Which unmet needs contribute to behavior problems in persons with advanced dementia?

The Unmet Needs Model states that problem behaviors of people with dementia result from unmet needs stemming from a decreased ability to communicate those needs and to provide for oneself. The purpose of this study is to describe the unmet needs of persons with dementia exhibiting behavior problems. Eighty-nine residents with dementia from six Maryland nursing homes were assessed by research assistants and nursing assistants for their unmet needs using multiple assessment tools. Three unmet needs per resident were identified on average, with informants rating boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activity as the most prevalent needs. Discomfort was associated with higher levels of verbally agitated behaviors (e.g., complaining). Based on results and independent ratings of pain, the authors estimate notable under-detection of discomfort and pain by both types of informants. The study demonstrates methodologies for uncovering unmet needs among persons with dementia and highlights the importance of developing programs that address those unmet needs, especially social and activity needs of nursing home residents. The detection of pain, and possibly that of discomfort, may require a different methodology.

The use and utility of specific nonpharmacological interventions for behavioral symptoms in dementia: an exploratory study

OBJECTIVE

This study compares different nonpharmacological interventions for persons with behavioral symptoms and dementia on frequency of use and perceived efficacy in terms of change in behavior and interest.

METHODS

Participants were 89 nursing home residents from six Maryland nursing homes with a mean age of 85.9 years (SD: 8.6 years). Research assistants presented interventions tailored to the participants' needs and preferences in a pre-intervention trial phase and in an intervention phase. The impact of each intervention on behavioral symptoms and on the person's interest was rated immediately after the intervention by a research assistant.

RESULTS

The most utilized interventions in both trial and treatment phases were the social intervention of one-on-one interaction, simulated social interventions such as a lifelike doll and respite video, the theme intervention of magazine, and the sensory stimulation intervention of music. In contrast, the least utilized interventions in both phases were sewing, fabric book, and flower arrangement. Interventions with the highest impact on behavioral symptoms included one-on-one social interaction, hand massage, music, video, care, and folding towels. Other high impact interventions included walking, going outside, flower arranging, food or drink, sewing, group activity, book presentation, ball toss, coloring or painting, walking, and family video.

CONCLUSIONS

The results provide initial directions for choosing specific interventions for persons with dementia and also demonstrate a methodology for increasing knowledge through ongoing monitoring of practice.

Efficacy of nonpharmacologic interventions for agitation in advanced dementia: a randomized, placebo-controlled trial

BACKGROUND

A randomized, placebo-controlled clinical trial was undertaken to determine the efficacy of nonpharmacologic individualized interventions (individualized to address unmet needs such as boredom or pain) in decreasing agitation in persons with dementia.

METHOD

Agitated nursing home residents with advanced dementia (from 9 nursing homes in 5 locations in Maryland, United States) were randomized into an intervention group (n = 89) and a placebo control group (n = 36). On the basis of data from baseline assessment, a systematic methodology for individualizing nonpharmacologic interventions, Treatment Routes for Exploring Agitation (TREA), was used with the intervention group: an unmet need was hypothesized, a corresponding treatment category was identified, and specifics of the treatment were chosen to fit the person's need, past identity, preferences, and abilities. (Unmet needs were hypothesized based on physician evaluations, structured staff interviews, relative questionnaires, direct observations of agitation with the Agitation Behavior Mapping Instrument [the primary outcome measure] and affect with Lawton's Modified Behavior Stream [the secondary outcome measure], and resident assessments.) TREA interventions were implemented for 2 weeks, and observations of agitation and affect were recorded. The study was conducted from June 2006 until December 2011.

RESULTS

Relative to a control group, TREA interventions for unmet needs produced statistically significant declines in total (P < .001), physical nonaggressive (P < .001), and verbal agitation (P = .004) and significant increases in pleasure (P < .001) and interest (P < .05).

CONCLUSIONS

This is the first large randomized controlled trial to demonstrate the efficacy of TREA and one of only a few such trials of nonpharmacologic interventions for agitation in persons with dementia. The translation of these findings into practice is sorely needed and would require structural changes dedicating staff time to observing each agitated resident, determining unmet needs, obtaining appropriate intervention materials, conducting the individualized nonpharmacologic interventions, and evaluating results.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00820859.

What are the barriers to performing nonpharmacological interventions for behavioral symptoms in the nursing home?

OBJECTIVE

Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms.

DESIGN

A descriptive study of barriers to intervention delivery in a controlled trial.

SETTINGS

The study was conducted in six nursing homes in Maryland.

PARTICIPANTS

Participants were 89 agitated nursing home residents with dementia.

INTERVENTION

Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined.

MEASUREMENTS

Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect.

RESULTS

Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment.

CONCLUSION

Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery.

The relationships of environment and personal characteristics to agitated behaviors in nursing home residents with dementia

OBJECTIVE

To explore the impact of personal attributes, environmental attributes, and the presentation of 9 categories of stimuli on agitation in nursing home residents with dementia.

METHOD

Participants in this randomized, controlled, observational cross-sectional study were 193 residents of 7 nursing homes, all with a diagnosis of dementia, for whom we obtained data pertaining to cognitive functioning (via the Mini-Mental State Examination), performance of activities of daily living (Minimum Data Set), and role-identity/activities of past interest (Self-Identity Questionnaire). Environmental attributes (eg, noise, lighting) and direct observations of agitation (primary outcome) were recorded via the Agitation Behavior Mapping Inventory. Engagement was measured using the Observational Measurement of Engagement. Both agitation and engagement were assessed for each stimulus (including a control condition).

RESULTS

Univariate findings (ie, for 1 explanatory variable at a time) showed agitation to be related to several personal attributes--ie, female gender was related to verbal agitation (P < .0001); low cognitive function was related to total, verbal, and physical agitation (P < .001 for each); low performance of activities of daily living was significantly related to all types of agitation (P < .01 for total agitation and P < .05 for each type of agitation); and unclear speech was significantly related to total agitation (P < .01). Eight of the 9 stimulus categories were significantly related to decreased levels of agitation, with ORs ranging from 0.37 (live human stimuli, P < .001) to 0.79 (inanimate social stimuli, P < .05). Higher levels of engagement were related to lower levels of agitation (P < .001 for total agitation). In the multivariate analyses, higher cognitive function (P < .001), male gender (P < .05), level of engagement with stimuli (eg, duration of engagement for 3 minutes or longer, P < .05), and all 9 stimulus categories, with the exception of music, were independently predictive of lower levels of agitation (P < .001).

CONCLUSIONS

The finding that both type of stimuli and engagement level with the stimuli were significant predictors of agitation underscores the importance of engagement as a determinant of agitation levels.

What affects pleasure in persons with advanced stage dementia?

We examined the impact of environmental, person, and stimulus characteristics on pleasure in persons with dementia. Study participants were 193 residents of 7 Maryland nursing homes who were presented with 25 stimuli from these categories: live human social stimuli, live pet social stimuli, simulated social stimuli, inanimate social stimuli, a reading stimulus, manipulative stimuli, a music stimulus, task and work-related stimuli, and two different self-identity stimuli. Systematic observations of pleasure in the natural environment were conducted using Lawton's Modified Behavior Stream. Analysis showed that pleasure is related to stimulus category, personal attributes and environmental conditions. In the multivariate analyses, all types of social stimuli (live and simulated, human and nonhuman), self-identity stimuli, and music were related to significantly higher levels of pleasure than the control condition. Females and persons with higher ADL and communication functional status exhibited more pleasure. Pleasure was most likely to occur in environments with moderate noise levels. These results demonstrate that these nursing home residents are indeed capable of showing pleasure. Caregivers of nursing home residents with dementia should incorporate social, self-identity, and music stimuli into their residents' care plans so that eliciting pleasure from each resident becomes the norm rather than a random occurrence.

The impact of stimuli on affect in persons with dementia

OBJECTIVE

To examine how presentation of different stimuli impacts affect in nursing home residents with dementia.

METHOD

Participants were 193 residents aged 60 to 101 years from 7 Maryland nursing homes who had a diagnosis of dementia (derived from the medical chart or obtained from the attending physician). Cognitive functioning was assessed via the Mini-Mental State Examination (MMSE), and data pertaining to activities of daily living were obtained through the Minimum Data Set. Affect was assessed using observations of the 5 moods from Lawton's Modified Behavior Stream. Baseline observations of affect were performed for comparisons. During the study, each participant was presented with 25 predetermined engagement stimuli in random order over a period of 3 weeks. Stimuli were categorized as live social, simulated social, manipulative, work/task-related, music, reading, or individualized to the participant's self-identity. The dates of data collection were 2005-2007.

RESULTS

Differences between stimulus categories were significant for pleasure (F(6,144) = 25.137, P < .001) and interest (F(6,144) = 18.792, P < .001) but not for negative affect. Pleasure and interest were highest for the live social category, followed by self-identity and simulated social stimuli for pleasure, and for manipulative stimuli in terms of the effect on interest. The lowest levels of pleasure and interest were observed for music. Participants with higher cognitive function had significantly higher pleasure (F(1,97) = 6.27, P < .05). Although the general trend of the impact of the different categories was similar for different levels of cognitive function, there were significant differences in pleasure in response to specific stimuli (interaction effect: F(6,92) = 2.31, P < .05). Overall, social stimuli have the highest impact on affect in persons with dementia.

CONCLUSIONS

The findings of the present study are important, as affect is a major indicator of quality of life and this study is the first to systematically examine the impact of specific types of stimuli on affect. As live social stimuli are not always readily available, particularly in busy nursing home environments, simulated social stimuli can serve as an effective substitute, and other stimuli should have a role in the activity tool kit in the nursing home. The relative ranking of stimuli was different for interest and pleasure. The findings demonstrate the differential effect of presentation of different types of stimuli on the affect of persons with dementia, and that, while the impact is greater on persons with higher levels of cognitive function, there is a different effect of varying stimuli even in persons with MMSE scores of 3 or lower. Future research should attempt to ascertain a person's degree of interest in stimuli prior to developing an intervention.

Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli?

OBJECTIVES

To assess the relative effect of different types of stimuli on agitated behaviors of nursing home residents with dementia.

DESIGN

Repeated-measures design with randomized assignment of conditions.

SETTING

Seven Maryland nursing homes.

PARTICIPANTS

One hundred eleven nursing home residents with a diagnosis of dementia who exhibited agitation.

INTERVENTION

Different types of stimuli (music, social stimuli, simulated social stimuli, and individualized stimuli based on the person's self-identity) were presented.

MEASUREMENTS

Agitation was directly observed and recorded using the Agitation Behavior Mapping Instrument.

RESULTS

All stimulus categories were associated with significantly less physical agitation than baseline observations, and all except for manipulative stimuli were associated with significantly less total agitation. Live social stimuli were associated with less agitation than music, self-identity, work, simulated social, and manipulative stimulus categories. Task and reading stimulus categories were each associated with significantly less agitation than work, simulated social, and manipulative stimulus categories. Music and self-identity stimuli were associated with less agitation than simulated social and manipulative stimuli.

CONCLUSION

Providing stimuli offers a proactive approach to preventing agitation in persons with dementia, with live social stimuli being the most successful.

Engaging nursing home residents with dementia in activities: the effects of modeling, presentation order, time of day, and setting characteristics

We examined the impact of setting characteristics and presentation effects on engagement with stimuli in a group of 193 nursing home residents with dementia (recruited from a total of seven nursing homes). Engagement was assessed through systematic observations using the Observational Measurement of Engagement (OME), and data pertaining to setting characteristics (background noise, light, and number of persons in proximity) were recorded via the environmental portion of the Agitation Behavior Mapping Inventory (ABMI; Cohen-Mansfield, Werner, & Marx, (1989). An observational study of agitation in agitated nursing home residents. International Psychogeriatrics, 1, 153-165). Results revealed that study participants were engaged more often with moderate levels of sound and in the presence of a small group of people (from four to nine people). As to the presentation effects, multiple presentations of the same stimulus were found to be appropriate for the severely impaired as well as the moderately cognitively impaired. Moreover, modeling of the appropriate behavior significantly increased engagement, with the severely cognitively impaired residents receiving the greatest benefit from modeling. These findings have direct implications for the way in which caregivers could structure the environment in the nursing home and how they could present stimuli to residents in order to optimize engagement in persons with dementia.

The impact of a Naturally Occurring Retirement Communities service program in Maryland, USA

Most older adults prefer to age in place and it is therefore vital to support them in maintaining a high quality of life in their place of residence. Many Naturally Occurring Retirement Communities (NORCs) have implemented services to fulfill a range of needs of their residents. Community Partners (CP) provided 58 NORC residents in six apartment buildings within two suburban neighborhoods in Maryland with health and social work services, activities and transportation services. Participants were compared with 70 residents who did not receive these services. Residents were assessed prior to initiation of services (e.g. transportation, social work and recreation) and after service usage through a membership program. Members had significantly increased satisfaction with recreational activities and social life in the community as well as significant decreases in depressed affect. Members' self-reports showed that they were more likely to get out of the house, felt less isolated, and were happier since joining CP activities. This study is unique in examining the impact of utilization of a variety of services for older persons, while comparing these individuals to a local group of community-dwelling older persons who are without NORC services.

The impact of past and present preferences on stimulus engagement in nursing home residents with dementia

OBJECTIVES

We examined engagement with stimuli in 193 nursing home residents with dementia. We hypothesized that activities and stimuli based on a person's past and current preferences would result in more engagement than other activities/stimuli.

METHOD

The expanded version of the self-identity questionnaire [Cohen-Mansfield, J., Golander, H. & Arheim, G. (2000)] was used to determine participants' past/present interests (as reported by relatives) in the following areas: art, music, babies, pets, reading, television, and office work. We utilized the observational measurement of engagement (Cohen-Mansfield, J., Dakheel-Ali, M., & Marx, M.S. (2009).

RESULTS

Analysis revealed that residents with current interests in music, art, and pets were more engaged by stimuli that reflect these interests than residents without these interests.

CONCLUSION

Our findings demonstrate the utility of determining a person's preferences for stimuli in order to predict responsiveness. Lack of prediction for some stimuli may reflect differences between past preferences and activities that are feasible in the present.

The impact of personal characteristics on engagement in nursing home residents with dementia

OBJECTIVE

To examine the impact of personal attributes on engagement in persons with dementia.

METHODS

Participants were 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Cognitive functioning was assessed via the Mini-Mental State Examination, and engagement was assessed via the Observational Measure of Engagement. Data pertaining to activities of daily living were obtained from the Minimum Data Set.

RESULTS

Women had longer mean engagement duration than men, and significant results were not seen with the other demographic variables. Significant, positive correlations were found between higher cognitive functioning and longer engagement duration, more attention, a more positive attitude, and a higher refusal rate. There was a positive and significant correlation between the comorbidity index and engagement duration, and between the number of medications and attention. All functional status variables yielded significance in a positive direction. Participants with poor hearing had a higher refusal rate. Cognitive status was the most consistent and potent predictor of engagement in this population.

CONCLUSION

Despite a higher refusal rate among those with higher cognitive levels, their overall engagement with stimuli is higher. Caregivers should anticipate higher refusal rates in those with poor hearing, and therefore compensatory methods should be used in presenting stimuli in this population. The potent role of cognitive and functional status on engagement of persons with dementia underscores the importance of tailoring activities to nursing home residents' needs, interests, and limitations.

The impact of different dog-related stimuli on engagement of persons with dementia

OBJECTIVE

To provide further empirical evaluation of the effectiveness of animal-assisted therapy in nursing home residents with dementia.

METHODS

Participants were 56 residents of 2 suburban Maryland nursing homes and had a diagnosis. Activities of daily living performance was assessed via the minimum data set and cognitive functioning assessed using the Mini-Mental State Examination. Engagement with dog-related stimuli was systematically assessed via the observational measurement of engagement.

RESULTS

Mean engagement duration was significantly lower for the small dog. Highest mean engagement duration was found for the puppy video, followed by the real dog and lowest was for the dog-coloring activity. Positive attitudes were found toward the real dogs, robotic dog, the puppy video, and the plush dog. No significant differences were found in engagement duration among our dog-related stimuli.

CONCLUSIONS

Nursing homes should consider animal-assisted therapy and dog-related stimuli, as they successfully engage residents with dementia.

The impact of stimulus attributes on engagement of nursing home residents with dementia

We examined the influence of stimulus attributes on the engagement of 69 nursing home residents with dementia. Specifically, we looked at work-related stimuli versus manipulative block stimuli, and whether the color, size, and material of a stimulus affect the duration and quality of engagement. Engagement was assessed using the Observational Measurement of Engagement (OME). Results revealed a clear preference for the work-related rather than manipulative block stimuli. In addition, the study participants showed a significant preference for small rather than large blocks, regardless of color or material. The effect of material and color was not statistically significant. These findings may assist nursing home caregivers who wish to provide appropriate stimuli for engaging nursing home residents with dementia.

Dressing of Cognitively Impaired Nursing Home Residents: Description and Analysis

PURPOSE

Getting dressed is an activity that is of particular difficulty for many persons with dementia, given the need for hand-eye coordination, fine motor skills, and overall planning skills. Despite several studies concerning interventions to improve dressing behavior, very little is known about the dressing process as it is currently performed. The purpose of this study is to characterize the dressing activity of daily living (ADL) of nursing home residents suffering from dementia and thereby identify ways to improve the dressing process.

DESIGN AND METHODS

We analyzed videotapes of dressing of 20 special care unit residents to describe the dressing process and the interaction between residents and staff members.

RESULTS

Staff members completely dressed the residents in the majority of cases. Interaction between the staff members and the residents was considered insufficient in most sessions.

IMPLICATIONS

The study identified possible intervention techniques, assistive devices, organizational routines, and environmental changes that may improve the dressing process. The results have implications that nursing homes may consider in their policies, care activities, staff training, and environment to facilitate safety, comfort, and satisfaction during the dressing process.