JAMDA 16 (2015) 527e534

JAMDA journal homepage: www.jamda.com

Letters to the Editor

Both Intravenous and Subcutanous Infusion Can Be Done in Nursing Homes To the Editor: The editorial by Lima Ribeiro and Morley regarding dehydration in the nursing home was timely and helpful, particularly in its endorsement of subcutaneous infusion (hypodermoclysis) as a valuable, yet easy intervention.1 Yet, I must take objection to the statement that, “In most cases, when intravenous fluid is necessary, hospitalization will also be required.” For some time, it has been recognized that nursing home residents are unnecessarily transferred to the hospital for conditions that can be treated in the nursing home.2 Among the resources that were considered by an expert panel as potentially helpful in preventing avoidable hospitalizations was intravenous therapy,3 which is commonly provided and easily performed in many, if not most, nursing homes. Although hypodermoclysis is certainly easier to initiate and maintain than an intravenous line, the use of intravenous therapy for hydration and antibiotics is well within the standard of care in nursing home practice and should not, by itself, be a reason for transfer to the hospital. References

we were taking a global view.2 As we have previously shown, the majority of nursing homes throughout the world are social or nursing lead nursing homes, where intravenous infusions are not undertaken.3 I agree that in the USA intravenous infusions can play an important role in reducing avoidable hospitalizations.4 Nevertheless, I would stress that even in the United States hypodermoclysis is simpler and often a preferable alternative.5,6 References 1. Zorowitz R. Both intravenous infusions and subcutaneous infusions can be done in nursing homes. J Am Med Dir Assoc 2015;16:527. 2. Ribeiro SML, Morley JE. Dehydration is difficult to detect and prevent in nursing homes. J Am Med Dir Assoc 2015;16:175e176. 3. Tolson D, Rolland Y, Katz PR, et al. An international survey of nursing homes. J Am Med Dir Assoc 2013;14:459e462. 4. Ouslander JG, Bonner A, Herndon L, Shutes J. The interventions to reduce acute care transfers (INTERACT) quality improvement program: An overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc 2014;15:162e170. 5. Dolamore MJ. The use of hypodermoclysis without hyaluronidase. J Am Med Dir Assoc 2009;10:75. 6. Thomas DR, Cote TR, Lawhorne L, et al. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc 2008;9:292e301.

John E. Morley, MB, BCh Division of Geriatric Medicine Saint Louis University School of Medicine St. Louis, Missouri http://dx.doi.org/10.1016/j.jamda.2015.03.018

1. Lima Ribeiro SM, Morley JE. Dehydration is Difficult to Detect and Prevent in Nursing Homes. J Am Med Dir Assoc 2015;16:175e176. 2. Saliba D, Kington R, Buchanan J, et al. Appropriateness of the decision to transfer nursing facility residents to hospital. J Am Geriatr Soc 2000;48:154e163. 3. Ouslander JG, Lamb G, Perloe M, et al. Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes and Costs. J Am Geriatr Soc 2010; 58:627e635.

Robert A. Zorowitz, MD, MBA, CMD Optum, Inc. New York, New York http://dx.doi.org/10.1016/j.jamda.2015.03.017

Pharmacologic Treatment of Behavioral and Psychological Symptoms of Dementia in Nursing Homes: Update of the 2008 JAMDA Recommendations To the Editor:

Response to the Letter from Robert A. Zorowitz, “Intravenous and Subcutaneous Infusions in Nursing Homes” To the Editor: Dr Zorowitz is correct in that in the United States intravenous infusions are commonly done in nursing homes.1 In our editorial,

JAMDA published in 2008 practical recommendations about the treatment of behavioral and psychological symptoms of dementia (BPSD) in nursing homes.1 Five years later, an update of the relevant scientific literature was undertaken to assess potential changes. The 3 algorithms describing the pharmacologic treatment of BPSD in nursing homes’ residents suffering from dementia were, therefore, updated. The algorithms are (1) depression management (Figure 1); (2) agitation management (Figure 2); and (3) sleep disturbances management (Figure 3). The same literature search strategy, as used by the original authors, was conducted from January 2008 to December 2014. Seven

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updated guidelines2e8 and 6 new guidelines9e14 were integrated to the original search (Appendix). Findings from this new search further confirm the absence of recommendations specific to older persons living in nursing homes, even though BPSD are frequent in this setting. Overall, recommendations proposed in the initial JAMDA publication remain valid, but significant new information, additional cautions, as well as controversies, were identified, especially regarding antipsychotic use in the management of BPSD. The main conclusions from this update regarding the management of depression, agitation, and sleep disturbances in nursing home residents with dementia are summarized hereafter. Pharmacologic Treatments of Depression in Residents With Dementia A systematic review was updated in 20112 concerning behavior disturbances associated to dementia, but results do not modify the algorithm proposed in the initial JAMDA publication.1 This updated systematic review now provides new information on melatonin and reports a significant positive effect of melatonin on mood, whereas no significant improvement was observed on cognitive impairment. Pharmacologic Treatments of Agitation in Residents With Dementia Growing evidence supporting the efficacy of atypical antipsychotics in older persons with dementia is counterbalanced by additional evidence of increased mortality associated with their use3: aripiprazole, olanzapine, and risperidone were tested off-label for the management of agitation and were all found superior to placebo. For other atypical antipsychotics, such as asenapine, iloperidone, and paliperidone, there were no or a few trials assessing their use.3 Furthermore, findings suggest the possibility to withdraw chronic antipsychotic medication in elderly persons with Alzheimer dementia and neuropsychiatric symptoms without negative consequences on behavior (uncertainty remains concerning the effect on cognition or psychomotor status). However, this did not apply to patients who previously responded well to agitation and psychosis nor to those with “more severe neuropsychiatric symptoms at baseline.”13 For moderate or severe symptoms of BPSD, for Agency for Healthcare Research and Quality: Advancing Excellence in Health Care (AHRQ) 2012 guidelines9 also stress the limited evidence supporting the practical use of antipsychotics but still state that these drugs may be considered for patients not responding to other treatments or when other treatments are inappropriate. Overall, a shared decision-making process is recommended (good practice point) that includes an assessment of the risk to benefit ratio, and a discussion with the patient and his/her caregiver on initiation of the drug therapy. For the treatment of psychosis in late complicated Parkinson’s disease, AHRQ 2011 guidelines10 still consider clozapine as a “level A” indication, but stress the need for blood monitoring because of its potential severe hematologic adverse events. Quetiapine could also possibly be considered in the same indication (good practice point); quetiapine appears safe and, contrary to clozapine, does not require blood monitoring. The Scottish Intercollegiate Guidelines Network 2010 guidelines11 also suggest the use of quetiapine at a low dose when blood monitoring is not possible. In the same indication, AHRQ 2011 guidelines10 do not recommend the use of olanzapine (level A), risperidone (level C), and aripiprazole (good practice point). Because of the risk of increased parkinsonism,

typical antipsychotics such as phenothiazines (eg, chlorpromazine) and butyrophenones (eg, haloperidol), are not recommended. In addition to the recommendations regarding the use of antipsychotics, AHRQ 2011 guidelines10 propose to consider adding cholinesterase inhibitors (rivastigmine, level B, and donepezil, level C) when not already prescribed. Controversies Alternative pharmacologic treatments to manage agitation in demented elderly persons have also been proposed. For instance, cholinesterase inhibitors (donepezil, galantamine, rivastigmine) are suggested if antipsychotics are ineffective in patients with Alzheimer and Lewy body dementias (not for vascular dementia).4 According to a 2011 Cochrane review, the use of antidepressants (citalopram, sertraline, and trazodone) for agitation and psychosis in dementia is an alternative, but data available are limited.12 Finally, another Cochrane review2 investigated the use of melatonin and concluded that “Melatonin may be effective for the treatment of dementia-related psychopathologic behavior disturbances.” Pharmacologic Treatments of Sleep Disturbance in Residents With Dementia A lack of evidence and a need for more trials were highlighted in a systematic review about pharmacologic treatments for sleep disturbances in Alzheimer disease.14 There was no evidence to support the use of melatonin (in moderate to severe dementia) or ramelteon (in mild to moderate dementia). There was some evidence supporting the use of trazodone (50 mg), but the balance of risks and benefits remains still uncertain.14 In conclusion, this literature review update provided substantial information regarding the pharmacologic treatment of BPSD but results in no major modification of practice recommendations compared with 2008. Nevertheless, a few summary key points should be highlighted. First, nonpharmacologic interventions should always be considered as the first line of therapy in the presence of BPSD. Second, before prescribing a pharmacologic treatment, one should always exclude other etiology (eg, infection, pain, constipation, etc.) potentially responsible for the observed BPSD. Finally, when these interventions do not improve the situation, a pharmacologic treatment must be introduced at low dose, slowly titrated upward when necessary and its indication periodically reevaluated. Overall, the risk to benefit ratio of these pharmacologic treatments always need a thorough assessment before treatment initiation. Practice recommendations published in JAMDA in 2008 remain valid, and their application continues to be a major challenge to promote quality and safety of care in vulnerable nursing homes residents suffering from dementia.

References 1. Locca JF, Bula CJ, Zumbach S, Bugnon O. Pharmacological treatment of behavioral and psychological symptoms of dementia (BPSD) in nursing homes: Development of practice recommendations in a Swiss canton. J Am Med Dir Assoc 2008;9:439e448. 2. Jansen SL, Forbes D, Duncan V, et al. Melatonin for the treatment of dementia. Cochrane Database Syst Rev 2006;1:CD003802. 3. Maglione M, Ruelaz Maher A, Hu J, et al. Off-Label Use of Atypical Antipsychotics: An Update. Comparative Effectiveness review No. 43. (Prepared by the Southern California Evidence-based Practice Center under Contract No.

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4.

5. 6. 7. 8. 9.

10.

11.

12. 13.

14.

HHSA290-2007-10062-1). Rockville, MD: Agency for Healthcare Research and Quality; 2011. National Collaborating Center for Mental Health. National Institute for Health and Clinical Excellence: Guidance. Dementia: A NICE-SCIE Guideline on Supporting People With Dementia and Their Carers in Health and Social Care. Leicester (UK): The British Psychological Society and The Royal College of Psychiatrists; 2007. Review decision date: April 2012. Kirchner V, Kelly CA, Harvey RJ. Thioridazine for dementia. Cochrane Database Syst Rev 2001;4:CD000464. Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in dementia. Cochrane Database Syst Rev 2002;2:CD002852. Lonergan E, Luxenberg J. Valproate preparations for agitation in dementia. Cochrane Database Syst Rev 2009;3:CD003945. Martinon-Torres G, Fioravanti M, Grimley EJ. Trazodone for agitation in dementia. Cochrane Database Syst Rev 2004;4:CD004990. Sorbi S, Hort J, Erkinjuntti T, et al. EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia. Eur J Neurol 2012;19: 1159e1179. Oertel WH, Berardelli A, Bloem BR, et al. Late (complicated) Parkinson’s disease. In: . In: Gilhus NE, Barnes MP, Brainin M, editors. European Handbook of Neurological Management. 2nd ed, Vol 1. Oxford, UK: Wiley-Blackwell; 2011. p. 237e267. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and pharmacological management of Parkinson’s disease. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010. Seitz DP, Adunuri N, Gill SS, et al. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev 2011;2:CD008191. Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013;3: CD007726. McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbances in Alzheimer’s disease. Cochrane Database Syst Rev 2014;3: CD009178.

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Isabelle Anguish, PharmD Jean-François Locca, PharmD, PhD Community Pharmacy School of Pharmaceutical Sciences University of Geneva University of Lausanne Lausanne, Switzerland Christophe Büla, MD Service of Geriatric Medicine and Geriatric Rehabilitation Department of Medicine University of Lausanne Hospital Center (CHUV) Lausanne, Switzerland Serge Zumbach, MD Service of Psychogeriatric Medicine Psychiatric Hospital Marsens, Switzerland Olivier Bugnon, PharmD, PhD Community Pharmacy School of Pharmaceutical Sciences University of Geneva University of Lausanne Lausanne, Switzerland http://dx.doi.org/10.1016/j.jamda.2015.03.014

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Appendix 1

Fig. 1. Recommended algorithm for depression management in residents with dementia (nursing homes in the canton of Fribourg). SSRI, selective serotonin reuptake inhibitor. *Such as behavior management (eg, reduction of repetitive verbalisations, management of eating behaviors, etc).4 yTake into account the CYP2D6 inhibition activity. zTake into account the a1-adrenoreceptor blocker activity, which likely contributes to side effects such as postural hypotension.

** ††

Fig. 2. Recommended algorithm for agitation management in residents with dementia (nursing homes in the canton of Fribourg). FTD, frontotemporal dementia; VD, vascular dementia. *Art therapy, aromatherapy, music therapy, or other approaches. yIn patient with dementia with presence of Lewy bodies, caution is advised with antipsychotic use. zStart at low dose, reassess regularly and withdraw after behavioural stability (review of 5 guidelines. Belgium).3 xClozapine: clinician should monitor white blood cell count before initiating therapy and throughout treatment. kConsider using it, only “in absence of alternative safe and effective management options”. Retrospective cohort study (residents enrolled between January 2004 and December 2005), including 62 cases and 116 controls (USA).14 Systematic review from randomized, placebo controlled trials; 14 studies matched the inclusion criteria. UK.15 {Does not concern patients with vascular dementia. **“Antidepressants such as citalopram, sertraline, and trazodone may improve symptoms of agitation and psychosis for some individuals with dementia and given that the tolerability and safety of these medications appears to be similar to placebo and certain antipsychotics, these medications may be considered as a potential treatment” (does not concern patients with frontotemporal dementia or Parkinson disease). yyBeware that melatonin is not reimbursed by insurances in Switzerland and that it might be an expensive treatment (Circadin 2 mg 21 pces, for CHF 37.75).

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Fig. 3. Recommended algorithm for management of sleep disturbances in residents with dementia (nursing homes in the canton of Fribourg). *Light therapy; warm drink; limit fluid intake before bedtime; expose to bright day light or other approaches. yTake into account the a1-adrenoreceptor blocker activity, which likely contributes to side effects such as postural hypotension.

References 1. Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, summary, and critique. Am J Geriatr Psychiatry 2001;9:361e381. 2. Moniz Cook Esme D, Swift K, James I, et al. Functional analysis-based interventions for challenging behaviour in dementia. Cochrane Database Syst Rev 2012;2:CD006929. 3. Azermai M, Petrovic M, Elseviers MM, et al. Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms. Ageing Res Rev 2012;11:78e86. 4. Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with dementia: A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network; 2006. 5. Savaskan E, Buerge M, Fischlin R, et al. Emfehlungen zur Dianostik und Therapie der behavioralen und psychologischen Symptome der Demenz (BPSD). Praxis 2014;103:135e148. 6. Bains J, Birks JS, Dening TR. The efficacy of antidepressants in the treatment of depression in dementia. Cochrane Database Syst Rev 2002;4:CD003944. 7. National Collaborating Centre for Mental H. National Institute for Health and Clinical Excellence: Guidance. Dementia: A NICE-SCIE Guideline on Supporting People With Dementia and Their Carers in Health and Social Care. Leicester (UK): The British Psychological Society and The Royal College of Psychiatrists; 2007. Review decision date: April 2012. 8. National Institute for Health and Clinical Excellence (NICE), National Collaborating Centre for Mental H. Depression: Management of depression in primary and secondary care. National Institute for Health and Clinical Excellence; 2004. 9. Waldemar G, Dubois B, Emre M, et al. Recommendations for the diagnosis and management of Alzheimer’s disease and other disorders associated with dementia: EFNS guideline. Eur J Neurol 2007;14:e1ee26.

10. Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in dementia. Cochrane Database Syst Rev 2002;2:CD002852. 11. Shekelle P, Maglione M, Bagley S, et al. Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics. Rockville MD: Agency for Healthcare Research and Quality; 2007. 12. Oertel WH, Berardelli A, Bloem BR, et al. Late (complicated) Parkinson’s disease. In: . In: Gilhus NE, Barnes MP, Brainin M, editors. European Handbook of Neurological Management. 2nd ed, Vol. 1. Oxford, UK: Wiley-Blackwell; 2011. p. 237e267. 13. Mosimann UP, McKeith IG. Dementia with lewy bodiesdDiagnosis and treatment. Swiss Med Wkly 2003;133:131e142. 14. Daiello LA, Ott BR, Lapane KL, et al. Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia. Am J Geriatr Pharmacother 2009;7:74e83. 15. Rodda J, Morgan S, Walker Z. Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer’s disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine. International Psychogeriatr/IPA 2009;21:813e824. 16. Seitz DP, Adunuri N, Gill SS, et al. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev 2011;2:CD008191. 17. Jansen SL, Forbes D, Duncan V, et al. Melatonin for the treatment of dementia. Cochrane Database Syst Rev 2006;1:CD003802. 18. International Psychogeriatric Association (IPA). Behavioroul and Psychological Symptoms of Dementia (BPSD) Educational Pack - Module 6. International Psychogeriatric Association, 1997. 19. Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias of late life. American Psychiatric Association. Am J Psychiatry 1997;154:1e39. 20. Alexopoulos GS, Streim J, Carpenter D, et al. Using antipsychotic agents in older patients. J Clin Psychiatry 2004;65:5e99.

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21. Alexopoulos GS, Jeste DV, Chung H, et al. The expert consensus guideline series. Treatment of dementia and its behavioral disturbances. Introduction: methods, commentary, and summary. Postgrad Med; 2005. Spec No:6e22. 22. Kirchner V, Kelly CA, Harvey RJ. Thioridazine for dementia. Cochrane Database Syst Rev 2001;4:CD000464. 23. Ather SA, Shaw SH, Stoker MJ. A comparison of chlormethiazole and thioridazine in agitated confusional states of the elderly. Acta Psychiatr Scand 1986; 329:81e91. 24. Rochon PA, Stukel TA, Bronskill SE, et al. Variation in nursing home antipsychotic prescribing rates. Arch Intern Med 2007;167:676e683.

Policy Recommendation: The National Center for Prevention of Resident-to-Resident Aggression in Dementia

 Develop strong inter-agency collaborations to ensure that longterm care residences have the needed external supports and resources to succeed in their efforts to address RRA in dementia.  Bridge the major gap in the Minimum Data Set 3.0 that currently does not enable to identify the target of aggressive behaviors by adding RRA-specific questions to the Behavior E Section14  Develop and maintain data repositories on RRA in dementia to track states’ progression toward reduction of incidence rates of RRA.  Secure federal, state, and local funding aimed at developing practical resources and training programs to reduce RRA in dementia.  Ensure that the voice of residents and their family members is represented in the development and implementation of all initiatives pertaining to RRA in dementia.

References To the Editor: Several research studies have shown that resident-to-resident aggression (RRA) in long-term care residences is a prevalent, concerning, but under-reported and understudied phenomenon with serious psychological and physical consequences for residents and staff members.1e9 In addition, numerous deaths subsequent to injury in RRA episodes have been reported in the media (as documented on the Archival Blog: The Center for Prevention of Aggression Between Residents with Dementia)10; Staff training programs in recognition, prevention, and de-escalation of RRA episodes are sorely needed. Only 1 such training program has been recently developed and evaluated11 and only 1 instrument has been developed and evaluated to address RRA behaviors.12 Findings from the small but growing number of research studies in the last decade suggest that there is an urgent need to develop and establish a National Center for Prevention of Resident-toResident Aggression in Dementia. In the words of Professor Pillemer13: “We talk about violence-free schools. Why we don’t talk about violence-free nursing homes? What about ending violence in nursing homes as a policy goal?” The primary goal of the Center for Prevention of Resident-toResident Aggression in Dementia will be to implement various initiatives and measures to ensure that residents with dementia and staff will be free from verbal, psychological, material, physical, and sexual harm commonly caused by RRA episodes. Through the following centralized, well-coordinated, interdisciplinary activities, the center will:  Raise awareness in the general public to this prevalent but under-recognized public health problem.  Engage in advocacy and policy initiatives aimed at implementation of measures to prevent RRA (eg, modify regulations; improve reporting policies; advocate for adequate reimbursement mechanisms as well as staff-resident ratios).  Develop resources (eg, reports, guidelines), specialized staff training programs and best practices to assist long-term care residences in their daily efforts to address RRA.  Translate and disseminate research findings to long-term care residences, residents (cognitively intact and those in earlystages of dementia), concerned family members, advocacy groups, policy makers, and government agencies. In addition, inform, initiate and/or collaborate on research studies on pressing but understudied aspects of RRA in dementia.

1. Shinoda-Tagawa T, Leonard R, Pontikas J, et al. Resident-to-resident violent incidents in nursing homes. J Am Med Assoc 2004;291:591e598. 2. Lachs M, Bachman R, Williams CS, O’Leary J. Resident-to-resident elder mistreatment and police contact in nursing homes: Findings from a population-base cohort. J Am Geriatr Soc 2007;55:840e845. 3. Rosen T, Lachs MS, Bharucha AJ, et al. Resident-to-resident aggression in longterm care facilities: Insights from focus groups of nursing home residents and staff. J Am Geriatr Soc 2008;56:1398e1408. 4. Pillemer K, Chen EK, Van Haitsma KS, et al. Resident-to-resident aggression in nursing homes: Results from a qualitative event reconstruction study. Gerontologist 2011;52:24e33. 5. Castle NG. Resident-to-resident abuse in nursing homes as reported by nurse aides. J Elder Abuse Negl 2012;24:340e356. 6. Sifford-Snellgrove KS, Beck C, Green A, McSweeney JC. Victim or initiator? Certified nursing assistants’ perceptions of resident characteristics that contribute to resident-to-resident violence in nursing homes. Res Gerontol Nurs 2012;5:55e63. 7. Snellgrove S, Beck C, Green A, McSweeney JC. Resident-to-resident violence triggers in nursing homes. Clin Nurs Res 2013;22:461e474. 8. Caspi E. Aggressive behaviors between residents with dementia in an assisted living residence. Dementia (London); 2013 Sep 3 [Epub ahead of print]. 9. Lachs M, Pillemer K, Teresi JA, et al. Resident-to-resident elder mistreatment: Findings from a large-scale prevalence study. Symposium. In: 67th Annual Scientific Meeting of the Gerontological Society of America; November 8, 2014; Washington DC, USA. 10. Caspi, E. Archival Blog: The Center for Prevention of Aggression between Residents with Dementia. Available at: http://eiloncaspiabbr.tumblr.com Accessed March 11, 2015. 11. Teresi JA, Ramirez M, Ellis J, et al. A staff intervention targeting resident-toresident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition, and reporting: Results from a cluster randomized trial. Int J Nurs Stud 2013;50:644e656. 12. Teresi JA, Ocepek-Welikson K, Ramirez M, et al. Development of an instrument to measure staff-reported resident-to-resident elder mistreatment (R-REM) using item response theory and other latent variable models. Gerontologist 2014;54:460e472. 13. Pillemer, K. Intervening in resident-to-resident elder mistreatment. In: 1-day meeting on Development of research agenda on resident-to-resident abuse, Institute for Life Course and Aging, University of Toronto. Funded by Canadian Institutes for Health ResearcheInstitute of Aging; May 20, 2014. 14. Caspi E. MDS 3.0: A giant step forward but what about items on resident-toresident aggression? J Am Med Dir Assoc 2013;14:624e625.

Eilon Caspi, BSW, MA, PhD Ocean State Research Institute Providence, Rhode Island Geriatrics and Extended Care Data and Analyses Center Canandaigua VA Medical Center Canandaigua, New York http://dx.doi.org/10.1016/j.jamda.2015.03.016

Pharmacologic Treatment of Behavioral and Psychological Symptoms of Dementia in Nursing Homes: Update of the 2008 JAMDA Recommendations.

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