Improving dressing behavior in cognitively impaired nursing home residents

Using an Interactive Video Simulator to Improve Certified Nursing Assistants' Dressing Assistance and Nursing Home Residents' Dressing Performance: A Pilot Study

This pilot study examined the initial effects and estimated effect size of a computer-based simulation education program on certified nursing assistants' level of assistance when dressing nursing home residents with dementia and on residents' dressing performance. Nine dyads, assigned to either the experimental or control group, completed the study. Both groups received a traditional 1-hour education module delivered by a research assistant. The experimental group was then instructed to undertake an additional 2-hour intervention using a video simulator that enabled nursing assistants to practice level of assistance skills. The appropriateness of dressing assistance from nursing assistants and residents' dressing performance was measured before and 6 weeks after the intervention. The results showed that the two groups did not significantly differ in either appropriate levels of dressing assistance (P = .42) or residents' dressing performance (P = .38). A lack of effort by some assistants to properly assist residents and low statistical power may explain the lack of significance. The effect sizes of the experimental intervention on appropriate levels of dressing assistance and resident dressing performance were 0.69 and 0.89, respectively. Incorporating a strategy to improve motivation should be considered in future studies.

Revising the Resistiveness to Care Scale

BACKGROUND AND PURPOSE

The Resistiveness to Care Scale for Dementia of the Alzheimer's Type was developed to quantify care-resistant behavior. The purpose of this article is to explain how the instrument was modified and tested in two clinical studies that examined interventions to improve the oral hygiene of persons with dementia who resist care.

METHODS

After pilot testing, the revised instrument (RTC-r) was used in 7 facilities (N = 83 residents). Systematic training procedures were implemented to preserve reliability.

RESULTS

Clinical validity was confirmed throughout the pilot and interventional studies. Reliability was assessed using inter-rater reliability, which ranged from 0.87 (p < .001) to 1.0 (p < .001) across 2,328 mouth care observations.

CONCLUSIONS

The RTC-r validly and reliably measures care-resistant behavior in persons with dementia.

Cognitive behavioural treatment for mild Alzheimer's patients and their caregivers (CBTAC): study protocol for a randomized controlled trial

Background

About 90 % of all persons with mild Alzheimer’s disease experience neuropsychiatric symptoms, most frequently apathy, depression, anxiety and irritability. These symptoms are associated with greater morbidity, a reduced quality of life for the patient, an increased burden and depression for the caregiver, and higher costs of care and nursing home placement. Psychosocial interventions based on behaviour therapy represent the most efficacious treatment of neuropsychiatric symptoms. However, there is no study, to our knowledge, that has evaluated a multicomponent treatment programme based on comprehensive, cognitive behavioural therapy (CBT). This randomized controlled trial aims to evaluate a CBT-based treatment programme consisting of 8 modules and 25 sessions.

Methods/design

Fifty patients with mild Alzheimer’s disease alone or with mild mixed dementia (Alzheimer’s disease and vascular dementia) who have any neuropsychiatric symptom will be included. A caregiver must be available. The patients and their caregivers will be randomized to either the CBT-based intervention group or to the control condition group, which receives treatment as usual. The primary outcome measure is depression in the patient with Alzheimer’s disease. The secondary outcome measures for a person with Alzheimer’s disease are other neuropsychiatric symptoms, quality of life and coping strategies. The secondary outcome measures for a caregiver are caregiver’s burden, depression, anxiety, anger, quality of life and coping strategies. Neuropsychological testing includes tests of cognitive function and activities of daily living and a global clinical assessment of severity. Participants in both groups will be assessed before and after the treatment phase (lasting approximately 9 months). Follow-up assessments will take place 6 and 12 months after treatment. All assessments will be conducted by blinded assessors.

Discussion

This trial has the potential to establish an empirically based psychological treatment for non-cognitive symptoms that reduce the quality of life of a person with dementia and a caregiver. This treatment approach focuses not only on the person with dementia, but also on the caregiver and on the dyad. The treatment manual will be published and training workshops will be offered, so that the information can be widely spread among healthcare professionals.

Trial registration

ClinicalTrials.gov NCT01273272.

Translation of function-focused care to assisted living facilities

Assisted livings settings are residential settings that provide housing and supportive services for older and disabled adults. Although individuals in assisted living settings are less functionally impaired than those in nursing home settings, they engage in limited amounts of physical activity and decline functionally more rapidly than their peers in nursing homes. Function-focused care for assisted living (FFC-AL) was developed to prevent decline, improve function, and increase physical activity among residents living in these settings. The purpose of this study was to translate the previously established, effective FFC-AL intervention to 20 assisted living facilities. Evidence of our ability to successfully translate function-focused care into these 20 assisted living facilities was determined using the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) model. Our findings supported our ability to translate FFC-AL effectively into 18 of these 20 settings, using our dissemination and implementation approach.

No more fighting and biting during mouth care: applying the theoretical constructs of threat perception to clinical practice

The purpose of this article is to describe how the neurobiological principles of threat perception and fear response can support clinical approaches to prevent and reduce care-resistant behaviors during mouth care. Nursing home residents who exhibit care-resistant behavior are at risk for poor oral health because daily oral hygiene may not be consistently provided. Poor oral health predisposes these older people to systemic problems such as pneumonia, cerebral vascular accidents, and hyperglycemia. Care-resistant behavior is a fear-evoked response to nurses' unintentionally threatening behavior during mouth care. Nurses can safely and effectively provide mouth care to persons with dementia who resist care by using personalized combinations of 15 threat reduction strategies.

Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvement

OBJECTIVES

A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement.

DESIGN/SETTING/PARTICIPANTS

Intervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.

INTERVENTION

The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs.

RESULTS

The intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups.

CONCLUSION AND IMPLICATIONS

Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.

Mobility of Vulnerable Elders (MOVE): study protocol to evaluate the implementation and outcomes of a mobility intervention in long-term care facilities

Background

Almost 90% of residents living in long-term care facilities have limited mobility which is associated with a loss of ability in activities of daily living, falls, increased risk of serious medical problems such as pressure ulcers, incontinence and a significant decline in health-related quality of life. For health workers caring for residents it may also increase the risk of injury. The effectiveness of rehabilitation to facilitate mobility has been studied with dedicated research assistants or extensively trained staff caregivers; however, few investigators have examined the effectiveness of techniques to encourage mobility by usual caregivers in long-term care facilities.

Methods/Design

This longitudinal, quasi-experimental study is designed to demonstrate the effect of the sit-to-stand activity carried out by residents in the context of daily care with health care aides. In three intervention facilities health care aides will prompt residents to repeat the sit-to-stand action on two separate occasions during each day and each evening shift as part of daily care routines. In three control facilities residents will receive usual care. Intervention and control facilities are matched on the ownership model (public, private for-profit, voluntary not-for-profit) and facility size. The dose of the mobility intervention is assessed through the use of daily documentation flowsheets in the health record. Resident outcome measures include: 1) the 30-second sit-to-stand test; 2) the Functional Independence Measure; 3) the Health Utilities Index Mark 2 and 3; and, 4) the Quality of Life - Alzheimer's Disease.

Discussion

There are several compelling reasons for this study: the widespread prevalence of limited mobility in this population; the rapid decline in mobility after admission to a long-term care facility; the importance of mobility to quality of life; the increased time (and therefore cost) required to care for residents with limited mobility; and, the increased risk of injury for health workers caring for residents who are unable to stand. The importance of these issues is magnified when considering the increasing number of people living in long-term care facilities and an aging population.

Trial Registration

This clinical trial is registered with ClinicalTrials.gov (trial registration number: NCT01474616).

Reducing care-resistant behaviors during oral hygiene in persons with dementia

Background

Nursing home residents with dementia are often dependent on others for mouth care, yet will react with care-resistant behavior when receiving assistance. The oral health of these elders deteriorates in the absence of daily oral hygiene, predisposing them to harmful systemic problems such as pneumonia, hyperglycemia, cardiac disease, and cerebral vascular accidents. The purpose of this study is to determine whether care-resistant behaviors can be reduced, and oral health improved, through the application of an intervention based on the neurobiological principles of threat perception and fear response. The intervention, called Managing Oral Hygiene Using Threat Reduction, combines best mouth care practices with a constellation of behavioral techniques that reduce threat perception and thereby prevent or de-escalate care-resistant behaviors.

Methods/Design

Using a randomized repeated measures design, 80 elders with dementia from 5 different nursing homes will be randomized at the individual level to the experimental group, which will receive the intervention, or to the control group, which will receive standard mouth care from research team members who receive training in the proper methods for providing mouth care but no training in resistance recognition or prevention/mediation. Oral health assessments and care-resistant behavior measurements will be obtained during a 7-day observation period and a 21-day intervention period. Individual growth models using multilevel analysis will be used to estimate the efficacy of the intervention for reducing care-resistant behaviors in persons with dementia, and to estimate the overall efficacy of the intervention using oral health outcomes. Activity-based costing methods will be used to determine the cost of the proposed intervention.

Discussion

At the conclusion of this study, the research team anticipates having a proven intervention that prevents and reduces care-resistant within the context of mouth care. Long-term objectives include testing the effect of the intervention on systemic illnesses among persons with dementia; examining the transferability of this intervention to other activities of daily living; and disseminating threat reduction interventions to nursing home staff, which may radically change the manner in which care is provided to persons with dementia.

Trial Registration

ClinicalTrials.gov: NCT01363258

Profile of nursing home residents with dementia who require assistance with mouth care

The majority of nursing home residents require assistance with activities of daily living, including oral care. Poor oral health is common in the nursing home because residents are not given appropriate assistance to support this aspect of their care. The purpose of this study was to describe the demographic, functional, and behavioral profile of nursing home residents with dementia who require verbal or physical assistance with mouth care. Residents who required verbal support to complete mouth care exhibited higher levels of physical function, higher levels of cognitive functioning in the domains of language and executive function, lower levels of passivity, and higher scores for the personality trait of openness than residents who required physical assistance. Best practices for implementing verbal and physical assistance during mouth care to persons with dementia are presented on the basis of these profiles.

An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study

The primary purpose of this pilot study was to test the feasibility of an intervention designed to reduce care-resistant behaviors (CRBs) in persons with moderate-to-severe dementia during oral hygiene activities. The intervention, Managing Oral Hygiene Using Threat Reduction (MOUTh), combined best oral hygiene practices with CRB reduction techniques. Oral health was operationalized as the total score obtained from the Oral Health Assessment Tool (OHAT). CRB was measured using a refinement of the Resistiveness to Care Scale. Seven nursing home residents with dementia received twice daily mouth care for 14 days. The baseline OHAT mean score of 7.29 (SD = 1.25) improved to 1.00 (SD = 1.26, p < .001); CRB improved from 2.43 CRBs/minute (SD = 4.26) to 1.09 CRBs/minute (SD = 1.56, t = 1.97, df 41, p= .06). The findings from this pilot study suggest that the MOUTh intervention is feasible and reduced CRBs, thus allowing more effective oral care.

The effectiveness of an exercise programme for elders with dementia in a Taiwanese day-care centre

The purpose was to examine the effectiveness of an exercise programme for elders with dementia in Taiwan aimed to maintain their activities of daily living such as feeding, dressing, grooming, washing and toileting. This was a single study group, repeated measure research design. Twenty-six dementia elders were recruited from a day-care centre located in southern Taiwan. Caregivers of the day-care centre provided all subjects an exercise programme. The exercise programme consisted of stretching and walking five times per week, and leg-weight bearing at least three times per week for 20-30 min each. The data were obtained three times (baseline, 2 months post intervention and 4 months post intervention). Results showed slight changes in the scores of one-leg-standing, 30 s chair rise, functional reach and get up and go test but were not statistically significant. Results also indicated that scores in the performance of activities of daily living were significantly higher than at baseline and at 4 months post intervention. In conclusion, this study provides information for dementia day-care centres in Taiwan about how elders with dementia can maintain physical fitness and perform activities of daily living.

Individualized skills training program for community-dwelling adults with mild Alzheimer's disease

The increasing incidence of Alzheimer's disease (AD) has created an enormous challenge to nurses. Nonpharmacological interventions that promote functional independence at home are vital to improving quality of life for individuals with AD and their caregivers. The purpose of this study was to explore the effectiveness of a skills training program for individuals with mild AD in the home setting. Although none of the participants achieved total independence in performing the meal task, all decreased their need for task prompting. The goal for this population may be to preserve and encourage a more functional state rather than to achieve total independence.

Using video simulated presence to reduce resistance to care and increase participation of adults with dementia

BACKGROUND

Cognitive and functional decline in dementia generally impairs performance of basic care activities. Staff assistance during these activities frequently results in confusion, anxiety, and distress, expressed through resistance to care (RTC).

METHODS

A single-system ABA withdrawal design (n = 1) evaluated the effect of video-simulated presence (VSP) for decreasing RTC and increasing participation. A family member pre-recorded videos for use during episodes of RTC, in which the family member spoke directly to the participant to encourage participation.

RESULTS

Introduction of the VSP significantly reduced RTC during the basic care tasks of feeding and talking medication. This effect was reversed when the intervention was withdrawn. Participation increased following VSP, demonstrating clear trends toward clinical significance.

CONCLUSIONS

This person-centered intervention, based on VSP of a family member, provides encouraging results for reducing RTC and increasing participation of adults with dementia in basic care tasks.

Challenges in tailored intervention research

Although individuals and nurses value tailored health interventions, incorporating tailored interventions into research is fraught with pitfalls. This manuscript provides guidance on addressing challenges on developing, implementing, and evaluating tailored interventions (TIs). The initial step in designing TIs involves selecting the individual characteristics on which to tailor the intervention. After selecting critical characteristics for tailoring, researchers must decide how to assess these characteristics. Then researchers can use manuals, algorithms, or computer programs to tailor an intervention and maintain treatment fidelity. If desired outcomes are not achieved, focus groups or individual interviews may be conducted to gather information to improve the intervention for specific individuals/groups. Then, incorporating study arms of TIs in intervention studies, investigators may compare TIs with standardized interventions statistically and clinically. We believe TIs may have better outcomes, promote better adherence, and be more cost efficient.

Direct observation of behavior: a review of current measures for use with older adults with dementia

This review article reports on methods of direct observation of behaviors for use in long-term care settings, particularly with older adults who have dementia. This article provides information on the theoretical roots, administration methods, and psychometric properties of measures of direct observation of individual behavior. It is hoped that this review will help gerontological nurses make informed choices about the direct observation measures that suit their specific needs, highlight the role of direct observation in quality improvement for dementia care, and facilitate a balance between identifying a gold standard and allowing flexibility to assess project-specific behaviors.

Elderspeak's influence on resistiveness to care: focus on behavioral events

Resistiveness to care (RTC) in older adults with dementia commonly disrupts nursing care. Research has found that elderspeak (infantilizing communication) use by nursing home (NH) staff increases the probability of RTC in older adults with dementia. The current analysis used general sequential querier (GSEQ) software to analyze behavior sequences of specific behavioral events. We found that older adults with dementia most frequently reacted to elderspeak communication by negative vocalizations (screaming or yelling, negative verbalizations, crying). Because negative vocalizations disrupt nursing care, reduction in elderspeak use by staff may reduce these behaviors thereby increasing the quality of care to these residents. The results clearly demonstrate that sequential analysis of behavioral events is a useful tool in examining complex communicative interactions and targeting specific problem behaviors.

Nursing home resident outcomes from the Res-Care intervention

OBJECTIVES

To test the effectiveness of a restorative care (Res-Care) intervention on function, muscle strength, contractures, and quality of life of nursing home residents, with secondary aims focused on strengthening self-efficacy and outcome expectations.

DESIGN

A randomized controlled repeated-measure design was used, and generalized estimating equations were used to evaluate status at baseline and 4 and 12 months after initiation of the Res-Care intervention.

SETTING

Twelve nursing homes in Maryland.

PARTICIPANTS

Four hundred eighty-seven residents consented and were eligible: 256 from treatment sites and 231 from control sites. The majority were female (389, 80.1%) and white (325, 66.8%); 85 (17.4%) were married and the remaining widowed, single, or divorced/separated. Mean age was 83.8 +/- 8.2, and mean Mini-Mental State Examination score was 20.4 +/- 5.3.

INTERVENTION

Res-Care was a two-tiered self-efficacy-based intervention focused on motivating nursing assistants and residents to engage in functional and physical activities.

MEASUREMENTS

Barthel Index, Tinetti Gait and Balance, grip strength, Dementia Quality-of-Life Scale, self-efficacy, and Outcome Expectations Scales for Function.

RESULTS

Significant treatment-by-time interactions (P<.05) were found for the Tinetti Mobility Score and its gait and balance subscores and for walking, bathing, and stair climbing.

CONCLUSION

The findings provide some evidence for the utility and safety of a Res-Care intervention in terms of improving function in NH residents.

'Knowing what makes them tick': motivating cognitively impaired older adults to participate in restorative care

Nursing home residents with dementia represent a majority of the most functionally impaired individuals residing in nursing homes. Although many perceive this population as having little restorative potential, maintaining resident functional abilities for as long as possible helps to optimize quality of life and decrease caregiver burden. This study used a qualitative design with a focus group methodology to explore facilitators and barriers to engaging cognitively impaired residents in functional activities and exercise. A purposive sample of seven geriatric nursing assistants who were experts in dementia care participated in the study. Twenty-seven codes were reduced to three themes: (i) knowing what makes them tick and move; (ii) teamwork and utilizing resources; and (iii) barriers to restorative care. The study findings were used to revise the Restorative Care for the Cognitively Impaired Intervention and could direct future implementation of programmes in nursing home settings.

Aggression in persons with dementia: use of nursing theory to guide clinical practice

With approximately four million people in the United States today diagnosed with dementia, one of the most devastating problems faced by caregivers and patients is dealing with aggressive behavior. Aggression occurs in half of persons diagnosed with dementia and is associated with more rapid cognitive decline, increased risk of abuse, and caregiver burden. This paper uses the Need-driven Dementia-compromised Behavior (NDB) model to explain aggression and discusses therapeutic approaches to care that combines non-pharmacological and pharmacological interventions targeting both the management of aggression crisis and preventing its future recurrence. A clinical algorithm guided by the NBD model is provided for practitioners.

The effects of Snoezelen (multi-sensory behavior therapy) and psychiatric care on agitation, apathy, and activities of daily living in dementia patients on a short term geriatric psychiatric inpatient unit

A randomized, controlled, single-blinded, between group study of 24 participants with moderate to severe dementia was conducted on a geriatric psychiatric unit. All participants received pharmacological therapy, occupational therapy, structured hospital environment, and were randomized to receive multi sensory behavior therapy (MSBT) or a structured activity session. Greater independence in activities of daily living (ADLs) was observed for the group treated with MSBT and standard psychiatric inpatient care on the Katz Index of Activities of Daily Living (KI-ADL; P = 0.05) than standard psychiatric inpatient care alone. The combination treatment of MSBT and standard psychiatric care also reduced agitation and apathy greater than standard psychiatric inpatient care alone as measured with the Pittsburgh Agitation Scale and the Scale for the Assessment of Negative Symptoms in Alzheimer's Disease (P = 0.05). Multiple regression analysis predicted that within the multi-sensory group, activities of daily living (KI-ADL) increased as apathy and agitation reduced (R2 = 0.42; p = 0.03). These data suggest that utilizing MSBT with standard psychiatric inpatient care may reduce apathy and agitation and additionally improve activities of daily living in hospitalized people with moderate to severe dementia more than standard care alone.

Elderspeak communication: impact on dementia care

Resistiveness to care is common in older adults with dementia. Resistiveness to care disrupts nursing care, increasing costs of care by 30%. Elderspeak (infantilizing communication used by nursing staff) may trigger resistiveness to care in individuals with dementia. Videotaped care episodes (n = 80) of nursing home residents with dementia (n = 20) were coded for type of staff communication (normal talk and elderspeak) and subsequent resident behavior (cooperative or resistive to care). Bayesian statistical analysis tested relationships between staff communication and subsequent resident resistiveness to care. The probability of resistiveness to care varied significantly with communication (Bayes P = .0082). An increased probability of resistiveness to care occurred with elderspeak (.55, 95% CrI, .44-.66), compared with normal talk (.26, 95% CrI, .12-.44). Communication training has been shown to reduce elderspeak and may reduce resistiveness to care in future research.

A randomized trial of the impact of a specific care plan in 1120 Alzheimer's patients (PLASA Study) over a two-year period: design and baseline data

OBJECTIVE

To describe the design anf baseline patient characteristics of a multicomponent specific care and assistance plan (PLASA) study in Alzheimer's Disease (AD). The study is designed to evaluate the effect of PLASA in AD primarily looking at change in functional capacity.

DESIGN

Two-years prospective cluster randomized controlled trial comparing PLASA and usual care.

SETTING

Forty-nine hospitals in France.

PARTICIPANTS

1120 community-dwelling AD.

INTERVENTION

Patients in the intervention group are evaluated biannually using a standardized comprehensive global assessment. In the case of decline in any one domain a standardized study protocol recommends specific physician directed intervention in addition to information and training for the caregiver.

MEASUREMENTS

Alzheimer Disease Cooperative Study-Activities of Daily Living scale, Resource Utilization in Dementia scale, Clinical Global Impression of Change.

RESULTS

At baseline, the two groups were similar regarding patient and caregiver characteristics. The mean patient age was 79.61+5.72 years and the mean MMSE 19.73+4.01 for the whole cohort. Time since dementia diagnosis was about 1.37+1.65 years in the whole cohort. Almost a third of the patients lived alone at baseline. Mean monthly time spent in caregiving in the whole cohort was 52.70+71.83 hours for instrumental activities and 17.73+51.38 hours for basic activities.

CONCLUSION

Persons with dementia suffer different losses at different stages of the disease and therefore accurate assessment of abilities and losses is critical to assist the person in planning for their future and for care needs. The PLASA intervention study is ongoing with 2 year follow-up to be completed in 2007.

The Development and Testing of a Questionnaire to Measure Complexity of Nursing Work Performed in Nursing Homes: NCCQ-NH

The quality of care in nursing homes has improved over the last 2 decades; however serious problems persist. Although staffing levels are a primary concern, studies show that ineffective management structures may be a contributing factor to poor quality care. Evidence suggests that the complexity of work performed within the organization is an important consideration in developing effective management structures. The purpose of this article is to describe the development and initial testing of an instrument to measure the complexity of nursing work in nursing homes. A sample of 168 nursing personnel (RNs, LPNs, CNAs) from 7 nursing homes participated in the study. The results of measures to determine the reliability and validity were generally acceptable for a new scale. A modified version of the original scale can be used to provide scientific evidence on which to base the design of management structures in nursing homes.

Caregivers' perceptions of dementia patients' functional ability

Dementia patients' caregivers often provide information about patients' daily functioning, but little is known about factors influencing caregivers' perceptions. Baseline data from an intervention trial were used to compare caregiver estimates of dementia patients' performance with their actual performance of instrumental activities of daily living (IADLs) and to assess relationships between measures of caregiver responses to caregiving, self-perceived sense of self-efficacy, and depression. We also assessed patient cognition, overall function and behavioral disturbance, and caregivers' perceptions of their patients' behavior as manipulative or deliberate. Disparities between these estimates and actual patient performance on structured IADL tasks were unrelated to any caregiver, patient, or relationship factor that we measured

The benefits of cholinesterase inhibitors: managing the behavioral and neuropsychiatric symptoms of Alzheimer's disease

Pharmacological treatment can be helpful to improve cognition, functional ability, and behavior symptoms in older adults with Alzheimer's disease, resulting in reduced caregiver burden, delayed nursing home placement, and reduced health care costs.

Improving outcomes of nursing home interactions

In this study, an intervention designed to improve staff-resident communication was evaluated in three nursing homes. Audio recordings of staff speech from baseline, and immediately and 2 months post-intervention, were compared on elderspeak (infantilizing speech) and rated for care, respect, and control. After the intervention, staff used less elderspeak (i.e., diminutives, collective pronoun substitutions, shortened statements, and simplistic vocabulary). Immediate post-intervention conversations were rated as less controlling, but more respectful and caring. After 2 months, communication was more controlling, less respectful, and less caring. Reduction in staff elderspeak use continued for psycholinguistic measures, but improvements in care, respect, and control decayed, suggesting the need for ongoing reinforcement of training.

Osteoarthritic knee or hip pain: possible indicators in elderly adults with cognitive impairment

Many elderly individuals with cognitive impairment (CI) suffer from chronic pain resulting from osteoarthritis (OA). They have diminished ability to communicate their pain to health care providers, and when pain is undetected, it may be untreated. A method of detecting chronic OA pain in elderly individuals with Cl and measuring treatment outcomes is thus urgently needed. This article examines indicators of chronic OA pain in cognitively intact elderly individuals that could be used to identify pain in elderly individuals with Cl. The review suggests that patients with severe knee or hip OA pain tend to show specific motor patterns, disturbances of gait patterns, and reduction of activity level. Therefore, these behaviors could serve as alternatives to verbal report of chronic pain in elderly individuals with Cl and knee or hip OA.

Effect of Individualized Social Activity on Sleep in Nursing Home Residents with Dementia

OBJECTIVES

To test the efficacy of an individualized social activity intervention (ISAI) on decreasing daytime sleep, improving nighttime sleep, and lowering the day/night sleep ratio and to determine its cost.

DESIGN

Pretest/posttest randomized with an experimental and control group.

SETTING

Seven nursing homes.

PARTICIPANTS

One hundred forty-seven residents with dementia.

INTERVENTION

One to 2 hours of individualized social activities for 21 consecutive days.

MEASUREMENTS

Twenty-four-hour sleep/wake patterns using an Actigraph.

RESULTS

The ISAI group had significantly less daytime sleep (P=.001) and a lower day/night sleep ratio (P=.03) than the control group, after adjusting for baseline values. Because 40% of the sample slept 7 or more hours at night, a secondary analysis was conducted. When only those residents with a sleep efficiency of less than 50% (n=50) were included, the ISAI group (n=20) had less daytime sleep (P=.005), a lower day/night sleep ratio (P=.02), fell asleep faster (P=.03), and were awake less at night (P=.04) than the control group (n=30), after adjusting for baseline values. The weekly cost of the ISAI was roughly $70 per participant. Initial training and supply costs were $1,944.

CONCLUSION

The ISAI provides an alternative to medications, without side effects.

Impact of the stage of dementia on the time required for bathing-related care: a pilot study in a Japanese nursing home

Time required for bathing-related care for nursing home residents with various stages of severe dementia were observed. Time required for each resident, including guiding to the bathroom, undressing, and dressing were plotted in graphs in order to make comparisons. The situations and conversations observed for the instances when additional time was needed were analyzed. Stage of dementia affected the amount of time required for the task of guiding to the bathroom, but did not appear to affect time required for dressing or undressing. For dressing and undressing, additional time was required when caregivers failed to keep to a specific routine.

The Family’s Role in Person-Centered Care: Practice Considerations

Effective implementation of person-centered care requires a shared understanding and commitment to make it a reality by administrative personnel, direct care providers, and residents and their family members. Long-term care facilities must seek ways to engage residents' families in person-centered care through its training, policies, care planning, and documentation. Doing so may require revisions to policies and work practices, and ongoing leadership efforts to maintain this care framework within the realities of staff turnover and regulatory requirements. Developing protocols and procedures that facilitate family members' communication with staff and build consensus and shared values will result in a system that represents and honors the unique perspectives, values, and needs of each resident receiving care. It is important for facility leadership to set the tone for acknowledging the importance of family involvement in person-centered care by modeling acceptance of concerns and criticisms as valid and by acknowledging that direct care providers, residents, and their family members have a voice in care decisions. Such an approach has the greatest chance of success in promoting person-centered care and the shared values necessary to ensure its successful implementation.

Treating depression in predominantly low-income young minority women: a randomized controlled trial

CONTEXT

Impoverished minority women experience a higher burden from depression than do white women because they are less likely to receive appropriate care. Little is known about the effectiveness of guideline-based care for depression with impoverished minority women, most of whom do not seek care.

OBJECTIVE

To determine the impact of an intervention to deliver guideline-based care for depression compared with referral to community care with low-income and minority women.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial conducted in the Washington, DC, suburban area from March 1997 through May 2002 of 267 women with current major depression, who attended county-run Women, Infants, and Children food subsidy programs and Title X family planning clinics. Outcomes Hamilton Depression Rating Scale measured monthly from baseline through 6 months; instrumental role functioning (Social Adjustment Scale) and social functioning (Short Form 36-Item Health Survey) measured at baseline and 3 and 6 months.

INTERVENTIONS

Participants were randomly assigned to an antidepressant medication intervention (trial of paroxetine switched to buproprion, if lack of response) (n = 88), a psychotherapy intervention (8 weeks of manual-guided cognitive behavior therapy) (n = 90), or referral to community mental health services (n = 89).

RESULTS

Both the medication intervention (P<.001) and the psychotherapy intervention (P =.006) reduced depressive symptoms more than the community referral did. The medication intervention also resulted in improved instrumental role (P =.006) and social (P =.001) functioning. The psychotherapy intervention resulted in improved social functioning (P =.02). Women randomly assigned to receive medications were twice as likely (odds ratio, 2.04; 95% confidence interval, 0.98-4.27; P =.057) to achieve a Hamilton Depression Rating Scale score of 7 or less by month 6 as were those referred to community care.

CONCLUSIONS

Guideline-concordant care for major depression is effective for these ethnically diverse and impoverished patients. More women engaged in a sufficient duration of treatment with medications compared with psychotherapy, and outcome gains were more extensive and robust for medications.

An assessment of strategies for improving quality of care in nursing homes

PURPOSE

Despite substantial regulatory oversight, quality of care in nursing homes remains problematic. This article assesses strategies for improving quality of care in these facilities.

DESIGN AND METHODS

This article reviews the research literature on eight strategies: strengthening the regulatory process, improving information systems for quality monitoring, strengthening the caregiving workforce, providing consumers with more information, strengthening consumer advocacy, increasing Medicare and Medicaid reimbursement, developing and implementing practice guidelines, and changing the culture of nursing facilities.

RESULTS

Although individual approaches vary, several themes emerge. First, several strategies require substantially more resources and will increase costs. Second, the research literature does not provide much guidance as to the effectiveness of these options. Third, several strategies assume a degree of data sophistication on the part of nursing homes that may not exist. Fourth, regulation is likely to continue to be the main strategy of quality assurance. Finally, the political saliency of nursing home quality issues is uneven.

IMPLICATIONS

Quality of care in nursing homes is a major issue for which there is no simple solution.