ORIGINAL STUDIES Modifiable Factors Related to Abusive Behaviors in Nursing Home Residents With Dementia Ladislav Volicer, MD, PhD, Jenny T. Van der Steen, PhD, and Dinnus H. M. Frijters, PhD Objectives: To determine modifiable factors related to abusive behaviors in nursing home residents with dementia. Design: Analysis of Minimum Data Set (MDS) of the Resident Assessment Instrument (RAI) information. Setting: We used MDS-RAI data from 8 Dutch nursing homes and 10 residential homes that volunteered to collect data for care planning. We included the data of residents within a 12-month time window for each facility separately, resulting in a range from April 4, 2007, to December 1, 2008. Participants: We selected 929 residents older than 65 with Alzheimer’s disease or other dementia who were dependent in decision making and not comatose. Measurements: Cognitive Performance Scale, MDS Depression Scale and several individual items from the MDS-RAI (ability to understand others, verbally and physically abusive behavioral symptoms, resist care, diagnosis of Alzheimer’s disease and of dementia other than Alzheimer’s disease, diagnosis of depression, presence of delusions, hallucinations, pain frequency and constipation, and number of days receiving medications). Results: Resistiveness to care, related to lack of under- standing, depression, hallucinations and delusions, was strongly related to abusive behaviors. Presence of depressive symptoms and delusions was also related to abusive behaviors independent of resistiveness to care. Only very few residents who understood others and were not depressed were abusive. Conclusion: Abusive behaviors may develop from lack of understanding leading to resistiveness to care. Behavioral interventions preventing escalation of resistiveness to care into combative behavior and the treatment of depression can be expected to de- crease or prevent abusive behavior of most nursing home residents with dementia. (J Am Med Dir Assoc 2009; 10: 617–622) Keywords: Dementia; depression; abusive behavior; resistiveness to care; nursing home Behavioral symptoms of dementia are often more difficult to manage than cognitive and functional impairments. Especially difficult to manage are behaviors that are labeled as violent, aggressive, or assaultive. Assaultive behaviors occur almost always during caregiving activities. Caregivers who are not able to effectively cope with these behaviors are prone to respond with abusive behavior toward the resident. 1 Actually, caregivers who exhibit state and trait anger are more likely to report being assaulted by a resident. Violence on the ward may cause need for medical and psychological care and leads to increased absenteeism and staff turnover, property damage, decreased productivity, and increased worker’s compensation. 1 Development of management strategies for these symptoms is complicated by confusing terminology and sometimes by an erroneous presumption that individuals with dementia may be inherently dangerous because of potential aggression toward caregivers. Aggressive behavior is considered to be a type of agitation when the term agitation is used to describe all behav- ioral symptoms of dementia. 2 This terminology prevents devel- opment of specific strategies for different behaviors. Behavior School of Aging Studies, University of South Florida, Tampa, FL, and Charles University 3rd Medical Faculty, Prague, Czech Republic (L.V.); EMGO Institute, Department of Nursing Home Medicine, Amsterdam, The Netherlands (J.T.V.d.S., D.H.M.F.); EMGO Institute, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands (J.T.V.d.S.). The authors have no conflicts of interest relating to this article. Address correspondence to Ladislav Volicer, MD, PhD, University of South Florida, School of Aging Studies, 2337 Dekan Lane, Land O’Lakes, FL 34639. E-mail: lvolicer@cas.usf.edu Copyright Ó2009 American Medical Directors Association DOI:10.1016/j.jamda.2009.06.004 ORIGINAL STUDIES Volicer et al 617