Linking resident behavior to dementia care communication: effects of emotional tone

Differences in Staff-Resident Care Interactions by Nursing Home Racial Composition: a Preliminary Analysis

Limited research has examined racial differences in the quality of staff-resident care interactions in long-term care settings. The quality of care interactions can significantly affect resident quality of life and psychological well-being among nursing home residents living with dementia. Limited research has assessed racial or facility differences in the quality of care interactions. The purpose of the present study was to determine if there were differences in the quality of care interactions among nursing home residents with dementia between Maryland nursing home facilities with and without Black residents. It was hypothesized that after controlling for age, cognition, comorbidities, and function, the quality of care interactions would be better in facilities with Black residents versus those in which there were only White residents. Baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) intervention study was used and included 276 residents. The results indicated that facilities in Maryland with Black residents had a 0.27 increase (b = 0.27, p < .05) in the quality of care interaction score compared to facilities without Black residents. The findings from this study will be used to inform future interventions to aid in reducing quality of care disparities in nursing home facilities with and without Black nursing home residents. Future work should continue to examine staff, resident, and facility characteristics associated with the quality of care interactions to improve quality of life among all nursing home residents regardless of race or ethnicity.

Model Testing of the Factors that are Associated with Care Interactions among Nursing Home Residents with Dementia

OBJECTIVE

The purpose of this study was to test a model of the resident and community factors that are associated with quality of care interactions among nursing home (NH) residents living with dementia and test for invariance between model fit when tested with the Black versus White residents and female versus male residents. It was hypothesized that resident age, gender, race, pain, comorbidities, quality of life, resistiveness to care, function, cognition, community profit status, overall community star rating, community size, and staffing star rating would be directly and/or indirectly associated with quality of care interactions. It was also hypothesized that the model fit would be invariant by resident race and gender.

DESIGN

This was a secondary data analysis using baseline, cross-sectional data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) intervention study.

SETTING AND PARTICIPANTS

The study included 528 residents from 55 NH facilities.

METHODS

Descriptive statistics and structural equation modeling was used to test the proposed model.

RESULTS

The results showed that the final model with significant paths only had a poor fit to the data (χ2/df = 10.79, comparative fit index = 0.57, Tucker-Lewis index = 0.15, normed fit index = 0.57, root mean square error of approximation = 0.13). However, the findings indicated that comorbidities, pain, profit status, and overall community star rating were significantly associated with quality of care interactions. There was no difference in model fit between Black residents versus White residents, and between male versus female residents.

CONCLUSIONS AND IMPLICATIONS

This study suggests factors that may influence quality of care interactions. Managing comorbidities, managing pain, and supporting higher quality of care in NH communities will likely help increase the frequency of positive care interactions. These findings can inform future interventions and training curricula for NH care staff to promote positive care interactions.

The needs of older people with dementia from culturally and linguistically diverse backgrounds living in residential aged care: An integrative review

AIMS AND OBJECTIVES

To synthesise information about the needs of older people with dementia from culturally and linguistically diverse backgrounds living in residential aged care from the perspectives of the residents, families and care staff.

BACKGROUND

Older people with dementia from culturally and linguistically diverse backgrounds living in residential aged care have care needs that are complex. Identifying these needs is critical to ensure quality care is delivered.

DESIGN

An integrative review of literature.

METHODS

Five databases were searched for relevant articles: APA PsychINFO, CINAHL, MEDLINE, Scopus and Google Scholar. The search and screening were guided by PRISMA guidelines and Whittemore and Knafl's five-step framework.

RESULTS

Fifteen papers were included in this review consisting of 4 quantitative, 9 qualitative and 2 mixed method studies. Two themes described the needs of older people with dementia from culturally and linguistically diverse backgrounds living in residential aged care. The first was related to culture-specific needs, and the second was related to dementia-specific care needs. Culture-specific needs comprised of three subthemes: (a) common language, (b) traditional food, and (c) social and spiritual requirements. Dementia-specific needs comprised of (a) focusing on comfort in addition to clinical requirements and (b) individualised care that addresses behavioural symptoms of dementia.

CONCLUSIONS

Identifying and meeting the needs of older people with dementia from culturally and linguistically diverse backgrounds will improve quality care delivery in addition to increased caregiving satisfaction among residents, families and care staff, and the management of behaviours that characterise dementia.

RELEVANCE TO CLINICAL PRACTICE

Care needs of older people with dementia from culturally and linguistically diverse backgrounds living in the residential setting can be complex. Education and training of care staff including nurses must be considered so that provision of care is inclusive of the cultural and dementia needs for older people in residential aged care.

Promoting Elderspeak Awareness: Adapting Changing Talk Online Communication Education for Adult Day Services Staff

Communication is fundamental for dementia care across long-term services and support (LTSS) settings. Education increasing nursing home (NH) staff awareness of person-centered communication has reduced staff elderspeak communication and reduced resistiveness to care of residents with dementia. The current study tested the Changing Talk Online (CHATO) education with adult day services (ADS) staff to identify strategies for adaptation for other LTSS settings. Three dementia-specific ADS sites participated in the CHATO education program. Participants completed knowledge assessment, communication ratings, and confidence ratings on providing care pre- and post-CHATO; a program evaluation; and rated their intention to use skills in practice. Findings were compared to an earlier study of CHATO in NHs. Focus groups evaluated feasibility, applicability, and directions for tailoring. Mean scores on the Changing Talk Scale knowledge test increased by 15 percentage points (p < 0.001). Confidence in providing dementia care scores also increased (p = 0.037). The mean Modified Diffusion of Innovation scale score was 2.2, similar to that in NHs, indicating intent to use skills; and program evaluation was positive. Focus group participants reported CHATO was valuable and recommended incorporating scenarios specific to ADS care. [Research in Gerontological Nursing, 16(2), 85-94.].

Association between Dementia Severity and Oral Hygiene Management Issues in Older Adults with Alzheimer's Disease: A Cross-Sectional Study

Oral hygiene management issues vary across types and clinical stages of dementia. We aimed to clarify the issues related to oral hygiene management in older adults with Alzheimer's disease (AD) according to stages defined by the Functional Assessment Staging of Alzheimer's Disease (FAST). In all, 397 records (45 men and 352 women; average age, 86.8 years; age range, 65-106) from older adults with AD were used for the cross-sectional study. We used data from a cohort of older adults (≥65 years old) who required long-term care and lived in the Omorimachi area of Yokote City, Akita Prefecture, Japan. Multilevel logistic regression analysis was conducted to examine the associations of the FAST stage, set as the exposure variable, with oral hygiene management parameters set as outcome variables. Compared to the reference category (combined FAST stage 1-3), FAST stages 6 and 7 had significantly higher odds ratios for refusal of oral health care, dependence in performing oral health care, and rinsing and gargling disability. FAST stages 4 and 7 were associated with dental plaque accumulation. Oral health care for older adults with AD should be planned appropriately according to dementia severity.

End-of-Life Costs of Cancer Patients With Alzheimer's Disease and Related Dementias in the U.S

CONTEXT

End-of-Life (EOL) care consumes a substantial amount of healthcare resources, especially among older persons with cancer. Having Alzheimer's Disease and Related Dementias (ADRD) brings additional complexities to these patients' EOL care.

OBJECTIVES

To examine the Medicare expenditures at the EOL (last 12 months of life) among beneficiaries having cancer and ADRD vs. those without ADRD.

METHODS

A retrospective cohort study used 2004-2016 Surveillance, Epidemiology, and End Results-Medicare data. Patient populations were deceased Medicare beneficiaries with cancer (breast, lung, colorectal, and prostate) and continuously enrolled for 12 months before death. Beneficiaries with ADRD were propensity score matched with non-ADRD counterparts. Generalized Estimating Equation Model was deployed to estimate monthly Medicare expenditures. Generalized Linear Models were constructed to assess total EOL expenditures.

RESULTS

Eighty six thousand three hundred ninety-six beneficiaries were included (43,198 beneficiaries with ADRD and 43,198 beneficiaries without ADRD). Beneficiaries with ADRD utilized $64,901 at the EOL, which was roughly $407 more than those without ADRD ($64,901 vs. $64,494, P = 0.31). Compared to beneficiaries without ADRD, those with ADRD had 11% higher monthly expenditure and 7% higher in total expenditures. Greater expenditure was incurred on inpatient (5%), skilled nursing facility (SNF) (119%), home health (42%), and hospice (44%) care.

CONCLUSION

Medicare spending at the EOL per beneficiary was not statistically different between cohorts. However, specific types of service (i.e., inpatient, SNF, home health, and hospice) were significantly higher in the ADRD group compared to their non-ADRD counterparts. This study underscored the potential financial burden and informed Medicare about allocation of resources at the EOL.

Developing Behavioral Coding to Understand Family Communication Breakdown in Dementia Care

Communication breakdown is a challenge for family caregivers of persons living with dementia. We adapted established theory and scales for computer-assisted behavioral coding to characterize caregiver communication for a secondary analysis. We developed verbal, nonverbal, and breakdown coding schemes and established reliability (κ > .85). Within the 221 family caregiving videos analyzed, 55% of exchanges were interactive, 30% were silence, 4% consisted of talking to self or others, and 8% included a breakdown. An average of 2.4 (SD = 1.9) breakdowns occurred per observation and were successfully resolved 85% of the time, with 31% being resolved most successfully following only one flag and repair strategy. Caregivers were the primary speakers (67%); their communication preceded most breakdown (65%), and they primarily initiated the repairs after a breakdown (70%). Common repair strategies included clarifications (31%), asking questions (24%), and repeating information (24%). Associations between communication strategies and repair success will provide evidence for caregiver training.

Changing Talk Online: Protocol for a cluster pragmatic trial testing communication education to reduce behavioral and psychological symptoms of dementia in nursing home care

Nursing home (NH) care of persons living with dementia is often made challenging by behavioral and psychological symptoms of dementia (BPSD) such as aggression, vocal outbursts, wandering, and withdrawal that occur due to cognitive and communication changes. Staff frequently communicate to NH residents using "elderspeak" which is patronizing speech similar to baby talk. Residents respond to elderspeak with increased BPSD that prompts use of psychotropic medication to control symptoms. The Changing Talk (CHAT) training educates staff about effective, person-centered communication strategies and reduces elderspeak by staff and subsequent BPSD among residents. This study will test effects of an adapted online version (CHATO) increasing access and dissemination of education to busy staff across diverse care settings. Nursing homes (N = 128) will be stratified and then randomized to CHATO education (n = 64) or to the control group (n = 64). Data on behavioral symptoms (primary outcomes) and psychotropic medication use (secondary outcomes) will be extracted from the Center for Medicare and Medicaid Services Minimum Data Set before and after education and will be compared between the groups using generalized linear mixed modeling. It is hypothesized that after completing the CHATO education residents will have reduced behavioral symptoms and psychotropic medication use compared to residents in control NHs. Additionally, factors related to NH participation and cost of the intervention will be determined. The overall goal of this study is to prepare for large scale dissemination and implementation of the evidence-based nonpharmacological CHATO intervention to reduce BPSD in residents with dementia across long-term care settings.

Understanding Elderspeak: An Evolutionary Concept Analysis

Background and Objectives

Elderspeak is an inappropriate simplified speech register that sounds like baby talk and is used with older adults, especially in health care settings. Understanding the concept of elderspeak is challenging due to varying views about which communicative components constitute elderspeak and whether elderspeak is beneficial or harmful for older adults.

Research Design and Methods

Rodgers’ evolutionary concept analysis method was used to evaluate the concept of elderspeak through identification of elderspeak’s attributes, antecedents, and consequences. A systematic search using the PubMed, CINAHL, PsycINFO, and Embase databases was completed.

Results

Eighty-three theoretical or research articles from 1981 to 2020 were identified. Elderspeak characteristics were categorized by semantic, syntactic, pragmatic, paralinguistic, and nonverbal attributes. The primary antecedent to elderspeak is implicit ageism, in which old age cues and signs of functional or cognitive impairment led to simplified communication, usually from a younger caregiver. Research studies varied in reporting whether elderspeak facilitated or interfered with comprehension by older adults, in part depending on the operational definition of elderspeak and experimental manipulations. Exaggerated prosody, a key feature of elderspeak, was found to reduce comprehension. Elderspeak was generally perceived as patronizing by older adults and speakers were perceived as less respectful. In persons with dementia, elderspeak also increases the probability of resistiveness to care, which is an important correlate of behavioral and psychological symptoms of dementia.

Discussion and Implications

Based on this concept analysis, a new definition of elderspeak is proposed, in which attributes that have been found to enhance comprehension are differentiated from those that do not. Recommendations for consistent operationalization of elderspeak in future research are made.

A proposal for a novel approach to reduce burdens of care for people with dementia: A hypothesis

Cognitive impairment of dementia patients affects their ability to communicate and cooperate with care. Dementia patients need a specialized communication to increase their cooperation during daily care and a scale to measure cooperation with care. To improve communication, we created and applied a digital communication platform (DCP) in an observational study. To measure cooperation with care, we created and tested psychometric properties of the Cooperation with Care Scale-Revised (CWCS-R) in an institutional review board-approved 6-week prospective study. DCP intervention was associated with decreased agitation and use of psychotropic medications for nursing home (NH) dementia patients. CWCS-R is both a reliable and valid tool to measure cooperation with care in NH dementia patients. Innovations in communication with dementia patients and a scale to measure cooperation with care could reduce burdens of care and improve quality of life for patients, their family members, and staff. It may potentially help decrease cost of dementia care.

Importance of Distinguishing Reactive and Proactive Aggression in Dementia Care

Aggressive behavior is one of the most disturbing symptoms of Alzheimer disease and other progressive neurodegenerative dementias. Development of strategies for management of aggressive behaviors in people with dementia is hindered by a lack of recognition that aggression is not a uniform behavioral construct. It is possible to distinguish 2 types of aggression: reactive or impulsive aggression and proactive or premeditated aggression. Research concerning aggressive behaviors in people with dementia is hindered by scales describing behavioral symptoms of dementia which do not distinguish between reactive and proactive aggressions because they do not consider the factors leading to these behaviors. Reactive aggression is caused by lack of understanding, leading to rejection of care, while proactive aggression could be caused by a psychopathic personality, hallucinations or delusions, and other determinants. It is difficult to underestimate the importance of distinguishing reactive and proactive aggressions in people with dementia because there are different strategies that can be used for management of these behaviors. For reactive aggression, delayed treatment, distraction, improved communication, and change in treatment strategy is useful, while antipsychotic medication may be needed for treatment of proactive aggression. Dementia is increasing the risk of both types of aggressions and antidepressant treatment can be helpful. Most importantly, persons exhibiting reactive aggression should not be labeled "aggressors" because this behavior could be caused by unmet persons' needs, pain and poor communication with care providers.

A Communicative Intervention to Improve the Psychoemotional State of Critical Care Patients Transported by Ambulance

BACKGROUND

Communication is key to understanding the emotional state of critical care patients.

OBJECTIVE

To analyze the effectiveness of the communicative intervention known as CONECTEM, which incorporates basic communication skills and augmentative alternative communication, in improving pain, anxiety, and posttraumatic stress disorder symptoms in critical care patients transported by ambulance.

METHODS

This study had a quasi-experimental design with intervention and control groups. It was carried out at 4 emergency medical centers in northern Spain. One of the centers served as the intervention unit, with the other 3 serving as control units. The nurses at the intervention center underwent training in CONECTEM. Pretest and posttest measurements were obtained using a visual analog scale to measure pain, the short-version State-Trait Anxiety Inventory to measure anxiety, and the Impact of Event Scale to measure posttraumatic stress disorder symptoms.

RESULTS

In the comparative pretest-posttest analysis of the groups, significant differences were found in favor of the intervention group (Pillai multivariate, F2,110 = 57.973, P < .001). The intervention was associated with improvements in pain (mean visual analog scale score, 3.3 pretest vs 1.1 posttest; P < .001) and posttraumatic stress disorder symptoms (mean Impact of Event Scale score, 17.8 pretest vs 11.2 posttest; P < .001). Moreover, the percentage of patients whose anxiety improved was higher in the intervention group than in the control group (62% vs 4%, P < .001).

CONCLUSION

The communicative intervention CONECTEM was effective in improving psychoemotional state among critical care patients during medical transport.

A communication model for nursing staff working in dementia care: Results of a scoping review

BACKGROUND

Communication between nursing staff and people with dementia can be challenging. According to the literature, communication is seen as a process of social- and/or informational exchange between a sender and a receiver in a context. Factors related to these elements determine the quality of communication. Insight into the factors involved in the communication process between nursing staff and people with dementia is limited and a comprehensive model of communication in dementia care is lacking.

OBJECTIVES

To identify and visualize factors associated with communication between nursing staff and people with dementia.

DESIGN

A scoping review of scientific literature.

DATA SOURCES

Scientific articles were retrieved from the bibliographic databases of PubMed, CINAHL and PsycINFO.

REVIEW METHODS

The reviewing process was directed by the Joanna Briggs guidelines for scoping reviews. Full-text articles describing the communication process between nursing staff and people with dementia were eligible for inclusion. A data extraction form was used to identify factors associated with communication. Following a directed content analysis approach, factors were categorized in one of three categories: nursing staff; people with dementia; or context. Each category was thematically analysed to identify themes and subthemes. Results were visualized into a communication model.

RESULTS

The review included 31 articles; in total, 115 factors were extracted. Thematic analysis of nursing staff factors (n = 78) showed that communication is associated with professional characteristics, individual experiences, verbal- and non-verbal communication skills, communication approach and values. Factors attributed to people with dementia (n = 22) concerned client characteristics, functional status, behaviour, verbal communication skills and values. Contextual factors (n = 15) related to organization of care, time and situation. Based on these results, the Contac-d model was constructed.

CONCLUSIONS

The Contac-d model gives a comprehensive overview of factors involved in the communication process between nursing staff and people with dementia, providing insight in potential starting points for communication improvement, e.g. respect for needs, identity and privacy of people with dementia, a flexible and adapted communication approach and matching language. Additionally, results suggest that an appealing location, longer duration of the interaction, and music in the surrounding may improve communication in certain situations. However, it was not feasible based on current literature to recommend what works to improve communication in which situations. Future studies should study factors and their interrelatedness in specific care situations. Authors further believe that more attention should be paid to strengths and capabilities of people with dementia and to non-modifiable factors that influence communication.

Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care

OBJECTIVES

People with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff-resident interactions.

DESIGN

An exploratory, cross-sectional study.

SETTING AND PARTICIPANTS

In total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed.

METHODS

Structured observations were carried out to assess the support of resident autonomy within staff-resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents' responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience.

RESULTS

In total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents' needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations.

CONCLUSIONS AND IMPLICATIONS

The findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents' individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy.

Beyond Messiaen's birds: the post-verbal world of dementia

This paper investigates the use of verbatim musical transcription as a research method in dementia care. It reports on an art-based ethnographic study (Aesthetic Research in Everyday Life (Aeriel)) in which verbatim transcription was applied to everyday interactions in dementia care, making use of musical-instead of verbal-notation. Starting from the notion that medical and healthcare settings can be sites of 'found performance', the paper reviews literature relating to artistic methodologies within medical humanities, music, ethnography and dementia care. From this review, it proposes a research design and method of verbatim musical transcription as a potential avenue of investigating communication between carer and cared for in dementia care. The paper offers an illustrative example from Aeriel and draws conclusions from the synthesis of verbal and musical data analysis. Findings indicate an important advance in studies of dementia care communication towards a concept of the 'post-verbal' enabled by a musical research method and the clinical applications that it offers.

Feasibility of a Dementia-Focused Person-Centered Communication Intervention for Home Care Workers

Objectives: This study assessed the feasibility of Be EPIC, a dementia-focused, person-centered communication intervention for personal support workers (PSWs). Be EPIC's foci includes the environment, person-centered communication, client relationships, and clients' abilities, social history and preferences.Methods: Feasibility was assessed using semi-structured interviews and focus groups with PSWs. We used a phenomenological approach to assess: acceptability, implementation, practicality, demand, and limited efficacy.Results: The theme supporting the criterion of acceptability was helpful/relevant training. Themes supporting implementation included realistic simulations, interactive training, and positive learning experience at the adult-day center. The theme supporting practicality was support to attend training. Demand for Be EPIC revealed two themes: participants' personal motivation and barriers to applying newly learned knowledge and skills. The theme reflecting limited efficacy was applying newly learned knowledge and skills with home care clients. Four themes emerged that mapped onto Be EPIC's foci.Conclusions: The findings support Be EPIC's feasibility and highlight the need to address structural barriers from employers and government to ensure the delivery of person-centered dementia care.Clinical Implications: The findings highlight the need for and positive impact of person-centered communication training on home care workers, especially the value of learning by doing, reflective practice, and peer support.

Elderspeak to Resident Dementia Patients Increases Resistiveness to Care in Health Care Profession

Resistiveness to care is very common among patients of dementia as these patients do not take medicines, meals or bath very easily. Indeed, it is a very challenging task for health caregivers and there is a significant rise in time and cost involved in managing dementia patients. Amongst different factors, the type of communication between resident dementia patients and health caregivers is an important contributing factor in the development of resistiveness to care. Elderspeak (baby talk) is a type of communication in which health caregivers adjust their language and style while interacting with elderly and dependent patients. It involves the use of short sentences, simple grammar, slow and high pitch voice, repeating phrases to provide a comfortable and friendly environment to patients. Most of the time, caregivers tend to adapt elderspeak as they handle weak and fragile older patients for routine activities. Although elderspeak is meant to provide support, warmth and care to patients, yet patients perceive elderspeak as patronizing and it induces negative feelings about self-esteem. Scientists have found a correlation between the development of resistiveness to care and the extent of elderspeak in communication. Therefore, there have been strategies to develop alternative communication strategies by avoiding the use of elderspeak. Moreover, the beneficial effects of such communications have been documented as it improves the quality of life, reduces aggression, agitation and psychosocial symptoms. The present review discusses the scientific studies discussing the use of elderspeak in communication and development of resistiveness to care in resident patients of dementia.

Communication behavior of cognitively impaired older inpatients : A new setting for validating the CODEM instrument

BACKGROUND AND OBJECTIVE

Acutely ill older patients with cognitive impairment represent a major subgroup in acute care hospitals. In this context, communication plays a crucial role for patients' well-being, healthcare decisions, and medical outcomes. As validated measures are lacking, we tested the psychometric properties of an observational instrument to assess Communication Behavior in Dementia (CODEM) in the acute care hospital setting. As a novel feature, we were also able to incorporate linguistic and social-contextual measures.

MATERIAL AND METHODS

Data were drawn from a cross-sectional mixed methods study that focused on the occurrence of elderspeak during care interactions in two German acute care hospitals. A total of 43 acutely ill older patients with severe cognitive impairment (CI group, Mage ± SD = 83.6 ± 5.7 years) and 50 without cognitive impairment (CU group, Mage ± SD = 82.1 ± 6.3 years) were observed by trained research assistants during a standardized interview situation and rated afterwards by use of CODEM.

RESULTS

Factor analysis supported the expected two-factor solution for the CI group, i.e., a verbal content and a nonverbal relationship aspect. Findings of the current study indicated sound psychometric properties of the CODEM instrument including internal consistency, convergent, divergent, and criterion validity.

CONCLUSION

CODEM represents a reliable and valid tool to examine the communication behavior of older patients with CI in the acute care hospital setting. Thus, CODEM might serve as an important instrument for researcher and healthcare professionals to describe and improve communication patterns in this environment.

Nurses' emotional tone toward older inpatients: Do cognitive impairment and acute hospital setting matter?

The emotional tone of nurses' voice toward residents has been characterized as overly controlling and less person-centered. However, it is unclear whether this critical imbalance also applies to acutely ill older patients, who represent a major subgroup in acute hospitals. We therefore examined nurses' emotional tone in this setting, contrasting care interactions with severely cognitively impaired (CI) versus cognitively unimpaired older patients. Furthermore, we included a general versus a geriatric acute hospital to examine the role of different hospital environments. A mixed-methods design combining audio-recordings with standardized interviews was used. Audio-recorded clips of care interactions between 34 registered nurses (M _age = 38.9 years, SD = 12.3 years) and 92 patients (M _age = 83.4 years, SD = 6.1 years; 50% with CI) were evaluated by 12 naïve raters (M _age = 32.8 years, SD = 9.3 years). Based on their impressions of the vocal qualities, raters judged nurses' emotional tone by an established procedure which allows to differentiate between a person-centered and a controlling tone (Cronbach's α = .98 for both subscales). Overall, findings revealed that nurses used rather person-centered tones. However, nurses' tone was rated as more controlling for CI patients and in the geriatric hospital. When controlling for patients' functional status, both effects lost significance. To our knowledge, this is the first study that examined nurses' emotional tone in the acute hospital setting. Findings suggest that overall functional status of older patients may play a more important role for emotional tone in care interactions than CI and setting differences.

An interactional perspective on sound prolongation in multilingual encounters in residential care

Elderspeak refers to adapting one's language to a  perceived language decline of an older interlocutor. Earlier studies have explored different features of elderspeak; some of these studies attribute positive outcomes to using elderspeak that facilitates communication, but other studies consider elderspeak a negative way of communicating that should be avoided. The aim of this study is to investigate a largely unexplored feature of elderspeak, namely sound prolongation in a multilingual context. There are five participants in this study: three carers and two care recipients in a residential care unit. The carers and care recipients have limited access to a shared spoken language. The data consist of video- and audio recordings of interaction between the participants. The recordings have been transcribed and analysed in accordance with Conversation Analytical methodology. The analysis shows that the carers use sound prolongation as part of their interactional repertoire in order to manage situations of distress. We conclude that in some distressful situations carers' use of sound prolongation may help mitigating the care recipient's emotional concerns since the source of agitations has been addressed properly. In other situations, the use of sound prolongation may lead to an escalation in distress, if the source of agitation is not addressed adequately. Our results bring to the fore that an interactional practice, such as the use of sound prolongation in the context of expressed distress must be interpreted in relation to the complexity of each and every situation participants find themselves in, their level of understanding, and the task/activity at hand.

Nonverbal Communication

The field of nonverbal communication (NVC) has a long history involving many cue modalities, including face, voice, body, touch, and interpersonal space; different levels of analysis, including normative, group, and individual differences; and many substantive themes that cross from psychology into other disciplines. In this review, we focus on NVC as it pertains to individuals and social interaction. We concentrate specifically on ( a) the meanings and correlates of cues that are enacted (sent) by encoders and ( b) the perception of nonverbal cues and the accuracy of such perception. Frameworks are presented for conceptualizing and understanding the process of sending and receiving nonverbal cues. Measurement issues are discussed, and theoretical issues and new developments are covered briefly. Although our review is primarily oriented within social and personality psychology, the interdisciplinary nature of NVC is evident in the growing body of research on NVC across many areas of scientific inquiry.

Impact of Intervention to Improve Nursing Home Resident-Staff Interactions and Engagement

Background and Objectives

For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement.

Research Design and Methods

We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success.

Results

Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff.

Discussion and Implications

The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.

Taking Another Look: Thoughts on Behavioral Symptoms in Dementia and Their Measurement

This article proposes taking another look at behavioral symptoms of dementia (BSDs) both from a theoretical perspective that informs research and practice and from a measurement perspective. We discuss why this rethinking of behaviors impacts current models of care and our ability to better detect outcomes from interventions. We propose that BSDs be viewed from a pattern perspective and provide some suggestions for how to identify and measure these patterns that can influence the timing and type of intervention. Evidence suggests that BSDs are complex, sequential, patterned clusters of behavior recurring repeatedly in the same individual and escalate significantly without timely intervention. However, BSDs are frequently viewed as separate behaviors rather than patterns or clusters of behaviors, a view that affects current research questions as well as the choice, timing, and outcomes of interventions. These symptoms cause immense distress to persons with the disease and their caregivers, trigger hospitalizations and nursing home placement, and are associated with increased care costs. Despite their universality and that symptoms manifest across disease etiologies and stages, behaviors tend to be underrecognized, undertreated, and overmanaged by pharmacological treatments that may pose more harm than benefit.

Effects of care assistant communication style on communicative behaviours of residents with dementia: a systematic multiple case study

OBJECTIVES

To determine whether varying the communication style of care assistants, encouraging them to use direct instructions and allowing more time for residents' responses influenced the communicative behaviour of care home residents living with dementia.

DESIGN

This study used a multiple systematic case study design. Participants were video-recorded during morning care routines in three communication conditions: usual communication, direct instructions and pacing (allowing more time for resident responses). Each dyad acted as its own control.

SETTING

The study took place in a residential care home in the East Midlands, UK.

PARTICIPANTS

Three dyads (person with dementia/care worker) MEASURES: The level of compliance with instructions was measured. Validated measures were used to rate positive communicative behaviour (engagement with care tasks, eye contact and initiation of interaction) and negative communicative behaviour (e.g. shouting and kicking).

RESULTS

Care assistants were able to employ direct instructions after brief training. The use of direct instructions was positively correlated with positive communicative behaviour from residents (p < 0.05). The pacing condition was not employed adequately to evaluate effectiveness. Negative communicative behaviour (resistiveness to care) was rare.

CONCLUSION

The use of direct instructions by care assistants holds promise for effective communication with people with dementia and warrants further investigation in larger samples and in varied contexts.

How do care staff in residential aged care facilities conceptualise their non-verbal interactions with residents with dementia and what relevance has this for how residents' preferences and capacity for decision-making are understood?

This paper considers the significance of how staff in residential aged care facilities interpret the non-verbal communication and behaviour of residents vis-a-vis their assessments of residents' preferences and ability to participate in decision-making. It highlights the risks associated with staff members' failure to interpret residents' non-verbal communication and behaviour with reference to residents' backgrounds and prior experiences. It also considers how non-verbal communication implemented by staff may impact residents' emotional state and, as a consequence, decision-making abilities. Drawing on interview data with aged care staff from Queensland and Victoria, it demonstrates that care staff in residential facilities appear to rely heavily on non-verbal signals in assessing the decision-making capacity and preferences of residents with dementia. It also indicates that many staff fail to consider residents' non-verbal communication and behaviour with due consideration of residents' individual histories.

A Concept Analysis of Resistiveness to Care

People with cognitive impairment often require assistance with activities of daily living. It is when providing assistance with these activities that many caregivers experience behaviors that have been categorized as disruptive or problematic and called resistiveness to care. These behaviors are considered to be a source of burden and job burnout for caregivers. Nurses wanting to help caregivers, who manage these trying situations, need to understand the concept of resistiveness to care and communicate this knowledge clearly with health care providers. Therefore, a literature search was conducted in 2012 within the databases CINAHL, Medline (PubMed), ProQuest, and PsychINFO. This produced 40 relevant articles. Because no concept analysis existed for resistiveness to care, a principle-based concept analysis was performed. The analysis helped construct a theoretically defined concept. Further analysis highlighted that more research is needed to advance the concept of resistiveness to care to enhance professional communication surrounding this phenomenon.

Person-Centered Communication for Nursing Home Residents With Dementia: Four Communication Analysis Methods

Person-centered communication recognizes the individual as a person and responds to the individual's feelings, preferences, and needs. This secondary analysis tested four interdisciplinary strategies to measure changes in person-centered communication used by nursing home staff following an intervention. Thirty-nine nursing assistants were recruited from 11 nursing homes and participated in the three-session Changing Talk communication training. Video recordings were collected at baseline, immediately postintervention, and at 3-month follow-up. Staff communication was analyzed using behavioral, psycholinguistic, and emotional tone coding of elderspeak communication and content analysis of communication topics. Sign rank test was used to compare postintervention changes for each measure of communication. Postintervention improvements in communication occurred for each measure; however, the changes were statistically significant only for behavioral and psycholinguistic measures. Methods and results for each communication measure were compared. Implications for future research and use of measures of person-centered communication as a tool to improve care are discussed.

Dementia management strategies associated with neuropsychiatric symptoms of elderly people with Alzheimer’s disease

This study aims to investigate the association between management and communication strategies and the presence of neuropsychiatric symptoms presented by elderly people with Alzheimer’s disease. One hundred and thirty-four family caregivers answered a questionnaire with socio-demographic data and questions regarding the care context, the Small Communication Strategies Scale, the Dementia Management Strategy Scale, and the Neuropsychiatric Inventory. Caregivers used the criticism management strategy more when the elderly presented hallucination, agitation, depression, anxiety, irritability, nighttime behavior, and appetite abnormalities. The encouragement strategy was more significantly used only in the presence of euphoria/elation. The caregivers who used the most active management strategy were those who cared for the elderly with delirium, hallucination, agitation, depression, anxiety, irritability, and appetite and eating abnormalities. The use of communication strategies did not differ between groups with or without neuropsychiatric symptoms. It is concluded that criticism management and active management strategies are strongly associated with neuropsychiatric symptoms. The results of this study may be useful for planning treatment interventions that aim to modify the use of management strategies used by caregivers.

Preliminary Psychometric Properties of the Verbal and Nonverbal Interaction Scale: An Observational Measure for Communication in Persons with Dementia

Little attention has been given to sociable/unsociable communication in persons with dementia despite the importance of these behaviors in maintaining engagement in marital relationships. An observational measure of verbal and nonverbal communication in persons with dementia (Verbal and Nonverbal Interaction Scale-CR) who were engaged in conversations with spouses was tested for reliability and validity. Married persons with dementia were video-recorded at home conversing with spouses over 10 weeks (N = 118 recordings). Reliability [inter-coder (.92), test-retest (r =.61-.77), internal consistency (α =.65 -.79)] were adequate. Following an intervention, the Verbal and Nonverbal Interaction Scale-CR predicted improved communication over 10 weeks. The ratio of sociable to unsociable communication improved by 4.46 points per session [β = 4.46, t(10) = 1.96, p =.039]. VNVIS-CR is recommended to describe sociable and unsociable communication in persons with dementia as they engage in conversations with spouses.

Maturation of the MOUTh Intervention: From Reducing Threat to Relationship-Centered Care

The purpose of the current article is to describe a personalized practice originally conceived as a way to prevent and minimize care-resistant behavior to provide mouth care to older adults with dementia. The original intervention, Managing Oral Hygiene Using Threat Reduction Strategies (MOUTh), matured during the clinical trial study into a relationship-centered intervention, with emphasis on developing strategies that support residents' behavioral health and staff involved in care. Relationships that were initially pragmatic (i.e., focused on the task of completing mouth care) developed into more personal and responsive relationships that involved deeper engagement between mouth care providers and nursing home (NH) residents. Mouth care was accomplished and completed in a manner enjoyable to NH residents and mouth care providers. The MOUTh intervention may also concurrently affirm the dignity and personhood of the care recipient because of its emphasis on connecting with older adults.

Roles of Communication Problems and Communication Strategies on Resident-Related Role Demand and Role Satisfaction

This study investigated the impact of dementia-related communication difficulties and communication strategies used by staff on resident-related indicators of role demand and role satisfaction. Formal/paid long-term care staff caregivers (N = 109) of residents with dementia completed questionnaires on dementia-related communication difficulties, communication strategies, role demand (ie, residents make unreasonable demands), and role satisfaction (measured by relationship closeness and influence over residents). Three types of communication strategies were included: (a) effective repair strategies, (b) completing actions by oneself, and (c) tuning out or ignoring the resident. Analyses using structural equation modeling revealed that communication problems were positively linked with role demand. Repair strategies were positively linked with relationship closeness and influence over residents. Completing actions by oneself was positively linked to role demand and influence over residents, whereas tuning out was negatively linked with influence over residents. The findings underscore that effective caregiver communication skills are essential in enhancing staff-resident relationships.

Adapting Telemonitoring Technology Use for Older Adults: A Pilot Study

Telehealth technologies are increasing health care access for patients in the home and in community, rural, and underserved areas. Older adults may be challenged to use new technologies due to aging-related changes, lack of experience, and different attitudes toward their use. The current pilot study evaluated potential issues in one-on-one training/instructions and use of a telemonitoring application. Older adults may benefit from specific adaptations and training to use new health care technologies, and behavioral coding is an effective way to evaluate the user interface for new technologies. Feedback from the current study will be used to adapt the application and training to support dementia caregivers.

The facilitators of communication with people with dementia in a care setting: an interview study with healthcare workers

Objectives: to describe the views of healthcare workers on the facilitators of communication with people with dementia in a care setting.

Design: thematic analysis of semi-structured interviews.

Setting: all participants were interviewed in their place of work.

Participants: sixteen healthcare workers whose daily work involves interacting with people with dementia.

Results: four overarching categories of themes were identified from the interviews that impact on communication: the attributes of a care worker, communication strategies used, organisational factors and the physical characteristics of the care environment.

Conclusion: many strategies used by healthcare workers to facilitate communication have not yet been studied in the research literature. Participants' views on training should be incorporated into future dementia training programmes.

Impact of caregivers' behaviors on resistiveness to care and collaboration in persons with dementia in the context of hygienic care: an interactional perspective

BACKGROUND

The role played by various physical and verbal behaviors of professional caregivers in the onset of resistiveness to care (RTC) and collaborative behaviors of nursing home residents with dementia was assessed in a daily hygienic care routine context.

METHODS

Two hundred and forty hygienic care routines, observed in eight nursing home residents, were analyzed with a video-assisted systematic observation methodology and a sequential statistical analysis strategy.

RESULTS

Caregiver and care recipient behaviors are interdependent in the hygienic care routine context. Physical instrumental behavior, neutral, negative and positive statements, positive and negative instructions, and verbal distraction emitted by caregivers are significantly and moderately associated with the onset of RTC in persons with dementia (PWD), but the strength of relationships observed depends on the care recipient's behavior prior to the caregiver's action. Positive instructions are moderately associated with the onset of collaboration in residents with preserved language abilities. However, for residents with severe language impairment, these same instructions were linked to RTC behaviors.

CONCLUSIONS

Although antecedents to RTC can be identified, the risk that caregiver behaviors trigger resistive responses is higher when care recipients are already exhibiting RTC, and is low when no particular behavior or collaboration is shown. Antecedents to collaboration are also identified and discussed. Although different caregiver behaviors may be more or less likely to elicit resistiveness or collaboration, it is the pre-existing state of the care recipient that will determine its reaction to the caregiver's behavior. Clinical implications emerging from these influential findings are elaborated.

Nursing Assistants’ Communication Styles in Korean American Older Adults With Dementia

As ethnic diversity increases in the United States with the anticipated increase in dementia, it is critical to understand the implications of dementia and culturally appropriate communication for ethnic minority older adults with dementia. Utilizing the Ethno-Cultural Gerontological Nursing model and the Progressively Lowered Stress Threshold model, this article describes the relationship between nursing assistants’ communication style and behavioral symptoms of dementia, focused on Korean American older adults with dementia residing in nursing homes. The discussion includes reviewing currently available studies, nursing implications, and suggestions for future studies.

“The Red Dress or the Blue?”

Respect for a person’s right to make choices and participate in decision making is generally seen as central to quality of life and well-being. When a person moves into a residential aged care facility (RACF), however, decision making becomes more complicated, particularly if the person has a diagnosis of dementia. Little is known about how staff in RACFs perceive that they support decision making for people with dementia within their everyday practice, and this article seeks to address this knowledge gap. The article reports on the findings of a qualitative study conducted in the states of Victoria and Queensland, Australia with 80 direct care staff members. Findings revealed that the participants utilized a number of strategies in their intention to support decision making for people with dementia, and had an overall perception that “a little effort goes a long way.”

Mental illness training on the Internet for nurse aides: a replication study

Internet training courses for nurse aides (NAs) in long-term care facilities (LTCs) have been shown to be effective. Little is known, however, about Internet training effects on NAs in a non-research context, or about continued utilization of an available training programme. In this research, a replication study was conducted with the Internet training programme Caring Skills: Working with Mental Illness. Three LTCs provided the training to all NAs, each within a 1-month interval scheduled during consecutive months. Supervisors were interviewed subsequently about their experiences organizing and supervising the training. Participants in all three LTCs showed positive pre-post-tests effects with large effect sizes on situational knowledge and self-efficacy, and knowledge about mental illness. Users rated the programme highly, and they indicated that it would improve quality of their resident care. Supervisors praised the training, and they said NAs were using recommended training behaviours. Although available to all staff, nursing and other staff made little use of the training in subsequent months. Training for NAs on the Internet thus appears feasible, and it is perceived to be beneficial for resident care. Plans for continued utilization and dissemination of best practices to other staff, however, should be integrated when planning for staff training on the Internet.

The use and characteristics of elderspeak in Swedish geriatric institutions

The aim of this study is to investigate the occurrence of elderspeak in a Swedish context and to describe its characteristics. Elderspeak refers to adjustments made in communication with elderly people; adjustments similar to those made in interaction with infants. Previous findings show that adjustments of communication are made within several linguistic domains, and are a part of the communicative environment of elderly people. Five people working in different forms of geriatric institutions participated in this study, and data consist of recordings of interactions between caregivers and residents (without dementia) and interactions between caregivers and colleagues. The recordings were transcribed and analyzed by means of perceptual, semantic and acoustic analyses. The findings demonstrate that caregivers, to a varying extent, adjusted their communication within several linguistic domains. The adjustments were mainly made within the prosodic domain, but there were also adjustments made within other language domains.

Experience of cognitively intact residents cohabitating with residents with dementia in long-term care facilities

A qualitative research approach was used to explore the life experience of cognitively intact (CI) residents cohabitating with residents with dementia in mixed placement facilities. Purposive sampling was used to recruit 21 CI residents from 6 long-term care facilities in southern Taiwan. Using a semi-structured interview guide, data were analyzed by content analysis. Two themes emerged: emotional diversity and coping. Emotional diversity described the wide range of responses, both positive and negative, expressed by the participants. Coping referred to the CI residents' ability to adapt to behaviors exhibited by the residents with dementia and the environment. Results of this study provide nurses and other health care providers with an understanding of the life experience of CI residents who live among residents with dementia. An understanding can lead to improved quality of life and positive social interactions among CI residents and those with dementia.

Comparing audio and video data for rating communication

Video recording has become increasingly popular in nursing research, adding rich nonverbal, contextual, and behavioral information. However, benefits of video over audio data have not been well established. We compared communication ratings of audio versus video data using the Emotional Tone Rating Scale. Twenty raters watched video clips of nursing care and rated staff communication on 12 descriptors that reflect dimensions of person-centered and controlling communication. Another group rated audio-only versions of the same clips. Interrater consistency was high within each group with Interclass Correlation Coefficient (ICC) (2,1) for audio .91, and video = .94. Interrater consistency for both groups combined was also high with ICC (2,1) for audio and video = .95. Communication ratings using audio and video data were highly correlated. The value of video being superior to audio-recorded data should be evaluated in designing studies evaluating nursing care.

Attitudes of long-term care staff toward dementia and their related factors

BACKGROUND

Attitudes of residential care staff toward residents with dementia affect the quality of care. We examined the attitude of frontline residential care staff toward residents with dementia, and how the presence of specialized care units or programs may affect staff attitude.

METHODS

Staff working in nursing homes participated in a survey which covered demographic data, current state of dementia care in workplace, opinion regarding dementia care, and perceived importance of dementia behaviors.

RESULTS

1,047 nurses and personal care workers participated. 78.8% respondents reported difficulties in managing dementia residents. Those who ranked positive symptoms as more important were 4.5 times more likely to report difficulties, independent of experience. Independent factors associated with positive attitudes toward further training were working in a non-profit home (OR 2.4, 95% CI 1.1, 5.0; p = 0.024) and having a dementia program or unit in the current workplace (OR 1.8, 95% CI 0.985, 3.302; p = 0.056). Only having a dementia program or unit in the current workplace was associated with a positive attitude toward commitment to stay in dementia care (OR 1.9, 95% CI 1.1, 3.2; p = 0.021), adjusted for gender, type of home, post, dementia prevalence in workplace, and work experience.

CONCLUSION

The majority of long-term care staff felt dementia care difficult yet hold positive attitude toward further training and were committed to stay in dementia care. Having a specialized dementia care unit or program in the current workplace was associated with commitment to stay in dementia care and was marginally associated with positive attitude toward further training.

Mental illness training for licensed staff in long-term care

Licensed care staff working in long-term care facilities may be poorly prepared to work with residents with mental illness. This research reports on the program evaluation of Caring Skills: Working with Mental Illness, a training program delivered on the Internet. It was tested with a randomized treatment-control design, with an eight-week follow-up. The training provided video-based behavioral skills and knowledge training. Measures included video situations testing and assessment of psycho-social constructs including empathy and stigmatization. ANCOVA analysis at 4-weeks posttest showed significant positive effects with medium-large effect sizes, which were largely maintained at the 8-week follow-up. The training was well-received by the users.

Psychometric Analysis of the Emotional Tone Rating Scale: A Measure of Person-Centered Communication

Psychometric analysis of the Emotional Tone Rating Scale (ETRS) was completed using ratings of naïve listeners who evaluated staff-resident communication in three nursing homes. Interrater consistency was high with ICC (2, 1) for agreement = 0.95 and consistency = 0.95. Factor analysis revealed two factors-person-centered communication and controlling communication-that explained 84.8% of the variance. Person-centered communication included seven descriptors (items) with loadings ranging from 0.84 to 0.98 and a coefficient alpha of 0.98. Controlling communication included five items that loaded from -0.63 to .99 with a coefficient alpha of 0.94. These factors were negatively correlated p = -.64 and demonstrated good ranges, standard deviations, and high item-total correlations. Person-centered communication correlated with higher resident engagement in conversation in contrast to controlling communication. The ETRS provides a measure of person-centered communication that can be used to evaluate interactions between nursing staff and older adults who reside in long term care settings.