What Is Really Needed to Provide Effective, Person-Centered Care for Behavioral Expressions of Dementia? Guidance from The Alzheimer's Association Dementia Care Provider Roundtable

Evaluating the Implementation of the Individualized Positive Psychosocial Interaction (IPPI) as a Quality Improvement Project in Nursing Homes

OBJECTIVES

The Individualized Positive Psychosocial Interaction (IPPI) is a non-pharmacological, person-centered, intervention for nursing home (NH) residents living with moderate to severe dementia. The purpose of this study was to assess the pragmatic implementation of the IPPI by leveraging Ohio's Nursing Home Quality Improvement Program (QIP).

METHODS

Implementation teams collected resident mood ratings pre- and post-IPPI and completed virtual interviews to assess their Organizational Readiness for Implementing Change as well as the acceptability, feasibility, and appropriateness of the IPPI. Implementation strategies included: providing ongoing consultation; identifying and preparing champions; assessing for readiness and identifying barriers; and developing and distributing effective educational materials.

RESULTS

Fifteen NHs completed the QIP (65% completion rate) and reported high organizational commitment to change and high change efficacy. NHs engaged n = 65 residents in n = 638 IPPIs. Residents experienced a positive mood change after 47% of IPPIs. NHs found the IPPI program to be highly acceptable, feasible, and appropriate.

CONCLUSIONS

Overall, 65% of NHs successfully implemented the IPPI QIP with people living with moderate to severe dementia.

CLINICAL IMPLICATIONS

Given the positive mood changes and high staff satisfaction, results suggest that these brief, individualized activities can be effective strategies to address the communication of distress among PLWD.

Virtual Reality-Based Education Program for Managing Behavioral and Psychological Symptoms of Dementia: Development and Feasibility Test

This study aims to develop a virtual reality-based education program for managing behavioral and psychological symptoms of dementia for family carers of persons living with dementia and investigate the feasibility for users. The program was developed through literature review, interviews with family carers, surveys, and expert content validity assessment. User feasibility was evaluated quantitatively through a questionnaire on usefulness, ease of use, and satisfaction, and qualitatively through participant interviews. The program was produced in two parts, Type 1 and Type 2, consisting of three and six episodes, respectively. Participants showed a high level of satisfaction with overall program scores of 4.28 ± 0.66 and 4.34 ± 0.41 for the two evaluations. Participants also expressed that both programs were helpful, Type 1 for achieving changes in attitude associated with more understanding of persons living with dementia and Type 2 for acquiring coping methods through communication training. Use of the virtual reality device was not inconvenient and was identified as helpful due to the high immersion experience. Results of this study confirmed that family carers had no resistance to education using new technologies such as virtual reality devices and that virtual reality-based education could be effective for training family carers.

Implementation Lessons Learned: Distress Behaviors in Dementia Intervention in Veterans Health Administration

BACKGROUND AND OBJECTIVES

Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide.

RESEARCH DESIGN AND METHODS

STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges.

RESULTS

STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation.

DISCUSSION AND IMPLICATIONS

STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health-nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice.

Improving Healthcare Quality and Clinical Outcomes for Persons with Dementia in the Sub-Acute Hospital Through Person-Centered Care Practice

Background

Person-centered care is considered beneficial for persons with dementia.

Objective

To evaluate the impact of a person-centered knowledge translation intervention on the quality of healthcare and outcomes for persons with dementia.

Methods

Over nine months, sub-acute hospital nursing, allied health, and medical staff (n = 90) participated in online and/or face-to-face person-centered education and were supported by senior nursing, allied health, and medical staff champions (n = 8) to implement person-centered healthcare. The quality of healthcare service, ward climate and care delivery were evaluated pre/post study intervention. In the week following hospital admission (Time 1) and week of discharge (Time 3), agitation incidence (co-primary outcome) was assessed in participants with dementia (n = 80). Participant delirium (co-primary outcome), accidents/injuries, psychotropic medicines, length of stay, readmission and discharge destination (secondary outcomes) were compared with a retrospective group (n = 77) matched on demographics, cognition and function in activities of daily living.

Results

Improvements occurred post-intervention in service quality by 17.5% (p = 0.369, phi = 0.08), ward climate by 18.1% (p = 0.291, phi = 0.08), and care quality by 50% (p = 0.000, phi = 0.37). Participant agitation did not change from Time 1 to Time 3 (p = 0.223). Relative to the retrospective group, significant reductions occurred in participant delirium (p = 0.000, phi = 0.73), incidents/injuries (p = 0.000, phi = 0.99), psychotropic medicine use (p = 0.030, phi = 0.09), and hospital readmissions within 30 days (p = 0.002, phi = 0.25), but not in discharge to home (p = 0.171).

Conclusions

When person-centered healthcare knowledge is translated through staff education and practice support, persons with dementia can experience improved healthcare services and clinical outcomes, while healthcare services can benefit through reductions in unplanned service use.

Developing a model to explain users' ethical perceptions regarding the use of care robots in home care: A cross-sectional study in Ireland, Finland, and Japan

To date, research on ethical issues regarding care robots for older adults, family caregivers, and care workers has not progressed sufficiently. This study aimed to build a model that universally explains the relationship between the use of care robots and ethical awareness, such as regarding personal information and privacy protection in home care. We examined data obtained from cross-sectional surveys conducted in Japan (n=528), Ireland (n=296), and Finland (n=180). We performed a confirmatory factor analysis by using responses to 11 items related to the ethical use of care robots. We evaluated the model based on the chi-square to degrees of freedom ratio, the comparative fit index, and the root mean square error of approximation. Subsequently, we compared the model with the Akaike's information criterion. Ten items were adopted in the final model. There were 4 factors in the model: 'acquisition of personal information', 'use of personal information for medical and long-term care', 'secondary use of personal information', and 'participation in research and development'. All factor loadings of the final model ranged between 0.63 and 0.92, which were greater than 0.6, showing that the factors had a high influence on the model. The final model was applied to each country; the fit was relatively good in Finland and poor in Ireland. Although the three countries have different geographies, cultures, demographics, and systems, this study showed that the impact of ethical issues regarding the use of care robots in home care can be universally explained by the same model.

Temporal Relationships Between Nursing Home Staff Care Approaches and Behaviors of Residents With Dementia During Mealtimes: A Sequential Analysis

Background and Objectives

Optimal dyadic interactions are critical to quality mealtime care and outcomes. Prior work supports associative relationships between staff approaches and individual mealtime behaviors, yet evidence on temporal relationships is limited. This study examined temporal associations between staff approaches and resident behaviors during mealtimes.

Research Design and Methods

Videotaped mealtime observations (N = 160) involving 36 staff and 27 residents (53 staff-resident dyads) in 9 nursing homes were analyzed. Sequential analyses using 5-, 10-, and 15-second time windows were conducted for resident positive, neutral, and challenging behaviors as antecedents as well as consequences of staff person-centered and task-centered approaches.

Results

Residents exhibited positive verbal (35.0%) and positive/neutral nonverbal (12.6%) behaviors, as well as challenging behaviors including functional impairments (27.7%) and resistive behaviors (24.7%). Staff primarily used person-centered approaches (54.1% verbal, 40.3% nonverbal); task-centered approaches were less frequent (5.6%). Immediately (within 5 seconds) after staff person-centered approaches, resident positive/neutral and resistive behaviors were more likely, and functional impairments less likely. After staff task-centered approaches, resident positive verbal and resistive behaviors were less likely. After resident positive/neutral behaviors, staff person-centered approaches were more likely. After resident functional impairments, staff person-centered verbal approaches were less likely, and task-centered approaches more likely. After resident resistive behaviors, all staff approaches were more likely. The strength of temporal relationships diminished in 10-second and 15-second time windows.

Discussion and Implications

Staff-resident positive interactions were associated with more subsequent positive interactions. Person-centered care was associated with fewer subsequent resident functional impairments and more subsequent resistive behaviors. Resident resistive behaviors were associated with more subsequent person-centered and task-centered care. Findings confirm the importance of facilitating positive staff-resident interactions and managing functional impairments using person-centered care. Resistive behaviors require additional awareness and attention beyond commonly used person-centered care approaches. Further investigation of temporal relationships is needed using larger diverse samples.

Application of the Person-Centered Care to Manage Responsive Behaviors in Clients with Major Neurocognitive Disorders: A Qualitative Single Case Study

OBJECTIVES

Our study aimed to describe "how" and "why" the person-centered care (PCC) approach was applied within a long-term care (LTC) community to manage responsive behaviors (RBs) in individuals with major neurocognitive disorders.

METHODS

A descriptive holistic single case study design was employed in the context of an LTC community in Quebec, using semi-structured interviews and non-participatory observations of experienced care providers working with clients with RBs, photographing the physical environment, and accessing documents available on the LTC community's public website. A thematic content analysis was used for data analysis.

RESULTS

The findings generated insight into the importance of considering multiple components of the LTC community to apply the PCC approach for managing RBs, including a) creating a homelike environment, b) developing a therapeutic relationship with clients, c) engaging clients in meaningful activities, and d) empowering care providers by offering essential resources.

CONCLUSIONS

Applying and implementing the PCC approach within an LTC community to manage clients' RBs is a long-term multi-dimensional process that requires a solid foundation.

CLINICAL IMPLICATIONS

These findings highlight the importance of considering multiple factors relevant to persons, environments, and meaningful activities to apply the PCC approach within LTC communities to manage RBs.

Person-centred and task-centred care: Impact on mealtime behaviours in nursing home residents with dementia

INTRODUCTION

Mealtime is a critical daily activity to ensure nutrition, hydration, function and socialisation. Interactions between staff and residents during mealtimes are complex and dynamic processes including verbal and/or nonverbal communication that can be positive/neutral or challenging. This study examined characteristics of and relationships between person-centred and task-centred care and positive/neutral and challenging mealtime behaviours in persons with dementia.

METHODS

This study was a secondary behavioural analyses of videotaped mealtime observations (n = 110) involving 42 unique staff-resident dyads (29 staff and 25 residents with dementia) in nine nursing homes. The refined Cue Utilization and Engagement in Dementia mealtime video-coding scheme was used to code videos during 2019-2020. Dependent variables representing resident mealtime behaviours included positive verbal behaviours, positive/neutral nonverbal behaviours, functional impairments (nonverbal) and resistive behaviours (verbal and nonverbal). Independent variables were staff person-centred and task-centred approaches (verbal and nonverbal). Relationships between resident mealtime behaviours and staff approaches were examined using bivariate analysis and logistic regression.

RESULTS

Staff person-centred verbal approaches were associated with resident positive verbal behaviours (OR = 1.38, 95% CI = 1.09-1.76), functional impairments (OR = 0.81, 95% CI = 0.66-1.00) and resistive behaviours (OR = 1.65, 95% CI = 1.18-2.31). Staff person-centred nonverbal approaches were associated with resident functional impairments (OR = 1.33, 95% CI = 1.02-1.74). Staff task-centred approaches were not associated with resident positive/neutral or challenging mealtime behaviours.

CONCLUSION

This study characterised staff approaches and resident behaviours during mealtime care and provided preliminary support on associations between staff person-centred approaches and resident positive and challenging behaviours. Person-centred mealtime care practice is recommended by focusing on support of common, challenging behaviours and reinforcement of positive behaviours with adequate consideration of individual needs and preferences.

Evaluating Implementation and Outcomes of a Person-Centered Care Model for People with Dementia in the Rehabilitation In-Patient Setting: Project Protocol

BACKGROUND

While Australian guidelines promote person-centered healthcare (PCC) for persons with dementia, healthcare systems, routines, rules, and workplace cultures can pose challenges in the provision of PCC.

OBJECTIVE

To present a knowledge translation protocol of the PCC model in a sub-acute rehabilitation hospital.

METHODS

The two-year pre/post/follow-up translation project will include (n = 80) persons with dementia, (n = 80) adult family/carers of patient participants, (n = 60) healthcare staff (medical, nursing, allied health), and (n = 8) PCC staff champions. Champions will complete six half-days' training in PCC. Medical, nursing, and allied health staff will be provided with PCC learning manuals, complete six hours of online PCC education and attend six face-to-face PCC education sessions. Champions will provide ongoing support to staff in PCC practice. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework will be used to evaluate: i) outcomes for prospective patients provided with PCC, compared with a matched sample of retrospective patients (primary outcomes agitation incidence and severity); 2) champion and staff PCC knowledge, confidence, engagement, and practice quality; 3) person, family/carer, champion, and staff satisfaction with PCC; 4) PCC costs and benefits; and 5) organizational structures, systems and policies required to implement and maintain PCC in sub-acute healthcare.

RESULTS

We will identify if PCC benefits persons with dementia, staff, and healthcare services, and we will generate evidence on the educational and organizational resources required to embed PCC in practice.

CONCLUSION

Project findings will inform tailored PCC education applications for dissemination in healthcare and produce evidence-based PCC practice guidelines to improve healthcare for persons with dementia.

Providers' Perspectives on High-Quality Dementia Care in Long-Term Care

OBJECTIVES

To understand dementia care providers' perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC).

DESIGN

A qualitative study using a directed content analysis approach.

SETTING AND PARTICIPANTS

Nine national LTC dementia care providers.

METHODS

We facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions.

RESULTS

The 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings.

CONCLUSIONS AND IMPLICATIONS

Emergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers' priorities for PLWD and emphasize the need to align research priorities with provider priorities.

How about an Educational Framework for Nursing Staff in Long-Term Care Facilities to Improve the Care of Behavioral and Psychological Symptoms of Dementia?

Behavioral and psychological symptoms of dementia (BPSD) are common in residents of long-term care facilities (LTCFs). In LTCFs, nursing staff, including nurses and care workers, play a crucial role in managing BPSD as those most in contact with the residents. However, it is ambiguous where their focus should be for effective BPSD care. Thus, this paper aims to reveal BPSD care competencies for nursing staff in LTCFs and to outline an initial frame of education. A multiphase mixed-methods approach, which was conducted through topic modeling, qualitative interviews, and a Delphi survey, was used. From the results, a preliminary educational framework for nursing staff with categories of BPSD care competence was outlined with the four categories of BPSD care competence: using knowledge for assessment and monitoring the status of residents, individualizing approaches on how to understand residents and address BPSD, building relationships for shared decision-making, and securing a safe environment for residents and staff in LTCFs. This preliminary framework illuminates specific domains that need to be developed for competent BPSD care in LTCFs that are centered on nursing staff who directly assess and monitor the changing and deteriorating state of residents in LTCFs.

Sequential relationships of food intake in nursing home residents with dementia: Behavioural analyses of videotaped mealtime observations

AIMS AND OBJECTIVES

This study examined the sequential relationships of food intake and the moderating role of the characteristics of intake and resident conditions.

BACKGROUND

Nursing home residents commonly experience insufficient food intake. While multilevel factors influence intake, evidence on sequential relationships is lacking.

DESIGN

The study was an observational study using secondary, behavioural analyses following the STROBE Statement.

METHODS

Videotaped observations (N = 160) collected from a dementia communication trial during 2011-2014 were coded using the refined Cue Utilisation and Engagement in Dementia Mealtime Video-coding Scheme during 2018-2019. The 160 videos involved 27 residents living with dementia and 36 staff in 9 nursing homes. Independent variables were the state (solid intake, liquid intake, no intake) of an intake episode occurring during mealtime (current episode), eating technique (resident-initiated, staff-facilitated) used in the next episode occurring after the current episode (subsequent episode), interval between adjacent episodes, and resident comorbidities and dementia stage. The dependent variable was the state of subsequent episode.

RESULTS

Successful liquid and solid intake increased odds of subsequent liquid and solid intake. Comorbidities were associated with decreased odds of subsequent liquid and solid intake for staff-facilitated episodes. When liquid intake occurred, staff-facilitation decreased odds of subsequent liquid intake; longer intervals between adjacent episodes increased odds of subsequent solid intake.

CONCLUSION

Food intake was strongly and sequentially associated, and such temporal relationships were dependent on characteristics of the intake process and resident conditions.

RELEVANCE TO CLINICAL PRACTICE

The study findings supported that initiating successful intake facilitates continuity of successful intake during mealtime. Behavioural interventions tailored by comorbidities that modify characteristics of the food intake process may improve food intake.

Applying Agile Methodology to Reengineer the Delivery of Person-Centered Care in a Nursing Home: A Case Study

Nursing home (NH) providers would benefit from adopting evidence-based measures for gathering and utilizing resident preference information in their daily care activities. However, providers face barriers when implementing assessment tools used to promote person-centered care (PCC). Although Agile methodology is not commonly used in NH settings, this case study shows how it can be used to achieve the goal of delivering preference-based, PCC, within a large NH. We present a road map for breaking down care processes, prioritizing, and implementing iterative plan, do, study, act cycles using Agile methodology to enhance group collaboration on quality improvement cycles, to achieve our goal of providing preference-based PCC. We first determined if care plans reflected each resident's important preferences, developed a method for tracking whether residents attended activities that matched their preferences, and determined if residents were satisfied that their preferences were being met. These efforts had positive effects throughout the NH particularly when COVID-19 limited visitors and significantly modified staff workflow. Specifically, Agile processes helped staff to know how to honor preferences during quarantines which necessitated a shift to individualized (and not group) approaches for meeting preferences for social contact, comfort, and belonging. The ready availability of preference-based reporting was critical to quickly informing new staff on how to meet residents' most important preferences. Based on lessons learned, we describe a developmental approach that other providers can consider for adoption. Implications of this work are discussed in terms of the need for provider training in Agile methodologies to support iterative improvements, the need for policies that reimburse providers for their efforts, and additional research around workflow processes.

Community Goal Setting and Attainment: Organizational Characteristics and Indicators of Staff Adoption

In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents' behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents' behavioral symptoms of distress. [Journal of Gerontological Nursing, 48(5), 5-12.].

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives

BACKGROUND

Behavioral and psychological symptoms of distress in dementia (BPSD) are major drivers of poor quality of life, caregiver burden, institutionalization, and cost of care in nursing homes. The Evidence Integration Triangle (EIT)-4-BPSD in nursing homes was a pragmatic Hybrid III trial of an implementation strategy to help staff use evidence-based non-pharmacological interventions to prevent and manage BPSD. This study aimed to describe and explore the stakeholders' perceptions of the process to implement the EIT-4-BPSD strategy including its utility, and the barriers and facilitators to implementation in real-world settings.

METHODS

EIT-4-BPSD was a multi-layer implementation strategy that engaged nursing home stakeholder groups to define community specific goals towards reducing BPSD over a 12-month period. Stakeholder groups from nursing homes that completed all 12-months of the implementation strategy were invited to participate in this process evaluation study. Qualitative data from focus group transcripts were analyzed using a conventional content analysis. Emerging codes were sorted into categories, then organized in meaningful clusters based on the domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.

RESULTS

The EIT-4-BPSD implementation strategy was completed in 21 nursing homes; 93 stakeholders participated in focus groups. Over half of participating nursing homes reported meeting their BPSD goals as expected or more. Challenges, facilitators, and contextual factors reported by stakeholder members explains variability in the implementation of EIT-4-BPSD strategy in 11 key categories: family; staff; organizational; staff, environmental, and resident outcomes; utility of EIT resources; adoption barriers and facilitators; care process adaptations; and future planning.

CONCLUSION

Stakeholders offered guidance on salient factors influencing the feasibility and utility of EIT-4-BPSD adoption and implementation to consider in future implementation research that aims to improve behavioral well-being in NH residents living with dementia. Engagement of family and staff at all levels of the organization (Management, leadership, and direct care); and measurement of staff, environmental, and resident outcomes were perceived as critical for future implementation success. While regulations, finances, and competing demands on staff time were perceived as reducing implementation success.

TRIAL REGISTRATION

The Testing the Implementation of EIT-4-BPSD study was registered in the ClinicalTrials.gov ( NCT03014570 ) January 9, 2017.

Know-Me: A Toolkit for Designing Personalised Dementia Care

Personalisation is a crucial element in providing person-centred care for people with dementia. This paper presents the development and evaluation of a design toolkit to facilitate the work of designers and healthcare professionals in personalising dementia care. This toolkit, named "Know-me", was grounded in the findings of Ergonomics in Aging, Co-design, and Data-enabled Design, derived from literature review and from the field during a four-year doctorate project. "Know-me" was designed to be easily accessible, flexible, and engaging, providing concrete and hands-on guidance for designers and healthcare professionals to use in designing for personalised dementia care. A proof-of-concept evaluation of the "Know-me" toolkit was conducted via student projects on design for dementia care. During this process, we found that "Know-me" could be adapted flexibly so that the care team could use some of the tools by themselves. A feature-by-feature comparison of the "Know-me" toolkit with similar state-of-the-art toolkits was conducted, and based upon this, the strengths and weaknesses of the "Know-me" toolkit are discussed. This preliminary study indicates that the "Know-me" toolkit is a helpful addition to the current pool of toolkits on designing for dementia care.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities

BACKGROUND AND OBJECTIVES

Assisted living (AL) residents with dementia commonly exhibit behavioral expressions (BEs), yet no study has examined how AL staff perceive of and respond to BEs in terms of the "ABC" model of antecedents, behaviors and consequences, or how perceptions relate to organizational characteristics. Understanding staff perceptions may inform interventions.

RESEARCH DESIGN AND METHODS

A convergent, mixed-methods design was used in a study of health care supervisors from 250 AL communities in seven states who reported 366 cases of resident BEs (one successful and one unsuccessful case). Qualitative analysis identified antecedents, BEs, staff responses, resident outcomes, and disposition (aging in place or discharge). Content analysis identified themes and compared case types. Descriptive statistics examined organizational characteristics associated with identifying antecedents.

RESULTS

One-quarter of cases recognized antecedents; slightly more were identified in successful (28%) compared to unsuccessful cases (20%); staff in dementia-only and smaller communities identified antecedents more often. Combativeness and anxiety were the most frequently reported BEs. The majority of both types of cases reported staff responses. Medication management was enacted as a response in 40% of cases compared to psychiatric assessment in 33% of cases.

DISCUSSION AND IMPLICATIONS

Staff training is indicated to increase AL staff recognition of antecedents; doing so might reduce use of antipsychotic medications. Psychiatric assessment plays an important role in dementia care in AL and warrants further examination. Results could be helpful for applied behavioral researchers interested in developing ways to improve identification of antecedents of BEs of persons with dementia.

Cognition-Enhancing, Antipsychotic, and Opioid Medication Use Among Assisted Living and Residential Care Residents in Oregon

OBJECTIVES

Explore community- and resident-level characteristics associated with polypharmacy and use of cognition-enhancing, antipsychotic, and opioid medications among a statewide representative sample of assisted living and residential care (AL/RC) residents.

DESIGN

Cross-sectional, descriptive.

SETTING AND PARTICIPANTS

A total of 1135 AL/RC residents living in 387 licensed communities in Oregon were recruited. One-third of residents lived in communities certified to provide memory care to residents with dementia.

METHODS

All licensed AL/RC communities received a mail survey with questions about 3 randomly selected residents' demographic, health service use, health conditions, medication use, and payment information. We estimated bivariate and multiple logistic regression models, resulting in unadjusted and adjusted odds ratios of resident- and community-level characteristics associated with each medication use indicator.

RESULTS

One in 5 residents took a cognition-enhancing medication (20%) in the prior 7 days. Just more than one-fifth (22%) and one-quarter (25%) of residents took opioid or antipsychotic medications, on a scheduled or as-needed basis in the prior 7 days, respectively. Residents with Alzheimer's disease or related dementia (ADRD) living in rural communities were half as likely to take cognitive-enhancing medications compared with their urban counterparts. When controlling for all resident and community covariates, residents with ADRD were almost 3 times as likely to receive an antipsychotic and half as likely to receive an opioid compared to residents without an ADRD diagnosis.

CONCLUSIONS AND IMPLICATIONS

Understanding variation in the use of medications associated with behavioral expressions of ADRD in AL/RC residents is a crucial clinical and policy area.