The implementation of the serial trial intervention for pain and challenging behaviour in advanced dementia patients (STA OP!): a clustered randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Pain (physical discomfort) and challenging behaviour are highly prevalent in nursing home residents with dementia: at any given time 45-80% of nursing home residents are in pain and up to 80% have challenging behaviour. In the USA Christine Kovach developed the serial trial intervention (STI) and established that this protocol leads to less discomfort and fewer behavioural symptoms in moderate to severe dementia patients. The present study will provide insight into the effects of implementation of the Dutch version of the STI-protocol (STA OP!) in comparison with a control intervention, not only on behavioural symptoms, but also on pain, depression, and quality of life. This article outlines the study protocol.</p> <p>Methods/Design</p> <p>The study is a cluster randomized controlled trial in 168 older people (aged >65 years) with mild or moderate dementia living in nursing homes. The clusters, Dutch nursing homes, are randomly assigned to either the intervention condition (training and implementation of the STA OP!-protocol) or the control condition (general training focusing on challenging behaviour and pain, but without the step-wise approach). Measurements take place at baseline, after 3 months (end of the STA OP! training period) and after 6 months.</p> <p>Primary outcome measures are symptoms of challenging behaviour (measured with the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and pain (measure with the Dutch version of the Pain Assessment Checklist for Seniors (PACSLAC-D) and the Minimum Data Set of the Resident Assessment Instrument (MDS-RAI) pain scale). Secondary outcome measures include symptoms of depression (Cornell and MDS-RAI depression scale), Quality of Live (Qualidem), changes in prescriptions of analgesics and psychotropic drugs, and the use of non-pharmacological comfort interventions (e.g. snoezelen, reminiscence therapy).</p> <p>Discussion</p> <p>The transfer from the American design to the Dutch design involved several changes due to the different organisation of healthcare systems. Specific strengths and limitations of the study are discussed.</p> <p>Trial registration</p> <p>Netherlands Trial Register (NTR): <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1967">NTR1967</a></p

The Relationships between Licensed Vocational Nurses\u27 Care, Documentation, and Perceptions of Dementia-Compromised Behaviors in the Nursing Home

Behavioral and psychological symptoms of dementia increase as Alzheimer\u27s disease and related dementias progress; these symptoms occur in as many as 80% of persons with dementia living in nursing homes. Behavioral and psychological symptoms of dementia, also known as dementia-compromised behaviors, are a source of stress for nursing home staff, family members, and other residents and adversely affect the quality of life and safety of residents. Ethnonursing, a qualitative research method, was used to examine the relationship between licensed vocational nurses\u27 responses to dementia-compromised behaviors, documentation, and perceptions of dementia care. Data analysis resulted in three overarching themes related to the licensed vocational nurse caring for persons with dementia residing in the nursing home who exhibit dementia-compromised behavior: (a) the resident with dementia; (b) the licensed vocational nurse; and (c) documentation of dementia-related behaviors. Licensed vocational nurses provided safe and effective care to persons with dementia residing in nursing homes. However, results of this study supported findings from previous research; while the licensed vocational nurses translated theory into practice, knowledge and practice were inconsistent in their documentation

Perception and Use of Communication Care Plans by Certified Nursing Assistants in Nursing Homes: The Role of Professional Support

The majority of individuals in nursing homes have cognitive-communication impairments which impact quality of care because direct care providers, certified nursing assistants, (CNAs) are unsure how to respond to resident’s communication behaviors. One intervention that facilitates staff-resident communication in nursing homes is communication plans; however, the research to date about communication plans has not specifically involved CNAs. The purpose of this study, using a grounded theory qualitative approach, was to describe development, implementation and evaluation of communication care plans (CCPs) for residents with cognitive-communication impairments in nursing homes by CNAs who did and did not receive professional support. Communication care plans are communication plans with the addition of autobiographical information. Twenty residents and ten CNAs from two nursing homes participated in the study. Once CCPs were created, CNA participants in one facility received support each day. Following two weeks, CNAs participated in a semi-structured interview. Interviews were transcribed and analyzed using open, axial and selective coding. Findings revealed a core category, meeting resident’s needs through professional support and communication, which describes the progressive process these CNAs underwent to effectively communicate with residents in nursing homes using CCPs. Evolution of this process occurred as CNA participants became familiar with residents. An underlying component facilitating this familiarity was support during CCP implementation. Initially, these CNAs had negative views about nursing home care because they were unsure how to communicate with residents and received little support from higher levels of nursing authority. Over time and with application of CCPs, CNAs became familiar with residents and their communication behaviors. Application of specific communication strategies on CCPs required ongoing support from the investigator/speech-language pathologist which was evident by the comments between CNA participants from each facility. Participants from both facilities reported positive experiences during application of the autobiographical information on the CCPs. This personal information coupled with increased knowledge about resident’s specific communication abilities fostered the formation of a relationship between residents and CNAs. In summary, support during application of CCPs supplements CNAs’ abilities to meet residents’ needs

Implementation of Doll Therapy for Agitated Residents with Dementia

Abstract The aim of this evidence-based practice (EBP) intervention project was to decrease agitated behaviors in residents with dementia as well as educate the staff on the proper implementation of doll therapy. The facility used was a local skilled nursing and rehabilitation center that offers short-term and long-term care processes to residents with dementia. A sample of residents with dementia (N = 8) and staff caring for the residents (N = 14) participated in the project. Residents and staff were evaluated before the EBP project and four weeks after the education program on introduction to EBP. Despite the limited sample size of the residents with dementia, the findings showed that doll therapy as an EBP project was effective in decreasing agitated behaviors in dementia residents. Similarly, findings showed that the education of nursing staff on the proper implementation of doll therapy was effective. Educational material was presented to the staff regarding how to implement doll therapy. In addition, a written protocol for doll therapy was developed and made available to the staff for their use. Keywords: doll therapy, dementia, evidence-based practice, residents, implementation

Oral Care in Long-Term Care Residents with Dementia

Manuscript Abstract Introduction: Poor oral health can lead to a number of health concerns, including pain, loss of teeth, and increased risk for pneumonia and heart disease. These issues are particularly salient for residents of long-term care facilities with a dementia diagnosis. Residents with dementia often require assistance with personal care, including oral hygiene, but may demonstrate agitated or resistive behaviors when care assistants attempt to provide care. Prior work on the related care activity of bathing has been done using person-centered care approaches and been found to effectively reduce levels of agitation and aggression. To determine whether an intervention is successful it is important to be able to reliably and validly measure components of care. The research design proposed herein proposes to characterize three measurements videotaped encounters of oral care provision in long-term care residents with dementia: a task completion form (TCF), caregiver behavior scale (CGBS), and a measure of resident behaviors during care (CAREBA-OC). Instrument Development: The included measures will be completed by raters who undergo extensive training on how to behaviorally code videotaped encounters. The framework for the TCF, CGBS, and CAREBA-OC is from a prior bathing study, and we describe how the original bathing measurement forms were altered to adequately measure similar behaviors and task components observed during oral care. Instrument Characterization: Each instrument will be evaluated for measures of reliability and validity. The TCF will undergo evaluation for face validity, inter-rater reliability, and within-rater reliability. The CGBS will under evaluation for face validity, inter-rater reliability, within-rater reliability, and internal consistency. The CAREBA-OC will be evaluated for face validity, concurrent criterion validity, inter-rater reliability, and within-rater reliability. Discussion: The proposed psychometric characterization will provide evidence of the usefulness of the included forms. While it is not possible to know precisely what the proposed measures of reliability and validity will be when actual measurement occurs, knowing the characteristics of the related bathing forms provides us with some general idea of what to expect. Furthermore, we are prepared to alter the forms and training procedure if any psychometric properties do not meet our predefined standards. Literature Review Abstract Objective: To conduct a brief review of the literature on nonpharmocologic strategies for reducing agitation and aggression during ADL provision in a long-term care setting in persons with dementia. Data Sources: PubMED and CINHAL were searched for English-language articles and papers published between 1990 and 2010. Bibliographies from articles identified through the included search strategies were then hand-searched to identify additional articles for inclusion. Data Selection: All original research designs, with the exception of case studies, were included due to the low number of clinical trials. Articles were selected for inclusion if they were original research; published in a peer-reviewed publication; targeted persons with dementia living in long-term or residential care facilities; addressed interventions to reduce agitation, aggression, and/or resistance to care during the provision of activities of daily living; and involved nonpharmacologic methods Results: A total of 6 articles were included which can be broadly categorized in three intervention types: the playing of preferred music, abilities-focused interventions which draw on occupational therapy techniques, and psychosocial/person-centered approaches. The heterogeneity of measurement, overall poor methods of selection, and lack of control for important confounding factors resulted in an overall limited quality of evidence for most approaches. The one exception to this trend was an article that which employed a person-centered approach to care provision, and was found to have low potentials for selection and measurement bias, and a medium potential for selection bias. Conclusions: While the quality of the research into nonpharmacologic research to improve agitation in long-term care residents with dementia was found to be lacking in a majority of included articles, it is possible to address these deficiencies and improve the state of knowledge in this area. Area for improvement are discussed, including improving the description of participant selection, reducing heterogeneity of measurement, and employing more robust research methodologies. The process of providing care for agitated persons with dementia is discussed in relation to the need-driven behaviors framework. This theoretical framework of understanding behaviors provides a strong foundation for psychosocial and person-centered care initiatives, which were the most numerous of the included intervention types.Master of Public Healt

Music and Dementia: A Caregiver’s Perspective of the Effects of Individualized Music Programming on Quality of Life for Seniors Living in Assisted Living Environments

For senior-care and service providers, the issue of quality of life has moved beyond marketing to, in effect, the measuring of health-related outcomes. Particularly when the challenge of caring for those with Alzheimer’s disease and related dementias is daunting, as it cannot be prevented or cured and treatment possibilities are framed in a broader perspective to include alternative interventions such as music. Through the eyes of the caregivers, this 6-week, longitudinal quantitative study investigated individualized (passive) music programming and its effect on the health-related quality of life of residents in assisted living. The Alzheimer’s Disease Related Quality of Life instrument (ADRQL) was used to assess quality of life, and the importance of music was captured by the Assessment of Personal Music Preference. The data revealed an increase in quality of life from baseline through the final assessment; and when using only the home health aide staff, a series of multivariate repeated-measures analysis of variance found statistically significant improvements in overall quality of life and in all five ADRQL domain subscales (F = 9.54, p = 000, η2 = .52). The data also showed no significant correlation between the importance of music prior to cognitive impairment and quality of improvements (r = –.09, p = .786). The study had limitations, most importantly the small convenience sample (N = 11); therefore, a formal inductive inference concerning the population cannot be made. More rigorous studies increasing the sample size, using a control group, including confounding variables, and qualitative interviews are recommended

Advances in Teaching & Learning Day Abstracts 2004

Proceedings of the Advances in Teaching & Learning Day Regional Conference held at The University of Texas Health Science Center at Houston in 2004

Meaningful Activities for Individuals with Dementia Living in Long-term Care

Among older adults with Alzheimer`s disease, 61% to 88% experience problematic passivity (Kolanowski, 1995), which has been linked to a loss of functional abilities (Colling, 1999). In order to prevent this functional decline, social isolation, and development of problematic passivity guidelines can be deduced from the Need-driven Dementia-compromised Behavior (NDB) model for identifying the causes of passive behavior, which can be addressed when designing specialized therapeutic recreation programs. The purpose of this study was to determine the efficacy of meaningful activities compared to traditional nursing home activities on the level of alert engagement among individuals with dementia living in a long-term care facility. A single-subject alternating treatment design was used to compare two traditional nursing home activities and a meaningful activity for each participant. Visual analysis of graphs did not consistently demonstrate significantly more alert behaviors during meaningful activity sessions than during traditional nursing home activity sessions

The Effect of Education on Elder Abuse

This study was designed examine the effect of education on prevention of abuse in a long term care center. Participants in this study included direct care worker staff at a nursing home and nursing home residents

A Resident-Centered Dementia Care Staff Education Project to Reduce Challenging Behaviors at a Long-Term Care Facility

Frequent use of antipsychotic medication (APM) for behavioral and psychological symptoms of dementia (BPSD) persists at high levels in long- term care (LTC) facilities despite extensive evidence of modest clinical benefits, serious adverse effects, public health advisories and a national initiative to improve dementia care. There is a gap between best-practice evidence and actual clinical practice related to pharmacological and nonpharmacological care for persons with dementia (PWD) and BPSD and/or neuropsychiatric symptoms (NPS) of dementia. The literature shows that clinicians often ignore FDA (Food and Drug Administration) warnings, CMS (the Centers for Medicare and Medicaid Services) initiatives and expert opinion regarding the use of APMs and other psychotropic medications. Surveyed nursing home staff believe pharmacological interventions are more effective than nonpharmacological interventions to manage challenging behaviors. Previous studies document that nonpharmacological interventions and patient/resident-centered education programs are effective in reducing the frequency and severity of BPSD. This project presents an evidence-based interdisciplinary education program developed and administered at a Long Term Care (LTC) facility in the northeast. This program was designed to help staff at long-term care facilities who work with persons with dementia (PWD). This educational intervention project teaches staff a resident-centered approach that enhances care-planning skills for behavior problems and emphasizes meaningful activities to improve the PWD\u27s quality of life, reduce distressing symptoms and decrease the use of psychotropic drugs. This project uses Watson\u27s Theory of Human Caring and integrates several effective patient-centered educational strategies including the STAR-VA program available in the public domain. The STAR-VA program has demonstrated that an intensive interdisciplinary staff education program and development of a behavioral support team can reduce the frequency and intensity of BPSD for PWD. The current project\u27s specific educational program for nurses, nurse managers, certified nursing assistants, activity staff, unit secretaries, and social workers includes five 30-45 minutes sessions. The results demonstrate that an education project can be implemented in a LTC facility to heighten awareness and help staff consider the use of meaningful individualized activities to decrease BPSD. Recommendations include the continued testing of the modified STAR-VA program in long-term care facilities with dissemination to assist staff in working with PWD to reduce BPSD with a nonpharmacological approach. Frequent use of antipsychotic medication (APM) for behavioral and psychological symptoms of dementia (BPSD) persists at high levels in long- term care (LTC) facilities despite extensive evidence of modest clinical benefits, serious adverse effects, public health advisories and a national initiative to improve dementia care. There is a gap between best-practice evidence and actual clinical practice related to pharmacological and nonpharmacological care for persons with dementia (PWD) and BPSD and/or neuropsychiatric symptoms (NPS) of dementia. The literature shows that clinicians often ignore FDA (Food and Drug Administration) warnings, CMS (the Centers for Medicare and Medicaid Services) initiatives and expert opinion regarding the use of APMs and other psychotropic medications. Surveyed nursing home staff believe pharmacological interventions are more effective than nonpharmacological interventions to manage challenging behaviors. Previous studies document that nonpharmacological interventions and patient/resident-centered education programs are effective in reducing the frequency and severity of BPSD. This project presents an evidence-based interdisciplinary education program developed and administered at a Long Term Care (LTC) facility in the northeast. This program was designed to help staff at long-term care facilities who work with persons with dementia (PWD). This educational intervention project teaches staff a resident-centered approach that enhances care-planning skills for behavior problems and emphasizes meaningful activities to improve the PWD\u27s quality of life, reduce distressing symptoms and decrease the use of psychotropic drugs. This project uses Watson\u27s Theory of Human Caring and integrates several effective patient-centered educational strategies including the STAR-VA program available in the public domain. The STAR-VA program has demonstrated that an intensive interdisciplinary staff education program and development of a behavioral support team can reduce the frequency and intensity of BPSD for PWD. The current project\u27s specific educational program for nurses, nurse managers, certified nursing assistants, activity staff, unit secretaries, and social workers includes five 30-45 minutes sessions. The results demonstrate that an education project can be implemented in a LTC facility to heighten awareness and help staff consider the use of meaningful individualized activities to decrease BPSD. Recommendations include the continued testing of the modified STAR-VA program in long-term care facilities with dissemination to assist staff in working with PWD to reduce BPSD with a nonpharmacological approach