International Psychogeriatrics

A prospective study of the effects of behavioral symptoms on the institutionalization of patients with dementia

Marjolein E. de Vugt a1, Fred Stevens a2, Pauline Aalten a1, Richel Lousberg a1, Niek Jaspers a3 and Frans R. J. Verhey a1c1
a1 Department of Psychiatry and Neuropsychology, University of Maastricht, the Netherlands
a2 Department of Medical Sociology, University of Maastricht, the Netherlands
a3 Department of Mental Health Care for the Elderly of the Regional Institute of Ambulant Mental Health Care the Netherlands

Article author query
vugt me   [PubMed][Google Scholar] 
stevens f   [PubMed][Google Scholar] 
aalten p   [PubMed][Google Scholar] 
lousberg r   [PubMed][Google Scholar] 
jaspers n   [PubMed][Google Scholar] 
verhey fr   [PubMed][Google Scholar] 


Background:Reports in the literature on the effects of behavioral problems in patients with dementia on the decision to institutionalize the patient have shown conflicting results. Few studies have taken into account the possibility that specific behavioral problems may have differential effects on the decision to institutionalize the patient. Moreover, it is probably not patient behavior itself that causes nursing home placement (NHP), but caregivers’ emotional reaction to it. The aim of the present study was to examine the impact of specific behavioral subsyndromes and caregivers’ emotional reaction on NHP.

Methods:A total of 119 patients with dementia and their informal caregivers were followed up for 2 years. Time to NHP was measured in months from the date of the baseline interview to the date of NHP. Behavioral disturbances in the patient and caregivers’ emotional reactions were measured with the Neuropsychiatric Inventory (NPI). Cox regression analyses were used to determine the probability that caregivers would institutionalize the patient when patient behavioral problems or caregiver distress were present at baseline.

ResultsForty-one percent of the patients were institutionalized during the 2-year follow-;up. Caregiver distress related to patient behavior was a significant predictor of NHP, while behavior in itself did not predict NHP. Contrary to our expectations, we did not find a differential impact of specific aspects of problem behavior. Children caregivers, especially daughters, were associated with shorter time to NHP compared to spouses.

Conclusions:Our findings indicate that the caregiver's emotional reaction to patient behavior is more important than problem behaviors per se in the decision to institutionalize patients. Interventions aimed at teaching caregivers strategies to better manage difficult patient behaviors may provide caregivers with the necessary resources to continue care at home. Future interventions need to account for the specific needs and problems of different caregiver groups.

(Received August 9 2004)
(returned for revision October 22 2004)
(revised version received March 17 2005)
(Accepted March 21 2005)

Key Words: Alzheimer's disease; behavioral problems; caregivers; nursing home placement.

c1 Correspondence should be addressed to: F. R. J. Verhey, Department of Psychiatry and Neuropsychology, University of Maastricht, PO Box 616, 6200 MD Maastricht, the Netherlands. Phone: +31 043 3877537; Fax: +31 043 3875444. Email: