Teaching and maintaining behavior management skills in the nursing home

Evaluation of an education intervention to implement a capability model of dementia care

This paper outlines an intervention protocol used to educate carers in a project that implemented and evaluated a capability model of dementia care (CMDC) in three long-term aged care facilities. It outlines an evaluation of the content of the education and processes used to deliver the intervention through an analysis of surveys and reflective field notes. The education protocol was designed for adult learners and grounded in the six assumptions of Knowles' learning theory. Results suggest the education protocol positively impacted on the knowledge, skills and attitudes of participants towards providing quality dementia care to residents in long-term care. The paper also acknowledges the challenges involved in sustaining a practice change through an educational intervention.

Communication skills training in dementia care: a systematic review of effectiveness, training content, and didactic methods in different care settings

BACKGROUND

Caring for and caring about people with dementia require specific communication skills. Healthcare professionals and family caregivers usually receive little training to enable them to meet the communicative needs of people with dementia. This review identifies existent interventions to enhance communication in dementia care in various care settings.

METHODS

We searched MEDLINE, AMED, EMBASE, PsychINFO, CINAHL, The Cochrane Library, Gerolit, and Web of Science for scientific articles reporting interventions in both English and German. An intervention was defined as communication skills training by means of face-to-face interaction with the aim of improving basic communicative skills. Both professional and family caregivers were included. The effectiveness of such training was analyzed. Different types of training were defined. Didactic methods, training content, and additional organizational features were qualitatively examined.

RESULTS

This review included 12 trials totaling 831 persons with dementia, 519 professional caregivers, and 162 family caregivers. Most studies were carried out in the USA, the UK, and Germany. Eight studies took place in nursing homes; four studies were located in a home-care setting. No studies could be found in an acute-care setting. We provide a list of basic communicative principles for good communication in dementia care. Didactic methods included lectures, hands-on training, group discussions, and role-play.

CONCLUSION

This review shows that communication skills training in dementia care significantly improves the quality of life and wellbeing of people with dementia and increases positive interactions in various care settings. Communication skills training shows significant impact on professional and family caregivers' communication skills, competencies, and knowledge. Additional organizational features improve the sustainability of communication interventions.

The CARES(®) Observational Tool: a valid and reliable instrument to assess person-centered dementia care

The goal of the current study was to develop a valid and reliable tool to measure whether person-centered care is delivered by direct care workers to persons with dementia. Face validity was initially established through multiple revisions of the CARES(®) Observational Tool (COT™) by members of the study team. Afterward, content validity of the COT was established by piloting the tool on 31 observations across 7 nursing homes and review by an interdisciplinary panel of nine scientific experts. The final 16-item version of the COT was then tested for inter-rater reliability by 5 reviewers across 5 standardized dementia care videos. An intra-class coefficient of all possible Kappa coefficients resulted in an ICC of .77. The brief and easy-to-use COT has potential to assess person-centered care interactions between direct care workers and persons with dementia.

Person-centered care training in long-term care settings: usefulness and facility of transfer into practice

The person-centered approach is increasingly recommended in long-term care facilities to increase quality of care. In Quebec, Canada,. caregivers were specifically trained in "relationship-based care. "This study analyzed caregivers' assessment of this approach's usefulness and their capacity, after training, to apply it to care practices. Questionnaires with open-ended questions were administered to caregivers (n= 392) one month after training. Caregivers' answers were categorized using a qualitative approach. Respondents perceive some features of this approach are beyond their reach or in opposition to their beliefs. They reported feeling pressure related to time constraints, their peers and the families of residents. These results indicate that training itself is insufficient to transform practice. Institutions wishing to implement such an approach must also act upon the beliefs of individuals, as well as upon work situations.

Improving nursing home resident integrity by optimizing interpersonal communication skills in clinical staff

In this article the authors discuss the prevalence of resident abuse and reported violations of care deficiencies and resident maltreatment in nursing homes in the United States. The number of nursing homes in the United States that are cited with abuse violations has increased in recent years. While the authors recognize that treatments (both positive and negative) received by residents are sometimes related to factors other than staff's lack of knowledge and poor attitudes, their purpose in this analysis is to enhance resident integrity through the improvement of staff interpersonal communication skills. In doing so, innovative strategies and specific interpersonal communication theories are examined as educational methods to confront and resolve care deficiencies and elevate and enrich residents' integrity, satisfaction, and outcomes.

A systematic review of staff training interventions to reduce the behavioural and psychological symptoms of dementia

Behavioural and psychological symptoms of dementia (BPSD) are highly prevalent and problematic in care settings. Given the limited effectiveness of medical treatments, training care staff to understand and manage these symptoms is essential for the safety and quality of life of people with dementia. This review evaluated the effectiveness of staff training interventions for reducing BPSD. A systematic literature search identified 273 studies. Twenty studies, published between 1998 and 2010, were found to meet the inclusion criteria. Overall, there was some evidence that staff training interventions can impact on BPSD: twelve studies resulted in significant symptom reductions, four studies found positive trends and four studies found no impact on symptoms. No links were found between the theoretical orientation of training programmes and their effectiveness. Training was also found to impact on the way staff behaved towards residents. A quality screening, using pre-specified criteria, revealed numerous methodological weaknesses and many studies did not adhere to the recommended guidelines for the conduct of cluster randomised controlled trials. There is an urgent need for more high quality research and evidence-based practice in BPSD.

Patient-centred communication intervention study to evaluate nurse-patient interactions in complex continuing care

BACKGROUND

Communication impairment is a frequent consequence of stroke. Patients who cannot articulate their needs respond with frustration and agitation, resulting in poor optimization of post-stroke functions. A key component of patient-centred care is the ability of staff to communicate in a way that allows them to understand the patient's needs. We developed a patient-centred communication intervention targeting registered and unregulated nursing staff caring for complex continuing care patients with communication impairments post stroke. Research objectives include 1) examining the effects of the intervention on patients' quality of life, depression, satisfaction with care, and agitation; and (2) examining the extent to which the intervention improves staff's attitudes and knowledge in caring for patients with communication impairments. The intervention builds on a previous pilot study.

METHODS/DESIGN

A quasi-experimental repeated measures non-equivalent control group design in a complex continuing care facility is being used. Patients with a communication impairment post-stroke admitted to the facility are eligible to participate. All staff nurses are eligible. Baseline data are collected from staff and patients. Follow-up will occur at 1 and 3 months post-intervention. Subject recruitment and data collection from 60 patients and 30 staff will take approximately 36 months. The Patient-Centred Communication Intervention consists of three components: (1) development of an individualized patient communication care plan; (2) a one-day workshop focused on communication and behavioural management strategies for nursing staff; and (3) a staff support system. The intervention takes comprehensive patient assessments into account to inform the development of communication and behavioural strategies specifically tailored to each patient.

DISCUSSION

The Patient-Centred Communication Intervention will provide staff with strategies to facilitate interactions with patients and to minimize agitation associated with considerable stress. The improvement of these interactions will lead to a reduction of agitation, which has the additional significance of increasing patients' well-being, quality of life, and satisfaction with care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01654029.

Interactions and relationships in long term care: photography and narratives by direct care workers

The challenge of hiring and retaining well-trained caregivers for the growing numbers of elders in need of care is a global concern. This study was designed to understand the views of direct care workers and included 15 nurse aides and med techs working in an assisted living and special care assisted living community for people with dementia. Each participant was provided with a digital camera and asked to take photographs "to show what caregiving means to you." Analysis is based on group discussions about the full set of photographs created by the direct care workers and individual written and oral narratives about four photographs chosen by each participant. The categories generated from these data represent the direct care workers' perceptions of the approaches to quality caregiving and the relationships involved in doing their jobs well. By focusing on the essential relationships and interactions, rather than primarily on the required care, we can begin to imagine the caregiving experience in terms of a communal rather than an institutional experience. We can then productively turn our focus to the people involved rather than emphasize their roles as providers or recipients of care.

Building capacity and resilience in the dementia care workforce: a systematic review of interventions targeting worker and organizational outcomes

BACKGROUND

Dementia increasingly impacts every health and social care system in the world. Preparing the dementia care workforce is therefore paramount, particularly in light of existing problems of staff retention and turnover. Training interventions will need to increase worker and organizational capacity to deliver effective patient care. It is not clear which training interventions best enhance workers' capacity. A review of the evidence for dementia care training interventions to enhance worker capacity and facilitate organizational change is presented.

METHODS

A systematic literature review was conducted. All selected randomized intervention studies aimed to enhance some aspect of dementia care worker or workforce capacity such as knowledge of dementia, psychological well-being, work performance, and organizational factors such as retention or service delivery in dementia care.

RESULTS

Seventy-four relevant studies were identified, but only six met inclusion criteria for the review. The six studies selected focused on worker and organizational outcomes in dementia care. All interventions were multi-component with dementia education or instructional training most commonly adopted. No interventions were found for the community setting. Variable effects were found for intervention outcomes and methodological concerns are raised.

CONCLUSION

The rigor of scientific research in training interventions that aim to build capacity of dementia care workers is poor and a strong need exists for evaluation and delivery of such interventions in the community sphere. Wider domains of interest such as worker psychological health and well-being need to be examined further, to understand capacity-building in the dementia care workforce.

Examining success of communication strategies used by formal caregivers assisting individuals with Alzheimer's disease during an activity of daily living

PURPOSE

To examine how formal (i.e., employed) caregivers' use verbal and nonverbal communication strategies while assisting individuals with moderate to severe Alzheimer's disease (AD) during the successful completion of an activity of daily living (ADL). Based on the literature, the authors hypothesized that caregivers' use of 1 proposition, closed-ended questions, and repetition would be of most benefit.

METHOD

Twelve caregiver-AD dyads participated in this observational study. Each dyad was videorecorded on 6 separate occasions while completing handwashing. Handwashing sessions were transcribed and systematically coded for the use of communication strategies during completion of the ADL.

RESULTS

Caregiver-AD dyads successfully completed 90% of all handwashing sessions, and caregivers employed a variety of communication strategies. Consistent with our hypotheses, during successful task completion, caregivers most frequently provided individuals with AD with 1 direction or idea (i.e., proposition) at a time, closed-ended questions, and paraphrased repetition. Caregivers also frequently used encouraging comments and the resident's name during the task; however, use of these strategies was not correlated to task success rate.

CONCLUSION

This study adds to the limited body of evidence supporting the use of specific communication strategies by caregivers assisting individuals with moderate to severe AD during successful completion of ADLs.

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.

The involvement of multiple caregivers in cognitive-behavior therapy for anxiety in persons with dementia

OBJECTIVES

Peaceful Mind, a cognitive-behavioral therapy for treating anxiety in persons with dementia, is a promising new treatment currently under investigation. This article reports results of our examination of a modification of the treatment protocol in two cases that included multiple caregivers in treating two persons with dementia.

METHOD

Two case presentations of the benefits and challenges of including multiple caregivers in treatment are discussed. Treatment outcome data for these cases were collected as part of a larger investigation of Peaceful Mind.

RESULTS

The involvement of multiple collaterals resulted in several benefits, including increased family communication, as well as increased opportunities for the practice of new skills. These cases have also presented unique challenges requiring alterations in therapy structure and attention to issues of family conflict.

CONCLUSIONS

Including multiple collaterals in cognitive-behavioral therapy for treating anxiety in persons with dementia is feasible and may be beneficial in maximizing treatment gains and increasing the family's investment in therapy.

The role of behavior analysis in the rehabilitation of persons with dementia

With the rapidly aging population, it is expected that increases in cases of dementia will double over the next 20 years. Currently, there is no cure for diseases such as Alzheimer's disease or frontotemporal dementia (FTD) that cause progressive dementia, and only a few pharmacological interventions that slow the progression of the decline exist. Given that there is no cure available, a rehabilitation approach that emphasizes maintaining existing abilities and removing excess disability (as opposed to emphasizing cure or recovery) for as long as possible is warranted. The current paper proposes that nonpharmacological rehabilitation efforts need to target 5 broad areas/targets: memory enhancement, altering social contingencies and communication styles, improving self-care skills, the arrangement of physical environments to maintain and improve functioning, and increasing physical fitness/physical activity. The purpose of this paper is to review specific behaviorally oriented interventions that target these 5 areas and show promise for inclusion in comprehensive rehabilitation efforts for individuals with dementia.

Monitoring quality of care for nursing home residents with behavioral and psychological symptoms related to dementia

BACKGROUND

Behavioral and psychological symptoms associated with dementia are common in nursing home residents. Quality indicators (QI) assessing quality of care for these residents are minimally risk adjusted and can provide inaccurate information regarding the quality of care provided by the facility.

OBJECTIVE

Evaluate the performance of a new QI for the incidence of worsening behaviors in nursing home residents with behavioral and psychological symptoms association with dementia.

DESIGN

Retrospective cohort study.

SETTING

A total of 381 Minnesota nursing homes with 26,165 residents.

DATA SOURCES

Minimum Data Set records for the first 2 calendar quarters of 2008.

MEASUREMENTS

We calculated incidence of worsening behaviors QI by comparing items from the "behavior" section of the Minimum Data Set records from 2 consecutive quarters and reported the incidence rates by both the residents' level of cognitive impairment and the presence or absence of special care unit for dementia (SCU).

RESULTS

The incidence rates of the worsening behavior QI in SCU ranged from 14% in residents with very severe cognitive impairment (a cognitive performance score = 6) to 30% in those with moderate cognitive impairment (a cognitive performance score = 3). The incidence QI rates among residents residing in conventional unit ranged from 15% among those with very severe cognitive impairment to 20% among those with moderate cognitive impairment. These differences in QI rates between the 2 units were statistically significant with a P value = .001. After risk adjustment for level of cognitive impairment, number of facilities with SCUs that flagged for problem behaviors dropped from 18.4% to 12.4% and the number of conventional units in the low-risk category from 16.8% to 4.7%.

CONCLUSION

Resident cognitive function and the facility utility of SCU are associated with worsening behavior QI and should be adjusted for in any nursing home quality reporting measure.

Advanced nursing assistant education program

BACKGROUND

Nursing assistants provide 90% of the care to the elderly residents of nursing homes, but are the least educated direct-care employees. Supervisory workers believe that nursing assistants require additional training to meet the increasingly complex needs of nursing home residents.

METHODS

A day-long training program for experienced nursing assistants was provided to supplement their basic education. Using a pre- and posttest design, the effectiveness of the program for knowledge acquisition and application was tested. Future education needs were identified through a gap analysis.

RESULTS

There was a significant improvement in knowledge for nursing assistants attending the program. The attendees expressed interest in receiving additional education on dementia and infection control. All attendees identified a problem unique to their facility and were able to plan a detailed intervention and develop outcome measures for that plan.

CONCLUSIONS

Nursing assistants enrolled in this advanced training program expressed a desire for additional education to help them advance their caregiving skills. Advanced education is one method to increase job satisfaction among nursing assistants that can improve the quality of care for nursing home residents.

An internet-based multimedia education prototype to enhance late-stage dementia care: formative research results

The goal of this project was to develop a portable, Internet-based multimedia education program (IBME) to provide a more efficient training resource for direct care workers (DCWs) who care for nursing home residents suffering from late-stage dementia. Thirty-four DCWs from 8 nursing homes in 8 states completed 5 posttest open-ended questions and 20 Likert items on the feasibility, strengths, and weaknesses of the IBME prototype. Pre- and post-test surveys also examined whether late-stage dementia care knowledge changed significantly. More than 90% of DCWs "agreed" or "strongly agreed" that the IBME prototype improved DCWs' feelings of competency and everyday care delivery. Open-ended comments offered several suggestions for improvement, including group-based discussion of the modules. Results also indicate that DCWs' late-stage dementia care knowledge significantly increased (P < .001) following completion of the IBME modules. The IBME prototype offers an online, asynchronous training strategy to enhance dementia-pertinent knowledge and skills related to everyday care delivery in nursing homes.

Improving care in care homes: a qualitative evaluation of the Croydon care home support team

OBJECTIVES

The Croydon care home support team (CHST) was developed in response to reports of patient abuse within long-term care. It presents a novel strategy for improving standards of care within care homes. A qualitative methodology was used to assess the perceived impact of the CHST.

METHOD

In-depth interviews were conducted with 14 care home managers and 24 members of care home staff across 14 care homes. Grounded theory principles guided the collection and analysis of the data.

RESULTS

Reports of improved communication between staff, improved staff development and confidence, and improved quality of care point towards the effectiveness of the CHST model. The collaborative approach of the CHST was considered pivotal to its success and presented as an effective method of engaging care home managers and staff. The CHST adopted a systemic approach that placed an equal emphasis on the social, mental health and nursing needs of residents and aimed to address the whole culture of care within the individual homes.

CONCLUSIONS

The data demonstrate the potential for specialist multi-disciplinary teams to raise standards of care across long-term care settings. Increased awareness of safeguarding issues, improved staff morale and communication and ongoing opportunities for discussion and problem solving promised to sustain improvements. Such services could be instrumental in meeting the government priority of preventing abuse among vulnerable adults.

A systematic review of communication strategies for people with dementia in residential and nursing homes

BACKGROUND

The impairment of verbal skills of people with dementia challenges communication. The aim of this review was to study the effects of nonpharmacological interventions in residential and nursing homes on (1) communication between residents with dementia and care staff, and (2) the neuropsychiatric symptoms of residents with dementia.

METHOD

Pubmed, PsychInfo, Web of Science, the Cochrane Library, and reference lists from relevant publications were systematically searched to find articles about controlled interventions with communication strategies. The data collected were pooled and subjected to a meta-analysis.

RESULTS

Nineteen intervention studies were selected for this review. They included structured and communicative "sessions at set times" for residents (e.g. life review) and communication techniques in activities of "daily care" applied by care staff (e.g. sensitivity to nonverbal communication). A meta-analysis of five set-time interventions (communication) and another meta-analysis of four set-time interventions (neuropsychiatric outcomes) found no significant overall effects. Individual set-time intervention studies report positive effects on communication when interventions are single-task sessions, like life review or one-on-one conversation. Interventions around daily care activities had positive effects on communication outcomes. Effects of both types of interventions on neuropsychiatric symptoms were divergent.

CONCLUSION

This review indicates that care staff can improve their communication with residents with dementia when strategies are embedded in daily care activities or interventions are single-task sessions at set times. These results offer the possibility of improving the quality of care, but not of directly reducing neuropsychiatric symptoms. More research is needed to study the effect of communication interventions on neuropsychiatric symptoms.

Institutionalized ghosting: policy contexts and language use in erasing the person with Alzheimer's

The ordinary social engagement of human life would not usually be considered an arena for language policy. Yet clinical evidence mounts that social interaction improves our lives as we age. Since social engagement decreases cardiovascular risks (Ramsay et al. in Ann Epidemiol 18:476-483, 2008) and delays memory loss among those living in communities (Ertel et al. in Am J Public Health 98:1215-1220, 2008), practices that prohibit social interaction threaten human well-being. For persons who have Alzheimer's disease (AD), social interaction continues to play an integral part in cognitive function and delays in memory loss, according to a longitudinal study of social networks (Bennett et al. in Lancet Neurol 5:406-412, 2007). Increasingly, person-centered care that promotes social engagement for those with AD is promoted as an institutional policy to improve outcomes of dementia care (Edvardsson et al. in Int Psychogeriatr 20:764-776, 2008). Yet the training of caregivers may neither reflect person-centered care nor include attention to communication, suggesting covert policies in practice.

Management of behavioral and psychological symptoms of dementia in long-term care facilities in Japan

BACKGROUND

An increasing number of old people, and their medical requirements, cannot be managed by their families in their homes, which has been the traditional and prevalent practice in Japan. The number of people with dementia is increasing and behavioral and psychological symptoms of dementia (BPSD) make care difficult. In the present study, we investigated management techniques for BPSD in long-term care facilities in Japan by using the data mining method, which looks at the reported behaviors of care providers.

METHODS

First, interviews were conducted with 15 care providers to develop items for a questionnaire. These data were analyzed qualitatively and synthesized with criteria from the professional literature. The resulting self-report questionnaire on techniques used to manage different symptoms of dementia was completed by 275 care providers. We applied the association rule as a data mining method examining 15 management techniques related to 13 BPSD.

RESULTS

Analysis identified four types of management techniques: (i) emotional and behavior-concordance techniques; (ii) acceptance and supportive techniques; (iii) restraining techniques; and (iv) avoidance techniques. Different management techniques, and combinations of techniques, were found to vary in use and effectiveness with different BPSD.

CONCLUSIONS

Good management techniques for many BPSD have been developed and are being implemented by care providers. The present study has the potential to inform researchers and care providers in Japan about the types of management techniques in current use, as well as areas of potential need for staff training.

A Pilot Study Evaluating the Feasibility of Psychological First Aid for Nursing Home Residents

OBJECTIVES: The objectives of the pilot study were to modify existing psychological first aid (PFA) materials so they would be appropriate for use with institutionalized elders, evaluate the feasibility of using nursing home staff to deliver the intervention to residents, and solicit feedback from residents about the intervention. The STORM Study, an acronym for "services for treating older residents' mental health", is the first step in the development of an evidence-based disaster mental health intervention for this vulnerable and underserved population. METHOD: Demographic characteristics were collected on participating residents and staff. Program evaluation forms were completed by staff participants during the pilot test and nurse training session. Staff and resident discussion groups were conducted during the pilot test to collect qualitative data on the use of PFA in nursing homes. RESULTS: Results demonstrate the feasibility of the PFA program to train staff to provide residents with PFA during disasters. CONCLUSIONS: Future research should focus on whether PFA improves coping and reduces stress in disaster exposed nursing home residents.

Moving forward: evaluating a curriculum for managing responsive behaviors in a geriatric psychiatry inpatient population

PURPOSE

The Gentle Persuasive Approaches (GPA) curriculum was developed as an adjunct to other educational initiatives that were part of Ontario, Canada's Alzheimer Strategy. GPA emphasizes that an individual's unique personal history has a direct application to the interpretation of and response to their behavior. It incorporates strategies into geriatric patient care to assist staff to respond effectively to verbal and physical expressions of need.

DESIGN AND METHODS

A pre- and postintervention approach was used to evaluate the effectiveness of GPA: (a) Staff Satisfaction Surveys immediately after GPA training and after 3 months, (b) risk event profiling to monitor aggressive behavior rates, (c) occupational health and safety records pre- and post-GPA training, and (d) Residential Assessment Instrument-Mental Health indicators pre- and post-GPA training.

RESULTS

Surveys revealed that GPA training significantly improved staff's response to challenging behaviors, understanding of how brain changes impact behavior, and learning strategies to respond to challenging behaviors. Specific body containment techniques were less employed on geriatric patients who experience responsive behaviors. Pre- and postphysical aggression rates declined over the 6-month period following GPA training. The training did not appear to impact occupational injury rates.

IMPLICATIONS

GPA appears to be a useful and positive approach for providing care to an inpatient geriatric psychiatry population. Specific body containment techniques may be less useful when employed with patients who have responsive behaviors. The program evaluation suggests that application of the GPA curriculum may be extended to patients with diagnoses other than dementia.

Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards

OBJECTIVE

To provide a systematic review of selected experimental studies of psychosocial treatments of behavioral disturbances in dementia. Psychosocial treatments are defined here as strategies derived from one of three psychologically oriented paradigms (learning theory, unmet needs and altered stress thresholds).

METHOD

English language reports published or in press by December 2006 were identified by means of database searches, checks of previous reviews and contact with recognized experts. Papers were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another.

RESULTS

Only 25 of 118 relevant studies met every specification. Treatment proved more effective than an attention control condition in reducing behavioral symptoms in only 11 of the 25 studies. Effect sizes were mostly small or moderate. Treatments with moderate or large effect sizes included aromatherapy, ability-focused carer education, bed baths, preferred music and muscle relaxation training.

CONCLUSIONS

Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were mostly small to moderate with a short duration of action. This limited action means that treatments will work best in specific, time-limited situations. In the few studies that addressed within-group differences, there were marked variations in response. Some participants benefited greatly from a treatment, while others did not. Interventions proved more effective when tailored to individuals' preferences.

Training in dementia care: a cluster-randomized controlled trial of a training program for nursing home staff in Germany

BACKGROUND

This study examines the effectiveness of a nursing home staff training program designed to improve the interaction between residents with dementia and their caregivers.

METHODS

A three-arm cluster-randomized and controlled population of 96 caregivers and 210 residents was used. Caregivers of the intervention group (IG) received a three-month training program in dementia care. Data were gathered at baseline, immediately after the training and at a six-month follow-up-assessment. Short- and long-term effects of the training program were assessed in comparison with another intervention referred to as the relaxation group (RG) and a wait-list control group (CG).

RESULTS

Results indicated significant positive effects of the training program on caregivers' knowledge immediately after the training and on the use of physical restraints at the six-month follow-up. Caregivers' overall competence increased significantly both in the IG and in the RG. No intervention effects were found on caregivers' level of burnout, their health complaints or on the use of sedative drugs. Relaxation training was more successful in the reduction of caregivers' health complaints.

CONCLUSIONS

Results of the study indicate both the effectiveness and the limitations of a general training program in dementia care. The complexity of the nursing home setting potentially needs more complex interventions. Ongoing and continued support of the caregivers, as well as changes in organization and environment, are more likely to be helpful in the long-term improvement in the quality of care. Future research should focus on studies of specific interventions, such as the interesting effects of relaxation training on the caregivers' state of health.

Therapeutic communication training in long-term care institutions: recommendations for future research

OBJECTIVE

The purpose of this review is to critique contemporary experimental research and to recommend future directions for research interventions on nursing aides' therapeutic communication with older adults who have cognitive impairment and/or dementia in institutional long-term care settings.

METHODS

This literature review covers 13 journal articles (1999-2006) and focuses on the strengths and weaknesses of experimental research interventions to improve nursing aides' therapeutic communication with older adults who have cognitive impairment and/or dementia in long-term care settings.

RESULTS

Based on this review, recommendations for improved experimental designs include a minimum of two groups with one being a control and randomization of subjects at the care unit level, an average 3-5h of total training, a minimum of a 6-month total evaluation period, and objective outcomes relevant to both nursing aides and residents. Findings from studies in this review indicate that the following therapeutic communication techniques can be taught and can benefit staffs and older adults' quality of life: verbal and non-verbal communication behaviors including open-ended questions, positive statements, eye contact, affective touch, and smiling.

CONCLUSIONS

Some evidence exists to support that nursing aides can improve their therapeutic communication during care.

PRACTICE IMPLICATIONS

Nursing aides need not only more training in therapeutic communication but also ongoing, dedicated supervision in psychosocial aspects of care.

Cognitive-behavioral treatment for anxiety in patients with dementia: two case studies

Anxiety is common in dementia and is associated with decreased independence and increased risk of nursing home placement. However, little is known about the treatment of anxiety in dementia. This article reports results from two patients who were treated with a modified version of cognitive-behavioral therapy for anxiety in dementia (CBT-AD). Modifications were made in the content, structure, and learning strategies of CBT to adapt skills to the cognitive limitations of these patients and include collaterals (i.e., family members, friends, or other caregivers) in the treatment process. The patients received education and awareness training and were taught the skills of diaphragmatic breathing, coping self-statements, exposure, and behavioral activation. The Clinical Dementia Rating (CDR) Scale was used to characterize dementia severity and determine eligibility for treatment (a CDR score of 0.5 to 2.0 was required for participation). Other measures included the Rating Anxiety in Dementia scale, the Neuropsychiatric Inventory Anxiety subscale, and the Mini International Neuropsychiatric Interview. Outcome data showed improvement in anxiety as measured by standardized rating scales. We conclude that CBT-AD is potentially useful in treating anxiety in dementia patients and that this technique merits further study.

Figuring it out in the moment: a theory of unregulated care providers' knowledge utilization in dementia care settings

BACKGROUND

Within the context of knowledge translation, the disconnect between the results of research and the practice patterns of nursing care providers has not been reported in the context of institutional dementia care practice. Therefore, little is known about how knowledge about best dementia care practice, defined broadly as the person-centered approach, gets used by institutional nursing care providers.

AIM

Unregulated care providers provide the majority of nursing care for older people with Alzheimer's disease and related disorders living in long-term care facilities. The purpose of this grounded theory study was to explore the process whereby these workers use knowledge about person-centered care in their dementia care practice.

METHODS

Transcribed data from tape-recorded interviews with 20 unregulated care providers among eight long-term care facilities in Ontario, Canada, were coded and categorized at progressively more abstract levels until concepts and the relationships among them were integrated in a middle-range theory of knowledge utilization.

RESULTS

The theory of Figuring it Out in the Moment illustrates how unregulated care providers in dementia care settings practice in the context of unpredictability, variability, and personal threat. Their use of knowledge about person-centered care is dependent on the existence of certain individual and relational conditions that interrelate with four separate, but interconnected, phases of clinical decision-making and action.

CONCLUSIONS

As a middle-range theory, Figuring it Out in the Moment is concrete and pragmatic information for promoting evidence-based dementia care not included in existing overarching knowledge utilization frameworks. Areas for further investigation include how knowledge utilization is conceptualized, as well as the influences of practitioners' clinical decision-making, the nature of caregiving with particular client populations, and the characteristics of individuals alone and in relationship on the utilization of best practice knowledge.

Prevalence of behavioral symptoms: comparison of the minimum data set assessments with research instruments

OBJECTIVE

To examine the total and domain-specific prevalence of verbally and physically abusive, socially inappropriate, and care-resistive behaviors according to the Minimum Data Set (MDS) compared with research instruments in nursing home residents with severe dementia.

DESIGN, SETTING, AND METHODS

As part of a longitudinal observational study, MDS behavioral symptoms data were compared with corresponding items from the Ryden Aggression Scale and the Cohen-Mansfield Agitation Inventory for 15 nursing home residents with severe dementia. McNemar's test was used to compare the difference in the proportion of subjects who experienced any symptoms, as well as specific symptoms in several domains, according to the MDS and the research instruments. Additionally, temporal fluctuations in behavioral symptoms were descriptively and graphically summarized.

RESULTS

The MDS significantly underestimated both the total proportion of subjects experiencing any behavioral symptoms (P = .016), as well as the proportion of subjects experiencing verbally abusive symptoms (P < .002), physically abusive symptoms (P = .008), or socially inappropriate behaviors (P = .016) compared with corresponding items from the research instruments. Moreover, these behaviors exhibited considerable temporal instability, suggesting that the systematic daily collection of measures of behavioral disturbances is imperative during the week in which the MDS assessment is to be completed.

DISCUSSION

Albeit from a small study sample, our findings call into question the validity of the MDS behavioral symptom items as they are currently recorded, and suggest that a simple intervention of twice daily completion of a behavioral symptoms checklist containing the MDS items during the week of the assessment may significantly improve the accuracy of the recorded data.

Effectiveness of staff training programs for behavioral problems among older people with dementia

This paper reviewed studies on staff training programs to address the behavioral problems associated with dementia among older people in residential care. The papers were classified according to whether or not the studies included a control group in the research design. The results of the review demonstrate that there has been a wide range of psychosocial and educational interventions to reduce behavioral problems among older people with dementia, with inconsistent results being obtained. However, many of these studies suffer from problems in their research design that make it difficult to evaluate their effectiveness. Problems in conducting research in the nursing home setting are highlighted, and suggestions for future research in this area are discussed.

Job satisfaction and career commitment among nursing assistants providing Alzheimer's care

As part of a statewide dementia-specific training collaborative, data were collected from nursing assistants and aides who provide paid Alzheimer's care. This study explored the relevance of previous education and practical experiences to specific constructs associated with worker recruitment and retention. Direct-care providers with prior training in gerontology and geriatrics had lower levels of extrinsic job satisfaction and career resilience than those without this kind of continuing education. Program participants who were currently or previously the primary caregiver for a friend or relative with Alzheimer's disease had higher levels of intrinsic job satisfaction but lower levels of career resilience than those with no informal caregiving experience. Current or previous informal caregiving experience may enhance intrinsic job satisfaction by increasing personal commitment to pursue formal care work and providing a kind of inoculation against the demoralization that is too often suffered in these very challenging jobs.

The behavioral assessment scale: a measure of community living skills

This study reports the development of a community living skills measure of long-term care AIDS residents. Community living skills impact numbers and types of care providers needed. The Behavioral Assessment Scale (BAS) used multiple sources of validity evidence to ensure community living skills construct representation. The BAS was piloted in four diverse long-term care facilities. Nurses rated residents using the BAS and the Nurse Perception Scale (NPS)-another community living skills measure. Researchers rated residents' community living skills through medical record notations (Interdisciplinary Notation Scale [INS]). Reliability coefficients over .6 (p < .001) were reported for the BAS in both the total sample and the individual samples. Evidence-based validity of the BAS was obtained via coefficients from the total sample (.422 [BAS and INS] and .526 [BAS and NPS], with p < .001 for both relationships), Cronbach's alpha (.851 for all community living skills tools), analysis of variance, and regression results. The BAS was substantiated for long-term care practice with AIDS residents.

Difficult behaviors in long-term care patients with dementia

Difficult behaviors are relatively common challenges that can occur throughout the natural progression of dementia, but are particularly common in the mid to late stages of disease. These behaviors can be challenging to manage in nursing and assisted care facilities, and can cause distress to the caregivers and to the patients themselves. Our ability to manage these symptoms can have a profound effect on the patient's quality of life. This article reviews the appropriate assessment of behavioral and psychological symptoms of dementia (BPSD) and the literature supporting various nonpharmacologic and pharmacologic treatments. Nonpharmacologic approaches should be the initial focus for treatment of most BPSD, but should these prove inadequate, a variety of medications are available with varying degrees of clinical research to support their use in ameliorating BPSD.

Using experiential techniques for staff development: liking, learning, and doing

Experiential techniques, such as role plays and simulations, are recommended to achieve nursing home staff training and development objectives. Experiential techniques can be customized to match the learning styles and preferences of all levels of nursing staff. Nursing staff's reactions to and benefits from such techniques are a necessary first step in the evaluation of a skills training program. Project RELATE (Research and Education for Living with Alzheimer's Disease: Therapeutic Eldercare) measured reactions to and knowledge gained by nursing staff using such techniques in training person-centered care. Findings suggest experiential techniques are efficacious as learning methods.

Difficult behaviors in long-term care patients with dementia

Difficult behaviors are relatively common challenges that can occur throughout the natural progression of dementia, but are particularly common in the mid to late stages of disease. These behaviors can be challenging to manage in nursing and assisted care facilities, and can cause distress to the caregivers and to the patients themselves. Our ability to manage these symptoms can have a profound effect on the patient's quality of life. This article reviews the appropriate assessment of behavioral and psychological symptoms of dementia (BPSD) and the literature supporting various nonpharmacologic and pharmacologic treatments. Nonpharmacologic approaches should be the initial focus for treatment of most BPSD, but should these prove inadequate, a variety of medications are available with varying degrees of clinical research to support their use in ameliorating BPSD.

Effects of a feeding skills training programme on nursing assistants and dementia patients

AIMS AND OBJECTIVES

The purposes of this study were to develop a comprehensive feeding skills training programme for nursing assistants and to test the effects of this training programme on their knowledge, attitude and behaviour and the outcome of dementia patients including total eating time, food intake and feeding difficulty.

BACKGROUND

Dementia patients have a high probability of feeding problems that result in a substantial risk of malnutrition. Assisting residents with eating is a major task for nursing assistants and they require better training to provide adequate quality of nutritional care.

DESIGN METHODS

A quasi-experimental study was conducted. Two convenience-chosen dementia-specialized long-term care facilities in North Taiwan were randomly assigned into either a control or a treatment group. Sixty-seven nursing assistants were enrolled (treatment: 31; control: 36). Twenty nursing assistants and the same number of dementia patients were observed during mealtime. The treatment group participated in a feeding skills training programme including three hours of in-service classes and one hour of hands-on training, whereas the control group did not receive any training.

RESULTS

The treatment group had significantly more knowledge (F = 47.7, P < 0.001), more positive attitude (F = 15.75, P = 0.001) and better behaviours (t = 6.0, P < 0.001) than the control group after the intervention. Dementia patients in the treatment group had significantly longer total eating time (t = 2.7, P < 0.05) and higher Edinburgh Feeding Evaluation in Dementia scores (more feeding difficulty) (t = 2.1, P < 0.05) than the control group. There was no significant difference on food intake between the two groups (t = 0.8, P = 0.49).

CONCLUSION

This feeding skills training programme has been found to change nursing assistants' knowledge, attitude, and behaviour as well as increasing the eating time for the dementia patients.

RELEVANCE TO CLINICAL PRACTICE

This study raises attention regarding on-the-job training for nursing assistants. Furthermore, the feeding problems among dementia patients should be further explored as well as the nutritional care.

Reducing assaults against nursing home caregivers

BACKGROUND

Nursing assistants (NAs) working in long-term care have the highest incidence of workplace assault among all workers in the United States.

OBJECTIVES

The objective of this study was to test the effectiveness of a violence-prevention intervention, on the basis of Social Cognitive Theory to increase knowledge, self-efficacy, and skills, and to decrease assaults.

METHODS

Investigators conducted a quasi-experimental study with 138 NAs in 3 intervention and 3 comparison homes. A baseline questionnaire was used to obtain information on demographics, employment, and violence experience. At pre-, post- and 6 months after the intervention, all participants completed the State Trait Anger Inventory and the Knowledge and Self-Efficacy Survey, carried an Assault log for 80 hr of work, and participated in a simulation exercise to assess violence-prevention skills. Tabulations, analysis of variance, and Poisson regression were used to analyze the data.

RESULTS

The intervention participants showed significant increases in knowledge, self-efficacy, and violence-prevention skills. Although the intervention had no significant main effect on the incidence of assaults, there was an interaction effect between the intervention and the number of preintervention assaults. The intervention had a significant effect on those NAs who had fewer than 6 assaults preintervention (p < .001) and no significant effect on those who had more than 7 assaults on preintervention. There were significant relationships between assaults and the following covariates: age, state anger, and the number of residents assigned.

DISCUSSION

Although the incidence of violence cannot be eliminated, it can be decreased and it should never be tolerated or accepted as "part of the job" because to do so devalues the NA.

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.

Review Article: Management of Behavioral Symptoms in Progressive Degenerative Dementias

Management of behavioral symptoms of Alzheimer's disease and other progressive degenerative dementias poses continuous challenge to both family and professional caregivers. Behavioral symptoms are complex in nature and require that caregivers understand their presumed causes and intervene appropriately using validated caregiving techniques. Unfortunately, confusing terminology hampers improvement in management techniques. This review attempts to clarify terminology and specifically the behavioral symptoms "agitation" and "resistiveness to care" that require different management techniques. Several conceptual frameworks for behavioral symptoms of dementia are presented. These frameworks include behavioral models, a psychiatric model, and a comprehensive model that combines both behavioral and psychiatric strategies. Using precise terminology consistently and providing care based on a conceptual framework will facilitate the education of caregivers in appropriate techniques for management of behavioral symptoms of dementias.

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.