Relation among Caregivers’ Burden, Abuse and Behavioural Disorder in People with Dementia

In e na ional Jou nal o En i onmen al Resea ch and Public Heal h A icle Rela ion among Ca egi e s’ Bu den, Abuse and Beha iou al Diso de in People wi h Demen ia Ignacio Gimeno 1, Sonia Val 2and Ma ía Jesús Ca doso Mo eno 1,*   Ci a ion: Gimeno, I.; Val, S.; Ca doso Mo eno, M.J. Rela ion among Ca egi e s’ Bu den, Abuse and Beha iou al Diso de in People wi h Demen ia. In . J. En i on. Res. Public Heal h 2021,18, 1263. h ps:// doi.o g/10.3390/ije ph18031263 Academic Edi o s: Me cedes Guilabe Mo a, Vi udes Pé ez-Jo e and I ene Ca illo Mu cia Recei ed: 29 Decembe 2020 Accep ed: 29 Janua y 2021 Published: 31 Janua y 2021 Publishe ’s No e: MDPI s ays neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a il- ia ions. Copy igh : © 2021 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). 1Depa men o Psychology and Sociology, Facul y o Heal h o Sciences, Uni e si y o Za agoza, 50009 Za agoza, Spain; [email p o ec ed] 2 EINA, Design and Manu ac u ing Enginee ing Depa men , Uni e si y o Za agoza, 50009 Za agoza, Spain; sonia@uniza .es *Co espondence: mca mo @uniza .es Abs ac : Demen ia p oduces a loss o independence o ca y ou he ac i i ies o daily li e. The g ea demand o ca e ha hese people need usually alls on he amily h ough in o mal ca e. This s udy aims o analyse he bu den showed by he in o mal ca egi e o a pe son wi h demen ia. In addi ion, we analyse whe he his bu den p esen in in o mal ca egi e s could be ela ed o abusi e beha iou . We also s udy he ela ionship be ween he s age o he disease, he appea ance o beha iou al diso de s and he le el o bu den in he ca egi e using he Scales o Za i , CASE and FAST. The da a showed ha 45.50 pe cen o ca egi e s ha e ligh bu den o bu den. A e he esea ch, i was iden i ied ha he p esence o beha iou al diso de s in pa ien s wi h demen ia showed a co ela ion wi h he inc ease in bo h he main ca egi e bu den and abuse. An inc ease in he le el o bu den is ollowed by an inc ease in he le el o abuse ( = 0.844; p= 0.000). Fu he mo e, we analysed se e al condi ions ha could ha e a co ela ion wi h his bu den and abuse. I was ound ha bu den in he ca egi e could be linked wi h he p esence o beha iou al diso de s, like agg ession ( = 0.577; p= 0.008) and i i abili y ( = 0.600; p= 0.005) a he mode a e s age o he disease. On he o he hand, he e is a posi i e co ela ion be ween he p obabili y ha people wi h demen ia su e abuse in he mode a e s age o he disease and he p esence o agg ession ( = 0.732; p= 0.000), lack o inhibi ion ( = 0.571; p= 0.009) and i i abili y ( = 0.827; p= 0.000). Taking his da a in o accoun , bu den and abuse seem o be linked o he p esence o beha iou al diso de s in pa ien s wi h demen ia in he mode a e s age. Keywo ds: demen ia; in o mal ca egi e s; bu den; ca egi e ’s abuse; beha iou al diso de s 1. In oduc ion The scien i ic and echnological ad ances gene a ed in ecen decades, especially in de eloped coun ies ha e allowed he ex ension o li e and ha e helped olde people o ully enjoy he inal s ages o hei li es. The inc ease in li e expec ancy and aging o he popula ion ine i ably a ou s he appea ance o hose diseases in which age is a undamen al isk ac o , as is he case wi h demen ia. The numbe o people wi h demen ia wo ldwide was es ima ed in 2016 a 46.8 million. Howe e , he inc ease in he elde ly popula ion, especially o people o e 80 yea s old, in which he isk o demen ia is accen ua ed, added o he absence o an e ec i e ea men and he di icul y o an ea ly diagnosis, can an icipa e ha his igu e will be doubled e e y 20 yea s, so i is es ima ed ha will a ec 131.5 million people in 2050. The e o e, demen ia is a eal public heal h p oblem wo ldwide, wi h a high economic and social cos , being conside ed one o he epidemics o he 21s cen u y [1,2]. Demen ia is, mo eo e , one o he condi ions ha mos limi s ou abili y o conduc daily ac i i ies, signi ican ly educing he quali y o li e and au onomy o he pa ien . Associa ed wi h a p og essi e, global and i e e sible cogni i e de e io a ion, demen ia causes a loss o memo y and o he highe cogni i e unc ions. I also leads o al e a ions In . J. En i on. Res. Public Heal h 2021,18, 1263. h ps://doi.o g/10.3390/ije ph18031263 h ps://www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2021,18, 1263 2 o 16 in beha iou and pe sonali y wi h impo an epe cussions on he pa ien unc ional capaci y [3–5]. This disease o en esul s in a si ua ion o comple e physical and psychological de- pendence and c ea e a need o con inuous supe ision and ca e as i e ol es. Howe e , he imbalance be ween he heal h demands gene a ed by he g owing inc ease in cases o demen ia and he insu icien esou ces a ailable, ha e mean ha he ca e and a en ion o hese dependen elde ly people has o en allen o he amily, on which he impac is in ensely nega i e [6–8]. The ies o a ec ion and emo ional closeness wi h he sick pe son mean ha , despi e he absence o emune a ion and aining o ca e, i is ca ied ou wi h g ea commi - men and dedica ion by he amily. Howe e , no all membe s o he pa ien ’s amily o su oundings ake on he esponsibili y o ca ying ou his a duous ask in he same way [9,10]. The Wo ld Heal h O ganiza ion indica es ce ain cha ac e is ics o he in o mal p i- ma y ca egi e : usually a pe son close o he pa ien , o en a emale, who ca es o he pa ien egula ly a home, in di icul condi ions and wi hou emune a ion. The ca egi e gene ally co e s he basic needs o he pa ien , on many occasions showing a lack o aining and skills o pe o m hei unc ion [11]. The main ca egi e , he e o e, suppo s he men al, physical and socioeconomic weigh in he managemen o he sick pe son h oughou he de elopmen o he disease. Thei ask equi es ime, ene gy and e o , signi ican ly in luencing hei quali y o li e. In addi ion, hey assume new esponsibili ies o which, gene ally, hey ha e no ecei ed any aining and which a e, some imes imposed by he amily, o en as a consequence o he lack o economic esou ces. All his, added o he leng h o ime he disease con inues o , con ibu es o he c ea ion o a ch onic s ess si ua ion in he ca egi e known as “bu den” [12–14]. Bu den, he e o e, is he esul o physical-emo ional wo k and social cons ain s gene a ed by he asks necessa y o he ca e o a sick pe son. I has nega i e epe cussions on he physical (ca dio ascula and immune) and men al (anxie y, dep ession, ange , exhaus ion, a igue, i edness) heal h o he ca egi e [ 15 ]. How well he ca egi e copes he si ua ion, hei mo i a ion o ca e, he suppo ne wo ks a ailable, and he ca egi e - a ec i e ela ionship a e decisi e in he appea ance o bu den [16–18]. On he o he hand, he loss o au onomy, he deg ee o cogni i e de e io a ion o he pa ien wi h demen ia, hei physical mani es a ions and, especially, hei beha iou al mani es a ions, also in luence bu den [ 19 – 21 ]. Howe e , some au ho s such as Van de Lee e al. [ 22 ] place mani es a ions o beha iou al diso de s as he aspec o demen ia ha has he g ea es impac on ca egi e bu den. The e ec o hese beha iou s is o such magni ude, ha hey cons i u e 50 pe cen o he p oblems ha a ise in demen ia consul a ions, being one o he aspec s o he disease ha mos wo ies he amily and ha mos complica es he ca e o hese people and some imes becoming a eason o ma ginaliza ion, ins i u ionaliza ion and e en ill- ea men by he ca egi e . The p esence o beha iou al diso de s gene a es high le els o s ess in he ca egi e and is associa ed wi h he appea ance o physical and psychological illnesses in 50 pe cen o hem, nega i ely a ec ing bo h he quali y o li e o he ca egi e and he quali y o li e o he pe son wi h demen ia by educing he quali y o he ca e hey gi e [23–25]. One o he consequences ha he ask o ca ing o a pe son wi h hese cha ac e is ics can ha e is he p esence o abuse exe cised by he main ca egi e owa ds he pe son wi h demen ia. Some s udies show an abuse a e o up o 50 pe cen in hese si ua ions. In his con ex , he abuse o he elde ly is de ined in The Uni ed Na ions Second Wo ld Assembly on Ageing [ 26 ] as “any single o epea ed ac , o lack o app op ia e ac ion ha occu s in any ela ionship supposedly o us , ha causes damage o dis ess o an elde ly pe son”. Abuse is conside ed, he e o e, as a ype o iolence in which, om he poin o iew o he ecological model, i is he esul o he in e ac ion o (1) indi idual ac o s In . J. En i on. Res. Public Heal h 2021,18, 1263 3 o 16 (impulsi i y, ha ing su e ed abuse, low educa ional le el e c.), (2) ela ional ac o s ( he way o ela ing o iends, amily, o he couple), (3) ela ing o communi y ac o s (school, wo kplace and neighbou hood), and (4) social ac o s (cul u al no ms, o social policies ha main ain socioeconomic inequali ies). Howe e , he p esence o bu den in he ca egi e and he mani es a ion o beha iou al al e a ions by he pa ien wi h demen ia, added o he inabili y o many o hese people o epo abuse and lack o social suppo can also be c i ical [27–29]. The p og essi e and disabling cogni i e impai men associa ed wi h he de elopmen o demen ia pu s hese pa ien s a isk o expe ience some o se e al o he di e en o ms o abuse men ioned. In addi ion, some s udies [ 30 , 31 ] link a g ea e occu ence o abuse o he con ex o in o mal ca e because o he complexi y o iden i ying and in e ening in hese abusi e si ua ions. Fi s ly, o he di icul y o he pa ien wi h demen ia o epo he abuse. Secondly o he social isola ion hey ace and hi dly he denial o he si ua ion ha may exis by he ca egi e . Ano he aspec o be conside ed is ha he p esence o beha iou al diso de s in he pe son wi h demen ia can cause an inc ease in ca egi e ´ s bu den. In u n, we mus bea in mind ha hese beha iou al diso de s do no mani es hemsel es uni o mly h oughou he disease [ 32 ]. As a consequence, we can deduce ha he g ea e he in ensi y o beha iou al diso de s, he g ea e he o e load on he ca egi e . These easons in addi ion o he lack o awa eness by heal h p o essionals, place hese non-ins i u ionalized pa ien s in a si ua ion o special ulne abili y. The e o e, iolence agains people wi h demen ia in he con ex o in o mal ca e, ep esen s a eal i al isk and a sou ce o su e ing and anguish o he pa ien and his amily. Based on he abo e, one o he hypo heses o ou wo k is ha ca egi e s o people wi h demen ia su e a high deg ee o bu den. In addi ion, i is conside ed ha he g ea e he deg ee o bu den, he g ea e he p obabili y o mani es ing abusi e beha iou . I mus also be highligh ed he ac ha he appea ance o beha iou al diso de s could cause a g ea e bu den on he ca egi e and inc ease he isk o abuse. In his ega d, he objec i e o his esea ch is o analyse he bu den showed by he in o mal ca egi e o a pe son wi h demen ia. In addi ion, we in end o e i y whe he his bu den p esen in in o mal ca egi e s would be ela ed o abusi e beha iou . We also s udy he ela ionship be ween he s age o he disease, he appea ance o beha iou al diso de s and he le el o bu den in he ca egi e . 2. Ma e ials and Me hods 2.1. Pa icipan s The sample o his s udy was composed o 33 in o mal ca egi e s o pa ien s wi h demen ia esiding in a Spanish ci y. The inclusion c i e ion used o he selec ion o he pa icipan s in his s udy was ha hey deal wi h people diagnosed wi h demen ia in any o i s o ms whose ca e was exe cised only by he in o mal ca egi e . People wi h demen ia who we e ins i u ionalized and hose si ua ions in which he ca e o he pe son wi h demen ia was pe o med by a p o essional ca egi e we e excluded om he s udy. Rega ding non ained ca egi e s, hose who, due o he exis ence o physical, cogni i e o cul u al ba ie s could no co ec ly ca y ou he ques ionnai es necessa y o he de elopmen o his esea ch, we e excluded. 2.2. Va iables and Ins umen s 2.2.1. Va iables Two ypes o a iables we e used in he s udy: independen and dependen . The dependen a iables we e demog aphic da a, pe sonal da a and he phase o demen ia in which he use is. The independen a iables we e: • Bu den wi h h ee le el: non bu den, ligh bu den and bu den. The ins umen chosen o i s measu emen was Ca egi e Bu den In e iew (ZARIT) In . J. En i on. Res. Public Heal h 2021,18, 1263 4 o 16 • Abuse wi h wo le els: non abuse and abuse. The ins umen chosen o i s measu e- men was Ca egi e Abuse Sc een (CASE). • Beha iou al diso de wi h 12 di e en le els acco ding o each beha iou al diso de . The ins umen chosen o i s measu emen was Beha iou al Diso de s Ques ionnai e. 2.2.2. Ins umen s Ca egi e Bu den In e iew (ZARIT) I is he mos widesp ead ques ionnai e o assess he le el o bu den expe ienced by in o mal ca egi e s o people wi h demen ia and o he diso de s. I was de eloped by Za i and his collabo a o s in 1980 [ 33 ] and la e adap ed o he Spanish popula ion by Ma ín e al. en 1996 [ 34 ]. I allows use s o ob ain a mul idimensional iew o he men al, social and physical s a e o he ca egi e , including he dimensions o quali y o li e and sel -ca e capaci y, social suppo ne wo k and compe encies o ace beha iou al and clinical p oblems o he pa ien ca e. Al hough he e a e di e en e sions, he one employed in his s udy [ 34 ] consis s o 22 ques ions like “Like ” wi h 5 op ions, in which he ca egi e mus indica e how o en he o she eels s ess, being (0) ne e , (1) wi h a ely, (2) some imes, (3) o en and (4) almos always. These esul s a e added up o a o al sco e ha can ange om 0 o 88 poin s. The ques ionnai e has good psychome ic p ope ies and allows hem o disc imina e be ween di e en le els o bu den, classi ying he si ua ion o he ca egi e in o: “absence o bu den” i he sco e ob ained is unde 46 poin s, “ligh bu den” i he sco e is be ween 47 and 55 poin s o “bu den” i he sco e is highe han 55 poin s. The in e nal consis ency o he scale is 0.91 and ealiabili y es- e es is 0.96 [35,36]. Func ional Assessmen S aging (FAST) I is a unc ional assessmen classi ica ion scale [ 37 ] c ea ed by Reisbe g in 1988. which has been designed o assess changes in unc ional pe o mance and he ac i i ies o he use ’s daily li e h oughou all s ages o demen ia. These changes a e closely ela ed o he p og essi e cogni i e decline associa ed wi h he de elopmen p ocess o his disease. The e alua ion p ocedu e consis s o he desc ip ion o 16 successi e s ages anging om a si ua ion o unc ional no mali y o he le els o dependence and unc ional impai men associa ed wi h he mos ad anced phases o he disease and hus ela ing he pa ien wi h he s age ha bes e lec s he si ua ion o he pa ien s. Func ional cha ac e is ics desc ibed abo e a e associa ed wi h clinical diagnosis as no mal (s age 1), subjec i e cogni i e impai men (s age 2), mild cogni i e impai men (s age 3) mild demen ia (s age 4), mode a e demen ia ( om s age 5 o s age 9) and se e e demen ia ( om s age 11 o s age 16). The Consis ency o his ins umen is 0.86 and he alidi y is 0.79 [37]. Ca egi e Abuse Sc een (CASE) I is a alida ed sc eening ool which se es as he i s wa ning o de ec he isk o abuse, psychosocial abuse o neglec by he ca egi e owa ds he pa ien wi h demen ia. I was c ea ed by Reis and Nahmiash in 1995 [ 38 ] and is alida ed in Spain by Ri e a-Na a o e al. [ 39 ]. I con ains 8 ques ions wi h dicho omous answe s abou si ua ions ela ed o iolence as ci ed. A sco e o 4 o mo e poin s on he scale would e lec he exis ence o abuse. The CASE scale has a mode a e in e nal consis ency ( α = 0.75) [ 39 ]. The eliabili y o his scale is 0.696 [40]. Beha iou al Diso de s Ques ionnai e This is a ques ionnai e de eloped o his s udy ha aimed o collec in o ma ion p o ided by ca egi e s abou beha iou al diso de s p esen in pa ien s wi h demen ia. This ques ionnai e shows 12 di e en beha iou al al e a ions o diso de s ha can be de ec ed in pa ien s wi h demen ia, along wi h a b ie explana ion o some beha iou commonly associa ed wi h such al e a ions w i en wi h colloquial wo ds o be e un- de s anding. The ca egi e should indica e how o en he pa ien exhibi s hese ypes o beha iou , wi h a sco e anging om ze o o en (being ze o “ne e ” and en “daily”). The In . J. En i on. Res. Public Heal h 2021,18, 1263 5 o 16 p esence o he symp om and i s mani es a ion was de ined based on he classi ica ion o he Neu opsychia ic In en o y (NPI) [ 41 ]. The NPI-Q Spanish e sion showed s ong es - e es eliabili y o o al symp om scale and o dis ess scale, besides con e gen alidi y wi h NPI o al symp om ( = 0.879). The di e en beha iou al al e a ions s udied a e: 1. Agg ession, such as any physical o e bal beha iou ha may cause physical o mo al/men al ha m; unjus i ied opposi ion o esis ance; agi a ion; c ies; age; io- lence; cons an c i icism, e c. 2. Dep ession, such as cons an sadness; loss o in e es o sa is ac ion in almos all ac i i ies; eeling like i ’s a bu den; lack o hope; demo i a ion; isola ion, e c. 3. Anxie y, such as ea o eeling o loss o con ol, exp essed e bally, h ough ges u es o h ough bodily language; ea ; ne ousness; panic, e c. 4. Eupho ia, such as abno mally high o inapp op ia e humou o he gi en ime o si ua ion, wi hou appa en cause; he’s suddenly e y happy o no appa en eason, e c. 5. Apa hy, such as lack o in e es ; lack o mo i a ion, eeling, emo ion o conce n; he inds himsel passi e, he does no hing; e e y hing doesn’ ma e o him/he , e c. 6. Lack o inhibi ion, such as lack o social ouch in language, body exp ession o o he beha iou ; ac s impulsi ely, e c. 7. I i abili y, such as bad mood; unjus i ied apid mood swings; impa ience; in ole ance; esponds badly o no eason; e e y hing makes him ang y, e c. 8. Mo o hype ac i i y, such as inc eased wande ing o o he ac i i y ha is no ex- plained by a cause; a emp s o escape; he pa ien ollows he ca egi e cons an ly; walks incessan ly, e c. 9. Repea ed ocaliza ions, such as epea ed annoying sounds o ocal exp essions; epea s o incessan ly asks o he same hing; says someone’s name cons an ly, e c. 10. Decay, such as loss o in e es ; dissa is ac ion in almos all ac i i ies; eeling like i ’s a bu den; lack o mo i a ion; lack o ela ionship wi h o he s; cons an sadness, e c. 11. Passi i y, such as he pa ien do no wan o pe o m any ac i i y; e e y hing doesn’ ma e o him/he ; lack o mo i a ion; indi e ence, e c. 12. Anguish, such as eeling o loss o con ol, exp essed e bally, ges u ally o h ough body mo emen s, e c. In o de o gi e g ea e alidi y o his ques ionnai e, desc ip ions o simila be- ha iou s we e used among some diso de s o which we e dep ession and decay, apa hy and passi i y, and inally anxie y and dis ess. Ob aining simila alues among hese beha iou al al e a ions e lec s a co ec execu ion and unde s anding o he ques ionnai e by he ca egi e . Demog aphic Da a The Pe sonal Ques ionnai e collec s pe sonal and demog aphic da a ela ed o he p ima y ca egi e and he pa ien , such as gende , ca egi e -pa ien kinship, age, ime o disease p og ession, ype o demen ia, and ime he ca egi e has been ac ing as he p ima y ca egi e . 2.3. P ocedu e This s udy ob ained a ou able opinion o i s implemen a ion by he Resea ch E hics Commi ee o A agón (CEICA) wi h E hical app o al code PI18/402, 30 Janua y 2019. The sea ch o he pa icipan s was made by a p o isional lis p o ided by he Compu e Se ice o he Lozano Blesa Uni e si y Clinical Hospi al o Za agoza, wi h he ele an pe mission o he Medical Coo dina ion. We con ac ed by elephone and/o ace o ace wi h 67 ca egi e s. The inclusion c i e ia used o he selec ion o he pa icipan s in his s udy a e: hey we e use s diagnosed wi h demen ia in any o i s o ms, and hei ca e was exe cised exclusi ely by in o mal ca egi e s. In . J. En i on. Res. Public Heal h 2021,18, 1263 6 o 16 Following we e conside ed exclusion c i e ia: he use was ins i u ionalized and ca e was ca ied ou by o mal ca egi e s. The exis ence o physical, cogni i e o cul u al ba ie s ha p e en he ca egi e om co ec ly comple ing he ques ionnai es was also conside ed as an exclusion c i e ion. 4 ou o 37 ca egi e s who me he inclusion/exclusion c i e ia decided o no pa ic- ipa e in he s udy. Finally, he sample o ou s udy was composed o 33 ca egi e s ha signed he pe mission o pa icipa e in he s udy. The Za i Scale, he Ca egi e Abuse Scale, and he Beha iou al Diso de s Ques ionnai e we e conduc ed by he p ima y ca egi e a home o wi h he help o he in e iewe , depending on he abili ies and p e e ences o he ca egi e . A e ha , we collec ed all he da a. FAST da a we e ob ained om he pa ien ´ s medical his o y. 2.4. Da a Analysis All analyses we e ca ied ou using he s a is ical package IBM SPSS 23 (IBM Co p: A monk, NY, USA). A i hme ic mean, s anda d de ia ion and pe cen ages we e analysed. Then, we used Kolmogo o -Smi no es whe he he dependen a iables con o med o a no mal dis ibu ion. As he a iables u ned ou o con o m o a no mal dis ibu ion, di e en pa ame ic es s we e used (Pea son co ela ion es , -S uden and ANOVAs). Among he demog aphic and pe sonal da a, he sex and age o bo h he ca egi e and he pe son wi h demen ia, he kinship o he ca egi e wi h he pa ien , he ype o demen- ia in he pa ien and he s age o demen ia in which hey a e ound we e eco ded. Also, we analysed pa ien ’s le el o unc ional impai men , ca egi e bu den, abuse and beha iou al diso de s. Con inuous ype a iables a e ep esen ed as he mean and s anda d de ia- ion, while ca ego ical a iables a e ep esen ed as pe cen ages and absolu e equencies. Pea son’s co ela ion coe icien has been used o analyse he linea dependence be ween bu den, abuse, beha iou al diso de and s age o disease a iables. Di e ences be ween he men ioned a iables we e in es iga ed using S uden ´ s - es . S a is ical signi icance was se a p< 0.05( wo- ailed). 3. Resul s 3.1. Demog aphic Da a The sample was composed by 33 in o mal ca egi e s o pa ien s wi h demen ia. Table 1 ep esen s he pe cen ages ela ing o sex and age, bo h o he ca egi e and he pe son wi h demen ia, he kinship o he ca egi e wi h he pa ien , he ype o demen ia ha he s age o demen ia. Table 1. Demog aphic da a o s udy sample (n= 33). DEMOGRAPHIC DATA % (n) Sex ca egi e Men 45.50 (15) Women 54.50 (18) Sex pa ien Men 30.30 (10) Women 69.70 (23) Kinship wi h he pa ien Couple 52 (17) Siblings 3 (1) Nephew/Niece 3 (1) O sp ing 39 (13) G andchild 3 (1) In . J. En i on. Res. Public Heal h 2021,18, 1263 7 o 16 Table 1. Con . DEMOGRAPHIC DATA % (n) Type o demen ia Alzheime D. 37 (12) Mixed D. 9 (3) Vascula D. 18 (6) Senile D. 24 (8) Pa kinson D. 12 (4) S age o demen ia Mild 21.20 (7) Mode a e 60.60 (20) Se e e 18.20 (6) Alzheime D.: Alzheime Demen ia; Mixed D.: Mixed Demen ia; Vascula D.: Vascula Demen ia; Senile D.: Senile Demen ia; Pa kinson D.: Pa kinson Demen ia. 3.2. Ca egi e Bu den Analysis Following he analysis o he da a ob ained in he Za i ques ionnai e, i is obse ed ha 45.50 pe cen o ca egi e s ha e ligh bu den o bu den (Table 2). Table 2. Ca egi e Bu den (n= 33). Bu den Le el % (n) Non-Bu den 54.5 (18) Ligh Bu den 27.3 (9) Bu den 18.2 (6) When we analyzed ca egi e bu den based on gende , we ound ha women p e- sen ed highe le els o bu den han men ( = 2.31; p= 0.027) (Table 3). Table 3. Ca egi e Bu den and Gende (n= 33). Ca egi e Bu den % (n) Men (n= 15) Women (n= 18) Non-Bu den 80 (12) 50 (9) Ligh Bu den 13.3 (2) 22.2 (4) Bu den 6.7 (1) 27.8 (5) 3.3. Ca egi e Abuse Sc een (CASE) When da a ob ained om he Ca egi e Abuse Sc een a e analyzed, we ound ha in mo e han hal o he cases, ca egi e s p esen ed beha iou s ela ed o abuse. (Table 4). No signi ican di e ences in abuse we e ound acco ding o sex ( = 0.790; p= 0.430). Table 4. Ca egi e Abuse Sc een (n= 33). Abuse % (n) Non-Abuse 48.50 (16) Abuse 51.50 (17) 3.4. Beha iou al Diso de s The ollowing able shows he in ensi y wi h which beha iou al diso de s appea ed in people wi h demen ia (Table 5). In . J. En i on. Res. Public Heal h 2021,18, 1263 8 o 16 Table 5. Beha iou al Diso de s. Beha iou al Diso de s Mean SD Agg ession 3.121 3.638 Dep ession 4.242 4.000 Anxie y 3.515 3.930 Eupho ia 2.121 3.039 Apa hy 5.515 3.726 Lack o inhibi ion 2.090 3.136 I i abili y 3.969 3.704 Mo o hype ac i i y 2.485 3.692 Decay 3.909 3.964 Anguish 4.424 3.992 Passi i y 5.212 3.855 Repea ed ocaliza ions 3.394 4.085 As i can be seen, apa hy and dep ession a e he diso de s ha appea mos equen ly. 3.5. Bu den and Abuse Ano he o he objec i es se ou in his s udy was o ind ou i he ca egi e ’s bu den migh be ela ed o abuse. The Pea son co ela ion es we e done be ween he p esence o bu den in he ca egi e and abuse owa ds he people wi h demen ia. The esul s ob ained e lec he exis ence o a s ong posi i e co ela ion be ween hese a iables ( = 0.844 ; p= 0.000 ) indica ing ha a highe le el o bu den co ela ed wi h abuse by ca egi e (Table 6). Table 6. Rela ion be ween bu den in ca egi e and abuse (n= 33). Abuse % (n) Non Abuse % (n) Pa ien 51.50 (17) 48.5 (16) Bu den Non-Bu den 29.40 (5) 81.25 (13) Ligh Bu den 35.30 (6) 18.75 (3) Bu den 35.30 (6) 00.0 (0) 3.6. Bu den and Beha iou al Diso de s A signi ican posi i e ela ionship has been ob ained be ween bu den and he p esence o beha iou al al e a ions o agg ession, dep ession, anxie y, eupho ia, apa hy, lack o inhibi ion, i i abili y, mo o hype ac i i y, decay and dis ess. Howe e , he e is no signi ican co ela ion be ween bu den and pa ien beha iou s o passi i y and epea ed ocaliza ions. This ells us ha he p esence o beha iou al diso de s in he pe son wi h demen ia has inc eased he bu den o he ca egi e , excluding ac s o passi i y and epea ed ocaliza ions (Table 7). Table 7. Co ela ions be ween Bu den and Beha iou al Diso de . Beha iou al Diso de s Pea son Co ela ion Coe icien ( ) p Agg ession 0.669 0.000 Dep ession 0.395 0.023 Anxie y 0.404 0.020 Eupho ia 0.346 0.048 Apa hy 0.219 0.022 Lack o inhibi ion 0.470 0.006 I i abili y 0.624 0.000 Mo o hype ac i i y 0.377 0.030 Decay 0.363 0.038 Anguish 0.394 0.023 Passi i y 0.147 0.413 (NS) Repea ed ocaliza ions 0.152 0.399 (NS) NS: non-signi ican . p: p obabili y. In . J. En i on. Res. Public Heal h 2021,18, 1263 9 o 16 3.7. Bu den and S age o he Disease The s udy da a indica e ha he le el o bu den in he ca egi e would also be ela ed o he s age o he disease in which he pa ien is loca ed (F = 15.70; p= 0.000). As shown in Table 8, he highes le el o bu den appea s in he mode a e s age o he disease. Table 8. Bu den and s age o he disease (n= 33). S age o he Disease %(n) U den (n) Mild Mode a e Se e e Non-Bu den 71,4 (5) 40 (8) 83,3 (5) Ligh Bu den 14,3 (1) 35 (7) 16,7 (1) Bu den 14,3 (1) B25 (5) 0 (0) 3.8. Bu den, Beha iou al Diso de s and S age o Disease Analyzed da a may indica e ha he beha iou al diso de s ha could gene a e he g ea es o e load on he ca egi e may a y h oughou he di e en phases o he disease (Table 9). In he mild s age, agg ession, decay and dep ession beha io s could co ela e wi h g ea e bu den on he ca egi e while in an in e media e phase o he disease he beha io s ha migh co ela e wi h g ea e o e load a e agg ession and i i abili y. In he se e e s age, i i abili y seems o be he beha iou ha migh co ela es wi h g ea e bu den on he ca egi e . Table 9. Co ela ions be ween Bu den, Beha iou al Diso de s and s age o disease. S age o he Disease Beha iou al Diso de s p Mild Agg ession 0.755 0.050 Dep ession 0.840 0.018 Decay 0.827 0.022 Mode a e Agg ession 0.577 0.008 I i abili y 0.600 0.005 Se e e I i abili y 0.851 0.032 : Pea son co ela ion coe icien . 3.9. Abuse and Beha iou al Diso de Analyzed da a may indica e ha abusi e beha io s could be associa ed wi h he p esence o conduc diso de s su e ed by people wi h demen ia (F = 9.35; p= 0.000). The beha io al diso de s ha mos ly gene a e abuse seems o bee agg ession, eupho ia, lack o inhibi ion, i i abili y and mo o hype ac i i y (Table 10). Table 10. Co ela ions be ween Abuse and beha iou al diso de s. 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