any significant neurological condition associated with cognitive impairment other than dementia (e.g., brain tumor), were enrolled in a hospice, or were admitted from a nursing home.

Procedures

After study information was provided, and the patient and family caregiver agreed to participate, an evaluation of capacity to provide consent was conducted, using the Evaluation to Sign Consent (ESC).51 Because decisional capacity was impaired in our patient sample, the patient was required to provide assent, and the legally authorized representative/family caregiver completed the consent process. After obtaining consent and screening for eligibility, the participants were evaluated by trained research staff blinded to the treatment conditions. Demographic, comorbidity, restraint use, and medication data were extracted from the electronic health record. Physical function was obtained upon admission from a family care partner’s report. Observational measures of cognition, pain, delirium severity, and behavioral symptoms were taken within 48 h of admission prior to the implementation of the Fam-FFC intervention.

Measures

Demographics included age, sex, race (Black/White), ethnicity (Hispanic/Latino or not), and educational level (high school graduate or higher). Comorbid conditions were classified with the Charlson Comorbidity Index, a weighted index that considers both the number and seriousness of different co-morbid diseases and is a valid and reliable measure of disease burden.52

Cognition was evaluated using the MoCA, which measures executive function, orientation, memory, abstract thinking, and attention and demonstrates excellent sensitivity and specificity, differentiating between mild cognitive impairment, no dementia, and dementia. The MoCA has been validated in different educational levels and culturally diverse populations.48,53

Physical function was assessed using the Barthel Index, a ten-item measure 54 as reported by the family care partner upon admission, describing activities of daily living performed that day. The Barthel Index has established reliability and validity when used with diverse older adults and when proxy respondents reported the functional abilities of persons with dementia. The items were evaluated based on the degree of assistance required. Scores ranged from 0 (total dependence in all ADLs) to 100 (total independence).54, 55

Pain was measured using the Pain Assessment in Advanced Dementia (PAINAD). PAINAD is a five-item observational tool that evaluates behaviors commonly found in people experiencing pain: breathing independent of vocalization, negative vocalization, facial expression, body language, and consolability. Scores range from 0 to 2 for each behavior, and the tool has demonstrated high inter-rater reliability and validity. A score of 1–3 indicates mild pain, 4–6 indicated moderate pain, and 7–10 indicated severe pain. 56

Medication variables included the total number of medications administered within the first 48 h of admission and the presence of sedative hypnotics, anxiolytics, antipsychotics, and narcotics. The use of physical restraints (mitts, wrist ties, vests, waist restraints, tabletops, and full length siderails) was evaluated as present or absent at any time during the first 48 hours.

The independent variable, delirium severity, was evaluated using an additive score for the four items of the Confusion Assessment Method Severity (CAM-S) Short Form. 57 Acute onset and fluctuating course were scored as no (0) or yes (1). Inattention and disorganized thinking are each scored as “absent” (0 points), present in mild form (1 point), or present in severe form (2 points). The fourth item, altered level of consciousness, was scored as alert or normal (0 points), vigilant or lethargic (1 point), and stupor or coma (2 points). Scores range from to 0–7, with a higher score indicating greater severity of delirium. The CAM-S short form has demonstrated strong psychometric properties and associations with important clinical outcomes. 57

The outcome measure, behavioral symptoms, was assessed using the Neuropsychiatric Inventory Questionnaire (NPI-Q), a 12-item, valid, and reliable informant-based assessment of delusions, hallucinations, agitation/aggression, dysphoria/depression, anxiety, euphoria/elation, apathy/indifference, disinhibition, irritability/lability, aberrant motor behaviors, night-time behavioral disturbances, and appetite/eating disturbances. Behavioral expressions were assessed in terms of severity on a three-point scale (1-mild, 2-moderate, 3-severe). The total NPI-Q severity score represents the sum of the individual symptom scores, and ranges from 0 to 36. 58,59

Data Analysis

Data analyses were conducted using SPSS and AMOS versions 27.60 Descriptive statistics (mean, standard deviation, and frequency distributions) were calculated to describe the sample. Pearson correlation coefficients were used to determine the association between DSD severity and BPSD, and the independence of the study variables. Variables that were not correlated with either the independent variable (delirium severity) or the dependent variable (behavioral symptoms) were not included in the mediation analysis. 61 Multicollinearity occurred when the variables were highly correlated (r > 0.9).61

To test whether our hypothesized clinical characteristics (i.e., physical function, cognitive function, pain, physical restraints, total number of medications, and use of sedative hypnotics, anxiolytics, antipsychotics, and narcotics) mediate the relationship between delirium severity (independent variable) and behavioral symptoms (dependent variable), a nonparametric bootstrapping approach with 5,000 samples was used.62, 63 Unstandardized path coefficients (a, b, c, and c’) were obtained in the multiple mediation model (see Figure 1). The a-path (a1-a9) is the relationship between delirium severity and mediator variables. The b-path (b1-b9) is the relationship between the mediator variables and behavioral symptoms. The c-path (total effect) and c’-path (direct effect) were the relationships between delirium severity and behavioral symptoms with and without the mediators, respectively. The mediation effect (indirect effect) represents the product of a path and b path on the outcome for each mediator and was measured as a*b. Mediation was established when the indirect effect was significant; the 95% bias-corrected confidence interval did not contain a zero.62, 63 Gender, age, race, educational level, and comorbidities were included as covariates in the mediation analysis. Significance levels were set at p ≤ 0.05 for all analyses.

Figure 1.

Figure 1

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Hypothesized multiple mediation model testing effects of potential mediators of the relationship between delirium severity and behavioral symptoms (BPSD)

Behavioral symptoms; a-path, direct effects between delirium severity and the mediator; b-path, direct effects between the mediators and behavioral symptoms; c-path, total effect between delirium severity and behavioral symptoms without the mediators; c’-path, direct effect between delirium severity and behavioral symptoms after controlling for the mediators.

Results

As presented in Table 1, most of the 455 participants were female (59.1%), had an average age of 81.5 (SD=8.4), and were either white (63.7%) or black (36.3%). Most participants were widowed (42%) and had completed high school, trade school, and some college (55.4%). On average, the participants had 4.3 (SD=2.8) comorbidities, 13.0 (SD=6.4) medications, and moderate to severe cognitive impairment with a score of 11.7 (SD=7.0) on the MoCA. The sample had mild pain based on the PAINAD score (mean 0.8, SD=1.5) and delirium severity based on the CAM-S score (mean 1.5, SD=1.7). Additionally, the participants had substantial functional impairments, with a mean score of 63.6 (SD=27.6) on the Barthel Index; only 2.4% were physically restrained. The use of medications included 9.9% antipsychotics, 14.7% anxiolytics, 3.3% sedatives/hypnotics, and 16.5% narcotics.

Table 1:

Characteristics of Sample (N=455)

Variable n (%)
Gender Female 269 (59.1)
Male 186 (40.9)
Race Black 165 (36.3)
White 290 (63.7)
Education Less than high school 90 (20.0)
High school, trade school, some college 252 (55.4)
College and beyond 101 (22.2)
Unknown 12 (2.6)
Marital Status Widowed 191 (42.0)
Married 169 (37.1)
Other 95 (20.9)
Antipsychotics 45 (9.9)
Anxiolytics 67 (14.7)
Narcotics 71 (15.6)
Sedatives/Hypnotics 15 (3.3)
Physical Restraints 11 (2.4)
Mean (SD)
Age 81.5 (8.4)
Number of Medications 13.0 (6.4)
Delirium Severity (CAM-S, range 0–7) 1.5 (1.7)
n (%)
 None (0) 181 (40)
 Mild (1) 105 (23)
 Moderate (2) 46 (10)
 Severe (3–7) 123 (27)
Behavioral Symptoms (NPI-Q, range 0–31) 7.7 (6.1)
Cognition (MoCA, range 0–25) 11.7 (7.0)
Comorbidities (CCI, range 0–17) 4.3 (2.8)
Function (BI, range 0–100) 63.6 (27.6)
Pain (PAINAD, range 0–10) 0.8 (1.5)
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CAM-S, Confusion Assessment Method Short Form; NPI-Q, Brief Neuropsychiatric Inventory; MoCA, Montreal Cognitive Assessment; CCI, Charlson Comorbidity Index; BI, Barthel Index; PAINAD, Pain in Advanced Dementia Scale.

The mean NPI-Q score for behavioral symptoms was 7.7 (SD=6.1). Ninety-three percent of the patients demonstrated at least one behavioral symptom; the mean number of behavioral symptoms was 4.3 (SD=2.6). The prevalence of behaviors in the NPI-Q is shown in Table 2. The most prevalent behavior was nighttime (56.0%), followed by agitation (52.1%) and irritability (49.7%). The least prevalent behavior was elation/euphoria (7.5%).

Table 2:

Prevalence of Behaviors on the NPI-Q (N = 455)

Behavior n (%)
Delusions 101 (22.2)
Hallucinations 86 (18.9)
Agitation/Aggression 237 (52.1)
Depression/Dysphoria 209 (45.9)
Anxiety 201 (44.2)
Elation/Euphoria 34 (7.5)
Apathy/Indifference 175 (38.5)
Disinhibition 101 (22.2)
Irritability/Lability 226 (49.7)
Motor Disturbance 92 (20.2)
Nighttime Disturbance 255 (56.0)
Appetite/Eating 194 (42.6)
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Table 3 shows the correlations between delirium severity, mediators, and behavioral symptoms. The highest correlation among the variables was .47, suggesting that all variables met the multicollinearity assumptions. The results indicated that a higher severity of DSD was associated with a greater BPSD. Anxiolytics, narcotics, and sedatives/hypnotics were not significantly associated with delirium severity or behavioral symptoms and therefore not included as mediators for further analysis.

Table 3:

Results from Bivariate Correlations

Variables 1 2 3 4 5 6 7 8 9 10 11
1. Delirium Severity - .29** .26** −.47** .34** .15** −.10* .23* −.01 −.09 −.06
2. Behaviors - - −.18** −.25** .15** .04 −.00 .27** −.01 −.06 −.08
3. Physical Function - - - .33** −.18** .03 −.03 −.05 .03 −.05 −.02
4. Cognitive Function - - - - −.21** −.12* .22** −.22** −.03 .13** .10*
5. Pain - - - - - .03 .05 .15** .01 .03 −.07
6. Physical Restraints - - - - - - −.06 .09 −.07 .05 −.03
7. Total Medications - - - - - - - .01 .17** .22** .18**
8. Antipsychotics - - - - - - - - .03 −.06 .06
9. Anxiolytics - - - - - - - - - .04 .17**
10. Narcotics - - - - - - - - - - .06
11. Sedatives/Hypnotics - - - - - - - - - - -
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*

p < .05

**

p < .01

Table 4 presents the results of the mediation analysis. The total effect of delirium severity on behavioral symptoms was significant (c-path; B = 1.071, p < .001), and after the mediators were added to the model, the direct effect was still significant with a reduced coefficient (c’-path; B = .582, p = .009). The a-paths were all significant (for physical function B = −4.169, p < .001; for cognitive function B = −1.948, p < .001; for pain B = .300, p < .001; for physical restraints B = .013, p = .002; for total medications B = −.365, p = .040; for antipsychotics B = .041, p < .001), and the b-path was only significant for physical function (B = −.021, p = .029), cognitive function (B = −.093, p = .028), and antipsychotics (B = 4.173, p < .001). Additionally, the indirect effects of physical function (B = .089, 95% CI [.008, .193]), cognitive function (B = .181, 95% CI [.002, .371]), and antipsychotics (B = .170, 95% CI [.067, .332]) were significant. The indirect effects of pain (B = .033, 95% CI [−.093, .185]), physical restraints (B = −.010, 95% CI [−.067, .023]), and total medications (B = −.006, 95% CI [−.055, .025]) were not significant. Thus, physical function, cognitive function, and antipsychotic medication partially mediated the relationship between delirium severity and behavioral symptoms. A higher severity of DSD was associated with lower physical function, which, in turn, was associated with greater manifestations of BPSD. Similarly, a higher severity of DSD was associated with lower cognitive function, which, in turn, was associated with greater manifestations of BPSD. Additionally, a higher severity of DSD was associated with greater antipsychotic use, and greater antipsychotic use, in turn, was associated with greater manifestations of BPSD.

Table 4:

Multiple Mediation Analysis

B SE Bootstrapped 95% CI
Lower Upper
Total effect (Delirium Severity → Behaviors) 1.071* .182 .621 1.336
Direct effect (Delirium Severity → Behaviors) .582* .207 .130 .946
Physical Function
a-path (Delirium severity → Physical Function) −4.169* .742 −5.707 −2.661
b-path (Physical Function → Behaviors) 0.021* .186 −.041 −.001
Indirect effect (ab) .089* .046 .008 .193
Cognitive Function
a-path (Delirium severity → Cognitive Function) −1.948* .171 −2.213 −1.667
b-path (Cognitive Function → Behaviors) −.093* .042 −.186 −.023
Indirect effect (ab) .181* .094 .002 .371
Pain
a-path (Delirium severity → Pain) .300* .039 .205 .408
b-path (Pain → Behaviors) .111 .186 −.309 .578
Indirect effect (ab) .033 .069 −.093 .185
Physical Restraints
a-path (Delirium severity → Physical Restraints) .013* .004 .003 .027
b-path (Physical Restraints → Behaviors) −.778 1.714 −3.618 2.170
Indirect effect (ab) −.010 .022 −.067 .023
Total Medications
a-path (Delirium severity → Total Medications) −.365* .178 −.706 −.016
b-path (Total Medications → Behaviors) .017 .041 −.073 .118
Indirect effect (ab) −.006 .019 −.055 .025
Antipsychotics
a-path (Delirium severity → Antipsychotics) .041* .008 .019 .063
b-path (Antipsychotics → Behaviors) 4.173* .897 2.055 6.350
Indirect effect (ab) .170* .065 .067 .332
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*

Estimates do not include zero in the 95% confidence interval.

Discussion

This study demonstrated a relationship between delirium severity and behavioral symptoms and partially supported the hypotheses that examined the mediators of DSD with behavioral symptoms. Physical function, cognitive function, and the use of antipsychotic medication partially mediated the effect of delirium severity on behavioral symptoms in persons with dementia upon admission to the hospital, controlling for age, sex, race, educational level, and comorbidity. These findings suggest that greater antipsychotic medication use, lower cognitive function, and more dependent physical function are potential risk factors that, if addressed in admission treatment plans, may mitigate the occurrence or severity of behavioral symptoms.

The co-occurrence of physical and cognitive functions as mediators of DSD and behavioral symptoms is not surprising, as these two functional indices tend to be present in tandem as significant predictors of hospital outcomes in older adults.64, 65 results suggest that hospitalization is an opportunity to develop a function-focused plan to optimize functional status and examine alternatives to antipsychotic use. Early mobilization and cognitive stimulation have demonstrated improvements in delirium and physical function in hospitalized older adults 64, 65 and may also improve behavioral outcomes, as indicated by research in long-term care. 66

Results corroborate previous research that demonstrated a relationship between the presence of delirium, coupled with an existing prescription for antipsychotic medication at admission intake, and behavioral symptoms.5 Kales and colleagues 67 recommend that antipsychotic utilization alone not be a clinical target when managing behavioral symptoms. Instead, they recommended a focus on identifying triggers for distress and responding to care interactions and environmental modifications, as indicated. Antipsychotic use may be a helpful marker to identify pre-admission behavioral symptoms to mobilize appropriate assessments and psychosocial interventions.

Anxiolytic use was present in 14.7 percent of the sample; its lack of association with either delirium or behavior may be attributed to an indication for pre-admission use other than for behavioral symptoms. The prevalence of anxiolytic use in community-dwelling older adults generally ranges from 9.5 to 20 percent, with long-term use common to manage everyday stress as opposed to behavioral symptoms. 68 In this study, the prevalence of behavioral symptoms (93%) was considerably higher than the prevalence rate (11.4%) found by Sampson et al.6 upon hospital admission of persons with dementia. However, it is difficult to compare prevalence rates owing to varying approaches to the measurement of behavioral symptoms. Aggression/agitation was one of the most predominant behaviors in both studies and was also identified in the work of Feast et al.13 as one of the most troubling symptoms for caregivers, along with depression, which was also one of the most common symptoms in this study.

Physical restraint use and pain were not mediators of DSD or behavioral symptoms. This may be attributed to the relatively low levels of both physical restraints and pain in the sample. Narcotics were used in a considerable percentage of the sample (15.6%), which may explain the lower levels of pain. Perhaps narcotic use was not a mediator because it was being used appropriately to treat pain, as opposed to inappropriately managing behavior.35 An examination of more severe pain in DSD may identify pain as playing a more significant role in the presentation of behavioral symptoms. Additionally, a more in-depth analysis of the contribution of polypharmacy and types of medications, including those with a high cholinergic burden to behavioral symptoms in DSD, is warranted.

Strengths and Limitations of the Study

The strengths of the study include a robust sample of persons with dementia, identified through a rigorous assessment process, and examination of behaviors upon admission to the hospital, an under-examined and particularly vulnerable point for the person with dementia. This study was limited because it was a secondary data analysis. Thus, variables that may have influenced the findings, such as individual resilience and coping, medical acuity and associated factors, the use of other medications to treat behavior, and non-pharmacological strategies for behavior, were not examined, but are an area for future inquiry. Future research that examines these factors, as well as external support provided by family and others, may disclose important influences on behaviors in DSD. Additionally, the evaluation of function was based on reports from family care partners; consequently, there may have been some bias in reporting. Finally, the study was conducted only in Pennsylvania hospitals, limiting its generalizability to hospitals in other geographic areas.

Conclusion

The complications of behavioral symptoms, including the development of hospital-acquired conditions such as falls and pressure ulcers, acute malnutrition, dehydration, and aspiration pneumonia,6, 9, 10 have become an increasing focus for quality initiatives.69 Consequently, behavioral symptoms are a relevant and meaningful clinical target for intervention in DSD care. This study provides preliminary evidence identifying antipsychotic use, low physical function, and significant cognitive impairment as specific targets for clinical intervention and quality improvement in patients with DSD upon hospital admission.69

Funding

This study was funded by the National Institute of Aging (NIA), Grant R01AG05442, R01AG040211, and R01 NS101483. The contents of the article are solely the responsibility of the authors, and do not necessarily represent the official views of the NIA.

Footnotes

Competing interests

The authors declare that they have no competing interests.

Contributor Information

Marie Boltz, The Pennsylvania State University, Ross and Carol Nese College of Nursing, 306 Nursing Sciences Building, University Park, PA 16802.

Ashley Kuzmik, Post-doctoral Fellow/Project Director, The Pennsylvania State University, College of Nursing.

Barbara Resnick, University of Maryland School of Nursing, 655 West Lombard Street Room 390, Baltimore MD 21201.

Rhonda BeLue, The University of Texas at San Antonio, College for Health, Community and Policy, One UTSA Circle, Main Building 2.306, San Antonio, TX 78249.

Ying-Ling Jao, The Pennsylvania State University, College of Nursing, Nursing Sciences Building, University Park, PA, 16802.

Anju Paudel, The Pennsylvania State University, College of Nursing, 203B Nursing Sciences Building, University Park, PA, 16802.

Liza Behrens, Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, Pennsylvania, USA.

Doug Leslie, Penn State College of Medicine, Hershey, PA.

Liron Sinvani, Northwell Health, 300 Community Drive, Manhasset, NY 11030.

James E. Galvin, University of Miami.

Availability of data and materials

The datasets analyzed in the current study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets analyzed in the current study are available from the corresponding author upon reasonable request.

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