Agitation in nursing home residents: the role of gender and social context

Patterns of physical activity among nursing home residents before and during the Covid 19 pandemic-a systematic observation

BACKGROUND

The Covid-19 outbreak in spring of 2020 posed an array of challenges for nursing homes, including promoting resident physical activity (PA). Given the diversity of factors affecting resident PA, we explored how activity patterns outside weekly-scheduled structured activities changed during the pandemic and what factors promoted or inhibited PA during the pandemic.

METHODS

We conducted systematic direct observations over 823.5 h in eight nursing homes in Southern Germany in 2020 and 2021.

RESULTS

In 2020, 84.7% of person observation units were classified as sedentary (average activity level: 1.14 MET). In 2021, the percentage increased to 91.6% of observed person units (average activity level: 1.08 MET) (t = 6.947; p = .000). According to tree classification, influencing factors of PA included mealtime and daytime in 2020 and 2021, as well as presence of men residents only in 2020 and guided low threshold activities in 2021.

CONCLUSIONS

Nursing homes constitute highly sedentary places-an issue exacerbated by access restrictions for external activity experts and significant others as well as behavioural restrictions for residents during the Covid-19 pandemic. Staff could not compensate due to existing time restraints and lack of training in PA promotion. Based on our findings, we recommend future studies to develop feasible and resource-low activities to be integrated into the daily routines of nursing homes.

The Relationship between Size of Core Network and Frequency of Contacts with Agitation and Positive Affect in Older Adults with Dementia

BACKGROUND

Few studies have explored the associations of agitation symptoms among older adults with core network size and with frequency of contact with core network care providers. The present study aimed to investigate the associations of agitation and affect among older adult people with dementia (PWD) with core network size and frequency of contact with core network care providers.

METHODS

A convenience sample of 98 Omani older adult PWD residing in their homes was recruited. Most of the participants (63.3%) were female, and the mean age of the participants was 80 years (standard deviation = 9.0). A total of 77 participants suffered from severe dementia, while the remaining 21 had mild to moderate dementia levels. Valid and reliable instruments completed by either the participating PWD or their caregivers were used to measure the study variables.

RESULTS

The main hypothesis of the study was not supported, whereby core network size and frequency of contact with the core network were not found to be significantly associated with activities of daily living (ADL) and instrumental ADL (IADL) core networks or agitation and affect. Further, the findings indicated no significant associations between core network size or closeness between PWD and their IADL and ADL caregivers and the amount of ADL and IADL care provided. The level of care provided by the caregivers and the participants' frequency of contact with the core network remained consistent throughout the progress of the dementia patients' conditions.

DISCUSSION/CONCLUSION

The findings of this study are incongruent with the findings of studies conducted in Western countries, which have reported that older adults prefer to have meaningful interactions with small, close social networks as opposed to large networks. Our findings may be explained by the strong cultural values in Oman which place great emphasis on caring for elderly family members. It is essential to understand these relationships in order to develop effective home care interventions for older adult PWD in Oman.

Factors Associated with Home Care Outcomes among Community-Dwelling Older Adult Patients with Dementia

Background

With the increase in the proportion of people with dementia (PWD), it is necessary to address dementia-related issues among older adults who live at home; however, there is no integrative review on this issue.

Objectives

To describe and analyze quantitative and qualitative studies from primary sources in order to identify the factors which impact home care outcomes among PWD.

Methods

A computer search of PsycINFO, MEDLINE (PubMed), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) was performed. This study was guided by Whittemore and Knafl's integrative review method.

Results

This review of the literature identified 3 main factors related to home care outcomes among PWD. These factors are environmental factors, caregiver-related factors, and social network factors.

Conclusions

Further research is required to investigate the impacts of multiple social and environmental factors on home care outcomes among PWD; which can eventually be used by nurses and family caregivers when providing care for older adult PWD.

COVID-19: Association Between Increase of Behavioral and Psychological Symptoms of Dementia During Lockdown and Caregivers' Poor Mental Health

BACKGROUND

From March 2020, the support and care systems for caregivers and people with dementia (PWD) were suspended or dramatically changed due to the lockdown during the world pandemic of COVID-19. Thus, these changes in living conditions have had deleterious consequences on the behavior of PWD and subsequently on their caregivers' mental health, the two being linked.

OBJECTIVE

Our study aimed to examine changes in behavior among PWD and to look for associations between the evolution of behavioral and psychological symptoms of dementia (BPSD) and caregivers' mental health in the context of COVID-19.

METHODS

The study was conducted among caregivers of PWD living at home in France. Caregivers were interviewed via an anonymous cross-sectional online survey during the first lockdown between April 15 and June 15, 2020.

RESULTS

Three hundred and eighty-nine caregivers accompanying a relative living at home participated in the study; 43.3%of the PWD presented a worsening of BPSD during the lockdown. With multivariate logistic regressions, a significant association was observed between "more BPSD" and burden, anxiety and depression, between "BPSD equivalent" and anxiety and depression, and between "emerging BPSD" and only depression.

CONCLUSION

The lockdown seems to have an impact on behavioral disorders in PWD and these disorders are associated with poorer mental health of caregivers. Our findings suggest attention should be given to caregivers of PWD who have BPSD before lockdown and the need for continued consultations and professional help in case of new lockdowns.

Gender differences in presentation and management of behavioral and psychological symptoms associated with dementia among nursing home residents with moderate to severe dementia

Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.

Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT

BACKGROUND

The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required.

OBJECTIVE

To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care.

DESIGN

A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors.

SETTING

Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub.

PARTICIPANTS

Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation.

INTERVENTION

Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert.

MAIN OUTCOME MEASURES

The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life.

RESULTS

There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified.

LIMITATIONS

The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important.

CONCLUSIONS

There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes.

FUTURE WORK

Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82288852.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.

Taking Another Look: Thoughts on Behavioral Symptoms in Dementia and Their Measurement

This article proposes taking another look at behavioral symptoms of dementia (BSDs) both from a theoretical perspective that informs research and practice and from a measurement perspective. We discuss why this rethinking of behaviors impacts current models of care and our ability to better detect outcomes from interventions. We propose that BSDs be viewed from a pattern perspective and provide some suggestions for how to identify and measure these patterns that can influence the timing and type of intervention. Evidence suggests that BSDs are complex, sequential, patterned clusters of behavior recurring repeatedly in the same individual and escalate significantly without timely intervention. However, BSDs are frequently viewed as separate behaviors rather than patterns or clusters of behaviors, a view that affects current research questions as well as the choice, timing, and outcomes of interventions. These symptoms cause immense distress to persons with the disease and their caregivers, trigger hospitalizations and nursing home placement, and are associated with increased care costs. Despite their universality and that symptoms manifest across disease etiologies and stages, behaviors tend to be underrecognized, undertreated, and overmanaged by pharmacological treatments that may pose more harm than benefit.

Severity of Neuropsychiatric Symptoms in Nursing Home Residents

We aimed at assessing time shift in the severity of neuropsychiatric symptoms (NPS) in nursing home residents between 2004/2005 and 2010/2011 and associations between NPS and socio-demographic variables, physical health status, dementia severity, and the use of psychotropic drugs. The Neuropsychiatric Inventory Nursing Home Version was used in 2004/2005 (n = 1,163) and 2010/2011 (n = 1,858). Linear mixed model analysis was applied. There was no time shift in the severity of apathy, psychosis, and affective symptoms, but agitation did exhibit a time shift. Agitation was less severe in 2010/2011 than in 2004/2005 in residents with a Clinical Dementia Rating (CDR) sum of boxes score ≤4, and more severe in residents with a CDR sum of boxes score >16. Higher CDR sum of boxes scores and use of psychotropic medication were associated with more severe apathy, agitation, psychosis, and affective symptoms. Poor physical health was associated with more severe apathy, psychosis, and affective symptoms. Women had more severe agitation and less severe affective symptoms than men. A longer stay in a nursing home was associated with more severe agitation and less severe affective symptoms. In conclusion, agitation was less severe in 2010/2011 than in 2004/2005 among nursing home residents with a milder degree of dementia, and more severe in residents with severe dementia.

Impact of caregivers' behaviors on resistiveness to care and collaboration in persons with dementia in the context of hygienic care: an interactional perspective

BACKGROUND

The role played by various physical and verbal behaviors of professional caregivers in the onset of resistiveness to care (RTC) and collaborative behaviors of nursing home residents with dementia was assessed in a daily hygienic care routine context.

METHODS

Two hundred and forty hygienic care routines, observed in eight nursing home residents, were analyzed with a video-assisted systematic observation methodology and a sequential statistical analysis strategy.

RESULTS

Caregiver and care recipient behaviors are interdependent in the hygienic care routine context. Physical instrumental behavior, neutral, negative and positive statements, positive and negative instructions, and verbal distraction emitted by caregivers are significantly and moderately associated with the onset of RTC in persons with dementia (PWD), but the strength of relationships observed depends on the care recipient's behavior prior to the caregiver's action. Positive instructions are moderately associated with the onset of collaboration in residents with preserved language abilities. However, for residents with severe language impairment, these same instructions were linked to RTC behaviors.

CONCLUSIONS

Although antecedents to RTC can be identified, the risk that caregiver behaviors trigger resistive responses is higher when care recipients are already exhibiting RTC, and is low when no particular behavior or collaboration is shown. Antecedents to collaboration are also identified and discussed. Although different caregiver behaviors may be more or less likely to elicit resistiveness or collaboration, it is the pre-existing state of the care recipient that will determine its reaction to the caregiver's behavior. Clinical implications emerging from these influential findings are elaborated.

Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study

BACKGROUND

Dementia is common in older people admitted to acute hospitals. There are concerns about the quality of care they receive. Behavioural and psychiatric symptoms of dementia (BPSD) seem to be particularly challenging for hospital staff. AIMS To define the prevalence of BPSD and explore their clinical associations.

METHOD

Longitudinal cohort study of 230 people with dementia, aged over 70, admitted to hospital for acute medical illness, and assessed for BPSD at admission and every 4 (± 1) days until discharge. Other measures included length of stay, care quality indicators, adverse events and mortality.

RESULTS

Participants were very impaired; 46% at Functional Assessment Staging Scale (FAST) stage 6d or above (doubly incontinent), 75% had BPSD, and 43% had some BPSD that were moderately/severely troubling to staff. Most common were aggression (57%), activity disturbance (44%), sleep disturbance (42%) and anxiety (35%).

CONCLUSIONS

We found that BPSD are very common in older people admitted to an acute hospital. Patients and staff would benefit from more specialist psychiatric support.

Visual Cues for Person-centered Communication

Nursing home communication is frequently limited and task-focused and fails to affirm resident personhood. We tested the feasibility and effects of automated digital displays of resident photographs to remind staff ( N = 11) of resident ( n = 6) personhood. Historical photographs were displayed in digital photo frames mounted in each resident’s room. To evaluate the intervention’s effects, staff–resident conversations were audio-recorded prior to displaying the frames and repeated 2 weeks and 3 months later. Conversations were transcribed and statements were topic coded (task-focused vs. interpersonal). Staff person-centered talk increased from 11% to 32% ( z = 2.37, p = .02) after the intervention and task-talk decreased from 64% to 40%. Resident interpersonal topics increased from 20% to 37%. Staff statements increased from 29 at baseline, to 37 postintervention, and 41 at 3-month follow-up and resident engagement and reminiscence also increased. Effects were reduced after 3 months. Automated photo displays are an easily implemented, low-cost intervention to promote person-centered communication.

Factors associated with problematic vocalizations in nursing home residents with dementia

PURPOSE OF THE STUDY

Problematic vocalizations (PVs) are the most frequent and persistent disruptive behaviors exhibited by nursing home residents with dementia. Understanding factors associated with these behaviors are important to prevent or reduce them. We used the Need-Driven Dementia-Compromised Behavior model to identify the characteristics of persons with dementia who are likely to display nonaggressive and aggressive PVs and the conditions under which these behaviors are likely to occur and persist.

DESIGN AND METHODS

This multisite descriptive study included 138 residents of 17 nursing homes, and approximately half had a history of PVs. Background data were gathered through interviews, chart reviews, and administration of physical and neuropsychological assessments. Proximal data were obtained from observations and videotapes.

RESULTS

When the 2 subscales of the Verbal Behavior Scale were used as the dependent variables, agreeableness and conscientiousness, positive affect, and discomfort were associated with nonaggressive vocalizations, and general health state (GHS), age, and negative and positive affect were associated with aggressive vocalizations. When the verbally agitated (nonaggressive) section of the Cohen-Mansfield Agitation Inventory was the dependent variable, the background factors of gender, agreeableness, GHS, and age remained predictors, as did the proximal factors of affect and discomfort.

IMPLICATIONS

We identified 5 background factors and 3 proximal factors as risk factors for PVs in persons with dementia, with variation between nonaggressive or aggressive PVs. These data provide direction for caregiving for persons with dementia and design of interventions to prevent or reduce PVs.

Alive and well: the state of behavioral gerontology in 2011

In this paper, the authors present a brief personal account of the senior author's 30 years of exploration in behavioral gerontology. The main thesis of the paper is that behavioral methods and interventions have found a home both in mainstream gerontology and at the National Institutes of Health (NIH). There are three sections: (a) a personal vignette discussing the problems inherent in using operant terminology in a nonoperant world; (b) a discussion, with examples from NIH sources, of the Institutes' views on behavior change; and (c) using Burgio and Burgio (1986) as a reference point, the authors show evidence of progress and vitality of behavioral gerontology in 2011.

The more physical inactivity, the more agitation in dementia

Epidemiological studies show a close relationship between physical activity and cognition. A causal relationship between physical activity and cognition has been observed in children, adolescents, older people without dementia, and in older people in a very early stage of dementia. Considering these positive effects, we argue that a decline in physical activity has a detrimental effect on cognition and behavior in patients with dementia. Merely living in a nursing home reduces the level of physical activity. The level of physical activity may even be reduced to a minimum when physical restraints are applied. The use of physical restraints coincides with stress, further aggravating the already existing neuropathology, which may increase stress and agitation even more. Exercise may reduce stress and agitation.

A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia

OBJECTIVES

This study, as part of a larger programme of research, sought to investigate the effect that participation in a 40-min live group music programme, involving facilitated engagement with song-singing and listening, three times a week for eight weeks, had on agitation and anxiety in older people with dementia.

METHODS

A randomized cross-over design, with music and reading control groups, was employed. Forty-seven participants with mild-moderate dementia, from two aged care facilities in Queensland, Australia, were recruited. Participants were assessed three times on the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF) and the Rating Anxiety in Dementia Scale (RAID).

RESULTS

A sub-analysis of 24 participants attending ≥50% of music sessions found a significant increase in the frequency of verbal aggression over time, regardless of group (F(2,46) = 3.534, p < 0.05). A series of multiple regressions found cognitive impairment, length of time living in the facility and gender to be predictors of agitation overall and by subtype.

CONCLUSION

Participation in the music programme did not significantly affect agitation and anxiety in older people with dementia. Both the music and reading group activities, however, gave some participants a 'voice' and increased their verbalization behaviour. Agitation was found to be predicted by a number of background factors (namely level of cognitive impairment, length of time in the facility and gender). Future studies would benefit more from in-depth participant assessment prior to study commencement, helping to moderate the influence of low scores, and by undertaking interventions at times when assessed symptoms are most prevalent.

Elderspeak's influence on resistiveness to care: focus on behavioral events

Resistiveness to care (RTC) in older adults with dementia commonly disrupts nursing care. Research has found that elderspeak (infantilizing communication) use by nursing home (NH) staff increases the probability of RTC in older adults with dementia. The current analysis used general sequential querier (GSEQ) software to analyze behavior sequences of specific behavioral events. We found that older adults with dementia most frequently reacted to elderspeak communication by negative vocalizations (screaming or yelling, negative verbalizations, crying). Because negative vocalizations disrupt nursing care, reduction in elderspeak use by staff may reduce these behaviors thereby increasing the quality of care to these residents. The results clearly demonstrate that sequential analysis of behavioral events is a useful tool in examining complex communicative interactions and targeting specific problem behaviors.

Elderspeak communication: impact on dementia care

Resistiveness to care is common in older adults with dementia. Resistiveness to care disrupts nursing care, increasing costs of care by 30%. Elderspeak (infantilizing communication used by nursing staff) may trigger resistiveness to care in individuals with dementia. Videotaped care episodes (n = 80) of nursing home residents with dementia (n = 20) were coded for type of staff communication (normal talk and elderspeak) and subsequent resident behavior (cooperative or resistive to care). Bayesian statistical analysis tested relationships between staff communication and subsequent resident resistiveness to care. The probability of resistiveness to care varied significantly with communication (Bayes P = .0082). An increased probability of resistiveness to care occurred with elderspeak (.55, 95% CrI, .44-.66), compared with normal talk (.26, 95% CrI, .12-.44). Communication training has been shown to reduce elderspeak and may reduce resistiveness to care in future research.

Practice style in the nursing home: dimensions for assessment and quality improvement

OBJECTIVE

Based on research staff observations during several studies in nursing homes and the findings of other studies, we propose a nomenclature of components of care for the elderly in nursing homes. The paper seeks thereby to operationalize those aspects of the nursing home practice style that can be improved.

METHODS

This operationalization examines two main components (staff and institutional components) of practice style of care in nursing homes. Four domains characterize staff conduct (knowledge, practice style proficiency, flexibility and individualization of care and communication) and three domains define institutional conduct (staff support, resources and flexibility/rigidity of policies).

RESULTS

The paper addresses critical aspects of staff conduct, and by extension, key features that require training, monitoring, and systemic change. Examples for each domain of practice style are provided.

CONCLUSIONS

After systematically reviewing the observations and findings it was concluded that enhancing practice styles in the nursing home requires knowledge, communication, flexibility, understanding, and genuine concern on the part of nursing home staff and administrators at all levels. We acknowledge and understand, of course, that changing practice styles in nursing homes is a difficult and time-consuming process.

Comparison of Caregiver and Occupational Therapist Ratings of Dementia Patients' Performance of Activities of Daily Living

Although proxy reports of activities of daily living (ADLs) are commonly used, especially when the care recipient has dementia, how well these caregiver reports correspond to professionals' ratings is not always clear. In this study, dementia caregivers completed an orally administered version of the Self-Care subscale of the Functional Independence Measure (FIM). ADL interactions were videotaped in the home, and independent raters assigned a FIM score to these interactions. An occupational therapist later viewed the videotaped ADLs and assigned FIM scores to those interactions. These three sets of scores were then compared. All possible correlations were significant (n = 21; p ≤ .005; r s = .620 to .933; Mdn = .862), and there were no significant differences among ratings obtained from the different sources. These results support earlier conclusions regarding the validity and clinical utility of caregiver proxy ratings of functional ability in elders with dementia.

Discomfort and agitation in older adults with dementia

Background

A majority of patients with dementia present behavioral and psychological symptoms, such as agitation, which may increase their suffering, be difficult to manage by caregivers, and precipitate institutionalization. Although internal factors, such as discomfort, may be associated with agitation in patients with dementia, little research has examined this question. The goal of this study is to document the relationship between discomfort and agitation (including agitation subtypes) in older adults suffering from dementia.

Methods

This correlational study used a cross-sectional design. Registered nurses (RNs) provided data on forty-nine residents from three long-term facilities. Discomfort, agitation, level of disability in performing activities of daily living (ADL), and severity of dementia were measured by RNs who were well acquainted with the residents, using the Discomfort Scale for patients with Dementia of the Alzheimer Type, the Cohen-Mansfield Agitation Inventory, the ADL subscale of the Functional Autonomy Measurement System, and the Functional Assessment Staging, respectively. RNs were given two weeks to complete and return all scales (i.e., the Cohen-Mansfield Agitation Inventory was completed at the end of the two weeks and all other scales were answered during this period). Other descriptive variables were obtained from the residents' medical file or care plan.

Results

Hierarchical multiple regression analyses controlling for residents' characteristics (sex, severity of dementia, and disability) show that discomfort explains a significant share of the variance in overall agitation (28%, p < 0.001), non aggressive physical behavior (18%, p < 0.01) and verbally agitated behavior (30%, p < 0.001). No significant relationship is observed between discomfort and aggressive behavior but the power to detect this specific relationship was low.

Conclusion

Our findings provide further evidence of the association between discomfort and agitation in persons with dementia and reveal that this association is particularly strong for verbally agitated behavior and non aggressive physical behavior.

A Case Study of Resistiveness to Care and Elderspeak

Resistiveness to care (RTC) by persons with dementia significantly adds to subjective and objective burden for caregivers and may be triggered by environmental factors, including communication. This case study evaluated behavioral responses of a nursing home resident with dementia to nursing staff use of elderspeak communication (infantilizing speech). Four videotaped staff-resident interactions that were previously recorded were coded for staff elderspeak communication and resident RTC. Total elderspeak scores (M= 29.5,SD= 25.74) and RTC scores (M= 8.75,SD= 13.79) were correlatedr= 0.93,p= .03. This preliminary single-subject observational study suggests a relationship between staff elderspeak communication and RTC in a nursing home resident with dementia that warrants further investigation. Limitations include the use of a convenient case study sample with inability to control time of day, medications, different care activities, staff characteristics, and other factors. Knowledge about communication in dementia care may inform nursing care practices to overcome behavioral symptoms such as RTC and improve quality of life for individuals with dementia and working conditions for nursing staff.

Prevalence and predictors of neuropsychiatric symptoms in cognitively impaired nursing home patients

The prevalence of neuropsychiatric symptoms and the influence of predictive factors in cognitively impaired nursing home patients were reviewed. Articles were identified by means of a MEDLINE and PsychInfo literature search. Neuropsychiatric symptoms were present in more than 80% of the cognitively impaired patients. Prevalences ranged considerably, from 3% to 54% for delusions, 1% to 39% for hallucinations, 8% to 74% for depressed mood, 7% to 69% for anxiety, 17% to 84% for apathy, 48% to 82% for aggression or agitation, and 11% to 44% for physical aggression. Neuropsychiatric symptoms seemed to be predicted not only by dementia type or stage but also by the psychosocial environment and the amount of psychoactive medication and physical restraints used. Neuropsychiatric symptoms are common and influenced by both the disease itself and the psychosocial environment of the institutional setting. The latter may have important consequences for staff planning and education and the future design of care facilities.

Agitation in Dutch institutionalized patients with dementia: factor analysis of the Dutch version of the Cohen-Mansfield Agitation Inventory

BACKGROUND/AIMS

To establish the construct validity of the Dutch version of the Cohen-Mansfield Agitation Inventory (CMAI-D) in institutionalized patients with dementia.

METHODS

The CMAI-D was administered to a large sample of 1,437 patients with moderate to severe dementia, receiving nursing home or outreaching nursing home care. Exploratory factor analysis was used to examine the behavioral dimensions underlying CMAI-D observations.

RESULTS

A restricted 3-factor solution showed 3 factors, i.e. physical aggression, physically nonaggressive behavior and verbally agitated behavior, with prevalences of 62, 67 and 62%, respectively. An unrestricted factor solution revealed 3 additional behavioral dimensions: hiding/hoarding, vocal agitation and a factor of miscellaneous items (i.e. repetitious mannerisms, spitting), which occurred in 30, 28 and 35% of the patients, respectively.

CONCLUSION

The 3-factor solution of physical aggression, physically nonaggressive behavior and verbally agitated behavior corroborates earlier findings in other patient samples and therefore establishes the construct validity in institutionalized patients with severe dementia. The robustness of these findings across different care settings suggests that agitated behaviors have a common basis. In addition, unrestricted factor analysis showed 3 other important independent behavioral symptoms in dementia, but they are in fact too small to be used as a subscale. These findings might add to the taxonomy of agitation and aggression in dementia.

Agitation in dementia: concept clarification

AIM

The aim of this paper is to clarify the concept of agitation in dementia through analysing definitions, critical attributes, components, boundaries, antecedents and consequences of agitation.

BACKGROUND

The concept of agitation is not well defined. In addition, there exists much confusion about the characteristics and boundaries of agitation, as well as the distinction between agitation and related concepts. Recently developed theoretical models for agitation in dementia require new interpretation and conceptualization of agitation.

METHODS

Morse's method of critical appraisal of the literature was used. In addition, some parts of Rodgers' evolutionary method were employed. Data were selected using six electronic databases and the key words 'agitation', 'agitated', 'dementia', 'demented' and 'Alzheimer'. The analysis included 86 empirical or theoretical papers and one book.

RESULTS

A transition from the observer's perspective to the patient's perspective in the interpretation of agitation was found. Five critical attributes of agitation in dementia were identified: excessive, inappropriate, repetitive, non-specific and observable. Patient factors, interpersonal factors, environmental factors and restraint were identified as precipitating antecedents. Mediating antecedents included discomfort, unmet need and misinterpretation. Consequences of agitation were identified at the levels of patient, caregiver and others.

CONCLUSIONS

This transition in perspectives has important implications as it can change health providers' attitudes and responses to agitation and lead to patient-focused and individualized care. Researchers and clinicians are encouraged to avoid labelling agitated behaviour as 'disturbing behaviour'.

Social interaction, premorbid personality, and agitation in nursing home residents with dementia

Agitation is exhibited by most nursing home residents with dementia and is a risk factor for poor health outcomes. Identifying the antecedents of agitation is essential for appropriate treatment because interventions require well-defined targets. This study explored relationships between level of social interaction (high vs. low), the premorbid personality trait of extraversion, and agitation using baseline data from a clinical trial that tested the efficacy of activity interventions for agitation. Most residents exhibited at least one agitated behavior over the 332 observation days. Agitation was significantly greater under high social interaction as compared with low social interaction (P < .0001) regardless of the extraversion score.

Improving outcomes of nursing home interactions

In this study, an intervention designed to improve staff-resident communication was evaluated in three nursing homes. Audio recordings of staff speech from baseline, and immediately and 2 months post-intervention, were compared on elderspeak (infantilizing speech) and rated for care, respect, and control. After the intervention, staff used less elderspeak (i.e., diminutives, collective pronoun substitutions, shortened statements, and simplistic vocabulary). Immediate post-intervention conversations were rated as less controlling, but more respectful and caring. After 2 months, communication was more controlling, less respectful, and less caring. Reduction in staff elderspeak use continued for psycholinguistic measures, but improvements in care, respect, and control decayed, suggesting the need for ongoing reinforcement of training.

Nursing home complaints: who's complaining and what's gender got to do with it?

Long Term Care Ombudsman Complaint data from one state's 261 nursing homes are examined in the study. We assessed differences between male and female groups, including chiefly residents, but also ombudsmen, the residents' relatives or friends, administrators, legal representatives, and others regarding types and rates of complaints as reported in the Administration on Aging (AoA) major categories of: Resident Care, Resident Rights, Administration, Quality of Life, and Complaints Not Against Facility. Proportionately, male residents lodged more complaints than females. Further, males complained more than females about Resident Rights violations and filed more Complaints Not Against Facility. Females lodged significantly more complaints about Care, Quality of Life and Administration.Thus, males were more likely to report technical, impersonal, and legalistic issues, than females, who were more likely to express concerns about personal care and socioemotional-environmental issues. Results yielded further evidence of gender differences in the patterns of resident complaints. Nursing home social workers are highlighted as agents in changing embedded stereotypes about residents and complaints.

Behavioral characteristics of agitated nursing home residents with dementia at the end of life

PURPOSE

The purpose of this study was to examine group differences in verbal agitation, verbal interaction, bed restraint, pain, analgesic and neuroleptic medication use, and medical comorbidity among agitated nursing home residents who died during a 6-month clinical trial compared with residents of the same gender and similar initial cognitive status who did not die during the trial.

DESIGN AND METHODS

We conducted a two-group secondary data analysis of prospective observational data from 10 nursing homes in Birmingham, Alabama. By means of chart review, resident assessments, surveys of certified nursing assistants, and direct observation of residents' daily behaviors and environment, 32 residents (87.34 +/- 7.29 years) with a Mini-Mental State Examination (MMSE) score = 4.31 (+/-5.54) who died were compared with 32 residents (84 +/- 6.96 years) with a mean MMSE score = 4.28 (+/-5.49) who did not die during the clinical trial.

RESULTS

Residents who died displayed more verbal agitation, less time in verbal interaction with staff, and almost twice as much time restrained in bed during observation time in comparison with residents who did not die during the clinical trial. However, groups did not differ significantly in severity of comorbid illness, functional status, number of painful diagnoses, certified nursing assistants' reports of residents' pain, or opioid or nonopioid analgesic prescription or dosage. Surviving residents were more likely to receive neuroleptic medication than residents who died.

IMPLICATIONS

Results suggest that agitated nursing home residents may exhibit a heightened level of verbal agitation, decreased verbal interaction with staff, and increased bed restraint up to 3 months prior to death. Prospective observational studies are needed to identify markers for imminent mortality among nursing home residents.

BEHAVIORS ASSOCIATED WITH DEMENTIA

Seemingly simple adjustments in care routines and approaches can make a significant difference in the experiences of people with dementia. This article provides an overview of cognitive impairment in older adults and suggests interventions that can help providers understand the "behavioral symptoms" of dementia, which are often considered a way of communicating unmet needs. By focusing on the person rather than on the disease, nurses promote comfort and functional autonomy in older adults whose cognitive impairments have progressed and yet who are very much alive and deserving of respectful, dignified care.

A TRAINING PROGRAM FOR Managing Agitation of Residents in Long-Term Care Facilities: DESCRIPTION AND PRELIMINARY FINDINGS

The purpose of this article is to describe a training program for managing agitation of long-term care residents and to report results of a pilot study. The program emphasizes the development of behavioral skills for the assessment, prevention, and reduction of both aggressive and non-aggressive agitated behavior. It includes 8 hours of class instruction followed by 8 hours of weekly supervision by the trainers. The nursing staff of all working shifts of a unit located in a large nursing home and the residents of this unit participated in the pilot study. Residents and staff were assessed prior to and after the 2-month training program. Staff members reported using behavioral techniques to a greater extent and feeling more effective in managing agitation after training. More than 90% of staff members were satisfied with the training program. During the supervision period, the staff developed and implemented individualized interventions for two residents. The interventions involved providing more attention to these residents and, in one case, modifying some aspects of the direct environment which seemed to trigger agitation. Both residents were less agitated after the interventions were implemented. Moreover, there was a reduction in the number and frequency of agitated behaviors for the other residents of the trainees' unit following staff training.

Les symptômes psychologiques et comportementaux de la démence : description et prise en charge

Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences for patients and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD. A committee of geriatricians, neurologists and psychiatrists specialized in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent literature reports, and was adapted to the French environment. This paper is a synthesis of this meeting, validated and corrected by the entire Thema 2 group.

Vocally disruptive behaviour in dementia: development of an evidence based practice guideline

Vocally Disruptive Behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests. It is one of the most challenging behaviours for nursing home staff, caregivers for people with dementia, and other nursing home residents. As with other behavioural disturbances, multiple causal factors have been identified in the literature and individual cases may have a number of interacting factors. There is a lack of consensus about how to treat VDB. Systematic treatment studies are few and there is a lack of empirical data supporting the effectiveness of specific interventions commonly used in clinical practice. This hinders clinicians and may result in the use of inappropriate treatments. Our aim was to systematically review the literature in order to develop a practice guideline for the assessment and management of VDB. The review will examine the typology, risk factors and management of VDB.

Gender Differences in Agitation After Traumatic Brain Injury

OBJECTIVE

To determine sex differences in extent and type of posttraumatic agitation during acute rehabilitation.

DESIGN

This prospective, observational study was performed at a Midwest, regional, university-based acute rehabilitation center.

RESULTS

In a total of 158 subjects, comprising 120 men (76%) and 38 women (24%), there were no significant differences between male and female subjects for age, Glasgow Coma Scale score, Rancho Los Amigos Level of Cognitive Functioning Scale, Mini Mental State Exam, days in acute hospital, and days in rehabilitation. No difference in incidence was observed between sexes based on the criterion of agitation as three or more abnormal total Agitated Behavior Scale scores in 48 hrs (P = 0.890). Also, no difference in posttraumatic agitation between the two sexes (P = 0.396) was observed with the criterion of agitation as two or more abnormal total Agitated Behavior Scale scores in 2 days. There were no differences observed between the sexes for peak intensity and average intensity for the total score or each of the factor scores of the Agitated Behavior Scale.

CONCLUSION

Posttraumatic agitation is seen in approximately 50% of patients after traumatic brain injury and usually lasts for <10 days. There are no significant sex differences in the frequency, duration, presentation, or extent of posttraumatic agitation. These data imply that both sexes, despite any predetermined notions, should be treated equally with respect to posttraumatic agitation management.

Predictors of agitation in nursing home residents

Agitation in nursing home residents presents a serious challenge to caregivers and may place residents at risk for harm. Understanding the etiology of agitation can assist clinicians in developing nonpharmacologic interventions for preventing and treating this problem. The purpose of this study was to examine independent and common predictors of resident agitation with structural equation modeling. Agitation was measured with both a standardized staff report rating scale and direct behavioral observation. No indirect or mediating effects were found. Cognitive impairment, vision and hearing impairment, and gender were found to be independent predictors of agitation as measured by direct behavioral observation. Only cognitive impairment was found to be predictive of agitation as measured by the standardized staff report scale. An unexpected finding was that vision impairment appeared to exert a protective effect for agitation in these severely cognitively impaired residents. The clinical implications of these findings are discussed as well as the relative merits of the two methods of measuring agitation.

Timed-event sequential analysis of agitation in nursing home residents during personal care interactions with nursing assistants

Computer-assisted behavioral observation data were collected from 66 nursing home residents while they received assistance during personal care routines from a certified nursing assistant (CNA). Data were collected both before and after a comprehensive behavior-management and communication-skills training program was delivered to the nursing staff. A total of 30 residents showed 6 or more episodes of disruptive vocalization or other forms of agitation during baseline observations, and timed-event sequential analysis methods were used to test whether certain CNA behaviors either elicited or prevented onsets of agitation in these 30 residents. Simple verbal prompts used by CNAs during personal care routines before staff training were found to elicit agitation onset ( p =.03), whereas positive statements to the resident were found to reduce the likelihood of agitation onset (p =.02). In a previous analysis of the effects of staff training, we found that rates of resident agitation were significantly lower after training compared with baseline and that CNAs increased their rates of positive statements to residents. In the present study, timed-event sequential analyses indicated that the verbal prompts used by CNAs during personal care routines were no longer associated with an increased rate of resident agitation after staff training among the 20 residents who showed 6 or more episodes of agitation both before and after staff training. These findings suggest that the staff training program improved the quality of CNA verbal prompts. The sequential analysis of observational data provides an important method for studying interpersonal interactions, including those of nursing home residents and the nursing staff who care for them.

Recognition and Management of Behavioral Disturbances in Dementia

Behavioral disturbances are seen in most patients with dementia at some point in their course. They cause immense patient suffering and are responsible for caregiver stress, institutionalization, and hospitalization. Identification of predisposing and precipitating factors is very important. The approach to the management of behavioral disturbances in dementia patients should be structured and thorough. Ensuring the safety of the patient and others should be paramount. Addressing the causes of behavioral disturbances such as comorbid medical illnesses, polypharmacy, pain, personal need, environmental factors, etc. is critical to a successful outcome. Many behavioral disturbances such as wandering and hoarding are not amenable to pharmacotherapy. Nonpharmacologic interventions are the mainstay of managing behavioral disturbances. Success of pharmacologic interventions will depend on accurate identification of specific syndromes, e.g., depression-anxiety and psychosis and severity of symptoms. Response to pharmacologic interventions is usually modest and may be associated with significant symptom resolution. Many behavioral disturbances can be prevented by avoiding inappropriate medications and educating patient, family, caregivers, and health care providers. Hospitalization can be avoided and institutionalization delayed by early recognition and treatment of behavioral disturbances. Leadership from physicians to implement preventive measures is recommended. Research to clarify the biological underpinnings of behavioral disturbances and to address cost-effectiveness of currently identified interventions is needed.