Development of the refined ADL Assessment Scale for patients with Alzheimer's and related disorders

Clinical factors associated with activities of daily living and their decline in patients with severe dementia

BACKGROUND

To identify the clinical factors affecting activities of daily living (ADL) at baseline and after 6 months.

METHODS

We conducted a single-centre observational study at two time points across 6 months (baseline and after 6 months) from April 2015 to March 2017. in a 270-bed rural recuperation hospital at Hyogo prefecture in Japan. The total number of participants was 131 (male 33, female 98; mean age: 87.0 ± 7.0; mild and moderate dementia, 38; severe dementia, 93). Measurement scales used were Personal Self-Maintenance Scale (PSMS) for assessing ADL, Mini-Mental State Examination and Cognitive Test in Severe Dementia (CTSD) for cognitive function, Neuropsychiatric Inventory-Nursing Home version and Cornell Scale for Depression in Dementia (CSDD) for behavioural/psychological symptoms of dementia, Mini Nutritional Assessment Short form (MNA-SF) for nutritional status, Pain Assessment in Advanced Dementia for pain, and Charlson comorbidity index (CCI) and the number of illness categories based on Cumulative Illness Rating Scale Geriatrics for comorbidities. Multiple regression analyses identified the association between PSMS score as the dependent variable and other variables as independent variables.

RESULTS

In participants with severe dementia, the PSMS scores at baseline were significantly associated with CTSD, CCI, MNA-SF, and CSDD scores. In the longitudinal analysis, only CTSD score was significantly associated with PSMS score after 6 months. It is noteworthy that for participants with severe dementia, the only factor associated with ADL after 6 months was cognitive function, as assessed by CTSD score.

CONCLUSIONS

The most important factor predicting functional decline is cognitive function, even at the severe and profound stage.

Oral care practices of long-term care home residents and caregivers: Secondary analysis of observational video recordings

AIMS AND OBJECTIVES

To describe the proportion of toothbrushing task steps, long-term care residents had an opportunity to complete; the duration and quality of toothbrushing by both residents and caregivers; and the feedback caregivers provided.

BACKGROUND

Poor oral health is widespread among older adults in long-term care homes; however, little is known about their actual oral health practices.

DESIGN

Secondary analysis of video recordings.

METHODS

A total of 58 video-recorded sessions were analysed from two long-term care homes in Canada. Eligible residents had at least one natural tooth, required oral care assistance, had Alzheimer's disease and understood English. Eligible caregivers spoke English and had worked for at least 1 year with people with dementia. Toothbrushing success was identified by the resident's participation in, and completion of, nine toothbrushing steps. Total time spent brushing teeth was calculated by summing the duration of time spent brushing teeth. Quality was described by time spent brushing the facial versus the lingual or occlusal surfaces. Caregiver verbal feedback was pulled from transcripts and analysed using content analysis. STROBE guidelines were used in reporting this study.

RESULTS

The two step residents most frequently completed or attempted were brushing their teeth (77% complete, 7% attempt) and rinsing their mouth (86% complete, 2% attempt). The average time spent brushing teeth was 60.33 s (SD = 35.15). In 66% of observed videos, toothbrushing occurred only on the facial tooth surfaces, with no time spent brushing the lingual or occlusal surfaces.

CONCLUSION

Caregivers are supporting residents to independently complete toothbrushing; however, the duration and quality of toothbrushing are not sufficient to ensure optimal oral health.

RELEVANCE TO CLINICAL PRACTICE

Clear, detailed guidelines are required to ensure adequate oral care for long-term care residents. Staff need to be aware that all surfaces should be brushed to ensure proper oral health.

Physical Activity in Severe Dementia Is Associated With Agitation Rather Than Cognitive Function

BACKGROUND

The authors examined associations between physical activity, cognitive function, activities of daily living, and behavioral and psychological dementia symptoms (BPSD) in severe and moderate dementia.

METHODS

A cross-sectional study was conducted to assess severe and moderate dementia groups according to the Clinical Dementia Rating. An actigraphy measured physical activity. Other measures included Mini-Mental State Examination, Cognitive Test for Severe Dementia, Hyogo Activities of Daily Living Scale, and Neuropsychiatric Inventory-Nursing Home.

RESULTS

Sixty-three participants were assessed (mean age = 89.3 ± 6.4). Physical activity was not associated with cognitive function among participants with severe dementia, although there was a trend-level association with cognitive function among those with moderate dementia. Physical activity was significantly associated with BPSD, specifically agitation/aggression symptoms, for participants with severe dementia, and there was a trend-level association with anxiety for participants with moderate dementia.

CONCLUSIONS

Physical activity appears to be associated with BPSD among individuals in the advanced stages of dementia.

The Alzheimer functional status instrument: An instrument to assess rehabilitation strategies for Alzheimer patients

The Alzheimer Functional St atus Inventory (AFSI) was developed to assess a kinesiotherapy program for 22 randomized pairs ofpatients with Senile Dementia of the Alzheimer Type (SDAT) residing in the Dementia Study Unit of the Edith Nourse Rogers Memorial VA Medical Center; Bedford, Massachusetts. The AFSI was developed by an interdisciplinary team to overcome some of the limitations of standard geriatric instruments to detect changes in functional status in SDAT patients following a rehabilitation program. The AFSI, which is performance-based, includes items adapted from Granger's PULSES Profile and activity disturbances itemsfrom the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), items on mood andbehaviorduring assessment, as well as, one on communication status. The AFSI thus includes items which evaluate physical, psychosocial, and cognitive dimensions offunctional status. These dimensions are:

• Sensory function; • Range of motion skills including lower limb and upper limbfunction; • Mood state; • Behavioral status; and • Time to complete tasks.

A Framework for Developing Nursing Knowledge About the Effects of Dementia on Older Persons' Abilities

A dearth of nursing knowledge exists about the specific effects of the cognitive and other changes of dementia on older persons' abilities. Consequently, limited direction is available to guide nursing research and practice in this context. Thus, the authors designed a framework that directs the development of such knowledge. In this article, the assumptions and elements of the framework are detailed. An extensive illustration of the application of the framework is provided concerning ideational apraxia in dementia and self-care abilities related to feeding. It is shown how nurses can draw information from the scholarship of other disciplines and incorporate it into an understanding of the effects of dementia on abilities. The framework can be used to systematically focus research and practice concerning the care of people suffering fromdementia.

Quantitative analysis of formal caregivers' use of communication strategies while assisting individuals with moderate and severe Alzheimer's disease during oral care

This cross-sectional observational study examined formal caregivers' use of task-focused and social communication strategies while assisting individuals with moderate and severe Alzheimer's disease residing in a long-term care facility during a basic activity of daily living: toothbrushing. Thirteen formal caregiver-resident dyads were observed during a total of 78 separate toothbrushing sessions. All caregiver utterances occurring during the task were transcribed and coded for type of communication strategy utilizing a multidimensional observational coding scheme, which was developed a priori. Overall, the majority of residents, irrespective of disease severity, successfully completed toothbrushing with the support of caregiver assistance. Caregivers assisting residents with moderate and severe AD were found to use a variety of communication strategies, with task-focused strategies accounting for the majority of use. For the most part, the communicative strategies employed did not differ across disease severity. However, some differences were identified including the use of one proposition, paraphrased repetition, using the resident's name, and provision of full assistance, with these strategies being used more often when assisting individuals with severe AD. This study adds to the emerging literature supporting the use of specific communication strategies while assisting residents with AD during the completion of daily tasks.

LEARNING OUTCOMES

From reviewing this study, readers will be able to identify a variety of communication strategies, both task-focused and relational, that formal caregivers utilize while assisting residents with moderate and severe Alzheimer's disease (AD) during a basic activity of daily living. Furthermore, the reader will be able to distinguish between communication strategies that are optimal when assisting individuals with moderate AD as compared to assisting individuals with severe AD.

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.

Evaluating the effectiveness of the abilities-focused approach to morning care of people with dementia

BACKGROUND AND PURPOSE

The abilities-focused approach demonstrated efficacy in promoting engagement of residents with dementia in care. The extent to which these resident outcomes can be replicated when the abilities-focused approach is implemented by nursing staff under the conditions of day-to-day practice was investigated in this study. The aim was to examine changes in resident outcomes before and after nursing staff' implementation of the abilities-focused approach and the contribution of this approach to resident outcomes.

METHODS

A one-group pretest-post-test design was used. Observational data were obtained from 65 residents with dementia. The data pertained to the implementation of abilities-focused strategies during episodes of morning care and residents' level of agitation, participation in morning care and physical and psychosocial functioning.

RESULTS

The number of abilities-focused strategies used during morning care increased at post-test. No clinically important changes in resident outcomes were observed over time. However, the implementation of some strategies was associated with residents' participation in care and functioning at post-test. The results provided preliminary evidence of the effectiveness of the abilities-focused approach in maintaining functioning in people with dementia. Additional research is needed to understand the mechanism underlying the effects of this person-centred approach to care on resident outcomes.

IMPLICATIONS FOR PRACTICE

Implementation of the abilities-focused approach assists people with dementia to participate in morning care.

Activities of daily living in patients with dementia: clinical relevance, methods of assessment and effects of treatment

Disability, characterised by the loss of ability to perform activities of daily living (ADL), is a defining feature of dementia that results in growing caregiver burden and the eventual need for alternative care or nursing home placement. Functional decline in patients with dementia can also result from causes other than dementia, such as comorbid medical and psychiatric illnesses and sensory impairment. ADL consists of instrumental ADL (IADL) [complex higher order skills, such as managing finances] and basic ADL (BADL) [self-maintenance skills, such as bathing]. Assessment of IADL and BADL is recommended to establish a diagnosis of dementia. Functional assessment also helps the healthcare provider to offer appropriate counselling regarding safety concerns and need for custodial care. Functional capacity measures have been used increasingly in pharmacological trials of patients with Alzheimer's disease (AD) and related dementias, although at the present time these measures are generally not primary outcome measures. Functional impairment is not a uniform construct; rather, it is multifaceted and can be measured with various clinical instruments. Many scales have been validated for use in patients with AD for characterising functional impairment and evaluating the efficacy of treatment. Research to date indicates that cholinesterase inhibitors have the potential for modest but meaningful beneficial effects on ADL in patients with mild-to-moderate AD. Memantine also has promising beneficial effects on functional abilities in persons with moderate-to-severe AD. Assessment of ADL as a primary efficacy measure using a validated scale that is non-gender biased and cross-nationally relevant is recommended in new treatment trials of patients with AD and related dementias.

Nursing intervention for grooming of elders with mild cognitive impairments in Korea

This study explores the effect of behavioral nursing intervention strategies to improve the grooming performance of elders with cognitive impairments in Korea. Eight residents with mild cognitive impairments were chosen in a special dementia care facility. A total of 21 sessions, including baseline, interventions, and postinterventions for each resident, were collected in the morning by using videotaped recordings of face-washing, toothbrushing, and hair-combing. The baselines of these activities and postinterventions were provided by nurse assistants, and the interventions were implemented by a trained nurse. The effect of Performance of Grooming Tasks (PGT) was determined. The results showed a decrease in assistance of PGT scores from 0.86, 0.77, and 0.73 at baseline to 0.60, 0.45, and 0.57 during intervention and an increase to 0.77, 0.71, and 0.71 at postintervention. The study showed a significant increase in grooming independence of elders with dementia in the nursing home when they were cared for with behavioral nursing intervention strategies.

Medication management ability assessment: results from a performance-based measure in older outpatients with schizophrenia

Patients with schizophrenia who adhere to physicians' recommended use of medications are less likely to relapse than those who do not. Self-report measures of adherence have been criticized on a number of grounds. Here we describe a performance-based measure of medication management, the Medication Management Ability Assessment (MMAA), which represents a modification of the Medication Management Test used in individuals with HIV infection. Subjects were 104 patients older than 45 years with diagnoses of schizophrenia or schizoaffective disorder, and 33 normal comparison subjects (NCs). Subjects participated in a role-play task (MMAA) that simulated a prescribed medication regimen similar in complexity to one that an older person is likely to be exposed to. The total number of pills over that prescribed, total number of pills under that prescribed, and total number of correct responses were calculated. Self-report and prescription record data on adherence as well as data on measures of psychopathology, global cognitive status, and other clinical measures were also gathered. MMAA role-plays required 15 minutes, and its 1-week test-retest reliability was excellent (intraclass correlation coefficient, 0.96). Patients committed significantly more errors in medication management compared with NCs. Significantly more patients were classified as being nonadherent (i.e., taking +/-5%, 10%, 15%, or 20% of prescribed pills) compared with NCs. Patients with more severe cognitive deficits performed worse on the MMAA. MMAA performance was significantly related to prescription refill records, performance-based measures of everyday functioning, and self-reported quality of life. The MMAA is a useful instrument for observing ability to manage medications in patients with schizophrenia. The measure was related to severity of cognitive impairment, suggesting that adherence may improve with psychotropic and psychosocial interventions that target these deficits.

Description of retained abilities in older persons with dementia

There have been suggestions in the literature that the care of people with dementia must be focused on abilities as opposed to disabilities. However, this approach has not been carefully defined in terms of what constitutes remaining abilities. This article provides a description of the abilities in people with dementia, which is based on a descriptive analysis of data derived from a larger study regarding the psychometric evaluation of an abilities assessment instrument. The sample comprised 112 male veterans with dementia who were living in a long-term care facility. Their mean age was 75 years. Data were collected in the areas of self-care, social, interactional, and interpretive abilities. Abilities were retained in all four areas. Furthermore, abilities were differently affected and varied considerably across subjects, which is consistent with evidence pertaining to cognitive changes in dementia. Our results provide support for an individualized, abilities-focused approach to the care of people with dementia.

Description of a self-care instrument for elders

The psychometric properties of the self-care component of the Abilities Assessment Instrument were studied with elderly women. Thirty of the participants were cognitively impaired and 20 participants were not. Nonparametric statistics were used as the data were not normally distributed. Using the Spearman rank order correlation coefficient, test-retest reliability was rs = .79; p < .01 (n = 10) and interrater agreement was rs = .97; p < .01 (n = 9). Cronbach's alpha was .97. Between two content experts, the index of content validity was .89. Concurrent validity was assessed by comparing the self-care scores with the MMSE scores (rs = .91; p < .01). To establish construct validity, the self-care scores of those with dementia were shown to be statistically different from those who did not have dementia (Mann-Whitney U = 85). This study provided evidence for the reliability and validity of this self-care instrument.

Nursing intervention to promote functional feeding

Results of this study suggest that specific nursing protocols can be designed to promote functional feeding for demented elders in nursing homes while enhancing the mealtime environment for both the demented elders and their caregivers. By nurses altering the feeding environment (context) alone, subjects received more food and drink, refused less food and showed more self-feeding. Major findings were that subjects demonstrated increased independence by refusing food more often and initiating self-feeding more frequently.