Agitation and touch in the nursing home

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.

Impact of ambient bright light on agitation in dementia

OBJECTIVE

To evaluate the effect of ambient bright light therapy (BLT) on agitation among institutionalized persons with dementia.

METHODS

High intensity, low glare ambient lighting was installed in activity and dining areas of a state psychiatric hospital unit in North Carolina and a dementia-specific residential care facility in Oregon. The study employed a cluster-unit crossover design involving four ambient lighting conditions: AM bright light, PM bright light, All Day bright light, and Standard light. Sixty-six older persons with dementia participated. Outcome measures included direct observation by research personnel and completion by staff caregivers of the 14-item, short form of the Cohen-Mansfield Agitation Inventory (CMAI).

RESULTS

Analyses of observational data revealed that for participants with mild/moderate dementia, agitation was higher under AM light (p = 0.003), PM light (p < 0.001), and All Day light (p = 0.001) than Standard light. There was also a trend toward severely demented participants being more agitated during AM light than Standard light (p = 0.053). Analysis of CMAI data identified differing responses by site: the North Carolina site significantly increased agitation under AM light (p = 0.002) and PM light (p = 0.013) compared with All Day light while in Oregon, agitation was higher for All Day light compared to AM light (p = 0.030). In no comparison was agitation significantly lower under any therapeutic condition, in comparison to Standard lighting.

CONCLUSIONS

Ambient bright light is not effective in reducing agitation in dementia and may exacerbate this behavioral symptom.

Effects of yokukansan, a traditional Japanese medicine, on aggressiveness induced by intracerebroventricular injection of amyloid beta protein into mice

The effects of yokukansan, a traditional Japanese medicine, on aggressiveness and motor activities were examined in mice after injection of amyloid beta protein (Abeta) into the lateral ventricle of the brain. The results were compared with those of conventional (haloperidol) and atypical (risperidone) antipsychotic medicines. A significant increase in aggressiveness was observed on day 7 after injection of Abeta, and it lasted until day 28. A single oral administration of yokukansan (1.0 g/kg) did not ameliorate the aggressiveness observed on day 7. However, a tendency toward amelioration of the aggressiveness was observed after the administration of yokukansan (0.5 and 1.0 g/kg) for 1 week (days 7-14). The 3 week administration (days 7-28) of yokukansan significantly ameliorated the aggressiveness in a dose-dependent manner without inhibition of motor activity. In contrast, a single administration of intraperitoneal haloperidol (0.03-0.1 mg/kg) or oral risperidone (0.1-0.3 mg/kg) on day 28 significantly reduced aggressiveness in a dose-dependent manner. However, motor activities were significantly suppressed. These results suggest yokukansan reduces aggressiveness without suppressing physical activity.

It's OK for people to feel angry': the exemplary management of imminent aggression

Ward managers working in a medium secure learning disability service were asked to identify members of staff who they believed to be superior in the management of violent and aggressive individuals. A grounded theory approach was used to interview staff about their management of imminent aggression. The participants explained their strategies in terms of the following eight themes, which were common to all interviews: safety and de-escalation, attribution and control, relationships, understanding and empowerment, anticipating reactions, creating a façade, communication, and humour. The participants described the importance of building up trusting relationships with clients when trying to understand the reasons for the client's behaviour. They also explained how they offer a ;get-out clause' to the client, a way for the client to decide to calm down without losing face. The participants also reported that creating the appearance of being in control can help, as does the use of humour to aid communication.

Bathing: A framework for intervention focusing on psychosocial, architectural and human factors considerations

The process of bathing is usually pleasurable and relaxing for most persons and, although it serves hygienic needs, it is often individualized to a person's preferences in order to enhance the pleasurable experience. In contrast, the bathing process for elderly people suffering from dementia is often a traumatic experience for both the persons with dementia and their caregivers. Agitated behaviors are manifested more often during bathing than at other times. Factors influencing the experience of the bathing process and resulting in agitated behaviors can be categorized into four broad groups: the needs of the person with dementia, the needs of the caregiver, the physical environment in which bathing takes place and institutional factors. A number of approaches have been employed to treat agitated behaviors during bathing; however, a comprehensive approach addressing all of the above factors has not been developed. This paper presents preliminary findings on the effectiveness of the Treatment Routes for Exploring Agitation (TREA) approach for non-pharmacological interventions within a larger framework of human factors, addressing the needs of residents and staff members, environmental factors as well as human factors analysis to improve the process of bathing. A case study demonstrates the efficacy of this approach in reducing agitated behaviors during bathing.

Agitation in dementia: concept clarification

AIM

The aim of this paper is to clarify the concept of agitation in dementia through analysing definitions, critical attributes, components, boundaries, antecedents and consequences of agitation.

BACKGROUND

The concept of agitation is not well defined. In addition, there exists much confusion about the characteristics and boundaries of agitation, as well as the distinction between agitation and related concepts. Recently developed theoretical models for agitation in dementia require new interpretation and conceptualization of agitation.

METHODS

Morse's method of critical appraisal of the literature was used. In addition, some parts of Rodgers' evolutionary method were employed. Data were selected using six electronic databases and the key words 'agitation', 'agitated', 'dementia', 'demented' and 'Alzheimer'. The analysis included 86 empirical or theoretical papers and one book.

RESULTS

A transition from the observer's perspective to the patient's perspective in the interpretation of agitation was found. Five critical attributes of agitation in dementia were identified: excessive, inappropriate, repetitive, non-specific and observable. Patient factors, interpersonal factors, environmental factors and restraint were identified as precipitating antecedents. Mediating antecedents included discomfort, unmet need and misinterpretation. Consequences of agitation were identified at the levels of patient, caregiver and others.

CONCLUSIONS

This transition in perspectives has important implications as it can change health providers' attitudes and responses to agitation and lead to patient-focused and individualized care. Researchers and clinicians are encouraged to avoid labelling agitated behaviour as 'disturbing behaviour'.

Touch-Stress Model and Alzheimer's Disease

This article presents a theoretical model for future nursing research and practice on the use of touch intervention in patients with Alzheimer's disease. A theory synthesis was conducted that built on a base of previous research findings pertaining to the phenomenon of interest identified by two conceptual models: the Progressively Lowered Stress Threshold (PLST) model and the Touch model. The literature review was restricted to published articles in nursing and health services journals from 1970 through 2000. The Touch-Stress model formulated through theory synthesis can contribute to theory development, serve to improve care of patients with Alzheimer's disease suffering from emotional and behavioral disturbances, and increase the quality of life for the caregivers and families of patients with Alzheimer's disease.

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

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

Calming music and hand massage with agitated elderly

BACKGROUND

Agitated behavior is a widespread problem that adversely affects the health of nursing home residents and increases the cost of their care.

OBJECTIVE

To examine whether modifying environmental stimuli by the use of calming music and hand massage affects agitated behavior in persons with dementia.

METHOD

A four group, repeated measures experimental design was used to test the effect of a 10-minute exposure to either calming music, hand massage, or calming music and hand massage simultaneously, or no intervention (control) on the frequency and type of agitated behaviors in nursing home residents with dementia (N = 68). A modified version of the Cohen-Mansfield Agitation Inventory was used to record agitated behaviors.

RESULTS

Each of the experimental interventions reduced agitation more than no intervention. The benefit was sustained and increased up to one hour following the intervention (F = 6.47, p<.01). The increase in benefit over time was similar for each intervention group. When types of agitated behaviors were examined separately, none of the interventions significantly reduced physically aggressive behaviors (F = 1.93, p=.09), while physically nonaggressive behaviors decreased during each of the interventions (F = 3.78, p< 01). No additive benefit resulted from simultaneous exposure to calming music and hand massage. At one hour following any intervention, verbally agitated behavior decreased more than no intervention.

CONCLUSION

Calming music and hand massage alter the immediate environment of agitated nursing home residents to a calm structured surrounding, offsetting disturbing stimuli, but no additive benefit was found by combining interventions simultaneously.

Physical touch in nursing studies: a literature review

In nursing contexts a distinction is made between two types of touch: physical touch and therapeutic touch. Physical touch may be experienced as therapeutic, but that is not its explicit purpose in the same way as with therapeutic touch. Most of the touch studies reviewed in this article are from the United States of America, Canada and the United Kingdom and thus represent the culture of modern western society. The area covered by these studies is far from coherent, and even the results are to some extent contradictory. It follows that it is difficult to draw any firm conclusions from this review of the concepts, methods and main results of touch studies.

Administrators and patients: using the personal touch

Although rarely discussed in management training, taking the time for a handshake or gentle touch on a patient's arm can yield multiple benefits for the administrator. The patient's confidence in the facility is increased, and the administrator is reminded that the patient is the true bottom line of the hospital. Moreover, both are reassured that, at the other end of the chain of service, there is another human being.

Caregiver distress. Related to disruptive behaviors on special care units versus traditional long-term care units

The link between staff stress and exposure to disruptive behaviors is an important issue in long-term care settings. This study compared the perceptions of two groups of formal caregivers (staff) regarding their distress from the behaviors of residents in their care. Staff on special care units for dementia were less distressed with disruptive behaviors than comparable staff on traditional units, although they reported higher exposure to these behaviors. These results were related to different perceptions of intent to harm and expectations of physical aggression as "part of the job." Implications for nursing include education and support for staff to enhance the quality of life for residents and staff on units where disruptive behaviors occur.

Development and testing of the Resistiveness to Care Scale

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

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.

Use of music to decrease aggressive behaviors in people with dementia

The purpose of this study was to examine the effects of recorded, preferred music in decreasing occurrences of aggressive behavior among individuals with Alzheimer's type dementia during bathing episodes. Eighteen older adults, age 55 to 95, with severe levels of cognitive impairment, participated in the study. They were randomly scheduled for observation during bath time under either a control (no music) condition or an experimental condition in which recorded selections of preferred music were played via audiotape recorder during the bathing episode. Following a 2-week (10 episode) observation period, conditions were reversed. A total of 20 observations were recorded for each individual. Results indicated that during the music condition, decreases occurred in 12 of 15 identified aggressive behaviors. Decreases were significant (p < 0.05) for the total number of observed behaviors and for hitting behaviors. During the music condition, caregivers frequently reported improved affect and a general increase in cooperation with the bathing task. The implications of these findings for improving the overall quality of care for severely cognitively impaired older adults are discussed.

Risk of behavior problems among nursing home residents in the United States

This study identified personal risk factors associated with behavior problems among nursing home residents using data based on a national survey of nursing home residents. Data are based on the Institutional Population Component of the 1987 National Medical Expenditure Survey and include nursing home residents living in licensed facilities on January 1, 1987. Multiple regression analyses were conducted to examine characteristics of residents that place them at risk of behavior problems. Independent variables include physical functioning, sensory impairment, cognitive impairment, psychiatric diagnoses, and demographics. Eleven behavior problems grouped into four categories based on factor analysis serve as dependent variables: wandering/safety, aggressive behaviors, collecting behaviors, and delusions/hallucinations. Risk factors emerging as predictors included sex (male), cognitive impairment, ADL dependency, incontinence, psychiatric history, receptive communication, walking, and difficulty seeing. Risk factors differ by type of behavior problem. Results suggest a multiple etiology in which biological, psychological, and sociocultural factors all play a role in generating behavior problems in the long-term care setting.

Physical aggressive resident behavior during hygienic care

Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Act (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was identified as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.

Developing an instrument for the observation of touching

This article describes the development of an instrument for the observation of nonnecessary touching and its purposes in interaction between nursing staff and elderly patients in long-term care. The work took place on three wards of a nursing home. The instrument is based on three main concepts: verbal communication, touch as a form of nonverbal communication, and nursing care situation. In its finalized form, the instrument consists of a single sheet of paper with the human body pictured from the front and from the back.

Agitation: measurement, management, and intervention research

Strategies for controlling and managing agitation of patients in long-term care populations has been identified as a research priority. Unfortunately, there is a paucity of literature on empirically tested therapeutic interventions for agitation. This manuscript summarizes the literature related to the measurement, management, and interventions for agitation and identifies a nursing research agenda for conducting research in this area. Nonpharmacological and nonrestraint interventions are highlighted and categorized by (1) alterations in care given, (2) environmental adaptations, and (3) behavioral approaches. Future research areas identified by the authors focus on additional types of environmental, interpersonal, and behavioral interventions as well as theoretical predictors of agitation; the influence and role of nursing personnel and caregiver; and the legal and ethical issues involved in caring for patients who manifest agitation.

Behavioral symptoms in dementia: an update

A descriptive literature review was done to identify research conducted in both community and institutional settings and published from 1986 to 1993 on the correlates of behavioral symptoms associated with dementia. Critical appraisal and synthesis of the 40 studies revealed theoretical and methodological problems that tempered conclusions about the relationships between behavioral symptoms and the correlates under study. While direct relationships were found in studies in which relationships between behavioral symptoms and cognitive impairment and contextual factors were examined, contradictory results were found in studies of demographic and functional variables. Recommendations for research-based practice are advanced, including the development and testing of alternatives to physical and chemical restraints in the care of persons with dementia.

Nursing-home staff perception of behavior disturbance and management of confused residents

An exploratory study was conducted to identify nursing-home staff's perceptions of confused residents' behavior problems and what they did to intervene. Six focus groups were conducted at two nursing homes. A convenience sample of 58 health care providers participated: registered nurses and licensed practical nurses; certified nursing assistants; social workers; clinical nurse specialists; therapeutic recreation therapists; and physical, speech, and occupational therapists. Four categories of behavior disturbances emerged: verbal, fear-related, wandering, and level of awareness-related. Four categories emerged from intervention data analysis: interpreting reality, maintaining normalcy, meeting basic needs, and managing behavior disturbances.

A nursing challenge: Assessment and management of agitation in Alzheimer's patients

1. Agitation in patients with Alzheimer's disease is a pervasive problem. The behaviors associated with agitation may have detrimental effects on the patient, health care providers, and other patients. 2. Management of these behaviors is particularly challenging and, at times, frustrating for nursing personnel. 3. Attempts to identify the causative factors are essential to the development of an individualized plan of care.

A descriptive study of physically aggressive behavior in dementia by direct observation

OBJECTIVE

To study, by direct observation, physically aggressive behavior (PAB) in a cohort of older persons with dementia.

DESIGN

Cross-sectional survey.

SETTING

A locked special care unit for Alzheimer's Disease and an ordinary skilled unit of two suburban nursing homes.

PARTICIPANTS

Twenty men and women with a history of PAB.

MEASUREMENTS AND MAIN RESULTS

Portable bar-code-readers and daily diaries were used to determine the frequency of PAB as well as to elucidate the antecedents and consequences of it. PAB was most often directed toward staff (23/28 episodes), usually in the context of personal care (15/23 episodes). In the majority of cases, verbal aggression or non-compliance preceded the PAB. Most often PAB was followed by a rapid return to non-aggressive behavior.

CONCLUSIONS

Very little PAB was truly spontaneous, nor was it usually the participant's normal behavior. Most PAB occurred in response to intrusion into the participant's personal space by staff or other residents. The PAB is better understood as a defensive response than an expression of anger.