Caregivers' perception of aggressive behavior in cognitively impaired nursing home residents

Bathing the Alzheimer's patient in long term care: Results and recommendations from three studies

In the management of persons with Alzheimer's disease and related dementias, bathing constitutes a major source of agitation and discomfort for care recipients, and represents a significant job stress for caregivers. This paper reports three studies that were conducted in nursing facilities to help guide staff and administrators in efforts to improve resident bathing. The first study, a mail survey of nursing directors or charge nurses in 71 skilled care facilities, documented a high level of problematic behaviors (43.2 percent) during bathing of residents with dementia, a concomitant low level of satisfaction (50.7 percent) with bathing, and a wide range of recommended environmental modifications to improve bathing areas. The second study, a review of 515 incident reports from bathing areas in 25 nursing homes, found that agitation was rarely reported, and that the majority of injuries occurred when a caregiver was absent. The third study, a critical review of 14 specialized tubs in terms of suitability for the Alzheimer patient, found wide differences in accessibility for caregivers, disinfection times, reported safety and repair records, and suitabilityfor persons at various stages of dementia. The results of these studies provide practical recommendations for nursing facilities, domiciliary care settings, and home caregivers interested in improving the bathing process for persons with Alzheimer's disease.

Japanese care workers' perception of dementia-related physically and psychologically aggressive behaviour symptoms

AIM

The purpose of this study was to explore Japanese care workers' attributions, beliefs and cultural explanations of physically and psychologically aggressive behaviour symptoms.

BACKGROUND

Physically and psychologically aggressive behaviour symptoms by older people with dementia have been associated with occupational stress among care workers in the United States and other Western countries and may contribute to staff turnover. However, few studies related to this issue have been conducted in Japan, where care worker reaction to physically and psychologically aggressive behaviour symptoms might be different because of cultural and customary differences in how care is provided for older people.

METHOD

This study reports on the results of three open-ended questions that were part of a larger study that explored Japanese care workers' experiences with aggressive behaviour symptoms in persons with dementia. Convenience sampling was used to recruit 137 care workers in 10 nursing homes in the northern and western areas of Japan. The answers to the open-ended questions were analysed using a content analysis.

FINDINGS

Most of the participants indicated that they believed that physically and psychologically aggressive behaviour symptoms came from residents' stress from dementia. Approximately, one-fourth of the participants responded that Japanese values such as chu (loyalty) and joge (hierarchy) influenced their work with residents with physically and psychologically aggressive behaviour symptoms. Seventeen participants (12%) commented either that they respected older people or that they respected older people as persons who had had many experiences in life. Interestingly, 43 responses (41.0%) indicated that physically and psychologically aggressive behaviour symptoms influenced quality of care positively, while, not surprisingly, about 30 responses indicated that those behaviour symptoms influenced quality of care negatively.

IMPLICATIONS FOR PRACTICE

Findings from this study indicate that the training and education needs to focus on understand and preventing the effects of stress for individuals living with dementia to reduce aggressive incidents and increase recruitment and retention of care workers.

Bathing residents with dementia in long-term care: critical incidents described by personal support workers

AIM AND OBJECTIVE

The aim of this study was to describe and gain insight into the critical incidents depicted by personal support workers (PSWs) in long-term care (LTC) related to bathing residents who have dementia.

BACKGROUND

Residents with dementia in LTC often display responsive/protective behaviours during bathing. Consequently, bathing is a source of stress for PSWs who provide most of the personal care for LTC residents in Ontario, Canada.

DESIGN

A qualitative descriptive study employing the critical incident technique (CIT) was used.

METHOD

Eight PSWs were interviewed and 24 incidents were collected and analyzed using thematic content analysis.

RESULTS

Findings revealed that PSWs experience the following during bathing: managing responsive/protective behaviours, working with limited resources, and dealing with communication difficulties. Participants used various strategies to respond to these challenges; however, they reported limited strategies to manage the most challenging behaviours.

CONCLUSIONS

Many of the bathing strategies described by the PSWs in this study are found in the literature about best bathing practices in dementia care. However, it is evident that further work is needed to support PSWs to manage the most difficult physical responsive/protective behaviours that occur during bathing.

IMPLICATIONS FOR PRACTICE

This study has clear implications for knowledge translation.

Failure to identify behavioral symptoms of people with dementia and the need for follow-up physical assessment

This descriptively designed study examined the sensitivity and specificity of staff nurses' identification of behavior change in nursing home residents with dementia. Behavior changes and whether further physical assessment was indicated were described and compared with judgments made by one expert advanced practice nurse. The convenience sample included 155 residents and 38 staff nurses from 11 nursing homes. Verbal symptoms and body part cues were the most prevalent behaviors, regardless of the assessor. Sensitivity, or probability of identifying a real behavior change, was generally low for the staff nurses, ranging from 35% to 65% for the different types of behaviors, while specificity was high at more than 95%. Additional assessment was believed to be needed for 51% of residents by the staff nurse and for 73% of residents by the expert. This study found that staff nurses are under-identifying behavior changes and the need for additional physical assessment.

Effect of Person-Centered Showering and the Towel Bath on Bathing-Associated Aggression, Agitation, and Discomfort in Nursing Home Residents with Dementia: A Randomized, Controlled Trial

OBJECTIVES

To evaluate the efficacy of two nonpharmacological techniques in reducing agitation, aggression, and discomfort in nursing home residents with dementia. The techniques evaluated were person-centered showering and the towel bath (a person-centered, in-bed bag-bath with no-rinse soap).

DESIGN

A randomized, controlled trial, with a usual-care control group and two experimental groups, with crossover.

SETTING

Nine skilled nursing facilities in Oregon and six in North Carolina.

PARTICIPANTS

Seventy-three residents with agitation during bathing (69 completed the trial) and 37 nursing assistants who bathed them.

MEASUREMENTS

Agitation and aggression were measured using the Care Recipient Behavior Assessment; discomfort was measured using a modification of the Discomfort Scale for Dementia of the Alzheimer Type. Raters who were blinded to subject status coded both from videotaped baths. Secondary measures of effect included bath duration, bath completeness, skin condition, and skin microbial flora.

RESULTS

All measures of agitation and aggression declined significantly in both treatment groups but not in the control group, with aggressive incidents declining 53% in the person-centered shower group (P<.001) and 60% in the towel-bath group (P<.001). Discomfort scores also declined significantly in both intervention groups (P<.001) but not in the control group. The two interventions did not differ in agitation/aggression reduction, but discomfort was less with the towel bath (P=.003). Average bath duration increased significantly (by a mean of 3.3 minutes) with person-centered showering but not with the towel bath. Neither intervention resulted in fewer body parts being bathed; both improved skin condition; and neither increased colonization with potentially pathogenic bacteria, corynebacteria, or Candida albicans.

CONCLUSION

Person-centered showering and the towel bath constitute safe, effective methods of reducing agitation, aggression, and discomfort during bathing of persons with dementia.

Assaultive Behavior in Alzheimer's Disease: IDENTIFYING IMMEDIATE ANTECEDENTS DURING BATHING

To identify immediate antecedents of bathing-related physical assaults against caregivers by nursing home residents with Alzheimer's disease and related disorders, videotapes of nursing home residents who physically assaulted nursing assistants during baths were analyzed. Caregiver behaviors that occurred significantly (p < .01) more often during the 5 seconds preceding an assault included: calling the resident by name, confrontational communication, invalidation of the resident's feelings, failure to prepare the resident for a task, disrespectful speech, any touch, absence of physical restraint, and hurried pace of bath. Assaults were significantly more likely when caregivers sprayed water without a verbal prompt; the resident's feet, axilla, or perineum were touched; residents exhibited signs of temperature discomfort; and multiple caregivers were present. Improved caregiver training and individualized, gentler bathing methods should be investigated as methods of reducing assaults.

Bathing. Pleasure or pain?

Bathing creates some of the highest levels of discomfort in the lives of individuals diagnosed with dementia. The present study measured the frequency of 14 agitated behaviors during bathing in 15 elderly residents with dementia residing in a continuing care center. Each resident was observed for four sessions of two different bathing methods, the conventional tub bath and a modification of the bed bath, known as the Thermal bath. The summed frequencies of all agitated behaviors was significantly less for the Thermal bath than the tub bath. This overall effect was greater in men than women and in one particular behavior, shivering. The results suggest that for individuals with dementia the Thermal bath offers a viable alternative to the conventional tub method. Further research may clarify other parameters, such as cost effectiveness and long-term effects of the use of non-rinse cleansers for elderly individuals.

Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers

OBJECTIVE

To conduct a controlled investigation to examine the effects of an abilities-focused program of morning care on the interaction behaviors and functioning of residents with dementia and on caregivers' interaction behaviors and perceptions of caregiving.

DESIGN

A quasi-experimental, repeated measures design.

SETTING

The study was conducted on four, nursing-home-level cognitive supports units in a geriatric care center. One of the units was randomly selected as the experimental unit; the other three served as controls.

PARTICIPANTS

The final sample consisted of 40 residents (20 each in the experimental and three control groups) and 44 caregivers (16 on the experimental unit and 28 on the three control units).

INTERVENTION

An educational program on delivering abilities-focused morning care, designed by the authors, was provided to caregivers on the experimental unit.

MEASUREMENTS

Measures were taken at baseline and at 3 and 6 months postintervention with regard to residents' interaction behaviors, level of agitation, and level of function and to caregivers' interaction behaviors, perceived ease of caregiving, and level of stress.

RESULTS

Repeated measures analysis of variance (RM-ANOVA) was used to compare the experimental and control groups in regard to changes in the outcomes over time. Results indicated that the abilities-focused program had statistically significant effects on (a) residents' personal attending and calm/functional behaviors, level of agitation, and levels of overall and social function, and (b) caregivers' verbal relevance and personal attending, relaxed, and social/flexible behaviors.

CONCLUSIONS

The evidence suggests that both residents and caregivers benefit from morning care that is oriented toward the abilities of people with dementia.

Identifying patterns of disruptive behavior in long-term care residents

OBJECTIVES

To determine the frequency, timing, and pattern of 45 operationalized disruptive behaviors (DB) in older people in long-term care units.

DESIGN

Nursing staff collected prospective descriptive data over 21 consecutive shifts for each patient to document prevalence, frequency, and co-occurrences of DBs.

SETTING

All of the eight long-term care units and one acute/admission unit of a large Veterans Administration Medical Center (VAMC). Each 40-bed unit had patients with varying levels of cognitive impairment and skilled nursing needs.

PARTICIPANTS

The sample consisted of 240 hospitalized VA patients with a mean age of 72.8 (SD = 8.6) years and mean length of stay of 4.02 (SD = 8.6) years. Residents had dementia, a psychiatric diagnosis, or mixed dementia and psychiatric diagnoses.

MEASUREMENTS

The Disruptive Behavior Scale (DBS), an instrument designed for collecting patient-level data on 45 separate DBs.

RESULTS

In a 24-hour period, the average frequency was 3.6 DBs per subject. We found that 41.2% of DB occurred during the day shift, 39.2% during the evening shift, and 19.6% during the night shift. In 32% of observed occurrences, only one DB occurred within the hour. In the remaining 68% of observations, two or more DBs occurred within the same hour. We found two behaviors, Does Not Follow Directions and Excessive Motor Activity, to occur with multiple behaviors in multiple categories. Several characteristic patterns were noted; e.g., physically aggressive behaviors rarely co-occurred with verbal DBs. Physically nonaggressive behaviors seemed to occur most frequently with other physically nonaggressive behaviors and, to a lesser extent, with verbal DBs.

CONCLUSIONS

These findings lend support to the existence of patterns of DBs in long-term care patients, a useful step toward targeting interventions early in the behavioral sequence.

The effectiveness of slow-stroke massage in diffusing agitated behaviors in individuals with Alzheimer's disease

Agitated behaviors of individuals with Alzheimer's disease (AD), often endured or unsuccessfully treated with chemical or physical restraints, markedly increase the stress levels of family caregivers. The Theoretical Model for Aggression in the Cognitively Impaired guided the examination of caregiver-provided slow-stroke massage on the diffusion of actual and potential agitation for community-dwelling individuals with AD. Characteristics and frequency of agitation were quantified by two highly correlated instruments, the Agitated Behavior Rating Scale Scoring Guide and the Brief Behavior Symptom Rating Scale. Expressions of agitation of patients with AD increased in a linear pattern from dawn to dusk. Verbal displays of agitation, the most frequently cited form of agitation in community-dwelling individuals with AD, were not diffused by slow-stroke massage. However, the more physical expressions of agitation such as pacing, wandering, and resisting were decreased when slow-stroke massage was applied. This study contributes to building a body of knowledge regarding the phenomenon of agitated behaviors in cognitively impaired elderly individuals--its nature, frequency of occurrence, measurement, associated factors, and management.

Severe disruptive vocalizers

OBJECTIVES

To describe the most severe disruptive vocalizers in nursing facilities, in regard to their clinical and behavioral characteristics, staff responses, and treatments used, and to report on their prognosis over 6 months.

DESIGN

A longitudinal cohort study.

SETTING

One hundred seven skilled nursing facilities.

PARTICIPANTS

The 203 residents who were among the two most disruptive vocalizers in their respective facilities and who vocalized at least 2 hours a day.

MEASUREMENTS

Telephone interviews of licensed nursing staff who cared for the subjects, conducted at baseline, 2, 4, and 6 months. Data gathered included subject demographics, physical function, diagnoses, medication and restraint use, behavioral problems, vocalization characteristics, treatments used, and status at follow-up.

RESULTS

Subjects tended to have dementia, to be dependent in most activities of daily living, to have multiple medical problems, to be physically restrained (48%), and to be taking psychotropic medication (76%). Nearly all (95%) were audible at least 50 feet away, with loudness associated with more severe cognitive impairment (OR 4.90, P = .001). When subjects who primarily made nonverbal noises ("screamers") were compared with those whose predominant expressions were words ("talkers"), hearing impairment, severe cognitive impairment, and greater dependency in activities of daily living characterized the screamers. Staff reported trying a variety of treatments with all subjects, often with little success. Two months after enrollment, 66% of surviving subjects vocalized fewer hours than at baseline, and 45% were rated as improved. Independent predictors of improvement included greater ADL independence, hearing and vision problems, shorter length of stay, urinary incontinence, and use of a treatment other than one-on-one interventions. Nearly one-quarter of subjects (23.4%) died within 6 months. Baseline factors associated independently with a higher probability of death included age, use of activity intervention, physical abusiveness, and absence of wandering.

CONCLUSION

Severe disruptive vocalization is associated with severe cognitive and physical impairment and with a high probability of mortality within 6 months. Subcategorization of severe vocalizers by vocalization type or other associated factors may be useful for prognostic and treatment purposes.

Development and testing of the Resistiveness to Care Scale

A conceptual model and objective scale for measuring resistiveness to care in individuals with advanced dementia of the Alzheimer type (DAT) were empirically generated from the perspective of nursing staff caregivers and through observation of residents with DAT. The resistiveness to care scale (RTC-DAT) was judged to have content validity and reduced to 13 items. Quantifiable scoring procedures and methods for rating videotapes and conducting clinical observations were developed. The RTC-DAT was tested with 68 subjects at three sites. The RTC has a range of 0-156. Initial testing provided reliability estimates of .82-.87 for internal consistency and good to excellent kappas. Criterion-related validity with observed discomfort and construct validity by factor analysis support the RTC-DAT. Measurement issues and recommendations for use in research are discussed.

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.

Physical aggressive resident behavior during hygienic care

Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Act (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was identified as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.

The effects of language used by caregivers on agitation in residents with dementia

In this study, We addressed the problem of whether residents with a diagnosis of dementia would become agitated if given verbal commands at a level of language complexity above their comprehension ability. The study used an A-B-A research design. The convenience sample of 15 subjects was comprised of 11 men and 4 women who resided in a long-term care institution. Their mean age was 86.6 years, and their average length of stay in the institution was 317.3 days. The results lent support to the hypothesis that exposing residents with dementia to language beyond their comprehension ability could result in agitated behavior. The predominant manifestations of agitation were general restlessness, strange noises, and negativism. An important implication for nursing practice is that the language used by caregivers should match the comprehension ability of residents. Caregiving can thereby facilitate communication and, potentially, prevent agitation.

Cognitive developmental approach to dementia

Systematic observations of people suffering from dementia of the Alzheimer's type (DAT) reveal they regress in behavior and become childlike. These observations have been used to structure clinical research and therapeutic interventions for dementia patients. However, no concise framework explains successful caregiving. Models for care exist but they lack an adequate framework for the long-term care of a person with DAT. This state of the science review describes what is known about cognitive functioning in people with DAT. It examines studies based on cognitive functioning. It also then relates this information to an emerging theory tentatively identified as a "cognitive developmental approach" which may be useful for understanding people with dementia and for predicting caregiver requirements.

Managing disruptive responses to bathing by elderly residents. Strategies for the cognitively impaired

1. Persons with altered cognition are more prone to display inappropriate behaviors because of decreased ability to accurately interpret environmental cues, and increased frustration in combination with reduced inhibition. 2. Disruptive and agitated behaviors are commonly associated with the provision of assistance with activities of daily living, particularly bathing and dressing. 3. A preventive approach intended to reduce the occurrence of distress and disruptive behaviors in cognitively impaired residents during showering and bathing respects long-standing routines and preferences of the patient.

Aggressive behaviors among the institutionalized elderly

OBJECTIVE

To describe the incidence and characteristics of aggressive behaviors in a group of institutionalized elderly.

DESIGN

Retrospective survey.

SETTING

350-bed, urban skilled nursing facility.

PATIENTS

All nursing home residents who had an incident report completed after an aggressive behavior.

MEASUREMENTS

Examination of all incident reports of aggressive behavior for 1 year.

RESULTS

There were 94 reports of aggressive behaviors. Twenty-nine residents exhibited one aggressive behavior, 12 residents two, and six residents exhibited three or more aggressive behaviors. These six residents accounted for 44% of all events. The incidence of aggressive behavior was 0.27 per resident per year for the entire facility; on the Alzheimer's unit the incidence was 0.75 per resident per year. Sixty-two percent of the victims of aggressive behavior were other nursing home residents, 37% were employees, and 1% were visitors. The charts of the six residents with three or more aggressive behaviors were reviewed. These residents received trials of multiple scheduled psychotropic medications, often exhibited several additional agitated behaviors around the time of the attack, were at risk for psychiatric hospitalizations during the study period, and often were noted to have underlying acute medical illnesses near the time of the attack.

CONCLUSION

Approximately two aggressive behaviors per week occurred in a large nursing home. Residents and staff of Alzheimer's units have a higher risk of being victims of aggressive behavior. A small number of patients account for nearly half of the behaviors, even on the Alzheimer's unit. Aggressive behaviors may be clinical indicators of underlying acute medical illnesses.

Aggressive behavior. Educating nursing assistants

Caring for cognitively impaired aggressive residents presents a challenge to nursing assistants in long-term care facilities. Nursing assistants participated in an educational program that included content about cognitive losses, precipitants of aggression, communication techniques, strategies for preventing aggressive behavior, and managing personal feelings. Following the educational intervention in this study, nursing assistants reported that caring for cognitively impaired residents was significantly more rewarding and less frustrating. The use of the clinical nurse specialist to teach and assist in role modeling direct care of residents was effective in improving nursing assistant skill in working with aggressive cognitively impaired residents.