Picking behaviour in cognitively impaired residents in geriatric settings: prevalence of the behaviour and characteristics of the residents

OR IG INAL ART ICLE

Picking behaviour in cognitively impaired residents in geriatricsettings: prevalence of the behaviour and characteristicsof the residents

Karin Johansson1RNT MSc,2 Per-Olof Sandman2

RN, PhD and Stig Karlsson3RN, PhD

1Department of Health Sciences, Lulea University of Technology, Lulea, 2Department of Nursing, Umea University, Umea and 3Department of

Community Medicine and Rehabilitation/Geriatric Medicine, Umea University, Umea, Sweden

Scand J Caring Sci; 2004; 18; 12–18

Picking behaviour in cognitively impaired residents

in geriatric settings: prevalence of the behaviour

and characteristics of the residents

This paper presents the findings of a point prevalence study

performed at all geriatric settings within a county in Nor-

thern Sweden. The aims of the study were twofold: to

investigate the prevalence of picking behaviour in cogni-

tively impaired residents in various kinds of geriatric care

settings and describe the characteristics of the residents,

and to investigate how the residents who exhibit picking

behaviour are experienced by their care providers. The

study comprises 1928 cognitively impaired residents. The

prevalence of picking behaviour was found to be 17%.

Multivariate analyses showed that behavioural and psy-

chiatric symptoms such as ‘often stands at the outer door

and wants to go out’, ‘wanders alone or with other patients

back and forth’, ‘aggressive threats to patients and staff‘ and

being ‘manic’ and ‘fearful’ were associated with picking

behaviour. Other factors associated with picking behaviour

were ‘taking part in daily tasks’, ‘can walk without assist-

ance’ and imposing a high psychological workload. Fur-

thermore, residents who exhibited picking behaviour were

experienced by care providers as more uncertain and

unhappier than residents who did not behave in this way.

Keywords: picking behaviour, cognitively impaired

residents, prevalence, characteristics, experiences, care

providers.

Submitted 24 March 2003, Accepted 24 November 2003

Introduction

Behavioural symptoms are common complications of

dementia and affect a majority of patients with the disease.

It has been estimated that 40–90% of people with Alz-

heimer’s disease suffer from behavioural symptoms at

some point during the course of the disease (1–3). The

literature on behavioural symptoms associated with

dementia mainly covers symptoms such as agitation (4),

aggressive behaviour (5) vocally disruptive behaviour (6)

and wandering (7). One behavioural symptom associated

with dementia that is less frequently described in the lit-

erature is picking behaviour, e.g. resident takes things from

fellow patients, packs things up, tears newspapers up,

hides things or rolls up table cloths, rearranges things,

carries things about, wraps things up and stows them

away, rubs and strokes things.

A review of the literature shows that picking behaviour

is often included under terms such as ‘purposeless activity’,

‘inappropriate activity’ (8), ‘destroying property’ (2),

‘repetitive motor movement’, ‘repetitive behaviours’ (9,

10), ‘repetitive sorting’, ‘hoarding’ (11), ‘physical attacks’,

‘repeats the same action over and over’ (12), or ‘pottering’

(13). Picking behaviour has been reported to be associated

with pain and wandering in people with dementia (14,

15). It has also been described as occurring among people

with dementia in care situations when they have insuffi-

cient stimulated activities (16).

The reason for and the underlying intention behind

picking behaviour have been described as difficult to

interpret by family members and care providers, but are

often understood as reflecting unsatisfied needs and

environmental influences (17). In addition, care providers

interpret the behaviour as arising from such factors as

restlessness and stress (18) and according to Johansson

et al. (17) care providers and family members interpret the

persons’ behaviour as striving after an ordinary everyday

life, an attempt to gain control and to establish contact

with others. It has also been argued that behavioural

symptoms are significantly correlated with perceived stress

Correspondence to:

Karin Johansson, Department of Health Sciences, Lulea University of

Technology, SE-96136 Boden, Sweden.

E-mail: [email protected]

12 � 2004 Nordic College of Caring Sciences, Scand J Caring Sci; 2004; 18, 12–18

in the caregiver (19) and that the behaviour symptoms

might be experienced as diminishing the quality of life for

both patients and caregivers (20).

It has been suggested that behaviour symptoms in

people with dementia have an impact on the workload

experienced by the staff. In a study by Novak and

Chappell (21: 105–20) it was found that the proportion

of cognitively impaired patients in a nursing assistant’s

caseload was significantly related to his/her feelings of

emotional exhaustion. They also showed that both str-

essor (frequency of disturbing patient behaviour) and

appraisal variables (reaction to patient behaviour)

affected nursing assistants’ feelings of being burned out

and that such feeling of burnout depended largely on

how the external conditions were interpreted. Duquette

et al. (22) have stated that nurses working in nursing

homes perceive more work stressors than those working

in hospitals.

A review of the literature indicates an extensive know-

ledge base concerning the prevalence of behavioural

symptoms associated with dementia. However, to date

little attention has been focused on picking behaviour

among residents with cognitive impairment. Therefore the

aims of the study were: to investigate the prevalence of

picking behaviour in cognitively impaired residents in

various kinds of geriatric care settings, to describe the

characteristics of residents exhibiting this behaviour and to

investigate how residents with picking behaviour are

experienced by their care providers.

Method

Sample

The present study is based on data from a point preval-

ence study that was performed in May 2000 in the

county of Vasterbotten, in the northern part of Sweden.

The county of Vasterbotten has a population of approxi-

mately 256 000 people, 44 211 of whom were aged 65 or

older in 2000. A rating scale was distributed to all geri-

atric settings in the county, including group-livings,

nursing homes, rehabilitation/short-stay wards, residen-

tial care facilities together with two geriatric and two

psycho-geriatric clinics. The total number of residents

living in the settings at the time of the study was 4297, of

which 3804 were assessed by means of a rating scale

(response rate 89%). To fulfil the aim of the study, all

residents assessed as cognitively impaired (n ¼ 1928)

were selected and became the study population. They

were living in group-livings for people with dementia

(n ¼ 594), nursing homes (n ¼ 587), rehabilitation/

short-stay wards (n ¼ 33), residential care facilities

(n ¼ 656), geriatric wards (n ¼ 22) and psycho-geriatric

wards (n ¼ 36). The mean age of the residents in the

sample was 83 years (±7.3) and 69% were females.

Instruments

The residents were assessed by means of the Multi-

Dimensional Dementia Assessment Scale, MDDAS (23).

The scale measures motor function, vision, hearing,

speech, ADL-functions, behavioural and psychiatric

symptoms, use of physical restraints, pain, use of psycho-

active drugs and physical and psychological workload im-

posed on the care providers. The scale has been tested for

inter- and intra-rater reliability and has been found to be

reliable (23).

A subscale developed by Gottfries and Gottfries (24), was

used to measure cognitive impairment. The scale consists

of 27 items measuring orientation ability and residents

scoring 24 points or less are considered to be cognitively

impaired. The cut-off score has been validated against the

corresponding cut-off score for the Mini-Mental State

Examination (MMSE) (25), with a sensitivity of 90% and a

specificity of 91% for differentiating between demented

and nondemented residents (23).

Based on previous research into picking behaviour

(17, 18) a ‘picking behaviour’ variable was constructed

by using six out of 25 items from the MDDAS scale

measuring behavioural symptoms. These items were

‘takes things from fellow patients’ drawers and cup-

boards’, ‘packs things and is often on the way home’,

‘piles chairs up and pushes tables and turns furniture

upside down’, ‘tears up newspapers’, ‘hides things’ and

‘rolls table cloths up’. In this study, residents who were

judged by the staff to exhibit one or more of the six

behaviour items daily were defined as exhibiting picking

behaviour.

Nine semantic differentials were used (26) to measure

how care providers experience residents exhibiting

picking behaviour. The care providers were asked to

describe their experiences of the resident by marking a

point on a long line 10 cm between two extremes, for

example, Liked–Abhorred, Happy–Unhappy (Table 3).

For the analysis, the line was divided into 10 equal parts,

where 1 was the most positive and 10 the most negative

extreme.

Procedure

The study took place over a period of 1 week. The rating

scales were distributed to the various settings with the

instruction that the scale should be completed for every

single resident by the person among the care providers

who knew the resident in question best. The ratings were

to be based on observations of the resident’s state during

the preceding week. Residents with a stay of less than

1 week were excluded because it was agreed that at least

1 week of observation was needed to produce a valid and

reliable assessment. The care providers who assessed the

residents were licensed practical nurses (54%), nursing

� 2004 Nordic College of Caring Sciences, Scand J Caring Sci; 2004; 18, 12–18

Picking behaviour in cognitively impaired residents1 13

aides (42%) and registered nurses (4%). The mean age of

the care providers was 41.0 ± 11.4 years.

Statistical analysis

SPSS� statistical software was used to analyse all data.

Continuous data were analysed using Student’s t-test, the

Mann–Whitney U-test and the chi-square test were used

for dichotomous data. A p value of <0.05 was considered as

statistically significant. Stepwise logistic regression ana-

lyses were performed in order to explore factors associated

with picking behaviour. An inclusion criterion of p < 0.05

was used for variables (n ¼ 29) entered into the model.

Results are reported using odds ratios (ORs) and 95%

confidence intervals (CIs).

Results

The prevalence of picking behaviour in cognitively

impaired residents was found to be 17% (n ¼ 318). The

highest proportion of residents exhibiting picking beha-

viour was found in psycho-geriatric care (28%) and

group-livings for people with dementia (25%). The cor-

responding figures in rehabilitation/short-stay wards were

15%, residential care facilities 14%, nursing homes 11%

and geriatric wards 9%, respectively.

The largest proportion of those defined as exhibiting

picking behaviour were ‘hides things’ (n ¼ 161); and ‘rolls

table cloths up’ (n ¼ 106). More uncommon were ‘takes

things from fellow patients’ drawers and cupboards’

(n ¼ 54); ‘packs things up and is often on the way home’

(n ¼ 68) ‘piles chairs up and pushes tables and turns

furniture upside down’ (n ¼ 60); tears newspapers up’

(n ¼ 36). Some of the residents exhibited more than one

of the behavioural symptoms.

A comparison between residents with and without

picking behaviour showed no statistically significant dif-

ferences with regard to age, sex and hearing ability

(Table 1). However, among residents with picking beha-

viour there was a significantly larger proportion who could

manage ADL functions, such as dressing, eating, bowel and

bladder function. Furthermore, a significantly larger pro-

portion could walk without assistance, had intact speech

and took part in daily activities (Table 1). Residents with

picking behaviour were judged to impose a heavier psycho-

logical but a lower physical workload on their care providers

than residents with no picking behaviour (Table 1).

Among residents with picking behaviour, a significantly

larger proportion were found to have hyperactive beha-

viour, such as wandering or ‘stands at the outer door and

wants to go out’, compared to residents with no picking

behaviour (Table 2). There was also a statistically signifi-

cant difference between the two groups regarding aggres-

siveness, anxiety, seeking help and constantly seeking the

attention of the staff. The residents with picking behaviour

presented these characteristics in a larger proportion. No

statistically significant difference in the prevalence of

screaming behaviour or pain was found between the two

groups (Table 2).

A statistically significantly larger proportion of the resi-

dents with picking behaviour were prescribed ben-

zodiazepines, 39 vs. 28%, (p < 0.001) or neuroleptics, 39

vs. 32% (p ¼ 0.013) (Table 2). More than 40% in both

groups were prescribed antidepressants.

Table 1 Comparison between residents with picking behaviour and residents with no picking behaviour concerning functions, abilities and workload

Residents with picking

behaviour n ¼ 318, n (%)

Residents with no picking

behaviour n ¼ 1610, n (%) p-Value*

Sex, female 227 (72) 1102 (69) 0.292

Age, years (mean ± SD) 82.6 ± 6.4 83.1 ± 7.5 0.272

Can manage own hygiene 25 (8) 88 (6) 0.099

Can manage own dressing 45 (14) 150 (9) 0.010

Can eat without assistance 179 (56) 652 (41) <0.001

Can control bladder 105 (33) 351 (22) <0.001

Can control bowel 202 (64) 746 (47) <0.001

Can walk without assistance 205 (66) 543 (34) <0.001

Confined to bed 2 (1) 76 (5) <0.001

Takes part in daily tasks everyday and sometime during a week 107 (34) 201 (13) <0.001

Intact speech 221 (71) 991 (64) 0.016

Hearing, good or moderately diminished 283 (92) 1399 (89) 0.118

Physical workload mean ± SD (range 1–5) 2.5 ± 1.3 3.0 ± 1.4 <0.001

Psychological workload mean ± SD (range 1–5) 3.1 ± 1.2 2.6 ± 1.3 <0.001

*p-Values from t-test and chi-square when appropriate.

The percentage and the mean value are not based on all subjects in each instance because of missing data.


14 K. Johansson et al.

There was a significant difference in how care providers

described their experiences of residents with picking

behaviour compared to residents with no picking beha-

viour in that the former were rated as more uncertain

(p ¼ 0.013) and more unhappy (p ¼ 0.028) (Table 3).

Analysis of the data in a logistic regression model

showed that behavioural and psychiatric symptoms such as

‘often stands at the outer door and wants to go out’,

‘wanders alone or with other patients back and forth’,

‘aggressive threats to patients and staff’, ‘manic’ and

‘fearful’ were associated with picking behaviour. Other

factors associated with picking behaviour were ‘takes part

in daily tasks’, ‘can walk without assistance’ and psycho-

logical workload (Table 4).

Discussion

This study shows that picking behaviour is a common

behavioural symptom (17%) among cognitively impaired

residents living in geriatric care settings. The prevalence

of picking behaviour was found to be comparable with

the prevalence of wandering and twice as common as

screaming and aggressiveness in our study sample. The

highest proportion of residents with picking behaviour

was found in psycho-geriatric wards (28%) and in group-

livings for people with dementia (25%). One explanation

for the high prevalence of picking behaviour in the

former could be that patients, mainly with dementia,

are admitted to these facilities for the assessment and

Table 2 Comparison between residents with picking behaviour and residents with no picking behaviour concerning behaviour symptoms, psychiatric

symptoms, pain, use of physical restraints and medication


behaviour n ¼ 318, n (%)


behaviour n ¼ 1610, n (%) p-Value*

Residents who everyday

Wander alone or with other residents back and forth 129 (41) 197 (12) <0.001

Often stand at the outer door and want to go out 57 (18) 41 (3) <0.001

Are overactive (‘manic’) 49 (15) 42 (3) <0.001

Fearful 59 (19) 132 (8) <0.001

Seek help 125 (40) 373 (23) <0.001

Constantly seek attention of the staff 144 (46) 364 (23) <0.001

Shriek and shout continuously 31 (10) 146 (9) 0.708

Use aggressive threats (words and gestures) to patients, staff 40 (13) 88 (5) <0.001

Residents

In pain 195 (62) 899 (57) 0.071

Physically restrained 73 (23) 440 (27) 0.107

Medication

Psycho-active drugs 221 (70) 1080 (67) 0.401

Neuroleptics 123 (39) 508 (32) 0.013

Benzodiazepines 123 (39) 449 (28) <0.001

Antidepressants 136 (43) 703 (44) 0.768

*p-Values from t-test and chi-square when appropriate.

The percentage is not based on all subjects in each instance because of missing data.

Table 3 Care providers’ experiences of the

residents with picking behaviour vs. no picking

behaviour measured with the Visual Analogue

Scale


behaviour n ¼ 318,

median (Q1, Q3)


behaviour n ¼ 1610,

median (Q1, Q3) p-Value*

Liked–abhorred 2 (1, 4) 2 (1, 4) 0.230

Loved–hated 2 (1, 5) 2 (1, 4) 0.409

Genuine–false 2 (1, 4) 2 (1, 4) 0.089

Warm–cold 2 (1, 5) 2 (1, 5) 0.546

Nice–horrible 2.5 (1, 5) 2 (1, 5) 0.554

Soft–hard 3 (1, 5) 2 (1, 5) 0.412

Certain–uncertain 5 (3, 8) 5 (3, 7) 0.013

Safe–afraid 5 (2, 7) 4 (2, 6) 0.158

Happy–unhappy 5 (3, 7) 5 (3, 6) 0.028

*p-Values from Mann–Whitney U-test.



treatment of psychiatric and behavioural symptoms. The

lower prevalence of picking behaviour among cognitively

impaired residents in nursing homes could be explained

by the fact that a high proportion of residents in these

facilities are characterized by severe functional impair-

ment (27). This is confirmed by the finding that the

proportion of those who could walk without assistance

was twice as high in the picking group as in the non-

picking group.

The high proportion of residents with picking behaviour

in group-livings could be explained by the fact that the

environment in these small units could prove provocative

because in them a group of moderately to severely

demented residents live together. Wimo et al. (28) discuss

the importance of this aspect in evoking stress in some

patients living in group-livings. Another explanation could

be that in group-livings the residents are surrounded by

their own property and have the chance to live an ordinary

everyday life with, e.g. involvement in household tasks

and examining if things can be taken apart and can be

carried out to a larger extent.

The finding that picking behaviour was associated with

hyperactive behaviour confirms the results of other stud-

ies, which have suggested that picking behaviour might be

an expression of stressors such as e.g. under-stimulation

and over-stimulation (18, 29).

Regarding ADL abilities it is obvious that a higher pro-

portion of the residents with picking behaviour can man-

age these functions compared to those with no picking

behaviour, probably because of their better physical

health. The same reason can be assumed for their greater

participation in daily tasks. Wimo et al. (28) stated that a

decline was seen in the ability to manage ADL in residents

in group-livings and nursing homes, except for motor

functions, which declined more slowly in residents in

group-livings. This slower decline in motor functions is

also in accordance with the larger proportion of picking

behaviour in residents living in group-livings in our study.

Even though picking behaviour is probably neither as

disturbing as screaming for those in the vicinity, nor as

hazardous for the resident as wandering, we found that

picking behaviour has a significant impact on the psy-

chological workload of the staff. One explanation for this

could be that residents with picking behaviour are often

mobile, take things from fellow patients’, pack things up

and are often on their way home, pile chairs up and push

tables and turns furniture upside down, etc., and these

actions can impose constant psychological strain on the

care providers.

Our study indicates that picking behaviour is often con-

nected with other behaviour disturbances. Forty-one per

cent of those with picking behaviour also exhibited wan-

dering behaviour. In interviews with care providers, picking

behaviour and wandering are described as often being pre-

sent simultaneously (18). Picking behaviour and wandering

can be seen as marks of motor activity caused by stressors

such as e.g. under-stimulation, over-stimulation, tiredness,

elimination needs, pain and discomfort (cf. 18, 29).

That people with picking behaviour showed a higher

proportion of anxious behaviour than the group with no

picking behaviour might reflect the inability of the former

to leave the setting even though they want to ‘go home’.

In this study, packing things up and being on the way

home is one of the items that constitute picking behaviour.

In a study by Zingmark et al. (30), the intention to go

home was identified as an escape from situations affecting

the residents with severe and moderate dementia

unpleasantly and was often connected with clearly and

distinctly agitated behaviour.

There are conflicting views about pharmacological

interventions for behavioural symptoms. Herrmann and

Lanctot (31) argue that the most commonly used and the

best-studied pharmacological intervention for behavioural

symptoms is neuroleptical medication. However, in a

1-year follow-up study Ballard et al. (32) showed that

there was no evidence that residents taking neuroleptics

were more likely to experience resolution of behavioural

and psychiatric symptoms than neuroleptic-free residents.

The same study indicates that short, focused periods of

treatment may be a more effective approach to manage-

ment when new symptoms develop. In our study we

found that a significantly higher proportion of the resi-

dents with picking behaviour were prescribed neuroleptics

and bensodiazepines compared to residents with no pick-

ing behaviour. However, the design of our study did not

make it possible for us to state definitely that the reason for

this medical treatment is picking behaviour or if there are

other reasons for this treatment.

It has been reported that picking behaviour in cogni-

tively impaired residents is, according to care providers, a

credible way of showing anxiety (18). Confirmation of this

Table 4 Logistic regression analysis of factors associated with picking

behaviour

Multivariate

OR 95% CI

Often stands at the outer door and

wants to go out

3.25 1.98–5.33

Overactive (‘manic’) 3.05 1.82–5.09

Takes part in daily tasks 2.54 1.82–3.56

Wanders alone or with other patients

back and forth

2.32 1.66–3.25

Aggressive threats (word and gesture) to

patients and staff

2.18 1.35–3.52

Can walk without assistance 1.98 1.42–2.76

Fearful 1.82 1.21–2.72

Psychological workload 1.20 1.07–1.35

Model chi-square 296.6, df ¼ 8, p < 0.001.



could be seen in that the care providers in our study

experienced the residents with picking behaviour as being

more uncertain than the other group of residents. How-

ever, further research is needed to determine the origin of

this assumption.

Some limitations should be considered when data are

collected on residents and care providers with widely dis-

tributed questionnaires and many informants, there is a

risk of losing of precision. However, the MDDAS has

proved valuable when important features of large groups

of institutionalized older patients are assessed, particularly

with regard to patients with cognitive impairment (23).

Another limitation might be that some behaviour which

could be defined as picking behaviour is not included in

our study, e.g. picking at bedclothes and clothes.

However, our results indicate that the prevalence of

picking behaviour in residents with cognitive impairment

living in geriatric settings is common. Furthermore, our

conclusion is that pickering presupposes a certain level of

health and physical functioning. Confirmation of this

could be seen in that residents exhibiting picking beha-

viour were less functionally disabled (e.g. ADL abilities)

compared to cognitively impaired residents with no pick-

ing behaviour. In addition our study indicates that picking

behaviour is often connected with other behaviour e.g.

wandering behaviour. Further conclusion is that residents

with picking behaviour imposed a heavier psychological

workload on the care providers than residents with no

picking behaviour.

One unanswered question remains – Is picking beha-

viour in cognitively impaired residents a positive strength

that should be encouraged or should there be interven-

tions to prevent such behaviour? Further research is nee-

ded to answer this question.

Acknowledgements

The authors are indebted to the Research Program ‘Arts in

Hospital and Care as Culture’, the County Council of

Stockholm, and the Department of Health Sciences of

Lulea University of Technology for economic support, and

to Ms Pat Shrimpton for assistance with the English lan-

guage.

Author contribution

Analysis work and drafting of manuscript was contri-

buted by KJ. SK and POS regularly met with KJ for

discussion and support and were responsible for the data

collection.

Funding

The Research Programme ‘Arts in Hospital and Care as

Culture’, the County Council of Stockholm, and the

Department of Health Sciences of Lulea University of

Technology provided economic support and allowed leave

of absence for study purposes periodically.

Ethical approval

Ethical approval was sought and granted by Ethics Com-

mittee of Umea University, Sweden (§93/00, dnr 00-070).

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Picking behaviour in cognitively impaired residents in geriatric settings: prevalence of the behaviour and characteristics of the residents