Improving documentation of aggressive behavior in 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.

Benefits and challenges of electronic surveillance in nursing home research

Cognitive impairment and frailty associated with dementia renders residents of long-term care (LTC) facilities particularly vulnerable to physical and emotional harm. Resident-to-resident violence affects not only the target of the aggression, but also the aggressor, as well as the formal and informal caregivers who must intervene. To date, little research has been conducted on resident-to-resident violence despite preliminary but emerging evidence that it is a common (and likely growing) problem in LTC settings. Exploration of this phenomenon presents multiple pragmatic and ethical challenges. This article presents a rationale for implementing newer technological methods to collect data in investigations of resident-to-resident violence associated with dementia. The advantages and disadvantages of electronic surveillance in LTC research and the ethical principles involved are discussed, and an argument is developed for using electronic surveillance in both the shared, as well as private, spaces of the facility.

Resident-to-Resident Aggression in Long-Term Care Facilities: An Understudied Problem

Resident-to-resident aggression (RRA) between long-term care residents includes negative and aggressive physical, sexual, or verbal interactions that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Although this problem potentially has high incidence and prevalence and serious consequences for aggressors and victims, it has received little direct attention from researchers to date. This article reviews the limited available literature on this topic as well as relevant research from related areas including: resident violence toward nursing home staff, aggressive behaviors by elderly persons, and community elder abuse. We present hypothesized risk factors for aggressor, victim, and nursing home environment, including issues surrounding cognitive impairment. We discuss methodological challenges to studying RRA and offer suggestions for future research. Finally, we describe the importance of designing effective interventions, despite the lack currently available, and suggest potential areas of future research.

Staff's experience of and the management of violent incidents in elderly care

Violence towards staff has become an important issue, since it has been reported to be common in various health care settings. This study aimed to describe emotional reactions among staff being exposed to violence in residential community care for the elderly: to investigate consequences from violent incidents and to describe the management of violent incidents. Data were collected by telephone interviews with nursing staff reporting incidents of violence. During the period of investigation, 97 of 848 staff (11.4%) reported that they had been exposed to violence. More than one-third of them reported subsequent wound and bruises from the incident and two of the exposed staff consulted a doctor because of the violent incident. The most frequently reported reactions among the staff were aggression, astonishment, and antipathy against the perpetrating care recipient, as well as insufficiency, powerlessness, insult and fear. A majority of the incidents were judged as intentionally perpetuating from the care recipient. Most of the violent incidents were managed by informal discussions in the working team. A low number of the reported incidents of violence involved formal discussions with nurse managers.

Aggressive behaviour and burnout among staff of homes for the elderly

This study examines relationships between experienced aggressive behaviour and burnout of staff caring for residents living in homes for the elderly (n = 551). Burnout was conceptualized as a three-dimensional syndrome consisting of emotional exhaustion, depersonalization and reduced personal accomplishment. From the results of the hierarchical regression analyses it appeared that physical and psychological aggression and the number of weekly working hours had a significant relationship with emotional exhaustion of staff. Psychological aggression was found to have a significant relationship with depersonalization. Neither sex nor age had a relationship with any of the burnout dimensions. Implications for research and suggestions for work and training of staff caring for the elderly are discussed.

Delirium in elderly patients: an overview of the state of the science

Delirium is a common and potentially preventable and reversible cause of functional disability, morbidity, mortality, and increased health care use among elderly individuals. Much has been learned about delirium in the past decade. Highlighted in this article are recent advances in the diagnosis of delirium, delirium in long-term care, use of health care resources, outcomes of delirium, etiologies, and interventions to prevent and treat delirium. Suggestions for future research also are proposed.

Acute confusion indicators: risk factors and prevalence using MDS data

Long-term care (LTC) Minimum Data Set (MDS) data from a Midwestern state were analyzed to validate whether components of a conceptual model developed from findings in acute care identified acute confusion risk variables in LTC. The prevalence of probable acute confusion in this sample was 13.98% (n = 324). Using a cross-sectional design, both univariate and unconditional stepwise logistic regression analyses were accomplished with presence or absence of probable acute confusion as the outcome variable (N = 2,318). Variables significantly related to acute confusion by univariate analysis were included in the logistic regression analysis. Inadequate fluid intake was the first variable to enter the stepwise equation and was highly significant (OR 3.40, 95% CI 2.99-3.81, p < .0001). Other significant variables included a diagnosis of dementia or a fall in the last 30 days. Implications for nursing practice, education and 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.

When caring leaves bruises: the effects of staff education on resident aggression

1. Physical aggression toward nursing staff by confused elderly residents is a very common and frustrating clinical nursing problem in long-term care facilities. 2. Some physical aggression may be associated with a lack of knowledge about dementia, therefore staff inservice education may be one way of reducing some forms of physical aggression. 3. The authors found a 50% reduction in reported physical aggression from elderly residents after a staff education program on dementia and aggression was implemented.

Nurses Helping Nurses Development of Internal Specialists in Long-Term Care

The prevalence of psychiatric disorders and behavioral disturbances among nursing home residents, combined with observed deficits in geriatric mental health/illness expertise among LTC staff, supports the need for creative approaches to improve the knowledge, understanding, and management of such problems among LTC providers. The train-the-trainer model described in this article proved to be a viable method to providing geriatric mental health consultation and training that targets both improved quality of life for residents and quality of work life for the staff in charge of residents' care. More collaborative efforts among nursing specialists, subspecialists, and generalists are needed to empower those who work in LTC to utilize strengths and abilities inherent to their positions. Nursing homes nurses, who are all too familiar with the problems and challenges of their patient population, may act not only as mental health trainers but also as resource persons, role models, liaisons with geropsychiatric specialists, and leaders in the application of geropsychiatric care principles to residents within their facility, thus promoting improved resident and staff care alike.

Nurses helping nurses: development of internal specialists in long-term care

1. Too often, expert assistance provided by psychiatrists and psychiatric nurse specialists to long-term care (LTC) providers of geriatric patients is short-lived and not effective in helping LTC staff deal with their patient's behavioral and psychological problems. 2. One of the main objectives of the study--and one that was found to have positive results--was to provide a mechanism by which LTC staff could develop their own expertise in the management of behaviorally difficult residents. 3. More collaborative efforts among nursing specialists, subspecialists, and generalists are needed to empower those who work in LTC to utilize the abilities and strengths inherent in their positions.

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.