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Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 8-13

A cross-sectional study to assess the relation between anxiety and physical aggression of dementia patients at the department of geriatric mental health

1 Sardar Patel Institute of Para Medical Sciences, Lucknow, Uttar Pradesh, India
2 Assistant Professor, KGMU College of Nursing, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission26-Feb-2020
Date of Decision21-Apr-2020
Date of Acceptance12-Jun-2020
Date of Web Publication08-Aug-2020

Correspondence Address:
Ms. Kanchan Sahu
Nursing Lecturer, Sardar Patel Institute of Para Medical Sciences, Lucknow - 226 025, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IOPN.IOPN_2_20

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Introduction: An increased in life expectancy for the past few decades has led to increased elderly population and thus dementia as growing health problem. The number of serious complications including behavioral and psychological symptoms in which anxiety and physical aggression is common. Aim and Objective: The aim of the study was to investigate the anxiety and physical aggression and relation between them of dementia patients. Materials and Methods: A quantitative approach and cross-sectional, descriptive design was used for data collection using nonprobability, purposive sampling technique from 55 dementia patients diagnosed by psychiatrist from the outpatient and inpatient departments of Geriatric Mental Health King George's Medical University, Uttar Pradesh, India, using the Hamilton Anxiety Rating Scale and Cohen Mansfield agitation inventory. Results: Among these patients, mostly belong to the age group of 70–79 living in the urban area, married, illiterate and had Alzheimer's type of dementia with duration of illness for more than 2 years and most of them had never been hospitalized for the treatment. Majority of them, 45.5% had mild-to-moderate anxiety, physical aggression was present in 36.38% and most of patients had mild cognitive impairment. A significant positive correlation was found between the anxiety and physical aggression. Most of the patients were on psychotropic medication, and acetylcholinesterase inhibitors were used by almost every patient. Significant association had been found of anxiety with gender, education, marital status, and occupation and of physical aggression a significant association with gender, education, and marital status of dementia patients.Conclusion: The anxiety is significantly positively correlated with physical aggression of dementia patients.

Keywords: Anxiety, dementia patients, physical aggression

How to cite this article:
Sahu K, Mishra S, Singh B. A cross-sectional study to assess the relation between anxiety and physical aggression of dementia patients at the department of geriatric mental health. Indian J Psy Nsg 2020;17:8-13

How to cite this URL:
Sahu K, Mishra S, Singh B. A cross-sectional study to assess the relation between anxiety and physical aggression of dementia patients at the department of geriatric mental health. Indian J Psy Nsg [serial online] 2020 [cited 2022 Nov 30];17:8-13. Available from: https://www.ijpn.in/text.asp?2020/17/1/8/291615

  Introduction Top

Anxiety and aggression are found commonly in dementia patients and may have severe consequences including the increased rates of mortality and need of institutionalization. Several studies have shown or assumed that agitation is outward manifestation of anxiety, while others have attempted to differentiate between the two. Anxiety and aggression are found to be associated in dementia patients.[1]

According to the WHO report 2019, about 50 million people have dementia and every year nearly 10 million new cases are found worldwide. There is an estimation that total number of about 82 million of people will have dementia in 2030 and 152 in 2050 and 60% of them are living in low- and middle-income countries.[2] In India, about more than 4 million people have some forms of dementia.[3]

The ABC symptoms of dementia include the activities of daily living, behavioral and psychological symptoms of dementia, and cognitive and memory symptoms. The initial stage of dementia, i.e., in the 1st–2nd year the clinical features such as mood changes, difficulty in talking or making decisions, anxiety, and depression are overlooked or unnoticed by the family members.

Thus, as the disease progresses, i.e., 2nd–5th year symptoms of behavioral and psychological symptoms of dementia appears which includes agitation, aggression, sleep disturbance, wandering, and delusion occur in the middle stage of dementia which causes strain on caregivers of dementia.[4]

Anxiety is common in dementia patients, with the prevalence estimating to be 8%–71% for anxiety symptoms and 5%–21% for anxiety disorders.[5]

When anxiety coexist with dementia, it causes additional burden on patients and caregivers[6] since it contributes to decreased independence,[7] increased limitation on ADL,[8] increased behavioral problems, and greater risk for nursing home placements.[9]

The behavioral with psychological symptoms of dementia commonly includes aggression occurs during illness.[10] An important clinical problem for dementia patients and their caregivers is the noncognitive mental and behavioral disturbances that afflict between 70% and 80% of patients over the course of illness.[11]

Aggression persists during the illness and may be expressed physically or verbally. Physical aggression has been found to be prevalence of about 35%–41%. It may cause threat to other patients, relatives, and caregivers. Aggression may place the caregiver and patient at risk of injury, stress, and social embarrassment.[12],[13]

Need of the study

Anxiety is very common symptoms of dementia patients which cannot only worsen the symptoms of dementia but can cause an adverse effect on their caregivers.[14] It is also associated with other behaviors such as wandering, sexual; misconduct, hallucinations, verbal threats, and physical abuse with a higher likelihood of increased anxiety.[15] Therefore, it is important to assess the anxiety of dementia patients to prevent these behaviors and distress of patients along with their caregivers and others.

Behavioral disturbances (synonymous with agitation in most studies) occur in up to 75% of nursing home residents; most of them have dementia.[16] More than half will exhibit 2 or more problem behaviors.[17] The aggressive behavior results into the injuries to about 22% in compare to nonaggressive patients, i.e., 2%.[18] Hence, it suggest to assess the physical aggression of dementia patients. There are few studies which depict the relation between anxiety and aggression of dementia patients. Thus substantial minority of patients with dementia exhibit physically aggressive behavior, and this aggression is strongly linked with the presence of anxiety.[1] An unprecedented size of aged population has led to highly prevalent conditions such as depression, hypertension, arthritis, and dementia and Alzheimer's disease.[19] Hence, it is important and possible that the identification and treatment of anxiety in dementia may be a means of preventing and managing physically aggressive behavior. Keeping above facts in view, the researcher is keen to assess the relation between anxiety and physical aggression of dementia patients.

The objectives of the study were to assess the anxiety and physical aggression and the relation between them of dementia patients.

  Materials and Methods Top

Data were collected after obtaining a formal permission from the Institutional Ethical Committee of King George's Medical University (KGMU) and a written formal permission from the Head of department of geriatric mental KGMU to conduct the study.

Research approach

Quantitative research approach was selected for the present study.

Research design

A cross-sectional, descriptive design had been used for the present study.

Research setting

The setting of study was the Department of Geriatric Mental Health, KGMU, Lucknow.

The study was conducted at the outpatient department (OPD) and inpatient departments (IPD) of Department of Geriatric Mental Health, KGMU, Lucknow.

Sampling technique

Sample was selected through nonprobability, purposive sampling technique.


All the dementia patients diagnosed as per International Classification of Diseases-10 (ICD-10) criteria by Psychiatrist at Department of Geriatric Mental Health, KGMU, Lucknow.

Sample size

Sample size was 55 calculated by statistician based on previous study.


The samples of the present study were the dementia patients who were present at the OPD or admitted in wards of Department of Geriatric Mental Health during the data collection period and who fulfilled the inclusion criteria of the study.

Sampling criteria

Inclusion criteria

  • All the dementia patients diagnosed by psychiatrist as per the ICD-10 at the Department of Geriatric Mental Health KGMU
  • Age between 60 years and above
  • All the dementia patients from OPD and IPD of Department of Geriatric Mental Health, KGMU
  • Patient who had given consent to participate in the research study.

Exclusion criteria

  • Patient who cannot respond due to severe medical illness.

Description of tools

In present study, semi-structured sociodemographic questionnaire, mini mental status examination, Hamilton Anxiety Rating Scale (HARS) Cohen Mansfield agitation inventory (CMAI) were used for data collection.

Semistructured questionnaire

Semistructured questionnaire consist of sociodemographic variables as age, gender, domicile, type of family, educational status, marital status, occupational status, and monthly family income and clinical variable as type of dementia, history of any mental illness, duration of present illness, duration of treatment taken, number of hospitalization, medical comorbidity, and psychotropic medications was developed for the study purpose. The reliability and validity of tool were found to be good.

Mini mental status examination

Minimental status examination a 30-point questionnaire that was originally introduced by Folstein et al. in 1959, in order to differentiate organic from functional psychiatric patients and is used extensively in the clinical and research settings for the assessment of cognitive impairment. The score is found to be ≥24 points out of 30, it indicates a normal cognition and moderate (10–18 points), mild (19–23 points), and ≤9 points indicate severe cognitive impairment.[20] The tool has good validity and high interobserver reliability with a mean kappa value of 0.97.[21]

The patients diagnosed with dementia by psychiatrist were assessed at bedside or OPDs for the severity of cognitive impairment based on his performance and examination of his various functions including orientation, attention, registration, recall, and language of this scale. It helps to understand the nature and severity of cognitive problems and thus appropriate and necessary information can be given to patient and family members regarding care of patient.

Hamilton anxiety rating scale

HARS developed by Max R. Hamilton in 1959 is a general measure of anxiety contains 14 items was used for anxiety. Each item scored on a numeric score of 0 (not present) to 4 (severe). In this a score of 17 or less indicates mild anxiety severity and a score from 18 to 24 indicates mild to moderate anxiety severity and score of 25–30 suggest moderate to severe anxiety severity.[22] The reliability and concurrent validity of this scale and its subscales were found to be sufficient.[23]

Cohen mansfield agitation inventory

CMAI developed by Jiska Cohen-Mansfield in the year 1991. It contains a diversified group of behaviors to assess the frequency of symptoms of the agitated behaviors in elderly persons. The CMAI is a caregivers' rating questionnaire consisting of 29 agitated behaviors and consist of four subscale, i.e., physical aggression, physical nonaggression, verbal aggression, and verbal nonaggression, each rated on a 7-point scale of frequency. Physical aggression consist of 11 items, i.e., hitting, kicking grabbing onto people, pushing, throwing things, biting, scratching, spitting, hurting self or others, tearing things or destroying property, and making physical sexual advances. The ratings applicable to the 2 weeks preceding the administration of the CMAI. Each item scored on numeric score of 1 (never) to 7 (several times an hour). The criteria for agitated/not agitated status used were as aggressive behavior occurring at least several times a week, i.e., at least one aggressive behavior occurring at a frequency of 4, or at least two aggressive behaviors occurring at a frequency of 3, or at least three aggressive behaviors occurring at a frequency of 2 or two aggressive behaviors occurring at a frequency of 2 and one at a frequency of 3.[24]

The reliability of the tool was assessed using the test retest alpha Cronbach and split half method was 0.92 and 0.82, respectively, and the validity of tool computed a correlational coefficient is significant between 0.43 and 0.90 (P < 0.01).[25] The permission was taken for using the tool for data collection of study.[25]

Method of data collection

After obtaining ethical approval from the Institutional Ethical Committee of KGMU and formal administrative permission from the Head of Department of Geriatric Mental Health KGMU, Lucknow, study was conducted. The data were collected from dementia patients OPD and IPD of Geriatric Mental Health KGMU, Lucknow, by the purposive sampling technique. Self-introduction and purpose of the study was explained to the subject, willingness to participate in the study was ascertained and written informed consent was taken. Confidentiality was maintained to all participants, demographic data were collected with self-structured sociodemographic tool and mini mental status examination was done. Time required for the administration was 10–15 min. Anxiety and physical aggression questionnaire was administered and time required for administration was 15–20 min. Total time taken to collect the data from the subject was approximately 30–35 min.

Strength of study

The specified population assessed in our research study and standardized tools used were the strength of the study.

  Results Top

Study population characteristics

The mean age of the participants was 73.95 (±7.72). The age range was 60–90 years, and most participants 25 (45.45%) were aged between 70 and 79 years, 17 participants (30.90%) were in 60–69 years. Twenty-eight participants (50.90%) were male, and 27 participants (49.09%) were female.

Majority of them, 30 participants (54.54%) were the residents of urban and thirty-five participants (63.93%) belong to the joint family. Most of the patients, 19 (34.54%) were illiterate, 32 (58.18%) were married, and 21 (38.18%) were widow/widower. Twenty-two participants (40%) were homemakers, and 17 participants (30.9%) were retired from job.

The monthly family income of majority of them, 22 participants (40%) were more than 20,000, and 22 (40%) had 15,000–19,000 of monthly family income.

[Table 1] depicts that most of patients, 40 participants (72.72%) had Alzheimer's disease, and 7 subjects (12.72%) had vascular dementia, and mostly, 48 subjects (87.27%) do not had history of any mental illness. Majority of them 20 participants (38.18%) had duration of more than 2 years of present illness, with no hospitalization in 33 participants (60%) for the treatment. Medical comorbidity found in most of the participants, 23 (41.81%) was hypertension.
Table 1: Frequency and percentage distribution of clinical profile of dementia patients (n=55)

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The findings revealed that for entire sample cognition level of dementia patients, only four participants (7.27%) had no cognitive impairment, with the average score of 8.66 (±0.47), 27 participants (49.09%) had mild cognitive impairment, 21 participants (38.18%) had moderate cognitive impairment, while three participants (5.45%) had severe cognitive impairment in dementia patients. The overall mean was found to be 19.23.

[Table 2] depicts that mean value of anxiety was 24.13 with standard deviation of ± 5.3 and nine participants (16.36%) had mild anxiety, 25 participants (45.46%) had mild to moderate anxiety, and 21 participants (38.27%) had moderate-to-severe anxiety.
Table 2: Frequency and percentage distribution of severity of anxiety as per (Hamilton Anxiety Rating Scale) dementia patients (n=55)

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[Table 3] exhibited data on physical aggression represents that about thirty subjects (63.63%) had no physical aggression whereas twenty-five (36.38%) were physically aggressive.
Table 3: Frequency and percentage distribution of physical aggression (as per Cohen Mansfield agitation inventory) of dementia patients (n=55)

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[Table 4] depicts the significant positive correlation between anxiety and physical aggression of dementia patients.
Table 4: Correlation (Spearman's correlation) of the anxiety (as per Hamilton Anxiety Rating Scale) and physical aggression (as per Cohen Mansfield agitation inventory) of dementia patients (n=55)

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The finding suggest that there is significant relationship of anxiety with gender, education, marital status, and occupation of dementia patients, and physical aggression also depicts a significant association with gender, education, and marital status of dementia patients.

  Discussion Top

In our study, the mean age of total sample was 73.95 ± 7.72 years (60–90 years). Similar finding were noted in a study by Breitve et al.;[26] they also found mean age of dementia patients to be 75.8 ± 7.6 years. The education of most of them was found to be similar with a mean of 9.6 ± 2.7 years to our study with mean 7.01 ± 3.1 years. In another study by Kwak et al.,[5] they found no sex differences in dementia patients with anxiety similar to the present study. Mukherjee et al.[27] found similar finding to our study that most of the patients belong to the urban area. In another study, they found that most of the patients were found to have Alzheimer's type of dementia (72.12%) and vascular dementia was about (12.72%) similar to the present study.[26]

The mean score of anxiety in our study was found to be 24.13 ± 5.3 similar to a study in which mean score was 24.4 ± 6.9 conducted by Noble et al.[28] In a study conducted by Liljegren et al. (2018)[29] found that the prevalence of physical aggression of neuropathological confirmed dementia diagnosis was 35% of them had history of exerting physical aggression on health staff and family members similar to the findings of present study. In contrary to this the physical aggression was found to be 18% in another study on dementia patients conducted by Lyketsos et al.[11]

In our study, a significant positive correlation was found between the anxiety and physical aggression of dementia patients. The relation between the anxiety and physical aggression of dementia patients has not been reported previously in any study. However, the relation between the anxiety and aggression of dementia patients was found to be significant in a study by Twelftree H (2001).[1] In another study, they found that unmet goal may cause the emergence of new problems areas for dementia patients such as behavioral symptoms, psychological problems as anxiety and depression, and most further leads to behaviors such as wandering, vocalizations and verbal or physical aggression.[30]

  Conclusion Top

The study concluded that out of 55 participants, majority of patients were in the age group of 70–79 years, were homemakers, uneducated belonging to urban area with Alzheimer's type of dementia had mild-to-moderate anxiety and was significantly positive correlated with physical aggression of dementia patients. Similar study can be replicated with a large sample size, in a multi-centered setting. The study can be undertaken to find physical nonaggression, verbal aggression, and verbal nonaggression and with two group of samples (institutional and community residing) dementia patients. Study can be replicated study can be undertaken to prepare structured teaching programs for family caregivers to manage anxiety and physical aggression of dementia patients.

Limitations of study

The limitations of the study were small sample size, the exhaustive set of variables that might have been associated with anxiety and aggression which had not been examined and the study was conducted in one setting but finding may vary in different setting.


The findings of the study can be implication in the various areas of nursing. Nursing personnel caring for dementia patients should be made aware of the anxiety and physical aggression to provide quality care. Nursing staff should focus on interventions for reducing or managing the anxiety which eventually help in preventing the aggression of dementia patients. Nursing staff should be trained in communication skills, person centered care, psych education, and dementia care mapping to treat or reduce anxiety which, in turn, helps in decreasing the aggression of dementia patients. Nurses working in the outpatient and in patients department can discuss the various specific needs of dementia patients which must be fulfilled by family caregivers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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