Table 4

Associations between relationship factors and challenging behaviour (BPSD) (eight studies)

Risk factorStudynFollow-upResults (95% CI; P value)Analyses adjusted for*Outcome assessment tool, scale range
Outcome: global challenging behaviour (BPSD) or problem behaviour (four studies)
 Emotional distancing/boundary ambiguityCaron et al366012 mCorr 0.27 (P<0.001) (overall)NRBEHAVE-AD, 0–75
 Non-adaptive copingde Vugt et al46696mMD NR (P=0.007)g, s, ctNPI, 1–144
6912 mMD NR (P=0.019)g, s, ct
 Avoidant attachmentPerren et al416824 mMD 0.23 (P<0.05)NRNPI, 1–144
 Expressed emotionVitaliano et al447715–18 mMD 1.9 (0.77 to 3.04; P<0.001)NRSCB, 0–8
Outcome: psychotic symptoms (three studies)
 MutualityBall et al3317124 mMD −0.1 (−0.24 to 0.04; P>0.05) (delusions)a, g, d, eNPI, 1–12
Ball et al3317124 mMD −0.04 (−0.16 to 0.08; P>0.05) (hallucinations)a, g, d, e
 Emotional distancing/boundary ambiguityCaron et al366012 mCorr 0.30 (P<0.001) (paranoia)NRBEHAVE-AD, 0–75
 Non-adaptive copingde Vugt et al466912 mMD NR (P>0.05) (psychosis)g, sNPI, 1–24
Outcome: depression (five studies)
 MutualityBall et al3317124 mMD −0.43 (−0.80 to -0.06; P<0.05)a, g, d, eHAM-D, 0–68
 Quality of relationshipBurgener and Twigg207018 mCorr 0.22 (P>0.05)NRCornell, 0–38
 Emotional distancing/boundary ambiguityCaron et al366012 mCorr 0.01 (P>0.05)NRBEHAVE-AD, 0–75
 Expressed emotionVitaliano et al447715–18 mMD 2.00 (−0.31 to 4.31; P>0.05)NRHAM-D, 0–68
 Cohesion quantityWright et al43146mCorr −0.302 (P>0.05)NRZung, 0–270
  Quality146mCorr −0.387 (P>0.05)NR
 Affection quantityWright et al43146mCorr −2.41 (P>0.05)NR
  Quality146mCorr −0.038 (P>0.05)NR
 Tension quantityWright et al43146mCorr 0.533 (P<0.01)NR
  Quality146mCorr −0.288 (P>0.05)NR
Outcome: other
 Non-adaptive copingde Vugt et al466912 mMD NR (P=0.512) (apathy)g, s, ctNPI, 1–48
 Non-adaptive copingde Vugt et al466912 mMD NR (P=0.005) (hyperactivity)g, s, ctNPI, 1–60
 MutualityMorgan et al34 and Kunik et al3217124 mMD −0.42 (−0.64 to 0.20; P<0.001)
HR 0.63 (0.45 to 2.87; P=0.006) (aggression)
NRCMAI, 0–156
 Emotional distancing/boundary ambiguityCaron et al36606mCorr 0.15 (P>0.05) (anxiety)NRBEHAVE-AD, 0–75
  • *Prespecified key confounders: a, age; d, dementia severity; g, gender; s, socioeconomic status. All other confounders:  ct,  carer type;  e,  ethnicity.

  • HR > 1 Indicates increased risk, HR < 1 indicates decreased risk . OR > 1 indicates increased odds of outcome, OR < 1 Indicates decreased odds of outcome.

  • BEHAVE-AD, Behavioural Pathology in Alzheimer’s Disease Rating Scale; BPSD, Behavioural and Psychological Symptoms of Dementia; CMAI, Cohen Mansfield Agitation Inventory; Corr, correlation (This is a number between −1 to +1 and indicates the degree to which the exposure and outcome vary together. Positive numbers indicate that exposure and outcome increase together, negative numbers indicate that the outcome increases as the exposure decreases. Larger numbers indicate stronger correlation); Cornell, Cornell Scale for Depression in Dementia; HAM-D, Hamilton Rating Scale for Depression;MD, mean difference in outcome (Large differences between groups suggests that the exposure might affect the outcome. For continuous exposures, mean difference represents the change in the outcome for one unit increase in the exposure); NPI, Neuropsychiatric Inventory; NR, information not reported (where possible results and 95%CIs were calculated from raw data); PoV, proportion of variance (This is a number between 0–1 indicating the proportion of variance in the outcome explained by the exposure. Higher numbers indicate greater explanatory power of the exposure); SCB, Screen for Caregiver Burden (selection of items); Zung, Short Zung Interviewer Assisted Depression Rating Scale.