"I can do it!" Dressing: promoting independence through individualized strategies

Reproducibility of Assessment Tests Addressing Body Structure and Function and Activity in Older Adults With Dementia: A Systematic Review

OBJECTIVE

The purpose of this study was to analyze the relative and absolute reliability of assessment tests addressing body structure and function and activity in older adults with dementia.

METHODS

Medline, Embase, Web of Science, The Cochrane Library, and Scielo were searched from inception until March 2021. Two independent reviewers performed the selection process based on titles, abstracts, and full text. Reliability studies of assessment tests in older adults with dementia were included. Methodological quality of the studies was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist. Relative reliability was analyzed using the intraclass correlation coefficient (ICC) interpreted based on Munro classification. Absolute reliability was analyzed using the minimal detectable change (MDC) and standard error of measurement.

RESULTS

Fifteen studies involving a total of 560 older adults with dementia were included. Nineteen assessment tests were identified: 13 addressing body structure and function (muscle strength, postural balance, cardiorespiratory fitness) and 6 addressing activity (walking and mobility). Studies determined test-retest and interrater reliability. Fifteen studies evaluated relative reliability using the ICC, with values ranging from no or small correlation to very high correlations. Ten studies evaluated absolute reliability using the MDC or standard error of measurement or both.

CONCLUSION

Relative reliability of the assessment tests for body structure and function and activity was high to very high based on ICCs, demonstrating good reproducibility. Regarding absolute reliability, the analysis of the MDC values revealed the need for substantial change to determine that a real change had occurred. Future investigations should consider the type of dementia and standardization of verbal encouragement during the assessment.

IMPACT

This review identified the good reproducibility of assessment tests of body structure and function (muscle strength, postural balance, cardiorespiratory fitness) and activity (walking and mobility) domains in older adults with dementia. Clinically important values may differ when older adults with dementia of diverse etiologies are analyzed together and older adults specifically with Alzheimer disease. Identifying the type of dementia, analyzing types of dementia separately, and standardizing verbal commands during the execution of tests is of considerable clinical importance for this population of older adults.

The Korean version of relative and absolute reliability of gait and balance assessment tools for patients with dementia in day care center and nursing home

[Purpose] This study was aimed to determine the relative and absolute reliability of Korean version tools of the Berg Balance Scale (BBS), the Timed Up and Go (TUG), the Four-Meter Walking Test (4MWT) and the Groningen Meander Walking Test (GMWT) in patients with dementia. [Subjects and Methods] A total of 53 patients with dementia were tested on TUG, BBS, 4MWT and GMWT with a prospective cohort methodological design. Intra-class Correlation Coefficients (ICCs) to assess relative reliability and the standard error of measurement (SEM), minimal detectable change (MDC₉₅) and its percentage (MDC_%) to analyze the absolute reliability were calculated. [Results] Inter-rater reliability (ICC_(2,3)) of TUG, BBS and GMWT was 0.99 and that of 4MWT was 0.82. Inter-rater reliability was high for TUG, BBS and GMWT, with low SEM, MDC₉₅, and MDC_%. Inter-rater reliability was low for 4MWT, with high SEM, MDC₉₅, and MDC_%. Test-retest (ICC_(2,3)) of TUG, BBS and GMWT was 0.96–0.99 and Test-retest (ICC_(2,3)) of 4MWT was 0.85. The test-retest was high for TUG, BBS and GMWT, with low SEM, MDC₉₅, and MDC_%, but it was low for 4MWT, with high SEM, MDC₉₅, and MDC_%. [Conclusion] The relative reliability was high for all the assessment tools. The absolute reliability has a reasonable level of stability except the 4MWT.

Inter-rater reliability of the Berg Balance Scale, 30 s chair stand test and 6 m walking test, and construct validity of the Berg Balance Scale in nursing home residents with mild-to-moderate dementia

OBJECTIVE

When testing physical function, patients must be alert and have the capacity to understand and respond to instructions. Patients with dementia may have difficulties fulfilling these requirements and, therefore, the reliability of the measures may be compromised. We aimed to assess the inter-rater reliability between pairs of observers independently rating the participant in the Berg Balance Scale (BBS), 30 s chair stand test (CST) and 6 m walking test. We also wanted to investigate the internal consistency of the BBS.

DESIGN

Cross-sectional study.

SETTING

We included 33 nursing home patients with a mild-to-moderate degree of dementia and tested them once with two evaluators present. One evaluator gave instructions and both evaluators scored the patients' performance. Weighted κ, intraclass correlation coefficient (ICC) model 2.1 with 95% CIs and minimal detectable change (MDC) were used to measure inter-rater reliability. Cronbach's α was calculated to evaluate the internal consistency of the BBS sum score.

RESULTS

The mean values of the BBS scored by the two evaluators were 38±13.7 and 38.0±13.8, respectively. Weighted κ scores for the BBS items varied from 0.83 to 1.0. ICC for the BBS's sum score was 0.99, and the MDC was 2.7% and 7%, respectively. The Cronbach's α of the BBS's sum score was 0.9. The ICC of the CST and 6 m walking test was 1 and 0.97, respectively. The MDC on the 6 m walking test was 0.08% and 15.2%, respectively.

CONCLUSIONS

The results reveal an excellent relative inter-rater reliability of the BBS, CST and 6 m walking test as well as high internal consistency for the BBS in a population of nursing home residents with mild-to-moderate dementia. The absolute reliability was 2.7 on the BBS and 0.08 on the 6 m walking test.

“The Red Dress or the Blue?”

Respect for a person’s right to make choices and participate in decision making is generally seen as central to quality of life and well-being. When a person moves into a residential aged care facility (RACF), however, decision making becomes more complicated, particularly if the person has a diagnosis of dementia. Little is known about how staff in RACFs perceive that they support decision making for people with dementia within their everyday practice, and this article seeks to address this knowledge gap. The article reports on the findings of a qualitative study conducted in the states of Victoria and Queensland, Australia with 80 direct care staff members. Findings revealed that the participants utilized a number of strategies in their intention to support decision making for people with dementia, and had an overall perception that “a little effort goes a long way.”

Staff outcomes from the caring for aged dementia care resident study (CADRES): a cluster randomised trial

BACKGROUND

Dementia care mapping and person centred care are well-accepted as processes for improving care and well-being for persons with dementia living in the residential setting. However, the impact of dementia care mapping and person centred care on staff has not been well researched.

OBJECTIVES

The impact of person centred care and dementia care mapping compared to each other and to usual dementia care on staff outcomes was examined in terms of staff burnout, general well-being, attitudes and reactions towards resident behavioural disturbances, perceived managerial support, and quality of care interactions.

DESIGN

A cluster-randomised, controlled trial.

SETTINGS

The study was conducted between 2005 and 2007 in 15 residential aged care sites in the Sydney metropolitan area, Australia, with comparable management structures, staffing mix and ratios, and standards of care.

PARTICIPANTS

194 consenting managers, nurses, therapists and nurse assistants working in the participating sites.

METHODS

Intervention care sites received training and support in either person centred care (n=5) or dementia care mapping (n=5); control sites continued with usual dementia care (n=5). Staff outcomes of those three groups were assessed before, directly after the four month intervention (post) and after a further four months (follow-up). The primary outcome measures were the Maslach Burnout Inventory-Human Services Survey and the 12-item General Health Questionnaire. Analysis involved repeated measures analyses of variance for each of the outcome measures and adjustment for potential confounders to limit bias.

RESULTS

The Maslach Burnout Inventory-Human Services Survey results showed that change over time in emotional exhaustion scores differed between the three groups. Post-hoc analyses for each group separately revealed that the only significant time effect was in the dementia care mapping group (p=0.006), with emotional exhaustion scores declining over time. At baseline, more perceived support from management was associated with less emotional exhaustion (r(s)=0.26, p=0.004, n=122) and less depersonalisation (r(s)=0.21, p=0.023, n=122), but not for any of the other outcome measures.

CONCLUSIONS

This study has shown that person centred approaches of care, in particular with dementia care mapping, may contribute to reducing staff job related burnout. The findings also highlight a potentially important role of managerial support and a whole of system approach.

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.

Perspectives of older persons on bathing and bathing disability: a qualitative study

OBJECTIVES

To understand the bathing experiences, attitudes, and preferences of older persons in order to inform the development of effective patient-centered interventions.

DESIGN

Qualitative study using the Grounded Theory framework.

SETTING

In-depth, semistructured interviews were conducted in participants' homes.

PARTICIPANTS

Twenty-three community-living persons aged 78 and older identified from the Precipitating Events Project (PEP).

MEASUREMENTS

Open-ended questions about bathing habits, personal meaning and purpose of bathing, difficulties and concerns about bathing, preferences for independent bathing, and attitudes toward different types of bathing assistance.

RESULTS

Three themes emerged: the importance and personal significance of bathing to older persons; variability in attitudes, preferences, and sources of bathing assistance; and older persons' anticipation of and responses to bathing disability.

CONCLUSION

The bathing experiences described by study participants underscore the personal significance of bathing and the need to account for attitudes and preferences when designing bathing interventions. Quantitative disability assessments may not capture the bathing modifications made by older persons in anticipation of disability and may result in missed opportunities for early intervention. Findings from this study can be used to inform the development of targeted, patient-centered interventions that can subsequently be tested in clinical trials.

Test-retest reliability and minimal detectable change scores for the timed "up & go" test, the six-minute walk test, and gait speed in people with Alzheimer disease

BACKGROUND

With the increasing incidence of Alzheimer disease (AD), determining the validity and reliability of outcome measures for people with this disease is necessary.

OBJECTIVE

The goals of this study were to assess test-retest reliability of data for the Timed "Up & Go" Test (TUG), the Six-Minute Walk Test (6MWT), and gait speed and to calculate minimal detectable change (MDC) scores for each outcome measure. Performance differences between groups with mild to moderate AD and moderately severe to severe AD (as determined by the Functional Assessment Staging [FAST] scale) were studied.

DESIGN

This was a prospective, nonexperimental, descriptive methodological study.

METHODS

Background data collected for 51 people with AD included: use of an assistive device, Mini-Mental Status Examination scores, and FAST scale scores. Each participant engaged in 2 test sessions, separated by a 30- to 60-minute rest period, which included 2 TUG trials, 1 6MWT trial, and 2 gait speed trials using a computerized gait assessment system. A specific cuing protocol was followed to achieve optimal performance during test sessions.

RESULTS

Test-retest reliability values for the TUG, the 6MWT, and gait speed were high for all participants together and for the mild to moderate AD and moderately severe to severe AD groups separately (intraclass correlation coefficients > or = .973); however, individual variability of performance also was high. Calculated MDC scores at the 90% confidence interval were: TUG=4.09 seconds, 6MWT=33.5 m (110 ft), and gait speed=9.4 cm/s. The 2 groups were significantly different in performance of clinical tests, with the participants who were more cognitively impaired being more physically and functionally impaired.

LIMITATIONS

A single researcher for data collection limited sample numbers and prohibited blinding to dementia level.

CONCLUSIONS

The TUG, the 6MWT, and gait speed are reliable outcome measures for use with people with AD, recognizing that individual variability of performance is high. Minimal detectable change scores at the 90% confidence interval can be used to assess change in performance over time and the impact of treatment.

Changes in habits related to self-care in dementia: the nursing home versus adult day care

Little is known about the changes that occur for older persons with dementia in the practice of self-care routines. This study assesses the concordance of past and current self-care practices of day care and nursing home persons using spouse reports, the degree of spouse awareness of these changes, and spouse perception of how important self-care practices had been to their partner. Participants were spouses of 12 older persons with dementia in day care and spouses of 20 nursing home residents. Self-care routines were assessed using the Self-maintenance Habits and Preferences in Elderly (SHAPE) questionnaire. Day care attendees showed few changes in self-care routines compared to nursing home residents. Spouses of nursing home residents underestimate the changes in self-care that occur with nursing home admission. The importance of being aware of self-care changes lies in the value of maintaining continuity with the customary preferences and routines of the older person.

Self-maintenance Habits and Preferences in Elderly (SHAPE): reliability of reports of self-care preferences in older persons

BACKGROUND AND AIMS

Self-care preferences can be used in designing programs of care. Yet little has been documented concerning the self-care habits and preferences of older adults.

METHODS

This study assessed the reliability of reports of self-care preferences and their importance among older adults using the Self-maintenance Habits and Preferences in Elderly (SHAPE) instrument. Twenty community-dwelling seniors completed the SHAPE questionnaire twice within a one- to two-week interval. Percent agreement, both exact and close/partial, was computed to assess the reliability of preference content, and intra-class correlations (ICCs) were used for preference importance. Test and subject factors affecting reliability were also investigated.

RESULTS

Exact agreement rate for item content was 73%, and that for close/partial agreement was 93%. Mean ICC for item importance was 0.72. Reliability was greater for dichotomous items than for either ordinal or categorical questions. Reliability of item content varied with number of response options and importance reliability varied with age and IADL status.

CONCLUSIONS

Information from SHAPE about self-care preferences can be used to plan services for seniors and to individualize care for older persons, especially those transitioning to new living environments or those receiving home care.

Do interventions bringing current self-care practices into greater correspondence with those performed premorbidly benefit the person with dementia? A pilot study

This article assessed whether bringing current self-care practices into greater correspondence with those performed before the onset of dementia benefits the dementia patient. Participants were 20 nursing home residents with dementia, their spouses, and nursing assistants. Past and current self-care routines were determined by proxy responses of spouses and nursing assistants, respectively, using the Self-maintenance Habits and Preferences in Elderly questionnaire. Interventions were proposed based on current practices that were inconsistent with those practiced in the past and that had been important to residents. Residents showed engagement with the interventions, as these resulted in significantly more positive than negative or neutral responses. There was no effect on agitation. Incorporating prior preferences into care routines can contribute to the quality of life of dementia patients.

Dressing of Cognitively Impaired Nursing Home Residents: Description and Analysis

PURPOSE

Getting dressed is an activity that is of particular difficulty for many persons with dementia, given the need for hand-eye coordination, fine motor skills, and overall planning skills. Despite several studies concerning interventions to improve dressing behavior, very little is known about the dressing process as it is currently performed. The purpose of this study is to characterize the dressing activity of daily living (ADL) of nursing home residents suffering from dementia and thereby identify ways to improve the dressing process.

DESIGN AND METHODS

We analyzed videotapes of dressing of 20 special care unit residents to describe the dressing process and the interaction between residents and staff members.

RESULTS

Staff members completely dressed the residents in the majority of cases. Interaction between the staff members and the residents was considered insufficient in most sessions.

IMPLICATIONS

The study identified possible intervention techniques, assistive devices, organizational routines, and environmental changes that may improve the dressing process. The results have implications that nursing homes may consider in their policies, care activities, staff training, and environment to facilitate safety, comfort, and satisfaction during the dressing process.

The Preference and Importance of Bathing, Toileting and Mouth Care Habits in Older Persons

PURPOSE

The goal of this study was to describe bathing, toileting, and mouth care habits and preferences of older persons, as well as the importance of such habits.

DESIGN AND METHODS

Fifty-eight community-dwelling older persons were administered the Self-maintenance Habits And Preferences in Elderly questionnaire (SHAPE) during a one-on-one interview with a research assistant. Preferences were described by frequency distributions and mean importance for each item was calculated. Gender differences in preferences were examined using chi(2) analyses, t tests were used to compare importance levels.

RESULTS

Women reported spending a longer time bathing, they were more likely to have privacy while bathing, to use a washcloth, a regular size towel, and less likely to use a large towel than were men. One-third of the women reported using some type of absorbent undergarment, while no men did so. Mouth care was the category that received the highest importance ratings. Although order of importance of items was similar across genders, women assigned higher levels of importance to these items than did men. Importance ratings given to atypical habits, such as unusually long or more than 1 bath/day, were higher than those attributed to more usual habits.

IMPLICATIONS

Knowledge of the range and importance of such self-care practices can provide information useful in the development of programs and for individualized care.

The Cognition-Sensitive Approach to DEMENTIA Parallels With the Science of Unitary Human Beings

1. Theory can provide practical guidelines for nursing interventions and research. 2. The Science of Unitary Human Beings, a grand theory, provides input into clarifying the Cognition-Sensitive Approach, a mid-range theory. 3. Cognition in the Alzheimer's disease process can be categorized hierarchically. 4. The Cognition-Sensitive Approach provides a theoretical base for holistic nursing interventions for people with Alzheimer's disease.

Interventions used by nursing staff members with psychogeriatric patients resisting care

Although resistance to care can have a major impact on the provision of care, relatively limited research has been reported on the topic. This research examined differences in the use of interventions by nurses in different care settings to manage resistance to care with eating and dressing. A convenience sample of 50 nurses (34 working in psychiatric hospitals and 16 in nursing homes) participated in the study. Nurses in both settings reported using similar interventions for both problems. Non-nursing interventions were consistently mentioned to be more common when resistance was accompanied by physical aggression than by verbal aggression.

Restoring dressing independence in persons with Alzheimer's disease: a pilot study

PURPOSE

Well meaning nursing facility staff may compromise the independence of older adults with dementia by performing activities of daily living for residents. We assessed the impact of teaching certified nursing assistants (CNAs) to use a graduated prompting procedure to increase dressing independence of persons with dementia.

DESIGN AND METHODS

This study was conducted in a seven-bed dementia care unit. Three residents and two CNAs participated in the study. We used a repeated-measures experimental design to evaluate the effect of a training workshop for CNAs on a strategy for increasing resident engagement in self-care activities.

RESULTS

During a series of baseline observations, we found that CNAs typically dressed residents with minimal resident involvement. Results showed that, following the training workshop for CNAs, resident independence in dressing increased and range of motion improved.

IMPLICATIONS

CNAs can provide restorative care that increases dressing independence and range of motion of older adults with dementia.

Analysis of key decision-making incidents in the life of a nursing home resident

PURPOSE

This study examined change in the decision-making autonomy of a single nursing facility resident.

DESIGN AND METHODS

This case analysis was part of a larger 3-year ethnographic investigation of decision-making events in four nursing facilities. In this case analysis, the resident, her daughter, and three staff members closely associated with the resident's care were each interviewed five times over a 15-month period.

RESULTS

Analysis of interview transcripts revealed four themes in decision making. Temporal change was evident in a complex scenario regarding room changes. Spatial context reflected the need for predictability and adaptability in decisions using space. Interdependence of decisions and decision makers was most evident with medical treatment and health care decisions. Awareness, being informed, and knowing what was going on was the final theme.

IMPLICATIONS

Despite having the best interests of the resident in mind, the process of decision making in nursing facilities may contribute to a pattern of gradual withdrawal of decisional autonomy from residents regardless of their ability to make decisions.

A conceptual framework for achieving high-quality care in nursing homes

Nursing home care accounts for 12% of healthcare expenditures in the United States, yet serious concerns remain about the quality of care provided in these settings. This article describes a comprehensive systems model that views organizational environments as consisting of four interacting dimensions: organizing arrangements, social factors, technology, and physical setting. This model is then used as a conceptual framework (vis-à-vis an extensive literature review) to identify factors that contribute to poor-quality care in nursing homes and to highlight previous research efforts. The literature review also provides a useful framework to guide nursing home administrators and healthcare quality professionals in their implementation of quality improvement processes and serves to help direct future research in this very important arena.

Individualized care in a Finnish healthcare organization

This paper reports the findings of a study exploring the provision of individualized care in a regional hospital in Finland. Individualized care was defined in terms of how patient individuality was taken into account and how patient participation in decision-making was facilitated. The data were collected from hospitalized patients (n = 203) using a questionnaire specially developed for this study. The response rate was 89%. A strong support to facilitate patient participation in decision-making was reported. Most shortcomings concerning the provision of individualized care related to consideration of the patient's cultural background and the involvement of the patient's family in the planning of care. Patients' age and the type of ward were associated with the provision of individualized care: patients aged 65 or over were more satisfied than younger age groups with the way in which their personal life situation had been taken into account. Patients from the gynaecological ward thought, more than patients from the surgical ward, that their situation had been taken into account during hospitalization.

Motivation to perform activities of daily living in the institutionalized older adult: can a leopard change its spots?

The concept of motivation has great relevance for the older adult because of the multiple problems that can result in functional limitations. The ability to overcome and transcend these problems is related to the individuals' motivation to maintain and/or improve function. The purpose of this study, which used a naturalistic or constructivist inquiry, was to explore what motivates the institutionalized older adult to perform functional activities. Primary selection was used to obtain the sample which included 44 older adults, 37 (84%) females, and 7(16%) males. The average of participants was 88 +/- 6.4, and they were institutionalized for 2.8 +/- 2.8 years. Semi-structured interviews were done in the participants room. Data analysis involved content analysis. A total of 27 codes were initially identified, and these were categorized and developed into five major themes: Personality, Goals, Beliefs, Fear and Physical factors. The participants indicated that basic personality had a major on motivation, i.e. 'a leopard can't change his spots'. Further findings suggested that although personality may be central to the individuals' motivation to perform, goals, fear, beliefs and physiological sensations also influenced motivation and behavior. Appropriate interventions can be used to foster motivation to perform functional activities for institutionalized older adults.

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.

Power to the patient

1. The move to a long-term care facility often strips elders of self-control and decision-making, leading to a sense of powerlessness and low self-esteem. 2. Life is measured day to day. Restoring choices in activities of daily living, nutrition and fluids, and social activities allows clients to function at maximum autonomy while reducing the workload of staff. 3. The key is a change of focus. Innovative changes providing variety and choice in long-term care facilities are achievable and cost-effective.