The Difficulty With Studying Challenging Behavior

Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior

BACKGROUND

People with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior.

METHODS

Three data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places.

RESULTS

Patients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one's own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient's biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low.

CONCLUSION

Highly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

Aggression Severity as a Predictor of Mortality in Dementia

OBJECTIVES

In psychogeriatric units for patients with dementia and behavioral problems, aggression is prevalent. Predictions and timely interventions of aggression are essential to create a safe environment and prevent adverse outcomes. Our study aimed to determine whether aggression severity early during admission to these units could be used as an indicator of adverse outcomes.

DESIGN

During one year, all aggressive incidents on a psychogeriatric unit were systematically recorded using the Revised Staff Observation of Aggression Scale (SOAS-R). The study investigated the link between the severity of incidents within the first 48 hours of admission and adverse outcomes.

SETTING AND PARTICIPANTS

All patients included in the study were admitted to a psychogeriatric unit for dementia and behavioral problems between November 2020 and October 2021.

METHODS

The study population was categorized into groups according to the level of aggression severity during the first 48 hours of admission. The impact of aggression severity on the duration of admission, aggression frequency and severity during admission, medication usage at discharge, discharge destination, and mortality risk were examined.

RESULTS

During the initial 2 days of admission, 9 of 88 patients had 1 or more severe aggression incidents. An early manifestation of severe aggression was significantly associated with more incidents during hospitalization, a higher total SOAS-R score, and a sevenfold higher 1-year mortality risk compared with patients who did not or only mildly manifested aggression in the first 48 hours of admission.

CONCLUSIONS AND IMPLICATIONS

An early manifestation of aggression not only poses a direct safety risk to all involved but is also an early indicator of patients at risk for more detrimental outcomes, specifically mortality risk. By identifying patients at higher risk for adverse outcomes early, health care providers can provide preventive or timelier interventions, mitigating the risk of adverse outcomes and optimizing care services.

Reduction and prevention of agitation in persons with neurocognitive disorders: an international psychogeriatric association consensus algorithm

OBJECTIVES

To develop an agitation reduction and prevention algorithm is intended to guide implementation of the definition of agitation developed by the International Psychogeriatric Association (IPA).

DESIGN

Review of literature on treatment guidelines and recommended algorithms; algorithm development through reiterative integration of research information and expert opinion.

SETTING

IPA Agitation Workgroup.

PARTICIPANTS

IPA panel of international experts on agitation.

INTERVENTION

Integration of available information into a comprehensive algorithm.

MEASUREMENTS

None.

RESULTS

The IPA Agitation Work Group recommends the Investigate, Plan, and Act (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and acting with an emphasis on shared decision-making; the success of the plan is evaluated and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Psychosocial interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal/circadian agitation; mild-moderate agitation or agitation with prominent mood features; moderate-severe agitation; and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a variety of venues-home, nursing home, emergency department, hospice-and adjustments to the therapeutic approach are presented.

CONCLUSIONS

The IPA definition of agitation is operationalized into an agitation management algorithm that emphasizes the integration of psychosocial and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision-making.

Well-being, multidisciplinary work and a skillful team: essential elements of successful treatment in severe challenging behavior in dementia

OBJECTIVE

Conceptualize successful treatment of persons with dementia and severe challenging behavior as perceived by professionals.

METHODS

In this concept mapping study 82 experts in dementia care participated. The study followed two phases of data collection: (1) an online brainstorm where participants completed the focus prompt: 'I consider the treatment of people with severe challenging behavior in dementia successful if.'; (2) individual sorting and rating of the collected statements followed by data analysis using multidimensional scaling and hierarchical cluster analysis, resulting in a concept map.

RESULTS

Three clusters were identified, the first addressing treatment outcomes and the latter two addressing treatment processes, each divided into sub-clusters: (1) well-being, comprising well-being of the person with dementia and all people directly involved; (2) multidisciplinary analysis and treatment, comprising multidisciplinary analysis, process conditions, reduction in psychotropic drugs, and person-centered treatment; and (3) attitudes and skills of those involved, comprising consistent approach by the team, understanding behavior, knowing how to respond to behavior, and open attitudes.

CONCLUSIONS

Successful treatment in people with dementia and severe challenging behavior focuses on well-being of all people involved wherein attention to treatment processes including process conditions is essential to achieve this.

The Influence of Everyday Acoustic Environments on the Challenging Behavior in Dementia: A Participatory Observation Study in Nursing Homes

Challenging behavior (CB) is a group of behaviors, reactions and symptoms due to dementia, which can be challenging for the caregivers. The study aims to research the influence of acoustics on CB in people with dementia (PwD). An ethnographic method was used to study the daily life of PwD in their nursing homes with a specific focus on how people react to everyday environmental sounds. Thirty-five residents were included in the sample based on purposeful, homogeneous group characteristics and sampling. Empirical data were collected using 24/7 participatory observations. The collected data were analyzed using a phenomenological-hermeneutical method: a naïve understanding, a structural analysis and a comprehensive understanding. The result shows that the onset of CB depends on whether the resident feels safe and is triggered by an excess or lack of stimuli. The excess or shortage of stimuli and whether and when it affects a person is personal. It depends on various factors, the person's state and the time of day, the nature of the stimuli, familiarity, or strangeness is also a determining factor for the onset and progression of CB. The results can form an essential basis for developing soundscapes to make the PwD feel safe and reduce CB.

Losing hope or keep searching for a golden solution: an in-depth exploration of experiences with extreme challenging behavior in nursing home residents with dementia

Background

Situations of extreme challenging behavior such as very frequent and/or severe agitation or physical aggression in nursing home residents with dementia can be experienced as an impasse by nursing home staff and relatives. In this distinct part of our WAALBED (WAAL-Behavior-in-Dementia)-III study, we aimed to explore these situations by obtaining the experiences and perspectives of nursing home staff and relatives involved. This can provide a direction in providing tools for handling extreme challenging behavior of nursing home residents with dementia and may improve their quality of life.

Methods

Qualitative multiple case study with individual interviews and focus group discussions. Interviewees were elderly care physicians, psychologists, care staff members, unit managers and relatives (n = 42). They were involved with nursing home residents with dementia and extreme challenging behavior living on dementia special care units in the Netherlands. For these residents, external consultation by the Centre for Consultation and Expertise was requested. Audio-recordings of the interviews were transcribed verbatim and analyzed with thematic analysis, including conventional content analysis.

Results

Seven cases were included. Forty-one individual interviews and seven focus group discussions were held. For six stakeholder groups (resident, relative, care staff, treatment staff, nursing home staff, and the organization), three main factors could be identified that contributed to experiencing a situation of extreme challenging behavior as an impasse: 1) characteristics and attitudes of a stakeholder group, 2) interaction issues within a stakeholder group and 3) interaction issues among (groups of) stakeholders. The experienced difficulties with the resident’s characteristics, as well as suboptimal interdisciplinary collaboration and communication among the nursing home staff are remarkable. Nursing home staff kept searching for a golden solution or lost hope.

Conclusions

This study offers important insights into situations of extreme challenging behavior in nursing home residents with dementia and offers caregivers targets for improving care, treatment and interdisciplinary collaboration, such as working uniformly and methodically.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03438-0.

Very frequent physical aggression and vocalizations in nursing home residents with dementia

OBJECTIVES

We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia.

METHOD/DESIGN

This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items 'hitting', pushing', 'biting' and 'kicking' of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on 'screaming' and 'making strange noises'. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses.

RESULTS

We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63-2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23-12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04-3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951-0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08-2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34-5.68) and euphoria (OR = 2.01, 95% CI: 1.22-3.31).

CONCLUSION

Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life.

Relationship between the severity of agitation and quality of life in residents with dementia living in German nursing homes - a secondary data analysis

BACKGROUND

Severe agitation and its relation to single dimensions of quality of life are not well understood. The aim of this study was to gain more knowledge about severe agitation and to examine the relationships between the severity of agitation and single dimensions of quality of life among residents with dementia living in German nursing homes.

METHODS

This exploratory secondary analysis included data from 1947 residents of 66 German nursing homes from the DemenzMonitor study. The construct of agitation was defined as a composite score of the items agitation/aggression, irritability/lability and disinhibition from the Neuropsychiatric Inventory Questionnaire (NPI-Q); the resident was classified as severely agitated if at least one of these symptoms was rated as 'severe'. The single dimensions of quality of life were measured with the short version of the QUALIDEM instrument. To avoid selection bias, two controls with mild or no agitation were selected for each resident with severe agitation using propensity score matching. Mixed linear regression models were then generated to determine the differences in the dimensions of quality of life for the severity of agitation and the defining items.

RESULTS

For four out of five dimensions of quality of life of the short version of QUALIDEM, residents with severe agitation had significantly lower values than residents without severe agitation. Converted to scale size, the greatest difference between both groups was found in the dimension social isolation with 23.0% (-2.07 (95% CI: -2.57, -1.57)). Further differences were found in the dimensions restless tense behaviour with 16.9% (-1.52 (95% CI: -2.04, -1.00)), positive affect with 14.0% (-1.68 (95% CI: -2.28, -1.09)) and social relations with 12.4% (-1.12 (95% CI: -1.54, -0.71)).

CONCLUSIONS

Severe agitation is a relevant phenomenon among nursing home residents with dementia and is associated with lower values of quality of life in the dimensions social isolation, restless tense behaviour, positive affect and social relations from the QUALIDEM instrument. Therefore, more attention should be paid to severe agitation in nursing practice and research. Moreover, care strategies used to reduce severe agitation should be considered in terms of their impact on the dimensions of quality of life.

Criteria for Psychosis in Major and Mild Neurocognitive Disorders: International Psychogeriatric Association (IPA) Consensus Clinical and Research Definition

Psychosis is common among individuals with neurocognitive disorders, is difficult to manage, and causes considerable burden and stress to patients and caregivers. Developing effective treatments is a substantial unmet medical need but research has been slowed by the need for updated consensus diagnostic criteria. To address this need, the International Psychogeriatrics Association initiated a process to develop criteria for clinical use, research, and treatment development efforts. The process included clinical, regulatory, and industry stakeholders as well as input from a global network of experts in geriatric psychiatry responding to two surveys (N = 336). Results from the consensus process confirmed that clinicians wanted elaboration of aspects of the definition proposed by Jeste and Finkel in 2000 to ensure that the criteria are applied appropriately. Based on discussions, the survey, and emerging research, criteria were revised to apply to psychosis occurring with all major and mild neurocognitive disorders. Other important changes include providing examples of hallucinations and delusions and clarifying time course, impact, and exclusionary criteria. This definition of psychosis in major and mild neurocognitive disorders can be used to advance many types of research including development of much needed pharmacologic and nonpharmacologic interventions for psychosis in patients with neurocognitive disorders.