Staging casual conversations for people with dementia

A conversational, small-story approach to narrative care for people with dementia living in care institutions: Strategies and challenges

The aim of the paper was to define what narrative care is and identify and discuss everyday conversational narrative care strategies regarding people living with dementia in long-term care institutional settings. To do so, we differentiate between two approaches to narrative care: a big-story approach (reflecting on life stories) and a small-story approach (enacting stories in everyday conservations). The paper is focused on the second approach, which appears to be particularly fit to be used with people living with dementia. We identify three main strategies to implement this approach in everyday care: (1) prompting and sustaining narratives; (2) valuing non-verbal and embodied cues; and (3) constructing narrative environments. Finally, we discuss some training, institutional and cultural barriers and challenges for providing conversational, small story-based narrative care for people living with dementia in long-term care institutions.

Why Men Fare Worse: A Mixed-Methods Study Examining Gender Differences in Nursing Home Resident Quality of Life

BACKGROUND AND OBJECTIVES

Despite research documenting gender differences in numerous outcomes in later life, we know little about gender differences in quality of life (QoL) for nursing home (NH) residents. This study examines the relationship between gender and residents' QoL, including possible reasons for differences observed.

RESEARCH DESIGN AND METHODS

We used a mixed-methods design including surveys with a random sample of Minnesota NH residents using a multidimensional measure of QoL (n = 9,852), resident clinical data, facility-level characteristics (n = 364), interviews with residents (n = 64), and participant observations. We used linear mixed models and thematic analysis of resident interviews and observations to examine possible gender-related differences in residents' QoL.

RESULTS

After controlling for individual and facility characteristics, men reported lower overall QoL than women, including significantly lower ratings in several QoL domains. In interviews, men noted being less satisfied with activities than women, having fewer friends, and being less able to rely on family for support. Some women described the NH as a place of respite, but men more often described being dissatisfied with life in the NH and undesirable for long-term living. Our observations were consistent with interview findings but provide additional nuances, such as that some men organized their own social groups.

DISCUSSION AND IMPLICATIONS

Our findings suggest that men and women experience QoL differently in NHs, with men reporting lower QoL in several domains. Tailoring more activities for men and finding ways to strengthen relationships for men in NHs could help reduce the gender differences in QoL we observed.

Social Connectedness among Long-Stay Nursing Home Residents with Alzheimer's and Dementia: Exploring Individual and Facility-Level Variation

INTRODUCTION

This study sought to explore individual and facility-level variation in social connectedness among long-stay nursing home residents with Alzheimer's or other dementias (ADRD).

METHODS

We identified 721,074 long-stay residents with ADRD using 2016 Minimum Data Set 3.0 data. Social connectedness was defined using the social connectedness index (SCI) (high: SCI = 5, lower: 0 < SCI ≤ 4). Adjusted odds ratios (aOR) provided estimates of the associations between resident-level and facility-level characteristics, and high SCI was derived from logistic models.

RESULTS

The SCI Cronbach's alpha was 0.69; 78.6% had high SCI scores. Men were less likely than women to have higher SCI scores (aOR = 0.97; 95% CI: 0.97-0.98). Increasing age was associated with higher SCI scores (e.g., aOR [85-94 vs. 40-64 years]: 1.07; 95% CI: 1.06-1.07). Those with moderate cognitive impairment (aOR: 0.87) and severe cognitive impairment (aOR: 0.85) had reduced odds of SCI = 5 relative to those with mild/intact cognitive function. Residents living in homes with special care dementia units and with higher percentage of residents with dementia had decreased odds of high social connectedness.

DISCUSSION/CONCLUSION

Understanding resident- and nursing home-level variation in social connectedness may be important for targeting interventions that reduce isolation among residents with ADRD.

"If You Just Stay With Me and Wait…You'll Get an Idea of What I'm Saying": The Communicative Benefits of Time for Conversational Self-Repair for People With Aphasia

PURPOSE

This study investigated the communicative benefits of self-repair during conversation for persons with aphasia (PWAs). Self-repair of trouble sources is an interactional priority that emphasizes autonomy and competence. Of equal importance, conversationalists desire to minimize silences and work together to ensure forward movement (progressivity) of conversation. Simultaneously achieving progressivity and self-repair is challenging in aphasia, and PWAs and their partners often make trade-off decisions between these two activities. Conversation-level aphasia interventions usually focus on supportive techniques that promote participation while maintaining progressivity, effectively favoring progressivity over self-repair. This study evaluates the benefits of an alternative approach that shifts the emphasis to self-repair, thereby highlighting potential trade-off costs of routinely forgoing self-repair to achieve progressivity.

METHOD

Ten people with mild-to-moderate aphasia each held two conversations with two different partners. When trouble sources characterized by silent and/or filled pauses occurred, partners maintained a supportive and engaged stance, allowing PWAs time to self-repair. We analyzed language produced during these "edited turns" using three paradigms considering form, content, and use.

RESULTS

The data yielded 311 edited turns. For form, on average, each edited turn resulted in 3.72 words; for content, most edited turns contained autobiographical information; for use, approximately 40% of edited turns introduced new information, and 40% added to the ongoing topic. The remainder were either ambiguous or comments such as, "I can't think of it."

CONCLUSIONS

When given engaged support and time to self-repair, PWAs contributed meaningful personal information to conversations for approximately 80% of edited turns. Importantly, self-repair often resulted in self-expression that directed the conversation, which is a communicative role critical for empowering agency and identity. This research opens a dialogue about benefits and limitations of approaches that prioritize either progressivity or self-repair and how to balance the two to optimize therapeutic benefits for each individual.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19379738.

Development and psychometric evaluation of the Social Connectedness Index in nursing home residents with Alzheimer's disease and dementia using the Minimum Data Set 3.0

OBJECTIVES

To develop a reliable and valid measure of social connectedness among nursing home residents with Alzheimer's disease and related dementias (ADRD) using items available in the Minimum Dataset 3.0 (MDS).

METHODS

We conducted a retrospective scale development study using the 2016 MDS with two populations of nursing home residents with ADRD: (1) new admissions (not post-acute care) (n = 146,694); (2) residents with comprehensive annual assessments (n = 294,704). Twenty-nine items were included for consideration. Psychometric evaluation included content validity, item analysis, internal consistency reliability, criterion-related validity, and exploratory factor analysis. Analyses were stratified by self- or staff-assessed pain.

RESULTS

The resulting five item Social Connectedness Index (SCI) has good content (Fleiss Kappa = 0.67), criterion-related and construct validity and adequate internal consistency reliability (Kuder Richardson-20: 0.63-0.74) in persons with ADRD. As anticipated, younger residents, men, and those with severe cognitive impairment, anxiety, and depression were more likely to be categorized in the low social connectedness group.

CONCLUSION

The SCI is a promising measure for estimating the amount of social connectedness present for nursing home residents with ADRD. Further work needs to be done to evaluate the usefulness of the SCI for evaluating health and well-being among this population over time.

Nursing home resident relationship types: What supports close relationships with peers & staff?

AIMS AND OBJECTIVES

To describe from the nursing home resident perspective (a) the types and dimensions of relationships residents develop with others in the nursing home and (b) the conditions that influence the development of close relationships.

BACKGROUND

Close relationships are considered the fundamental building block of person-centred care. Prior studies have examined the various types of relationships residents develop with peers and staff, but few have focused specifically on articulating the characteristics and dimensions of a close relationship or the factors that can support or detract from their development.

DESIGN

Grounded theory.

METHODS

Fifteen cognitively intact residents from two nursing homes were recruited for one-on-one, unstructured interviews. Interview questions started broadly and became more focused as the study progressed. Data were analysed using open, axial and selective coding.

RESULTS

Residents described developing a range of relationships with peers and staff (adversarial, utilitarian, and friendly). Residents used "friendly" to describe many different types of relationships including acquaintanceships, casual friendships and close friendships. Few residents had close relationships with peers or staff. Several conditions promoted development of positive and friendly relationships. Physical proximity and access to peers with similar interests, who could communicate clearly, fostered friendly peer relationships. Spending noncare time, providing little extras, treating residents as special and responding positively to care requests fostered friendly staff relationships.

CONCLUSIONS

Findings add new evidence regarding nuances in resident relationships and demonstrate how development of close relationships may be limited in practice. Careful assessment of resident relationship needs and goals may be critical to setting appropriate social goals.

RELEVANCE TO CLINICAL PRACTICE

Nurses can be intentional about resident placements in the facility to promote social interactions and keep social goals in mind when making medical or staffing decisions to prevent interruption of important relationships.

Weaving social reality around the grandparent/great-grandparent with dementia to maintain relational presence: A verbal and non-verbal dementia interactions model

We proposed a dementia interactions model based on analyses of five focus groups with grandchildren of grandparents with dementia. Interactions with their grandparent with dementia motivate grandchildren to maintain connection with a grandparent who is relationally present. To do so, they weave a social reality around the grandparent. To help the grandparent remain connected, grandchildren engage in scripts and routines and employ three intertwined psychological processes: perspective taking, vigilance, and knowledge about the grandparent's preferences, personality, state of mind, and context. Grandchildren use four relationship anchors to help the grandparent remain relationally present: family members, meaningful sensory objects and activities, physical space/context, and themselves. Implications for improving social interactions with close others with dementia are discussed.

Participatory arts programs in residential dementia care: Playing with language differences

This article examines connections between language, identity, and cultural difference in the context of participatory arts in residential dementia care. Specifically, it looks at how language differences become instruments for the language play that characterizes the participatory arts programs, TimeSlips and the Alzheimer’s Poetry Project. These are two approaches that are predominantly spoken-word driven. Although people living with dementia experience cognitive decline that affects language, they are linguistic agents capable of participating in ongoing negotiation processes of connection, belonging, and in- and exclusion through language use. The analysis of two ethnographic vignettes, based on extensive fieldwork in the closed wards of two Dutch nursing homes, illustrates how TimeSlips and the Alzheimer’s Poetry Project support them in this agency. The theoretical framework of the analysis consists of literature on the linguistic agency of people living with dementia, the notions of the homo ludens (or man the player) and ludic language, as well as linguistic strategies of belonging in relation to place.

Everyday conversation in dementia: a review of the literature to inform research and practice

BACKGROUND

There has been increasing interest in dementia care in recent years, including how practitioners, service providers and society in general can help individuals to live well with the condition. An important aspect to this is provision of advice to ensure conversation partners effectively support the person with dementia in conversation.

AIMS

To provide a descriptive review of the literature examining everyday conversation in dementia in order to inform practice and research.

METHODS & PROCEDURES

This review used a method specifically developed for reviewing conversation analytic and related literature. A range of databases were searched using key words and explicitly described inclusion criteria leading to a final corpus of 50 titles. Using this qualitative methodology, each paper was examined and data extracted. The contribution of each of these is described and the implications for practice and research are outlined.

MAIN CONTRIBUTION

This review examined studies into conversation in Alzheimer's disease, vascular dementia and Lewy body dementia, grouping these into: early influential studies; work drawing on positioning theory; studies using social and linguistic approaches; collaborative storytelling; formulaic language; studies specifically using conversation analysis; and conversation as a target for individualized therapy. In addition, more recent work examining primary progressive aphasia and behavioural variant frontotemporal dementia was explored. Overall, this review indicates that research examining conversation in natural settings provides a rich source of data to explore not just the challenges within conversation for those taking part, but also the skills retained by the person with dementia. An important aspect of this understanding is the notion that these skills relate not only to information exchange but also aspects of social interaction. The role of others in scaffolding the conversation abilities of the person with dementia and the potential of this for developing interventions are discussed.

CONCLUSIONS & IMPLICATIONS

The review indicates that interventions targeting conversation in dementia are often advocated in the literature but currently such approaches remain to be systematically evaluated. In addition, many of the important insights arising from these studies have yet to inform multidisciplinary dementia care practice.

Young Adults' Concerns and Coping Strategies Related to their Interactions with their Grandparents and Great-Grandparents with Dementia

Young adults' concerns and coping strategies related to their face-to-face interactions with their grandparents/great-grandparents with dementia were explored through the lens of a solidarity-conflict conceptual framework. Participants indicated concerns about their inability to maintain the relational connection, not knowing what to say or how to behave, their lack of perspective-taking skills and emotion-regulation strategies, interacting with an ever-changing other, as well as concerns about other co-participants in the interaction. Participants' coping strategies were driven by two interaction motives: maintaining solidarity (e.g., desire to maintain and improve the interaction with the grandparent by seeking the other's company, loving the other, and maintaining the other's personhood) and dealing with conflict (e.g., dealing with self-focused concerns about lack of skills and knowledge by engaging in substitute avenues for communication and down-regulating negative affect). Implications for improving interactions between young adults and their grandparents/great-grandparents with dementia are discussed.

Communicative Coping Behavior Checklist: Observation of Persons With Dementia in the Home Environment

PURPOSE OF THE STUDY

Communication contributes to increased stress, mortality, and decreased quality of life (QOL) for persons with dementia (PWD) and caregivers. PWD use communicative coping behaviors (CCBs) to manage the demands of the disease. However, most assessments neither look for nor give credit to communication behaviors. This is the first study to examine CCBs in the home environment as measured by the Communicative Coping Behavior Checklist (CCBC).

DESIGN AND METHODS

This cross-sectional quantitative study included 26 dementia and 18 cognitively normal control dyads. Raters observed their partners' CCBs at home, over several weeks and completed the CCBC. We analyzed the endorsement rates (how often behaviors were observed by a rater) of emotion and activity-focused CCBs in dementia and control dyads.

RESULTS

The primary outcome was rate of CCB endorsement. Secondary outcomes included dementia diagnosis, cognitive status, depressive mood, life satisfaction (SWL) and QOL. Dementia dyads endorsed 11 of 23 CCBs significantly more than control dyads. Action-focused CCBs (p < .001) were more frequent than emotion-focused CCBs (p = .004) in dementia dyads. Specific CCBs such as humor correlated with higher caregiver QOL (p = .019) and PWD's SWL (p = .003). Another CCB, general humor, correlated with lower PWD's SWL (p = .024).

IMPLICATIONS

This was the first study to examine CCBs in the home environment comparing dementia and control dyads. Higher endorsement rates of action-focused than emotion-focused CCBs were seen in dementia dyads. We conclude that attention to CCBs during treatment and care will improve QOL and SWL of PWD and caregivers.

Behavioral/Nonpharmacological Approaches to Addressing Cognitive-Linguistic Symptoms in Individuals With Dementia

Despite current barriers to developing and implementing nonpharmacological or behavioral cognitive-linguistic treatments for dementia, a growing evidence base indicates that individuals with dementia may indeed benefit from a range of nonpharmacological intervention approaches in terms of helping them maintain and/or improve their language and cognitive abilities as well as general functioning and emotional well being. With respect to the current dementia literature, this article describes restorative and compensatory approaches for cognitive symptoms, including direct stimulation of cognitive functions and internal and external strategies to maximize use of residual cognitive skills. We also summarize various language treatment techniques designed to address word retrieval deficits or functional communication issues in a range of dementia types and severity. Broader stimulation approaches such as Montessori-based treatment, reminiscence therapy, and exercise/movement therapy are also reviewed given their potential to benefit not only the cognitive-linguistic symptoms of individuals with dementia, but also other aspects of physical, emotional, and behavioral functioning. Last, we conclude by highlighting limitations in the current research literature along with factors to consider for maximizing nonpharmacological treatment effects (i.e., generalization and maintenance of treatment gains) in clinical or research settings.

Residents Perceptions of Friendship and Positive Social Networks Within a Nursing Home

PURPOSE OF THE STUDY

(i) To describe nursing home residents' perceptions of their friendship networks using social network analysis (SNA) and (ii) to contribute to theory regarding resident friendship schema, network structure, and connections between network ties and social support.

DESIGN AND METHODS

Cross-sectional interviews, standardized assessments, and observational data were collected in three care units, including a Dementia Specific Unit (DSU), of a 94-bed Sydney nursing home. Full participation consent was obtained for 36 residents aged 63-94 years. Able residents answered open-ended questions about friendship, identified friendship ties, and completed measures of nonfamily social support.

RESULTS

Residents retained clear concepts of friendship and reported small, sparse networks. Nonparametric pairwise comparisons indicated that DSU residents reported less perceived social support (median = 7) than residents from the other units (median = 17; U = 10.0, p = .034, r = -.51), (median = 14; U = 0.0, p = .003, r = -.82). Greater perceived social support was moderately associated with higher number of reciprocated ties [ρ(25) = .49, p = .013].

IMPLICATIONS

Though some residents had friendships, many reported that nursing home social opportunities did not align with their expectations of friendship. Relationships with coresidents were associated with perceptions of social support. SNA's relational perspective elucidated network size, tie direction, and density, advancing understanding of the structure of residents' networks and flow of subjective social support through that structure. Understanding resident expectations and perceptions of their social networks is important for care providers wishing to improve quality of life in nursing homes.