Behavioral approaches for reducing agitation in residents of long-term-care facilities: critical review and suggestions for future research

Disruptive behaviors in individuals with Alzheimer's disease: A behavioral approach

Many patients with Alzheimer's disease (AD) demonstrate disruptive behaviors that are distressing to themselves and to their caregivers. This article will examine how to use a behavioral approach to help manage such behaviors. The approach is based on four steps involving the clinician and the caregiver:

• Analysis of the behavior

• Identification of behavioral strategies

• Choice and implementation of a behavioral intervention

• Evaluation followed by modification of the plan as required.

A synopsis of available behavioral strategies are included here to help the clinician discuss alternatives with caregivers.

Determinants of Neuroleptic Drug Use in Long-Term Facilities for Elderly Persons

Neuroleptics, also called antipsychotic drugs (e.g., haloperidol, risperidone) are the cornerstone drug therapy for psychiatric disorders. Despite the fact that they are widely used in nursing homes, little is known about their clinical determinants. The goal of this cross-sectional study was to determine the prevalence rate of neuroleptic administration and to identify their determinants among 2,332 elderly residents in nursing homes. Among the residents, 649 (27.8%) had taken at least one neuroleptic drug. According to the logistic regression, the factors associated with neuroleptic drug consumption were younger age, few hours of family visits, severe cognitive impairment, insomnia, physical restraint, and disruptive behavior. In conclusion, neuroleptic drugs are administered to more than a quarter of residents in nursing homes. Alternative solutions to sleep problems and disruptive behaviors of the elderly living in long-term-care facilities should be implemented in order to reduce unnecessary use of neuroleptics.

Change and predictors of change in social skills of nursing home residents with dementia

BACKGROUND

Social skills are of primary importance for those with dementia and their care providers, yet we know little about the extent to which basic social skills can be maintained over time and the predictors of change.

METHODS

A total of 18 nursing homes with 149 newly admitted residents with moderate to severe dementia, 195 direct care staff, and 135 family members, in British Columbia, Canada, contributed data on change in social skills from admission to 6 months and 1 year later.

RESULTS

Three-quarters of residents maintained or improved their basic social skills during both the time periods. Decline was explained primarily by cognitive status at the time of admission, notably present orientation. However, staff-to-resident communication becomes more important over time.

CONCLUSIONS

Social skills appear to present an opportunity to maintain interaction with these residents. The findings also suggest that a focus on the present orientation before and following admission and on staff-to-resident communication may be beneficial.

The effects of enhanced program review and staff training on the management of aggression among clients in a long-term neurobehavioral rehabilitation program

OBJECTIVE

This article examined the effects of staff training, staff support groups, and increased client behavior monitoring on the rate of physical aggression toward peers and objects in an older neurobehavioral population treated in a long-term neurorehabilitation program.

METHODS

During the 15 months of data collection, programmatic enhancements were introduced including: Staff training and support groups, comprehensive assessment and individualized program development, and client-centered weekly and systemic monthly behavior management review. Incidents of physical aggression were assessed using staff report. Data were corroborated using multiple sources including, medical records, written incident reports, and Overt Aggression Scale-Modified for Neurorehabilitation - Extended (OAS-MNR-E).

RESULTS

A total of 267 clients were present in the facility during the reporting period. The clients had neurobehavioral disability of various origins, 73% had a psychiatric diagnosis in addition to one or more medical diagnoses, and 58% had a dementia diagnosis. An already low rate of incidents of physical aggression per client month (0.02) was reduced by 77% following the implementation of programmatic enhancements.

CONCLUSION

Enhanced systematic behavioral review of clients provided concurrently with staff training in non-aversive principles and ongoing staff support groups reduced the incidents of behavioral disregulation in older persons with psychiatric diagnoses, medical comorbidities, and neurobehavioral disabilities.

The use of behavioural reinforcement in the management of behaviours of concern associated with dementia

EXECUTIVE SUMMARY

Introduction People with dementia often require high-level care due to behaviours that are associated with dementia such as verbal and physical aggression. Behavioural therapies that utilise approaches such as behavioural reinforcement are one possible strategy to manage such behaviours.Aims The objective of this review was to synthesise the best available evidence in relation to the use of behavioural reinforcement in the management of behaviours associated with dementia.

INCLUSION CRITERIA

Types of participants Participants were adults aged over 60 years who had a clinical diagnosis of dementia and who exhibited any of the following behaviours associated with dementia e.g. verbal and physical aggression, vocalisations and wandering.Types of intervention Any behaviour therapy modality that used reinforcement techniques was considered.Types of outcomes The outcome of interest was a change in the behaviour associated with dementia.Types of studies Any quantitative or qualitative study designs were considered. In the absence of high quality studies, designs such as case series were considered.Search strategy The search strategy aimed to find both published and unpublished studies using a three-step approach. Papers were limited to the English language and a date restriction of 1990 to 2009 was set.

METHODS OF REVIEW

Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion.Data extraction Quantitative data was extracted from papers included in the review using a standardised data extraction tool.Data synthesis Only quantitative papers met the review's inclusion criteria and were subsequently included. Due to the heterogeneity in the study design, populations, interventions and outcomes of papers, meta-analyses could not be undertaken. A narrative summary of each paper is thus provided.Results Only five papers were included; one repeated measures quasi-experimental study, three case series and one case report. Priority was given to the quasi-experimental study due to its design and quality score. The methodological quality of the other papers was weak. In total only eleven subjects were included that focussed on different schedules of reinforcement and different behaviours. The quasi-experimental study did not demonstrate significant results between presenting a visual stimulus continuously or intermittently and wandering. The preliminary evidence from the case series/report all reported a reduction in the undesirable behaviour following implementation of a reinforcement method.Conclusions Due to the evidence currently available, the utilisation of reinforcement approaches to assist in reducing or eliminating behaviours associated with dementia can be neither recommended nor refuted.Implications for practice There is weak evidence to suggest that implementing a reinforcement schedule may reduce behaviours such as physical or verbal aggression and vocalisations. The evidence for wandering is equivocal. Making a decision to utilise this type of behavioural approach should be based on clinical judgement, the preference of the patient or family and the context in which the care is delivered.Implications for research Due to the limited available evidence on this topic that can only provide weak empirical evidence, further experimental investigations such as controlled trials should be conducted to test the hypothesis that reinforcement strategies may assist in reducing or eliminating behaviour/s associated with dementia.

Efficacy of integrated interventions combining psychiatric care and nursing home care for nursing home residents: a review of the literature

BACKGROUND

Nursing home residents needing both psychiatric care and nursing home care for either somatic illness or dementia combined with psychiatric disorders or severe behavioural problems are referred to as Double Care Demanding patients, or DCD patients. Integrated models of care seem to be necessary in order to improve the well-being of these residents.

OBJECTIVES

Two research questions were addressed. First, which integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are described in the research literature? And second, which outcomes of integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are reported in the literature?

METHOD

A critical review of studies was done that involved integrated interventions combining both psychiatric care and nursing home care on psychiatric disorders and severe behavioural problems in nursing home patients. A systematic literature search was performed in a number of international databases.

RESULTS

Eight intervention trials, including four RCTs (2b level of evidence), were identified as relevant studies for the purpose of this review. Seven studies, three of which were RCTs, showed beneficial effects of a comprehensive, integrated multidisciplinary approach combining medical, psychiatric and nursing interventions on severe behavioural problems in DCD nursing home patients.

CONCLUSIONS

Important elements of a successful treatment strategy for DCD nursing home patients include a thorough assessment of psychiatric, medical and environmental causes as well as programmes for teaching behavioural management skills to nurses. DCD nursing home patients were found to benefit from short-term mental hospital admission.This review underlines the need for more rigorously designed studies to assess the effects of a comprehensive, integrated multidisciplinary approach towards DCD nursing home residents.

Managing disruptive behaviors with neuroleptics: treatment options for older adults in nursing homes

Disruptive behaviors are frequent among elderly individuals in long-term care centers. Neuroleptics remain the most common pharmacological treatment for controlling these challenging behavioral manifestations. However, their effectiveness is a subject of controversy and it is unclear what specific behaviors are more likely to be managed with neuroleptic medications. The objective of this study was to identify the types of disruptive behaviors for which neuroleptics are given to elderly individuals in long-term care facilities and determine if the frequency of these behaviors increases the risk of being prescribed neuroleptics. A cross-sectional study was conducted with 2,332 participants ages 65 or older living in 28 long-term care facilities. Among them, 27.8% had taken at least one neuroleptic drug in the prior week. The administration of neuroleptics was not linked to the presence of any one specific disruptive behavior. However, a significant finding was that the greater the frequency of disruptive behavior exhibited by an elderly individual, the greater the risk of them being administered a neuroleptic medication. A multi-dimensional approach to the assessment of disruptive behaviors is recommended to facilitate the identification of the underlying causes of those behaviors. Accordingly, it is suggested that non-pharmacological treatment plans be adapted to each situation and then implemented to potentially reduce the use of neuroleptics.

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.

Measuring and enhancing self-efficacy among professional caregivers of individuals with dementia

Nurses who provide care for individuals with Alzheimer's disease and other dementias are at risk of burnout. Self-efficacy is a psychological construct with the potential to help reduce or prevent the impact of caregiver stress. Evidence supporting a link between higher levels of self-efficacy and lower levels of stress is emerging among lay caregivers. However, concurrent research for professional caregivers lags behind, partly due to a lack of appropriate self-efficacy measures for this population. We developed an intervention to enhance self-efficacy and an inventory to measure its improvements among long-term care nurses. Training resulted in lasting improvements in knowledge and self-efficacy regarding the management of challenging team, resident, and family situations. Short-term reductions in caregiver burnout were also evident. Suggestions for maintaining improvements in caregiver burnout over longer periods are offered.

Improving geriatric mental health nursing care: making a case for going beyond psychotropic medications

Providing high-quality mental health nursing care should be an important and continuous preoccupation in the gerontological nursing field. As the proportion of elderly people in our society is growing, the emphasis on high-quality care will receive increasing attention from administrators, politicians, organized groups, researchers and clinical nurses. Recent findings illustrate unequivocally the important contribution of nurses to achieving the goal of high-quality geriatric care. However, the quality of care for the elderly with psychological difficulties has not been addressed. The objective of this article is to illustrate that while nurses can accomplish much to improve the well-being and mental health of the elderly, their skills are often underutilized. Psychotropic drugs are often the first-line interventions used by health-care professionals to treat mental health concerns of elderly persons. Alternative therapies that could be implemented and evaluated, such as psychological counselling, supportive counselling, education and life review, are infrequently used. Nevertheless, current scientific data suggest that it would be very advantageous if nurses were to play a dominant role in the care of elderly people who are depressed or experiencing sleep pattern disturbances. The same can be said about elderly chronic users of benzodiazepines, as well as those with cognitive impairment. Evidence for the use of psychotropic medications as a viable treatment option for the elderly both in the community and in the long-term care setting who are experiencing mental health challenges is examined. Alternative non-pharmacological approaches that nurses can use to augment care are also briefly discussed.

Assessment of behavioral and psychological symptoms of dementia

In spite of their prevalence and persistence, why are behavioral and psychological symptoms of dementia difficult for clinicians to assess and manage? This paper provides an overview of the methodological challenges encountered in measuring behavioral disturbances of dementia. Specifically, conceptual constructs of behavioral and psychological symptoms of dementia, the strengths and weaknesses of the currently existing rating instruments, analytic methodologies, and the utility of technological devices are outlined in the service of formulating future directions in behavioral and psychological symptoms of dementia assessment research.

Theory-based intervention for dementia behaviors: a within-person analysis over time

The historic "black-box" approach to treatment effectiveness research has hampered the development of effective activity interventions for persons with dementia. The purpose of this case study is to test the effectiveness of activities derived from the Need-Driven Dementia-Compromised Behavior Model. Activities that matched skill level and personality style of interest resulted in a pattern of greater time on task (p =.0012), participation (p =.004), and positive mood (p =.0001) and fewer dementia-related behaviors (p =.009) compared with activities matched to skill level only. Practitioners may improve behavioral outcomes for persons with dementia by prescribing activities based on an assessment of skill level and style of interest.

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.

Dimensions of care for dementia sufferers in long-term care institutions: are they related to outcomes?

OBJECTIVES

This study empirically examined whether dimensions of care cluster in special care units (SCUs) compared with non-SCUs. The relationship between SCU status plus separate measures of the dimensions of care and outcomes for dementia sufferers was then investigated.

METHODS

Data were drawn from the Intermediate Care Facility Project. The sample (N = 510) included residents with dementia, aged 65 and older, in intermediate care facilities throughout the province of British Columbia. Canada. Longitudinal data included 6 outcomes: cognitive function, behavioral problems of agitation and social skills, physical functioning, and quality of life measured through affect and expressive language skills. Separate multiple linear regression equations were estimated, relating each of these outcomes to 5 dimensions of care: preadmission and admission procedures. staff training and education, nonuse of physical and chemical restraints, flexible care routines and resident-relevant activities, and the environment.

RESULTS

The results showed there is virtually no clustering of dimensions along SCU/non-SCU lines. Neither SCU status nor the individual dimensions were highly predictive of outcomes. Residents' affect at t1 emerged as a characteristic that was significantly correlated with other outcomes.

DISCUSSION

This Canadian research can be added to the few but growing number of rigorous studies that suggest SCUs are not homogeneous and do not necessarily provide better care than non-SCUs. Moreover, it raises questions about the benefits of "best practice" dimensions of care, regardless of SCU status.