Temporal patterns of agitation in dementia

OBJECTIVE:: This study investigated the temporal pattern of agitated behaviors in nursing home residents with dementia and compared it with temporal patterns of pleasure, interest in the environment, and sleep. METHODS:: Trained research assistants recorded direct observations of agitation and affect by the Agitation Behavior Mapping Instrument and the Lawtons Modified Behavior Stream for 174 participants from 12 nursing homes. RESULTS:: The temporal pattern found for total agitation showed a gradual increase from the morning until approximately 4 pm with a decrease thereafter. Only 26% of the sample showed a clear increase of their agitation in the later hours in comparison to the morning hours based on our criterion. Pleasure did not show a consistent pattern, whereas levels of interest peaked during lunch and dinner times. CONCLUSIONS:: The results fit with a hypothesis of fatigue of daytime nursing staff members and disruption during shift change and may also be partially accounted for by resident fatigue. Although the literature supports the notion that there is a peak in overall agitation around 4 pm, the term "sundowning" is not supported and should be replaced. The phenomenon of increased levels of agitation during later hours characterizes only a minority of agitated nursing home residents, albeit the most highly agitated.