Dementia Unit Research Articles

Behavioral and Psychological Symptoms of Dementia of Psychogeriatric Inpatients on Admission to a Psychiatric Hospital

Prevalence of Behavioral and Psychological Symptoms of Dementia (BPSD) was measured in 75 (45 men, 30 women) new admissions to an acute care dementia unit in a psychiatric hospital. Participants aged 64-97 years were administered a Mini Mental Status Examination within one or two days of admission. The behaviors of the participants were evaluated in each of the three work shifts (i.e., at 7:00 a.m., 3:00 p.m., and 11:00 p.m.) using the Behavioral Severity Scale. The three ratings per day were obtained each day for two weeks upon admission, and one month later each day for one week. Results indicate that the prevalence of challenging behaviors in the patients observed in this study is very low. There was less evidence for a “sundowning (i.e., progressive deterioration over the course of the day) effect than a day in contrast to night effect.

Decisions to Forgo Hospitalization in Advanced Dementia: A Nationwide Study

To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia. Cross-sectional study. All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states. NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521). Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas). Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations. Directives to forgo hospitalization for U.S. NH residents with advanced dementia are uncommon and are associated with the organizational features of the facilities caring for them and the intensity of end-of-life care practiced in the region, as well as individual resident characteristics.

The New Israeli Law “The Dying Patient” and Relief of Suffering Units

The new Israeli Law "The Dying Patient" provides avenues for possible medical, ethical, and Halachic (Jewish religious law) solutions in view of the complexity of the treatment of an end-stage dementia patient. The establishment of a hospice-like setting for dementia patients in Israel, based on palliative treatment only, similar to the Jewish hospices in the United States, is extremely important. This article proposes a new, alternative approach and setting for patients with end-stage dementia that could pertain to the Israeli setting and could possibly also be acceptable in other countries. Short hospitalization periods of approximately 1 month and treatment in Relief of Suffering End-of-Life With Dementia Units may be a new palliative approach and present a possible solution for coping with the burden of the suffering of end-state dementia patients, their families, and the medical and nursing staff.

Satisfaction with End‐of‐Life Care for Nursing Home Residents with Advanced Dementia

To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia. Cross-sectional study. Thirteen NHs in Boston. One hundred forty-eight NH residents aged 65 and older with advanced dementia and their formally designated HCPs. MASUREMENTS: The dependent variable was HCPs' score on the Satisfaction With Care at the End of Life in Dementia (SWC-EOLD) scale (range 10-40; higher scores indicate greater satisfaction). Resident characteristics analyzed as independent variables were demographic information, functional and cognitive status, comfort, tube feeding, and advance care planning. HCP characteristics were demographic information, health status, mood, advance care planning, and communication. Multivariate stepwise linear regression was used to identify factors independently associated with higher SWC-EOLD score. The mean ages+/-standard deviation of the 148 residents and HCPs were 85.0+/-8.1 and 59.1+/-11.7, respectively. The mean SWC-EOLD score was 31.0+/-4.2. After multivariate adjustment, variables independently associated with greater satisfaction were more than 15 minutes discussing advance directives with a care provider at the time of NH admission (parameter estimate=2.39, 95% confidence interval (CI)=1.16-3.61, P<.001), greater resident comfort (parameter estimate=0.10, 95% CI=0.02-0.17, P=.01), care in a specialized dementia unit (parameter estimate=1.48, 95% CI=0.25-2.71, P=.02), and no feeding tube (parameter estimate=2.87, 95% CI=0.46-5.25, P=.02). Better communication, greater resident comfort, no tube feeding, and care in a specialized dementia unit are modifiable factors that may improve satisfaction with care in advanced dementia.

Methods of pain assessment in residents of long-term care facilities: A pilot study

Structured programs for routine pain assessment and treatment are necessary to optimize care for residents of long-term care facilities (LTCFs). A pilot study was designed to develop, implement, and evaluate a system for pain assessment and monitoring in a LTCF. Additional goals were to determine whether a verbal and/or non-verbal tool adequately assess pain in residents of LTCFs and whether the pharmacologic therapy for pain changes with the implementation of a pain assessment and monitoring system. Quantitative, nonexperimental design using two pain assessment tools. The study was conducted at a LTCF in a rural midwestern setting. The study population for phase I included residents on any pain medication (regularly scheduled or as needed) on the secure dementia unit. The target population for phase II consisted of residents on any pain medication on an open unit. Training was provided to the nursing staff on how to use two pain assessment tools, one verbal (colored visual analog scale) and one nonverbal (observed pain target behaviors), and documentation. In addition, a continuing education program on pain assessment and management in elderly residents and barriers to pain management in LTCFs was offered to medical providers. Evaluation with the colored visual analog scale (CVAS) occurred twice daily. Pain target behaviors were monitored throughout the day and recorded by nursing staff at the end of each shift. All residents in the study population were monitored daily for six months. Most of the residents on both units were unable to use the verbal tool; however, the nonverbal tool was used successfully for all residents studied. On the dementia unit, the use of pain medications increased, and pain target behaviors decreased during the study period; on the open unit, the use of pain medications remained stable, and pain target behaviors decreased. These data suggest that an increase in awareness of pain may facilitate an improvement in the assessment and management of pain in residents of LTCFs. The feasibility of the nonverbal pain monitoring method shown in this study has positive implications on quality of care issues if generalizable to a larger population.

Focused supervision of high-risk fall dementia patients: a simple method to reduce fall incidence and severity.

Dementia units in nursing homes have a disproportionately high number of demographic risk factors for falls. Many residents have a previous history of falls, the inability to call for assistance, and the inability to remember safety instructions. For interdisciplinary falls review committees, this population may be the most difficult to manage. The Virginia Veterans Care Center (VVCC) Dementia Unit Interdisciplinary Fall Team instituted a novel practice for reducing the number and severity of falls among the highest risk group of dementia patients. Certified nursing assistants (CNAs) were assigned to high-risk residents for focused supervision. The patients received consistent supervision by selected CNAs during the day and evening shifts. Eight residents identified as high risk who continued to have falls despite multiple interventions were selected for the study. A comparison of four months of intervention with the four months prior to the intervention revealed a significant (p = 0. 024) fall reduction during the intervention months. Individually, seven of the eight participants had reduced falls during the intervention period. A 5-point scale for fall severity demonstrated an overall reduction in fall severity during that period. Individually, five of the eight patients had a decreased fall severity, and one had no change. Two patients experienced an increase in fall severity due to ongoing medical problems. While the small number of patients in the study limits the power of the results, this novel intervention of using designated CNAs to supervise high-risk fall residents with dementia may prove helpful for staff in other nursing facilities.

A Team Effort for Treating Depression in Dementia

Managing depression or other challenging behaviors in people with dementia requires a team effort for optimal treatment outcomes. Developing a team approach in a dementia unit requires planning and coordination. Teamwork concepts and practical guidelines are described including: (a) Why a team approach is necessary, (b) Deciding who should be involved in a team effort, (c) When to involve the team in developing behavior management programs, (d) Using formal versus informal mechanisms to coordinate teamwork, (e) Focusing team based behavior management planning by using basic categories of intervention strategies, and (f) Different team dynamics to consider when developing or troubleshooting team functioning.

Nursing Home Characteristics Associated with Tube Feeding in Advanced Cognitive Impairment

To identify nursing homes factors associated with the use of tube feeding in advanced cognitive impairment. Descriptive study. The On-line Survey Certification of Automated Records (OSCAR) was used to obtain facility characteristics from 1,057 licensed nursing homes in six states from 1995 to 1996. Residents aged 65 and older with advanced cognitive impairment who had a feeding tube placed over a 1-year period were identified using the Minimum Data Set. Nursing home characteristics independently associated with feeding tube placement were determined. Having a full-time speech therapist on staff, more licensed nurses and fewer nursing assistants were independently associated with greater use of tube feeding in severely cognitively impaired residents. Other features associated with tube feeding included larger facility size, higher proportion of Medicaid beds, absence of an Alzheimer's disease unit, pressure ulcers in 10% or more of residents, and a higher proportion of residents lacking advance directives and with total functional dependency. Assessment by a speech therapist, staffing ratios, advance directives, fiscal considerations, and specialized dementia units are potentially modifiable factors in nursing homes that may influence the practice of tube feeding in advanced cognitive impairment.

The Physical and Social Environments of Small Rural Nursing Homes: Assessing Supportiveness for Residents with Dementia

ABSTRACTThe physical and social environments are recognized as important therapeutic tools in the care of nursing home residents with dementia, yet little is known about the environments of rural nursing homes. This study was conducted in one rural health authority (16,000 km 2) in the province of Saskatchewan. Long-term institutional care was provided in seven small (15 to 35 beds), publicly funded nursing homes, none of which had separate dementia special care units (SCUs). The Physical Environmental Assessment Protocol (PEAP) was used to evaluate the facilities on nine key dimensions of dementia care environments. Facilities were most supportive in provision of privacy and least supportive on maximizing awareness and orientation. Focus groups were conducted with registered nurses, nursing aides, and activity workers. Staff caregivers identified six special needs of residents with dementia that were difficult to meet in the nursing homes, two of which were related to the physical environment (safety and a calm, quiet environment) and four of which were related to the social environment (meaningful activity and one-to-one contact, opportunity to use remaining abilities, flexible policy, and knowledgeable caregivers who enjoy working with persons with dementia). Staff suggested separate dementia SCUs as one approach to managing dementia care but also identified challenges in creating dementia units in small rural facilities. Results provide support for conceptual models of dementia care settings that emphasize the interaction of organizational, social, and physical factors.

Use of plant essential oils in treating agitation in a dementia unit 10 case studies

Use of plant essential oils in treating agitation in a dementia unit 10 case studies

Decreasing aggressive, agitated, or disruptive behavior: perticipation in a behavior management unit.

A 32-bed Behavior Management Unit was opened in a long-term care facility to care for dementia patients who exhibit aggressive, agitated, or disruptive (AAD) behaviors. The purpose of the study was to evaluate the effectiveness of the Behavior Management Program (BMP) in decreasing such behaviors. The sample consisted of all patients (N = 32) who resided in the unit for at least 3 months. The Nursing Home Behavior Problem Scale (NHBPS) was used to collect data. Hypothesis 1, predicting participation in the BMP would decrease the total number of AAD behaviors was supported, with a significant decrease from the baseline to 6-month measurements. Hypothesis 2, predicting participation in the BMP would decrease the frequency of occurrence of specific AAD behaviors was supported, with 7 behaviors being significantly reduced by 6 months. Nurses in long-term care often treat patients with AAD behavior. Because staff members on general long-term care units and even in dementia units may not be experts in caring for patients with AAD behaviors, the implications of this study might be helpful. The interventions that were effective in reducing AAD behaviors included verbal distraction, time-outs, activity diversion, getting to know the patient well, and managing the environment.

Windows to the heart: creating an acute care dementia unit.

In 1999, Dr. Jeffrey Nichols, chief of geriatrics at Cabrini Medical Center (CMC) in New York City, and medical director of the Cabrini Center for Nursing and Rehabilitation (CCNR), and his colleagues received a grant from the United Hospital Fund to develop an eight-bed, family-centered acute care unit for patients with dementia at CMC, a 500-bed hospital. Because of their location in Lower Manhattan, these institutions serve an ethnically diverse population, including many non-English-speaking people of Hispanic and Asian origin, and they have a high proportion of elderly patients, including patients with dementia. This inpatient unit was created to address the widely recognized problem that when dementia patients are hospitalized, the experience is frequently highly stressful for both patients and family or nonkin caregivers. Patients with advanced Alzheimer’s disease and other dementias often suffer a precipitous decline in function during and after hospitalization, which places additional burdens on the patients and their caregivers. After some focus group research with family caregivers of dementia patients, Dr. Nichols and his colleagues realized that it was not sufficient to “tweak this, tweak that” in the traditional system of care in the hospital in order to meet the identified needs; rather, they had to take a comprehensive, carefully orchestrated, and holistic approach to change—encompassing the physical, operational, and cultural environment of the institution. In the following interview with Innovations associate editor Karen S. Heller, Dr. Nichols describes the challenges he and his colleagues faced in starting this kind of unit in the acute care hospital setting and provides some preliminary evidence for its success. This interview is excerpted from the thematic issue, “Supporting Family Caregivers,” Volume 3, Number 2, 2001 of the online journal Innovations in End-of-Life Care at .

‘This is your home now!’: conceptualizing location and dislocation in a dementia unit

In this chapter, I discuss ethnographic work in a residential unit for Alzheimer’s patients located in the southeastern part of the United States. The borders of home and work in this nursing home are analyzed in order to unpack meanings of ‘home’ for residents. Postmodern discussions of location and dislocation for contemporary identities have relevance for an analysis of this setting. The concepts of non-place ( non-lieu) from the work of Marc Augé and of location ( lieu) from the work of Pierre Bourdieu are employed in the analysis. In this unit, well-to-do white residents are cared for by working-class black women. Intersections of race and class, as well as gender and age, form an important context for social relationships within this space. The case of one resident who daily asked for her car so that she could go home is used to illustrate the social and spatial arrangements in this setting and the ‘location’ of both patients and staff.

Workplace learning as postmodernist enactment: a model from dementia

Workplace learning confronts much traditional educational thinking, since it engages the local, informal and capricious nature of the workplace experience, and tries to make these educatively worthwhile. Using staff learning experiences in certain dementia units in Melbourne as empirical data, the paper builds up a model of workplace learning, utilizing insights from postmodernist scholarship. It confronts in this way some of the central notions of truth and knowledge explicit in more modernist epistemologies, whilst adhering to a modernist ontology – that is, to the assumption that a mind-independent reality persists. If the analysis is successful, educators can be encouraged to develop a new epistemology of (workplace) learning, which has much to contribute to the arrival of vocational education at the centre of lifelong education theorisations and practices, especially research practices.

Quality indicators for dementia in vulnerable community-dwelling and hospitalized elders.

Dementia is a leading cause of disability among older adult patients. Appropriate attention to early identification, the assessment of medications and health conditions that may be contributing to ...

Special Feature: Montessori-Based Activities for Long-Term Care Residents with Dementia

Activities programming in long-term care can be an extension of geriatric rehabilitation if activities use rehabilitation principles. Twenty-five residents of a dementia unit participated in a study comparing effects of Montessori-based activities to regular activities programming. Montessori programming uses rehabilitation principles such as task breakdown, guided repetition, and progressing from simple to complex. It also utilizes principles of dementia interventions such as external cue usage and reliance on implicit memory. Montessori programming elicited more constructive engagement and pleasure and less passive engagement and negative affect than other programming. The implications for collaboration among rehabilitation, recreational, and nursing staff are discussed.

Professional environmental assessment procedure for special care units for elders with dementing illness and its relationship to the therapeutic environment screening schedule.

The Professional Environmental Assessment Procedure (PEAP) was developed as a global quality-assessment measure for use by trained professionals in special care units for older people in dementia units of nursing homes. The PEAP consists of nine ratings whose relationship to another assessment device, the Therapeutic Environment Screening Schedule (TESS), is reported. Although designed to be multidimensional, the PEAP as tested in 43 special care units seems to reflect primarily a single evaluative dimension. It correlates highly with the TESS and may be used either separately or in combination with the TESS.

Effectiveness of Special Care Unit (SCU) placements in reducing physically aggressive behaviors in recently admitted dementia nursing home residents

Using a sample of new dementia admissions who entered selected nursing facilities December 1992 through June 1994, this paper compares special care dementia units (SCUs) to non-specialized (traditional) nursing home care in their effectiveness in reducing physically aggressive behaviors within six-months of placement. Findings indicate that SCUs admit younger and more highly aggressive residents. Our results indicate that when differences in age and baseline levels of disruptive behaviors are controlled, SCU placement showed no positive or negative effect on the frequency of aggressive behaviors. Rather than SCU placement, it was the increased use of psychotropic medications and the reduction in the use of physical restraints that showed a relationship with lower levels of physically aggressive behaviors. While SCUs do not appear to be the hoped for panacea with regard to reducing physically aggressive behaviors, they still appear to serve a useful function within the broader context of the provision of services for residents with dementia within the nursing home.

Behavioral Syndromes in Alzheimer’s Disease: Description and Correlates

Introduction: Behavioral disturbances in patients with Alzheimer’s disease (AD) are ill-defined conditions. We hypothesize that the many behavioral disturbances hitherto described and studied might be grouped into few syndromes with separate determinants and correlates. Patients and Methods: 162 consecutive patients with probable AD admitted to a dementia unit were assessed by the UCLA Neuropsychiatric Inventory (NPI). Results: Factor analysis was carried out on NPI subscales, leading to three syndromes: ‘mood’, ‘psychotic’ and ‘frontal’. Patients with the ‘psychotic’ syndrome were older, had older age at dementia onset, had poorer cognition, were more often males, and had faster rate of dementia progression. Patients with the ‘frontal’ syndrome had higher education, longer disease duration, and slower rate of progression. Discussion: Some combinations of behavioral disturbances occur more frequently together and might represent separate behavioral syndromes. Different clinical correlates of the syndromes suggest separate etiologies.

Neuropsychiatric inventory. Propiedades psicométricas de su adaptación al español

The purpose of this study was to examine the reliability and validity of the Spanish (Spain) version of the Neuropsychiatric Inventory. The Neuropsychiatric Inventory was administered to the caregivers of 63 subjects from the Dementia Unit, Hospital Santa Caterina, Girona. All patients had detailed neuropsychological assessment, and their non-cognitive symptoms were also examined with the CAMDEX. There was a high level of internal consistency reliability. The Neuropsychiatric Inventory subscores correlated with those of the CAMDEX, indicating an acceptable level of validity. The most frequent symptom was apathy (56%), followed by irritability (38%), depression/dysphoria (35%), aberrant motor behavior (30%), agitation/aggression (29%), anxiety (27%), disinhibition (24%), delusions (19%), hallucinations (14%) and euphoria (3%). This study showed that the Spanish version of the Neuropsychiatric Inventory is a reliable instrument, which can briefly assess non-cognitive symptoms in demented patients. The Neuropsychiatric Inventory is a useful instrument for research and clinical practice in different culture around the world.