Skip to main content
Download PDF

Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy

BMC Geriatrics volume 24, Article number: 559 (2024) Cite this article

Abstract

Objective

40–60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD.

Methods

Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools.

Results

6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI).

Conclusions

The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.

Key points

• The agitation domain of the Spanish Neuropsychiatric Inventory (NPI), Neurobehavioural Rating Scale (NBRS), and the Pittsburgh Agitation Scale (PAS) demonstrated high sensitivities for agitation and may be reasonable for clinical implementation. However, many commonly used agitation tools have yet to be assessed for their diagnostic accuracy.

• Only one study described diagnostic accuracy measures for only aggression, with a moderate sensitivity reported.

• More rigorous studies are needed to understand the diagnostic accuracy of common agitation and/or aggression tools within the context of dementia.

Peer Review reports

Introduction

Dementia is a progressive neurodegenerative disorder characterized by cognitive and functional impairment [1]. Persons living with dementia (PLWD) commonly experience burdensome neuropsychiatric symptoms, including depression, anxiety, apathy, agitation and aggression [2]. These comorbid symptoms often go under-recognized, indicate impending cognitive decline, and are elusive to treat [3]. Of these symptoms, agitation and aggression are particularly common and distressing symptoms among PLWD, with an overall prevalence of 30% and 50% within the dementia population, respectively [4, 5]. This prevalence varies by the underlying pathology and severity of dementia [6].

In 2015, the International Psychogeriatric Association formally published a definition for agitation, as a syndrome that includes any type of excessive motor activity, verbal aggression, or physical aggression causing distress [7]. Aggression refers to verbal and physical behaviour (e.g., hitting, throwing, etc.) with the potential to harm one’s self or others [8, 9]. Despite being separate constructs, they often are presented together among PLWD. Ultimately, PLWD who are experiencing either agitation or aggression have a poorer quality of life, difficulty accomplishing their daily activities, and are more likely to be admitted to long-term care facilities [1]. Likewise, caregivers of PLWD experiencing co-existing agitation or aggression face higher caregiver burden, a higher risk for injuries, and poorer quality of life [8, 10].

Early and accurate detection of agitation and aggression is beneficial to identify the antecedent contributors either intrinsic or extrinsic, enable early intervention and prevent harm [4, 11]. A systematic review of all interventions for symptoms of agitation and/or aggression in PLWD identified a lack of consistency in tools used to measure these symptoms, thus awareness of tool validity can also inform research in this area [12]. Moreover, these tools must be taken in the context of the PLWD and surrounding factors including antecedent events, severity, and personal attributes [12]. Although many tools have been created and examined, there is a lack of diagnostic accuracy information (e.g. sensitivity and specificity) for these tools. Diagnostic accuracy (e.g. sensitivity and specificity) is considered the ability of a tool or test to discriminate between the presence and absence of a condition (i.e. agitation and aggression) as compared to a reference standard [13].

Until 2015, there lacked a consensus-based definition of agitation, and consequently a reference standard diagnosis [14]. The lack of definition resulted in challenges in formally validating currently used agitation and/or aggression tools outside of expert opinion as the reference standard, resulting in a knowledge gap around the diagnostic accuracy of agitation and aggression tools [15]. Watt et al. (2019) identified the Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD), Neuropsychiatric Inventory (NPI), and Cohen-Mansfield Agitation Inventory (CMAI) as the most commonly used agitation and/or aggression detection tools among randomized controlled trials (RCTs) [12]. Although many of these tools have established content validity in the literature [16], the diagnostic accuracy is unclear. Therefore, the objective of this systematic review is to determine which tools are validated for detecting agitation and/or aggression among PLWD, in any setting.

Methods

The study protocol was created a priori, follows the methods of the Cochrane collaboration, and is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Diagnostic Test Accuracy (DTA) standards and guidelines. This was registered on PROSPERO (CRD42020156708) [17]. The PRISMA DTA checklist is also provided for this study (Supplemental Appendix 10).

Selection criteria

The population included persons with any type or severity of dementia in any setting (i.e. clinic, nursing home, etc.). In the literature, the majority of studies refer to both agitation and aggression together. Therefore, we looked for studies that used any tools or questionnaires for detecting either agitation or aggression (i.e. Cohen-Mansfield Agitation Inventory, etc.), or both. However, we considered agitation and aggression as separate constructs. Given that the criteria for agitation and/or aggression is variable across settings and locations, we included any relevant reference standard, including any healthcare provider’s diagnosis of agitation and/or aggression using standard criteria (i.e. IPA criteria), or a diagnosis by a physician with expert training, such as psychiatrists and/or geriatricians [18]. The specific healthcare providers considered for the reference standard included geriatricians, general practitioners, or any other certified medical doctor (MD) working in geriatric care. As a secondary objective, we included articles that compared between two or more agitation and/or aggression tools, to understand how agitation and/or aggression tools correlated with one another.

Search strategy

The search strategy was created and refined alongside an experienced librarian (HLR) and experienced clinician scientists (Z.G, Z.I, J.W). The databases MEDLINE, Embase, and PsycINFO were searched from inception until April 22, 2024 (Supplemental Appendix 1). The main search clusters were “dementia terms”, “agitation and/or aggression terms” and “diagnostic accuracy terms”, and each cluster was combined using the term “and” (Supplemental Appendix 8). Within each main cluster, keywords and database-specific words were searched, with each combined using the term “or” (Supplemental Appendix 8). All types of dementia were included in the search. There were no language, age of patient, or year of publication restrictions placed on articles. A grey literature search was conducted until September 4th, 2021 (Supplemental Appendix 2). Grey literature included all literature not formally published in an academic journal or book, to ensure our search was the most exhaustive [19].

Screening and eligibility

The abstract screening was completed after a calibration (with B.W, P.W, Z.G, J.W), by B.W and P.W. independently and in duplicates. All articles that discussed a group or sub-group of persons living with dementia and an agitation and/or aggression tool were included at the abstract stage. If any disagreement arose between authors at the first stage it was included to full text.

The full text screening process was calibrated between four authors (B.W, P.W, Z.G, J.W) and then screened in duplicates by the same independent authors (B.W, P.W). A list of exclusion criteria at the full text stage are reported in Fig. 1. All study designs except reviews, non-experimental studies, and letters were included. Two separate syntheses were conducted at the full text screening stage. Firstly, eligibility at the full-text stage required the use of a group or subgroup of persons living with any type of dementia, an agitation and/or aggression diagnostic tool, and a reference standard diagnosis of agitation and/or aggression. Studies were included for data extraction if they stated diagnostic accuracy measures of an agitation and/or aggression tool, against the reference standard. We defined diagnostic accuracy as the ability of the test to discriminate between agitation and/or aggression and lack thereof among PLWD [13]. We focused on measures of sensitivity, specificity, and positive and negative likelihood ratios as our outcomes of choice, given that we can best measure validity by comparing index tools against the reference standard diagnosis of agitation and/or aggression. We also considered positive and negative predictive values and the area under the ROC curve or minimum clinically important differences as additional diagnostic accuracy measures. Secondly, if a reference standard was not present, the article was searched for a comparison between two agitation and/or aggression tools to examine correlation coefficients as a secondary outcome and included in the final data extraction. This data was considered a measurement of construct validity, given that the tools we compared measured the same constructs of agitation and/or aggression. Included articles were verified between authors (B.W, P.W), with any discrepancies settled with an adjudicated third author (Z.G). As well, we screened the list of references for all included articles for any other potentially relevant articles. All non-English texts were translated with online translation software (Google Translate). Any French or Spanish articles were translated by a fluent speaker.

Fig. 1
figure 1

The PRISMA diagram [62] depicting the search and screening methodologies throughout the review

Full size image

Assessment of risk of bias

We assessed the quality of each included study with the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool by two independent authors (B.W, P.W) [20]. The completed Risk of Bias assessment was subsequently reviewed by an experienced clinician scientist (Z.G).

Data extraction and synthesis of evidence

The data extraction form was developed by two authors (B.W, P.W) and verified by the experienced clinicians (Z.G, Z.I, J.W). Data extraction was conducted independently in duplicate (B.W, P.W). Demographic information and characterization of the type and severity of dementia were collected. The specific agitation and/or aggression tool and the reference standard were identified, along with respective agitation and/or aggression prevalence rates determined by either measure. Sensitivity and specificity values along with positive and negative likelihood ratios, and positive and negative predictive values were extracted. Finally, for studies focused on comparing two agitation and/or aggression tools, correlation coefficients were extracted as a secondary diagnostic accuracy measure along with the aforementioned demographic information.

Results

Database searches

The initial database searches yielded 9919 total results, and upon removal of duplicates, 6961 articles remained. The grey literature search found 2561 articles. There were 274 articles included for full-text screening (Fig. 1). After full-text screening, a total of 36 articles were included in the final data extraction stage. These articles are comprised of 6 articles reporting diagnostic accuracy measures compared to a reference standard, along with 30 articles reporting a comparison between tools. Given the low number of included articles reporting diagnostic accuracy measures, there was insufficient data for a meta-analysis.

Summary of included studies comparing tools to a reference standard

Six studies were included that explored the diagnostic accuracy of agitation and/or aggression tools among PLWD compared to a reference standard [14, 15, 21,22,23,24]. One study reported diagnostic accuracy measures for only aggression [22], and five studies reported measures for only agitation [14, 15, 21, 23, 24]. They were published between 1999 and 2022, and conducted in Canada (n = 1), Spain (n = 1), France (n = 2), and the United States (n = 2) (Table 1) [14, 15, 21,22,23,24]. Sample sizes ranged from 30 to 19,424 participants [14, 15, 24]. The types of dementia included were Alzheimer’s Disease (n = 2), Vascular Dementia (n = 1), dementia with Lewy bodies (n = 2), mixed dementia (n = 1), probable Alzheimer’s disease (n = 1), frontotemporal dementia (n = 1), or unspecified dementia (n = 4) (Table 1) [14, 15, 21,22,23,24]. Dementia was diagnosed using the DSM [15, 21], DSM-IV-TR [22], the dementia diagnosis section of the CAMDEX [23] and DSM-III [24], with one study not reporting the method of diagnosis [14]. Dementia severity was assessed with the Mini Mental State Examination (MMSE) tool [14, 21, 22] and the dementia severity section of the CAMDEX [23]. Severity ranged from mild [14, 23] to severe [22], with three studies not reporting dementia severity [15, 24] (Table 1). The agitation and/or aggression tools used include the Empirical Behavioral Pathology in Alzheimer’s Disease Rating Scale (E-BEHAVE-AD) (n = 1), Neurobehavioural Rating Scale (NBRS) (n = 2), the agitation domain of the Neuropsychiatric Inventory (NPI, English and Spanish versions) (n = 3), the IPA definition of agitation constructed via items from the Neuropsychiatric Inventory Questionnaire (NPI-Q) (n = 1), French- Rating Scale for Aggressive Behaviour in the Elderly (F-RAGE) (n = 1), Pittsburgh Agitation Scale (PAS) (n = 1), Cohen Mansfield Agitation Inventory (CMAI) (n = 1), CMAI-IPA (n = 1) and NPI-C-IPA (n = 1) [14, 15, 21,22,23,24] (Supplemental Appendix 6). The reference standards were the Clinical Global Impression – Severity (CGI-S) scale (n = 1) [21], a subsection of the Spanish CAMDEX assessing agitation and/or aggression symptoms (n = 1) [23], the Alzheimer’s Disease Cooperative Study-Clinical Global Impression of Change (mADCS-CGIC) (n = 1) [15] or a psychiatrist’s or clinician’s diagnosis (n = 3) [14, 22, 24]. Vilalta-Franch et al.’s (1999) study was presented in Spanish, and was translated via Google Translate, whilst all other articles written in English [23]. The type and prevalence of agitation and/or aggression among studies comparing tools to a reference standard are reported in Table 2.

Table 1 Demographic information of included studies that compared agitation and/or aggression tools to a reference standard within a population of dementia
Full size table
Table 2 Prevalence of agitation and/or aggression among PLWD in studies comparing tools to a reference standard*
Full size table

Summary of tools

The NPI, NBRS and PAS are observational scales [21, 25]. The NPI is the main tool used for RCTs, with use reported among (n = 39) RCTs [12]. The NPI is a common informant-rated questionnaire used to assess neuropsychiatric symptoms in PLWD [26]. Within each of 12 domains, the informant is first asked a screening question for each neuropsychiatric symptom [27]. Should they initially indicate any problems in the agitation domain, the informant is then asked an additional 8 items in the agitation domain, with the frequency, severity, and distress of agitation calculated on Likert scales [28]. Only 1 domain is focused on agitation and/or aggression, and the overall tool is not focused solely on these symptoms.

Only one of 27 items on the NBRS focuses on assessing agitation [29]. Specifically, it assesses motor manifestations of overactivation [29]. Lastly, the PAS was developed to specifically examine agitation and/or aggression. It has 4 items assessing severity of agitation and/or aggression in four domains: aberrant vocalizations, motor agitation, aggressiveness, and resisting care [25]. The PAS is the only scale that solely analyzes agitation and/or aggression symptoms.

The BEHAVE-AD is a severity scale, used for dementia-related behavioural changes. It contains a global assessment of the overall magnitude of disturbance to the caregiver and patient due to the behavioural symptoms. The RAGE is an informant-rated scale that assesses verbal and physical aggression in institutionalized or hospitalized elderly patients.

Outcomes of studies comparing tools with a reference standard (table 3)

Table 3 The sensitivity and specificity values of agitation and/or aggression diagnostic tools used within a dementia population among included studies that compared tools to a reference standard
Full size table

Seven tools assessing agitation or aggression were identified that compared to a reference standard. Mauleon et al.’s (2021) study demonstrated the minimal clinically important difference (MCID) of the CMAI, agitation domain of the NPI-C, CMAI-IPA, and NPI-C-IPA [15]. The MCID, although not the same as sensitivity and specificity, represents an important construct. It identifies the minimal difference in score needed to show a beneficial change in symptoms as reported by a patient [30]. The MCID thus crucially identifies how useful a tool is for detecting clinically meaningful differences in agitation and/or aggression symptoms over time.

E-BEHAVE-AD

The E-BEHAVE-AD was evaluated for agitation detection by one study [21]. The sensitivity was 79.0% and specificity was 73.0%, compared to the CGI-S as the reference standard (Table 3). In the context of agitation, the CGI-S is an observer-rated instrument measuring the severity of agitation at one point in time, based on a clinician’s understanding of agitation in PLWD [21]. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 2.93 and 0.28, respectively.

NBRS

The NBRS was evaluated by two studies [21, 24] for agitation. Sensitivity ranged from 89.0 to 95.2%, whilst specificity ranged from 28.6 to 85.0% (Table 3). Ismail et al. (2013) used the CGI-S as the reference standard, while Rosen et al. (1999) used a psychiatrist’s diagnosis of agitation. Ismail et al., (2013) reported a PLR value of 5.93 and an NLR of 0.13 (Supplemental Appendix 9).

NPI

The agitation domain of the NPI was evaluated by a single study [21] for its ability to assess agitation. A sensitivity of 86.0% and specificity of 76.0% were obtained, compared to the CGI-S as a reference standard (Table 3). The PLR and NLR values reported were 3.58 and 0.18, respectively (Table 3). Mauleon et al., (2020) assessed the MCID of the agitation domain of the NPI-C, and the NPI-IPA against the mADCS-CGIC. They reported an MCID of -3 and − 5 for the NPI-C and NPI-IPA at one month, respectively [15]. These MCID scores mean that a clinically meaningful decline in agitation and/or aggression symptoms can be detected over a -3 and − 5 difference in scores when administered consecutively over 1 month, respectively. The MICD scores at 3 months were − 3 and − 5 for the NPI-C and NPI-C-IPA, respectively.

Sano et al. (2022) constructed the IPA definition of agitation using items 4 (agitation), 11 (motor disturbance) and 10 (irritability) of the Neuropsychiatric Inventory-Questionnaire (NPI-Q). They measured this construct against a clinician’s diagnosis of agitation as a reference standard. They reported a sensitivity of 79.0%, and a specificity of 69.0%. The PLR and NLR values were 2.55 and 0.30, respectively (Table 3).

Spanish NPI

The agitation domain of the Spanish NPI was used as a diagnostic tool for agitation, against the agitation subsection of the Spanish CAMDEX as a reference standard by one study [23]. A sensitivity of 100.0% and specificity of 97.8% were reported (Table 3). PLR and NLR values reported were 44.84 and 0.00, respectively (Supplemental Appendix 9).

PAS

The PAS was evaluated by one study to detect agitation, and was found to have a sensitivity of 85.7% and a specificity of 57.1%, when compared a psychiatrist’s diagnosis for agitation (Table 3) [24]. No PLR or NLR values were reported.

CMAI

The CMAI and CMAI-IPA were assessed in one study for their abilities to assess agitation, via MCID scores against the mADCS-CGIC [15]. They reported MCID scores of -5 and − 2 for the CMAI and CMAI-IPA at 1 month, respectively. These MCID scores mean that a clinically meaningful decline in agitation and/or aggression symptoms can be detected over a -5 and − 2 difference in scores when administered consecutively over 1 month, respectively. The MCID scores at 3 months were − 17 and − 5 for the CMAI and CMAI-IPA, respectively.

F-RAGE

The F-RAGE, was evaluated by a single study for physical and verbal aggression, demonstrated a sensitivity of 74.0%, and a specificity of 98.0% (Table 3) [22]. The reference standard was a psychiatrist’s diagnosis. The PLR was 37.00 and NLR was 0.26 (Supplemental Appendix 9).

Summary of included studies comparing between tools (table 4)

Table 4 Demographic and validity measures of included studies that compared two or more agitation and/or aggression tools
Full size table

Thirty articles comparing agitation and/or aggression tools (i.e., no reference standard), were included as part of our secondary objective [16, 22, 25, 31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58]. These studies determined the correlation between known agitation and/or aggression tools in PLWD. They were conducted in North America (n = 11) [25, 31, 33,34,35, 40, 48, 49, 51, 55, 57], Asia (n = 7) [32, 38, 39, 47, 52, 53, 56] South America (n = 1) [34], Europe (n = 8) [22, 34, 36, 43,44,45,46, 54, 58], and Australia (n = 1) [41]. Furthermore, four studies did not report their location [16, 37, 42, 50]. The studies were published between 1989 and 2023 [42, 58]. Dementia severity was determined mainly with the MMSE, or variations thereof, (n = 25) [22, 25, 31,32,33,34, 36,37,38,39,40,41, 43,44,45,46,47,48, 50,51,52,53,54,55,56, 58] with other studies using the Functional Assessment Staging Scale (FAST) (n = 2) [16, 35], and Global Deterioration Scale (GDS) (n = 1) [49]. Two study did not report how dementia severity was measured [42, 57]. The types of dementia reported include Alzheimer’s Disease, Vascular, Lewy Body, or general dementia not otherwise specified. However, multiple articles did not report the type (n = 11) [16, 22, 25, 35, 41,42,43,44, 49, 56, 58] or severity (n = 19) [25, 32, 33, 35, 37, 39,40,41,42,43,44,45,46,47,48, 53, 54, 56, 57] of dementia in their population.

Specific comparisons are listed in Table 4 and descriptions of each tool are shown in Supplemental Appendix 7.

Outcomes of studies comparing between tools (table 4)

Pearson or Spearman’s correlation coefficients were reported among 28 articles, with 1 article not reporting the type of correlation coefficient [53] and another reporting the use of a non-specific convergent correlation coefficient [57].

CMAI

The CMAI was compared in 18 studies, demonstrating the highest correlation coefficient with the BEAM-D, with a Pearson’s value of 0.91 for agitation assessment [41]. The lowest correlation coefficient was a Pearson’s value of 0.20 between the CMAI and the ABMI in terms of overall combined agitation [33].

NPI

The NPI, or its various language translations, were compared to tools in (n = 11) studies. Among all tools, the K-NPI demonstrated the highest correlation with the ABSS, with a Correlation Coefficient value of 0.72 [52]. The type of correlation coefficient was not reported (Table 4) [52]. The weakest correlation was with the ABS, with a Spearman’s Correlation Coefficient of 0.10 [55].

BEHAVE-AD

The BEHAVE-AD, or variations of it, was compared to tools in (n = 7) studies. The highest correlation coefficient reported was a Spearman’s Correlation Coefficient of 0.81 between the BEHAVE-AD and RAGE, and between the CMAI-K and BEHAVE-AD-K [36, 47]. The lowest was a Pearson’s Correlation Coefficient of 0.52 between the BEHAVE-AD and the NPI-C [45].

DBRS: The DBRS was compared with only the Nurse’s Assessment Rating Scale in one study [42]. A series of Pearson’s correlation coefficients were reported for the severity and distress of physical and verbal aggression, as well as for physical and verbal agitation (Table 4).

PAS: The PAS was compared with the CMAI-O (n = 1), and the OASS (n = 1) in two studies [16, 25]. The highest correlation coefficient reported was with the OASS, with a Pearson’s correlation coefficient of 0.81 [25].

SOAPD: The SOAPD scale was only compared to the Agit-VAS scale (n = 1) [54]. The total (verbal and physical) Pearson correlation coefficient score for agitation was 0.90.

Risk of bias assessment

Studies comparing tools to a reference standard: (supplemental appendix 3)

Included studies demonstrated low risk that the included patients and target condition did not match the review question (n = 6) [14, 15, 21,22,23,24]. Two studies reported blinding between the index and reference tools, and had low concern that the conduct of the index test was biased [22, 24]. Another three studies had unclear blinding between index and reference tools, potentially introducing bias in the results [14, 21, 23]. One study reported no blinding [15]. Lastly, there was concern about the time between administration of the reference standard and index tool across studies (n = 6) [14, 15, 21,22,23,24].

Studies comparing tools: (supplemental appendices 4 and 5)

Most included studies demonstrated low concern that the included patients did not match the review question (n = 29) [22, 31,32,33,34,35,36, 16, 37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54, 25, 58, 56, 57], with one study demonstrating unclear concern [55] due to unclear exclusion criteria. Many studies did not indicate whether test administrators were blinded (n = 22) [25, 33, 34, 36, 38,39,40,41,42, 44, 45, 47,48,49,50,51,52,53,54, 56,57,58], with (n = 3) [16, 32, 55] studies indicating no blinding, thus there was varying concern regarding the conduct between the two tools (Supplemental Appendices 4 and 5). Nonetheless, there was low concern that the target condition (i.e., agitation and/or aggression) as defined by both tools did not match the review question across studies (n = 30) [16, 22, 25, 31,32,33,34,35,36, 36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58]. Additionally, the time interval between administration of both agitation and/or aggression tools was often not reported or ambiguous (n = 29) [16, 22, 25, 31,32,33,34, 36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58]. This area could have also introduced bias in the results, where knowledge about the first tool could have influenced participants’ responses on the second tool.

Discussion

We identified six studies comparing either agitation or aggression tools to reference standards. To detect the presence of agitation, the agitation domain of the Spanish NPI demonstrated the highest sensitivity of 100% [23] compared to the agitation subsection of the Spanish CAMDEX, in a single study. In comparison, the NBRS, and PAS demonstrated similarly high sensitivities of 95.2% and 85.7%, respectively, both compared to a psychiatrist’s diagnosis of agitation and/or aggression [24]. The Spanish NPI has a higher sensitivity compared to its English counterpart, likely due to differences in study design, along with the use of the CAMDEX as the reference standard compared to other studies [23]. Overall, based on single studies, the Spanish NPI, NBRS, and PAS appear favorable among PLWD to detect agitation.

Mauleon et al. (2020) mapped items from the CMAI and NPI-Clinician (NPI-C) onto IPA agitation criteria domains to create IPA-informed agitation scales [15]. Both the NPI-C-IPA and the NPI-C demonstrated reasonable MCID scores (-5 and − 3, respectively) [15]. Their results suggest how the IPA agitation domain may be helpful to improve the agitation diagnostic abilities of a tool, compared to those that do not involve the IPA (i.e. NPI-C and CMAI).

From our analysis, only one study reported diagnostic accuracy measures for an assessment tool assessing aggression (i.e. F-RAGE) [22]. In the literature, there is a lot of overlap and mixing between agitation and aggression among studies [59]. This issue makes it difficult to identify validity constructs for each separate symptom. More research is thus needed to validate aggression tools to understand their efficacy at bedside.

Another 30 studies were identified that compared the correlation in agitation or aggression symptoms between two or more tools. Correlation coefficients were most commonly drawn between the CMAI and other agitation tools, in 18 studies. The highest correlation coefficient drawn was between the CMAI and BEAM-D of 0.91 [41]. Although useful to understand the comparative validity of these tools, clinically this can be harder to use when it comes to implementation and accuracy at bedside.

Due to widespread disagreement on the definition of agitation before 2015, the best reference standard prior was considered a physician’s clinical diagnosis, as there were no set criteria for agitation among PLWD [14, 60]. Without a reference standard diagnosis, the validity of older tools lacks clarity, with most studies conducted prior to 2015 examining construct validity rather than diagnostic accuracy measures (e.g. sensitivity, specificity). We have found seven tools compared to a reference standard such as clinician diagnosis, but still few studies use the IPA criteria.

Currently the most commonly used agitation and/or aggression scales among RCTs include the BEHAVE-AD (n = 10), the agitation/aggression domain of the NPI (along with variations of it) (n = 39), and the CMAI (n = 173) [12]. However, we only found (n = 1) and (n = 2) studies validating the BEHAVE-AD and NPI, respectively, compared to a reference standard [21, 23]. No diagnostic accuracy studies reporting sensitivity or specificity measures were obtained for the CMAI. Therefore, the validity of these tools are unclear, despite their recurrent use in clinical trials. More research is thus needed to validate the most common agitation and/or aggression tools amongst PLWD to improve clinical research. Additionally we found no evidence on tools such as Behaviour and Symptom Mapping Tools and the Aggressive Behaviour Scale in the RAI-Minimum Data Set (MDS) 2.0 [59]. The Behaviour and Symptom Mapping Tools primarily notes behavioural trends in response to events, in a qualitative fashion, and are often a key part of assessing antecedent events for behaviors [61], so it is unlikely tools such as this may be compared to a reference standard.

Despite the myriad of tools, few studies have assessed them for diagnostic accuracy. Future studies can address gaps looking at comparisons of diagnostic accuracy measures between the many tools, different languages, or ethnicities, various pathologies and severity of dementia, as well as different types of care settings. The CMAI, and BEHAVE-AD are commonly used scales in the literature, but more is needed to examine diagnostic accuracy of these tools. Certain tools as demonstrated by Mauleon et al. (2021) and Sano et al. (2022) overlap with the IPA criteria of agitation, more is needed to compare to the IPA criteria [14, 15].

Strengths and limitations

Our study had a rigorous search procedure and following all PRISMA reporting guidelines. Although we completed an extensive search, few studies with diagnostic accuracy measurements were identified, thus a meta-analysis could not be performed. As well, separate searches for the found instruments were not performed after relevant articles were included, thus serving as a potential limitation to our data collection methods. We also did not include the names of specific tools in our searches. There is also the chance that we may have missed literature despite the exhaustive nature of our search. We did not have any language restrictions on studies, however the use of translation software (i.e. Google translate) may have posed as a limitation to the interpretation of results.

Among included studies, the risk of bias assessment showed that many (n = 24) did not indicate whether administrators were blinded to one another, or did not specify the flow and timing of the study (n = 30). These unclear aspects can impact the precision in determining a given test’s diagnostic accuracy. Additionally, given the limited number of included studies, we lack data on the accuracy of these tools across different dementia pathologies, dwellings (community vs. long term care) or severities of dementia.

Conclusion

We found few studies reporting a comparison of agitation and/or aggression tools to a reference standard. Thus, we lack evidence on the sensitivity and specificity of these tools. From our current knowledge, the agitation domain of the Spanish NPI, NBRS, and PAS demonstrated the highest sensitivity for assessing symptoms of agitation and/or aggression, yet their accuracy at bedside is still unclear. More rigorous studies are needed to understand the diagnostic accuracy of tools for the detection agitation or aggression in PLWD.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Duong S, Patel T, Chang F, Dementia. What pharmacists need to know. Can Pharm J. 2017;150(2):118–29. https://doi.org/10.1177/1715163517690745

    Article  Google Scholar 

  2. García-Martín V, de Hoyos-Alonso MC, Ariza-Cardiel G, et al. Neuropsychiatric symptoms and subsyndromes in patients with different stages of dementia in primary care follow-up (NeDEM project): a cross-sectional study. BMC Geriatr. 2022;22(1):71. https://doi.org/10.1186/s12877-022-02762-9

    Article  PubMed  PubMed Central  Google Scholar 

  3. Lanctôt KL, Amatniek J, Ancoli-Israel S, et al. Neuropsychiatric signs and symptoms of Alzheimer’s disease: new treatment paradigms. Alzheimers Dement Transl Res Clin Interv. 2017;3(3):440–9. https://doi.org/10.1016/j.trci.2017.07.001

    Article  Google Scholar 

  4. Carrarini C, Russo M, Dono F, et al. Agitation and dementia: Prevention and treatment strategies in Acute and chronic conditions. Front Neurol. 2021;12:644317–644317. https://doi.org/10.3389/fneur.2021.644317

    Article  PubMed  PubMed Central  Google Scholar 

  5. Dettmore D, Kolanowski A, Boustani M. Aggression in persons with dementia: use of nursing theory to guide clinical practice. Geriatr Nurs N Y N. 2009;30(1):8–17. https://doi.org/10.1016/j.gerinurse.2008.03.001

    Article  Google Scholar 

  6. Livingston G, Barber J, Marston L, et al. Prevalence of and associations with agitation in residents with dementia living in care homes: MARQUE cross-sectional study. BJPsych Open. 2017;3(4):171–8. https://doi.org/10.1192/bjpo.bp.117.005181

    Article  PubMed  PubMed Central  Google Scholar 

  7. Cummings J, Mintzer J, Brodaty H, et al. Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition. Int Psychogeriatr. 2015;27(1):7–17. https://doi.org/10.1017/S1041610214001963

    Article  PubMed  Google Scholar 

  8. Wolf MU, Goldberg Y, Freedman M. Aggression and Agitation in Dementia. Contin Minneap Minn. 2018;24(3, BEHAVIORAL NEUROLOGY AND PSYCHIATRY):783–803. https://doi.org/10.1212/CON.0000000000000605

  9. Miller J. Managing acute agitation and aggression in the world of drug shortages. Ment Health Clin. 2021;11(6):334–46. https://doi.org/10.9740/mhc.2021.11.334

    Article  PubMed  PubMed Central  Google Scholar 

  10. Morgan RO, Sail KR, Snow AL, Davila JA, Fouladi NN, Kunik ME. Modeling causes of aggressive behavior in patients with dementia. Gerontologist. 2013;53(5):738–47. https://doi.org/10.1093/geront/gns129

    Article  PubMed  Google Scholar 

  11. Khan SS, Ye B, Taati B, Mihailidis A. Detecting agitation and aggression in people with dementia using sensors—A systematic review. Alzheimers Dement. 2018;14(6):824–32.

    Article  PubMed  Google Scholar 

  12. Watt JA, Goodarzi Z, Veroniki AA, et al. Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network Meta-analysis. Ann Intern Med. 2019;171(9):633–42. https://doi.org/10.7326/M19-0993

    Article  PubMed  Google Scholar 

  13. Šimundić AM. Measures of diagnostic accuracy: Basic definitions. EJIFCC. 2009;19(4):203–11.

    PubMed  PubMed Central  Google Scholar 

  14. Sano M, Zhu CW, Neugroschl J, Grossman HT, Schimming C, Aloysi A. Agitation in Cognitive disorders: Use of the National Alzheimer’s Coordinating Center Uniform Data Set (NACC-UDS) to Evaluate International Psychogeriatric Association Definition. Am J Geriatr Psychiatry. 2022;30(11):1198–208.

    Article  PubMed  Google Scholar 

  15. De Mauleon A, Ismail Z, Rosenberg P, et al. Agitation in Alzheimer’s disease: novel outcome measures reflecting the International Psychogeriatric Association (IPA) agitation criteria. Alzheimers Dement J Alzheimers Assoc. 2021;17(10):1687–97. https://doi.org/10.1002/alz.12335

    Article  Google Scholar 

  16. Griffiths AW, Albertyn CP, Burnley NL, et al. Validation of the Cohen-Mansfield Agitation Inventory Observational (CMAI-O) tool. Int Psychogeriatr. 2020;32(1):75–85. https://doi.org/10.1017/S1041610219000279

    Article  PubMed  Google Scholar 

  17. Making the Case for Investing in Mental Health in Canada. Published Online 2013. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Investing_in_Mental_Health_FINAL_Version_ENG_0.pdf

  18. Deeks JJ, Bossuyt P, Leeflang MM, Takwoingi Y. Cochrane Handbook for systematic reviews of Diagnostic Test Accuracy. Cochrane; Wiley Blackwell;; 2023.

  19. Paez A. Grey literature: An important resource in systematic reviews. J Evid-Based Med. Published online December 21, 2017. https://doi.org/10.1111/jebm.12265

  20. Whiting PF, Rutjes AWS, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529–36. https://doi.org/10.7326/0003-4819-155-8-201110180-00009

    Article  PubMed  Google Scholar 

  21. Ismail Z, Emeremni CA, Houck PR, et al. A comparison of the E-BEHAVE-AD, NBRS, and NPI in quantifying clinical improvement in the treatment of agitation and psychosis associated with dementia. Am J Geriatr Psychiatry off J Am Assoc Geriatr Psychiatry. 2013;21(1):78–87. https://doi.org/10.1016/j.jagp.2012.10.013

    Article  Google Scholar 

  22. Adama B, Benjamin C, Jean-Pierre C, Miche DC, Prado-Jean A. French version of the rating scale for aggressive behaviour in the Elderly (F-RAGE): psychometric properties and diagnostic accuracy. Dement Neuropsychol. 2013;7(3):278–85. https://doi.org/10.1590/S1980-57642013DN70300008

    Article  PubMed  PubMed Central  Google Scholar 

  23. Vilalta-Franch J, Lozano-Gallego M, Hernández-Ferrándiz M, Llinàs-Reglà J, López-Pousa S, López OL. [The neuropsychiatric inventory. Psychometric properties of its adaptation into Spanish]. Rev Neurol. 1999;29(1):15–9.

    CAS  PubMed  Google Scholar 

  24. Rosen J, Bobys P, Mozumdar S. OBRA regulations and neuroleptic use: defining agitation using the Pittsburgh Agitation Scale and the Neurobehavioral Rating Scale. Annals Long-term Care. 1999;7(12):429–36.

    Google Scholar 

  25. Yudofsky SC, Kopecky HJ, Kunik M, Silver JM, Endicott J. The overt agitation severity scale for the objective rating of agitation. J Neuropsychiatry Clin Neurosci. 1997;9(4):541–8. https://doi.org/10.1176/jnp.9.4.541

    Article  CAS  PubMed  Google Scholar 

  26. Lai CKY. The merits and problems of Neuropsychiatric Inventory as an assessment tool in people with dementia and other neurological disorders. Clin Interv Aging. 2014;9:1051–61. https://doi.org/10.2147/CIA.S63504

    Article  PubMed  PubMed Central  Google Scholar 

  27. Neuropsychiatric Inventory. American Psychological Association. Accessed October 31. 2021. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/neuropsychiatric-inventory

  28. Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994;44(12):2308–14. https://doi.org/10.1212/wnl.44.12.2308

    Article  CAS  PubMed  Google Scholar 

  29. Levin HS, High WM, Goethe KE, et al. The neurobehavioural rating scale: assessment of the behavioural sequelae of head injury by the clinician. J Neurol Neurosurg Psychiatry. 1987;50(2):183–93. https://doi.org/10.1136/jnnp.50.2.183

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Cook CE. Clinimetrics Corner: the minimal clinically important change score (MCID): a necessary pretense. J Man Manip Ther. 2008;16(4):E82–83. https://doi.org/10.1179/jmt.2008.16.4.82E

    Article  PubMed  PubMed Central  Google Scholar 

  31. Whall AL, Kim H, Colling KB, Hong GR, DeCicco B, Antonakos C. Measurement of aggressive behaviors in dementia: comparison of the physical aggression subscales of the Cohen-Mansfield Agitation Inventory and the Ryden Aggression Scale. Res Gerontol Nurs. 2013;6(3):171–7. https://doi.org/10.3928/19404921-20130321-01

    Article  PubMed  Google Scholar 

  32. Choy CN, Lam LC, Chan WC, Li SW, Chiu HF. Agitation in Chinese elderly: validation of the Chinese version of the Cohen-Mansfield Agitation Inventory. Int Psychogeriatr. 2001;13(3):325–35. https://doi.org/10.1017/s1041610201007712

    Article  CAS  PubMed  Google Scholar 

  33. Cohen-Mansfield J, Libin A. Assessment of agitation in elderly patients with dementia: correlations between informant rating and direct observation. Int J Geriatr Psychiatry. 2004;19(9):881–91. https://doi.org/10.1002/gps.1171

    Article  PubMed  Google Scholar 

  34. de Medeiros K, Robert P, Gauthier S, et al. The neuropsychiatric inventory-clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia. Int Psychogeriatr. 2010;22(6):984–94. https://doi.org/10.1017/S1041610210000876

    Article  PubMed  PubMed Central  Google Scholar 

  35. Deslauriers S, Landreville P, Dicaire L, Verreault R. Validité et fidélité de l’Inventaire d’agitation de Cohen-Mansfield. Can J Aging Rev Can Vieil. 2001;20(3):373–84. https://doi.org/10.1017/S0714980800012836

    Article  Google Scholar 

  36. Gormley N, Rizwan MR, Lovestone S. Clinical predictors of aggressive behaviour in Alzheimer’s disease. Int J Geriatr Psychiatry. 1998;13(2):109–15. https://doi.org/10.1002/(sici)1099-1166(199802)13:2%3C109::aid-gps740%3E3.0.co;2-f

    Article  CAS  PubMed  Google Scholar 

  37. Kim HJ, Choi KH, Kim SH, Cummings JL, Yang DW. Validation study of the Korean Version of the brief clinical form of the neuropsychiatric inventory. Dement Geriatr Cogn Disord Extra. 2016;6(2):214–21. https://doi.org/10.1159/000445828

    Article  Google Scholar 

  38. Lam CL, Chan WC, Mok CCM, Li SW, Lam LCW. Validation of the Chinese challenging Behaviour Scale: clinical correlates of challenging behaviours in nursing home residents with dementia. Int J Geriatr Psychiatry. 2006;21(8):792–9. https://doi.org/10.1002/gps.1564

    Article  PubMed  Google Scholar 

  39. Lam LC, Tang WK, Leung V, Chiu HF. Behavioral profile of Alzheimer’s disease in Chinese elderly–a validation study of the Chinese version of the Alzheimer’s disease behavioral pathology rating scale. Int J Geriatr Psychiatry. 2001;16(4):368–73. https://doi.org/10.1002/gps.345

    Article  CAS  PubMed  Google Scholar 

  40. Logsdon RG, Teri L, Weiner MF, et al. Assessment of agitation in Alzheimer’s disease: the agitated behavior in dementia scale. Alzheimer’s Disease Cooperative Study. J Am Geriatr Soc. 1999;47(11):1354–8. https://doi.org/10.1111/j.1532-5415.1999.tb07439.x

    Article  CAS  PubMed  Google Scholar 

  41. Miller RJ, Snowdon J, Vaughan R. The use of the Cohen-Mansfield Agitation Inventory in the assessment of behavioral disorders in nursing homes. J Am Geriatr Soc. 1995;43(5):546–9. https://doi.org/10.1111/j.1532-5415.1995.tb06104.x

    Article  CAS  PubMed  Google Scholar 

  42. Mungas D, Weiler P, Franzi C, Henry R. Assessment of disruptive behavior associated with dementia: the disruptive behavior rating scales. J Geriatr Psychiatry Neurol. 1989;2(4):196–202. https://doi.org/10.1177/089198878900200405

    Article  CAS  PubMed  Google Scholar 

  43. Politis AM, Mayer LS, Passa M, Maillis A, Lyketsos CG. Validity and reliability of the newly translated Hellenic Neuropsychiatric Inventory (H-NPI) applied to Greek outpatients with Alzheimer’s disease: a study of disturbing behaviors among referrals to a memory clinic. Int J Geriatr Psychiatry. 2004;19(3):203–8. https://doi.org/10.1002/gps.1045

    Article  PubMed  Google Scholar 

  44. Røen I, Selbæk G, Kirkevold Ø, Engedal K, Lerdal A, Bergh S. The reliability and validity of the Norwegian version of the quality of life in late-stage dementia scale. Dement Geriatr Cogn Disord. 2015;40(3–4):233–42. https://doi.org/10.1159/000437093

    Article  PubMed  Google Scholar 

  45. Sahin Cankurtaran E, Danişman M, Tutar H, Ulusoy Kaymak S. The reliability and validity of the Turkish version of the neuropsychiatric inventory-clinician. Turk J Med Sci. 2015;45(5):1087–93. https://doi.org/10.3906/sag-1405-111

    Article  CAS  PubMed  Google Scholar 

  46. Selbaek G, Kirkevold O, Sommer OH, Engedal K. The reliability and validity of the Norwegian version of the neuropsychiatric inventory, nursing home version (NPI-NH). Int Psychogeriatr. 2008;20(2):375–82. https://doi.org/10.1017/S1041610207005601

    Article  PubMed  Google Scholar 

  47. Suh GH. Agitated behaviours among the institutionalized elderly with dementia: validation of the Korean version of the Cohen-Mansfield Agitation Inventory. Int J Geriatr Psychiatry. 2004;19(4):378–85. https://doi.org/10.1002/gps.1097

    Article  PubMed  Google Scholar 

  48. Victoroff J, Nielson K, Mungas D. Caregiver and clinician assessment of behavioral disturbances: the California Dementia Behavior Questionnaire. Int Psychogeriatr. 1997;9(2):155–74. https://doi.org/10.1017/s1041610297004316

    Article  CAS  PubMed  Google Scholar 

  49. Villanueva M, Smith T, Erickson J, Lee A. Pain Assessment for the Dementing Elderly (PADE): reliability and validity of a new measure. J Am Med Dir Assoc. 2003;4(1):1–8. https://doi.org/10.1097/01.JAM.0000043419.51772.A3

    Article  PubMed  Google Scholar 

  50. Weiner MF, Koss E, Patterson M, et al. A comparison of the Cohen-Mansfield agitation inventory with the CERAD behavioral rating scale for dementia in community-dwelling persons with Alzheimer’s disease. J Psychiatr Res. 1998;32(6):347–51. https://doi.org/10.1016/s0022-3956(98)00027-2

    Article  CAS  PubMed  Google Scholar 

  51. Weiner MF, Williams B, Risser RC. Assessment of behavioral symptoms in community-dwelling dementia patients. Am J Geriatr Psychiatry off J Am Assoc Geriatr Psychiatry. 1997;5(1):26–30.

    Article  CAS  Google Scholar 

  52. Youn JC, Lee DY, Lee JH, et al. Development of a Korean version of the behavior rating scale for dementia (BRSD-K). Int J Geriatr Psychiatry. 2008;23(7):677–84. https://doi.org/10.1002/gps.1960

    Article  PubMed  Google Scholar 

  53. Abe K, Yamashita T, Hishikawa N, et al. A new simple score (ABS) for assessing behavioral and psychological symptoms of dementia. J Neurol Sci. 2015;350(1–2):14–7. https://doi.org/10.1016/j.jns.2015.01.029

    Article  CAS  PubMed  Google Scholar 

  54. Hurley A, Volicer L, Camberg L et al. Measurement of observed agitation in patients with dementia of the Alzheimer type. 1999;5:117–32.

  55. Smart KA, Herrmann N, Lanctôt KL. Validity and responsiveness to change of clinically derived MDS scales in Alzheimer disease outcomes research. J Geriatr Psychiatry Neurol. 2011;24(2):67–72. https://doi.org/10.1177/0891988711402347

    Article  PubMed  Google Scholar 

  56. Sun FC, Lin LC, Chang SC, Li HC, Cheng CH, Huang LY. Reliability and validity of a Chinese version of the Cohen–Mansfield Agitation Inventory-Short Form in assessing agitated Behavior. Int J Environ Res Public Health. 2022;19(15):9410.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Curyto KJ, Jedele JM, Mohr DC, Eaker A, Intrator O, Karel M, An. MDS 3.0 distressed behavior in Dementia Indicator (DBDI): a clinical Tool to capture change. J Am Geriatr Soc JAGS. 2021;69(3):785–91.

    Article  Google Scholar 

  58. Kratzer A, Scheel-Barteit J, Altona J, Wolf-Ostermann K, Graessel E, Donath C. Agitation and aggression in people living with dementia and mild cognitive impairment in shared-housing arrangements - validation of a German version of the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF). Health Qual Life Outcomes. 2023;21(1):51–51.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Wong B, Ismail Z, Watt J, Holroyd-Leduc J, Goodarzi Z. Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care. BMC Geriatr. 2024;24(1):330. https://doi.org/10.1186/s12877-024-04919-0

    Article  PubMed  PubMed Central  Google Scholar 

  60. Jones E, Aigbogun MS, Pike J, Berry M, Houle CR, Husbands J. Agitation in dementia: real-world impact and burden on patients and the Healthcare System. J Alzheimers Dis JAD. 2021;83(1):89–101. https://doi.org/10.3233/JAD-210105

    Article  PubMed  Google Scholar 

  61. Wong B. Developing a Novel Care pathway for symptoms of agitation or aggression in persons living with dementia in long-term care: a multi-methods implementation Research Study. Published online November 2023.

  62. Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred reporting items for systematic reviews and Meta-analyses: the PRISMA Statement. PLOS Med. 2009;6(7):1–6. https://doi.org/10.1371/journal.pmed.1000097

    Article  Google Scholar 

  63. Reusberg B. BEHAVE-AD behavioural Pathology in Alzheimer’s Disease. Published 1997. https://www.cgakit.com/p-3-behave-ad

  64. Lam LC, Chui HF. Aggressive behaviour in the Chinese elderly–validation of the Chinese version of the rating scale for aggressive behaviour in the elderly (RAGE) in hospital and nursing home settings. Int J Geriatr Psychiatry. 1997;12(6):678–81. https://doi.org/10.1002/(sici)1099-1166(199706)12:6%3C678::aid-gps610%3E3.0.co;2-r

    Article  CAS  PubMed  Google Scholar 

  65. Finkel SI, Lyons JS, Anderson RL. Reliability and validity of the Cohen–Mansfield agitation inventory in institutionalized elderly. Int J Geriatr Psychiatry. 1992;7(7):487–90. https://doi.org/10.1002/gps.930070706

    Article  Google Scholar 

  66. Ravyts SG, Perez E, Donovan EK, Soto P, Dzierzewski JM. Measurement of aggression in older adults. Aggress Violent Behav. 2021;57. https://doi.org/10.1016/j.avb.2020.101484

  67. Perlman CM, Hirdes JP. The aggressive behavior scale: a New Scale to measure Aggression based on the Minimum Data Set. J Am Geriatr Soc. 2008;56(12):2298–303. https://doi.org/10.1111/j.1532-5415.2008.02048.x

    Article  PubMed  Google Scholar 

  68. Sinha D, Zemlan FP, Nelson S, et al. A new scale for assessing behavioral agitation in dementia. Psychiatry Res. 1992;41(1):73–88. https://doi.org/10.1016/0165-1781(92)90020-4

    Article  CAS  PubMed  Google Scholar 

  69. Gitlin LN, Marx KA, Stanley IH, Hansen BR, Van Haitsma KS. Assessing neuropsychiatric symptoms in people with dementia: a systematic review of measures. Int Psychogeriatr. 2014;26(11):1805–48. https://doi.org/10.1017/S1041610214001537

    Article  PubMed  PubMed Central  Google Scholar 

  70. Brasure M, Jutkowitz E, Fuchs E, et al. Nonpharmacologic interventions for agitation and aggression in Dementia. Agency for Healthcare Research and Quality (US); 2016.

  71. Teri L, Truax P, Logsdon R, Uomoto J, Zarit S, Vitaliano PP. Assessment of behavioral problems in dementia: the revised memory and behavior problems checklist. Psychol Aging. 1992;7(4):622–31. https://doi.org/10.1037/08827974.7.4.622

    Article  CAS  PubMed  Google Scholar 

  72. Ray WA, Taylor JA, Lichtenstein MJ, Meador KG. The nursing home Behavior Problem Scale. J Gerontol. 1992;47(1):M9–16. https://doi.org/10.1093/geronj/47.1.m9

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to give a special thanks to librarian Helen Lee-Robertson at the University of Calgary for assisting us with developing the search strategy.

Funding

This systematic review is unfunded.

Author information

Authors and Affiliations

  1. Department of Community Health Sciences, University of Calgary, Calgary, Canada

    Britney Wong & Zahra Goodarzi

  2. Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada

    Pauline Wu & Zahra Goodarzi

  3. Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada

    Zahinoor Ismail & Zahra Goodarzi

  4. Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada

    Zahinoor Ismail

  5. Department of Psychiatry, University of Calgary, Calgary, AB, Canada

    Zahinoor Ismail

  6. Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Britney Wong, Pauline Wu, Zahinoor Ismail & Zahra Goodarzi

  7. O’Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada

    Zahra Goodarzi

  8. Division of Geriatric Medicine, University of Toronto, Toronto, ON, Canada

    Jennifer Watt

  9. Department of Medicine, University of Toronto, Toronto, ON, Canada

    Jennifer Watt

Authors
  1. Britney Wong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Pauline Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Zahinoor Ismail
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jennifer Watt
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zahra Goodarzi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization, B.W, P.W, J.W, Z.I, Z.G; search strategy, B.W, J.W, Z.I, Z.G; Screening – Level 1, B.W, P.W, Z.G; Screening – Level 2, B.W, P.W, Z.G; Risk of Bias Assessment, B.W, P.W, J.W, Z.G; Data Extraction, B.W, P.W, J.W, Z.G; Writing – original draft preparation, B.W; writing – review and editing, P.W, J.W, Z.I, Z.G.

Corresponding author

Correspondence to Zahra Goodarzi.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

No conflict of interests are present for authors BW, PW, and JW. ZG holds independent peer-reviewed project funding from the Canadian Institutes of Health Research (CIHR), Brenda Strafford Foundation, Hotchkiss Brain Institute (HBI) and O’Brien Institute of Public Health at the University of Calgary. ZI holds voluntary positions as Chair of the Canadian Conference on Dementia, and the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, but no conflict of interests are associated with either position.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wong, B., Wu, P., Ismail, Z. et al. Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy. BMC Geriatr 24, 559 (2024). https://doi.org/10.1186/s12877-024-05143-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12877-024-05143-6

Keywords

BMC Geriatrics

ISSN: 1471-2318

Contact us