Disruptive behaviors of a cognitively impaired nursing home resident

Confined to barracks: The effects of indoor confinement on aggressive behavior among inpatients of an acute psychogeriatric unit

While there is evidence to suggest that in long term residential care settings the provision of more choices and better designed environments have a positive effect on agitation and disturbed behaviors, there are no controlled studies on the effect of imposed confinement in these settings or in acute units.

The effect of mandatory confinement indoors on the incidence of verbal and physical aggression and psychotropic medication use among patients with dementia and associated psychiatric and behavioral disturbance was studied. The setting was an acute psychogeriatric admission unit accommodated in a colonial building originally built as a military barracks. A convenience sample was studied to assess changes in levels of aggression and nurse-initiated psychotropic medication use during and after a 32-day period of indoor confinement. Correlations with gender, diagnosis, pre-admission disturbed behavior and ultimate discharge outcome were examined.

Release from mandatory confinement indoors was correlated with decreases in both verbal and physical aggression as well as medication use. Correlations could be identified between decreases in aggression and male gender, pre-admission aggressive behavior and discharge outcome. Decreased medication use was correlated with discharge outcome. The freedom to go outdoors or have access to extra space should be an important component of the environmental design and care philosophy for the acute admission of people who experience dementia and associated psychiatric and behavioral disturbance.

Conflict Resolution Styles: A Comparison of Assisted Living and Nursing Home Facilities

In this exploratory study, the authors investigated how interpersonal conflict is resolved in assisted living and nursing home facilities. In particular, the authors examined whether conflict resolution styles differed between type of facility and between residents and staff in each type of facility. Four focus groups were conducted--two with residents and two with staff from each type of facility. The focus groups centered on discussing the occurrence of conflict and how each participant handled it. Discourse analysis was employed to identify participants' use of three styles of conflict resolution: controlling, solution-oriented, and non-confrontational. The results indicate that staff in each care context showed a preference for the solution-oriented approach. Residents in each setting reported equal use of the non-confrontational and solution-oriented styles. The findings suggest that preferred conflict resolution styles may vary more as a function of the role of each communicator than the context of the care setting.

Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities

BACKGROUND

Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism.

METHODS

The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2,332).

RESULTS

The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.

CONCLUSION

Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.

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

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

Disruptive vocalizations: a means to communicate in dementia?

Disruptive vocalizations (DVs) constitute a serious problem in geriatric nursing homes. The current literature suggests that DV can be interpreted as a way for demented persons with language limitations to communicate with others. In an attempt to test this hypothesis, 59 participants were recruited from six nursing homes to form two groups: one group of individuals with preserved language skills (PLS) and another group with altered language skills (ALS). They were compared on the frequency and types of DV. The results indicate that individuals with ALS manifest DV at a greater frequency than those with PLS. These persons also present a greater number of distinct DV forms. The results are interpreted in terms of language deterioration associated with dementia.

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.

Bathing. Pleasure or pain?

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

Family members' and care providers' interpretations of picking behavior

The meaning of so-called "behavior disturbances" among people with dementia is often difficult to interpret. In this exploratory study, the aim was to explore family members' and care providers' descriptions of picking behavior in people with severe dementia and their interpretations of the behavior's meaning. Three threads of meaning were identified in these interpretations: striving for an ordinary, everyday life, striving for control, and striving to be in touch with others. The possibilities of uniting the past and the present by means of collaboration among family members and care providers are discussed.

Interaction relating to privacy, identity, autonomy and security. An observational study focusing on a woman with dementia and "behavioural disturbances", and on her care providers

AIM

The study aims to illuminate how one woman with severe dementia and so-called behavioural disturbances acts in relation to her care providers and how the care providers act in relation to her.

METHODS

Fourteen participant observations, including one woman with dementia and six care providers, were performed. A reflective dialogue focusing on the interaction between the woman and her care providers followed each observation. The tape-recorded observational notes and reflective dialogues were fixed as a text, which was subjected to a thematic content analysis.

FINDINGS

The main findings are that the interaction between a woman with severe dementia and "behavioural disturbances" and her care providers relates to privacy, identity, autonomy and security. The phenomena are intertwined and also in conflict with each other. Interaction is a complex dialectic process in which those who are engaged meet problems that can be solved and are involved in dilemmas that cannot be solved, only related to.

Nursing staff perceptions of the behaviour of older nursing home residents and decision making on restraint use: a qualitative and interpretative study

This study examined staff perceptions of the behaviour of older nursing home residents and how these perceptions govern their decision making on restraint use. Data were collected in unstructured interviews with 20 trained and untrained nursing staff from two Swiss nursing homes. Data analysis was based on Colaizzi's phenomenological method. Two main themes were extracted from the data: (i) situations in which behaviour is perceived in terms of a problem that needs to be controlled and consequently leads to restraint use; and (ii) situations in which behaviour is perceived in terms of something one has to learn to live with and consequently leads to avoidance of restraint. Staff members' choices to perceive resident's behaviour from the angle they did were clearly associated with the rights and responsibilities of both nursing staff and older people. It is concluded that the primary source of change towards the avoidance of restraint use does not necessarily lie in external factors, but in staff members themselves.

Development and testing of the Resistiveness to Care Scale

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

Probable reasons for expressed agitation in persons with dementia

Nursing home patients with dementia were videotaped in three previous studies. Sixty sequences of nine patients exhibiting agitated behaviors were examined to identify the most probable antecedents to agitation. Probable reasons were interpreted and applied to the Progressively Lowered Stress Threshold model, which suggests that agitation is stress related. Analysis suggests that agitation often serves as a form of communication. Two underlying reasons seem to be that the patient had loss of control over the situation and deficient autonomy. The most common causes for expressed agitation were interpreted as discomfort, a wish to be served immediately, conflict between patients or with nursing staff, reactions to environmental noises or sound, and invasion of personal space. It is recommended that nursing staff promote autonomy and independency for this group of patients whenever possible. By evaluating probable reasons for expressed agitation, the nursing staff can take steps to prevent or alleviate agitation.

Cognitive developmental approach to dementia

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

The use of contingency management in the treatment of a geriatric nursing home patient with psychogenic vomiting

A substantial percentage of nursing home residents evidence psychosocial and behavioral problems. However, surprisingly little is known about how effectively to treat geriatric patients with behavioral problems. The present study reports the behavioral treatment of a patient with psychogenic vomiting. The patient was successfully treated by changing the contingencies of her illness behavior and of behavior associated with rehabilitation goals. This indicates the importance of nursing home staff attending to the operants of illness behavior. Specifically, independent behavior should be rewarded by praise and attention and illness behavior should be ignored in terms of attention.

The influence of environmental factors in incidents of disruptive behavior

1. Disruptive behavior is an annoying and potentially dangerous problem in most nursing homes. Disruptive behaviors can be both physical and verbal. 2. Changes associated with termination of disruptive behaviors included the reduction of external environmental stimuli, reduction of perceived threats to the patient's personal freedom and fulfillment of basic physical needs, fulfillment of needs for interpersonal support, a simple request to the disruptive person that the behavior be discontinued, provision for increased freedom by releasing the person from a gerichair or wheelchair with rollbar, separation of residents involved in disputes, and resolution of disputes over belongings. 3. In order to initiate changes that will reduce the frequency of such behavior or mitigate its harmful effects, nurses must have a better understanding of how environmental factors influence the evolution of disruptive episodes and plan appropriate and specific nursing interventions.

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.

Risk profiles for nursing home placement of rural elderly: a cluster analysis of psychogeriatric indicators

In an effort to better understand the clinical and functional status of patients served by our Rural Elder Outreach Program, more effectively identify risk groups, and more efficiently target services, we performed a cluster analysis on 92 older adults served by our program. The first cluster included patients with very poor health, mild cognitive impairment, very high care demands, and migrating toward active risk for institutionalization. The second cluster included patients with poor physical but good mental health, intact cognition, high care demands, and at passive risk. The third cluster comprised patients with high functional, physical, and cognitive impairment, intensive care demands, moderate mental health problems, poor insight into their situation, and at active risk for institutionalization.

Psychiatric mental health nursing in a biopsychosocial era

Clients in long-term facilities carry a wide array of psychiatric diagnoses, often with equally diverse medical problems. This "back ward" population requires a specialized area of psychiatric mental health nursing practice. The need for comprehensive assessment and adequate interventions, and the various frustrations of nursing staff, are discussed using a case example.

Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment

Relaxing music was hypothesized to buffer the general noise level typically found in dining rooms of nursing homes, exert a calming effect, and thus reduce agitated behaviors among residents with severe cognitive impairment. Twenty-nine nursing home residents with severe cognitive deficits participated in a 4-week protocol in which, following baseline observations (week 1), relaxing music was introduced (week 2), removed (week 3), and reintroduced (week 4). Subjects were observed in terms of total number of behaviors of the Cohen-Mansfield Agitation Inventory present during a given week, and the number of behaviors present on the subscales of aggressive, physically nonaggressive, verbally agitated, and hiding/hoarding behaviors. Significant reductions were observed on the cumulative incidence of total agitated behaviors (63.4%); as well as the cumulative incidence of physically nonaggressive behaviors (56.3%) and verbally agitated behaviors (74.5%). No significant reductions were noted in terms of aggressive behaviors and hiding/hoarding behaviors. Where significant reductions were achieved, a distinct pattern was observed. Agitation decreased during week 2, increased again during week 3, only to decrease again in week 4. In addition, variance effects were noted as well, as ranges and standard deviations of agitated behaviors narrowed over time. These findings are interpreted within Hall and Buckwalter's (1988) model of a progressively lowered stress threshold among dementia patients.