Need-driven Dementia-compromised Behavior Model Research Articles

Care rejection and aggression among veterans with dementia with and without posttraumatic stress disorder: A multi-group analysis

BackgroundIn residential long-term care, military service veterans with co-occurring posttraumatic stress disorder (PTSD) and dementia encounter a range of physical and social stimuli that may serve as triggers of trauma-related distress that manifests as care rejection or aggression. Yet, PTSD rarely has been examined in research to understand behaviors of care rejection and aggression in veterans with dementia. ObjectivesGuided by the need-driven dementia-compromised behavior model, we examined the moderation effect of PTSD on pathways from background factors and interpersonal triggers to rejection of care and aggression among veterans with dementia with and without co-occurring PTSD. DesignSecondary data analysis of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention evaluation by the U.S. Veterans Health Administration healthcare system. Setting76 Veterans Health Administration-operated nursing homes. Participants315 veterans with dementia who participated in STAR-VA. MethodsWe converted text data on the occurrence of care rejection and aggression to binary variables, combined them with data on sociodemographic and PTSD status obtained using medical chart review, and measured anxiety, cognition, depression, and function using validated instruments. A multi-group structural equation modeling analysis was then conducted to test the moderating effect of PTSD on rejection of care and aggression. ResultsAlthough multi-group structural equation modeling did not support the hypothesis of overall moderation by PTSD, distinct patterns between the two groups were observed with respect to how background factors and interpersonal triggers related to care rejection and aggression. The magnitude of the direct effects of interpersonal triggers on rejection of care was greater in veterans with PTSD (β = 0.42, p = .014 compared to those without β = 0.29, p = .008). Depression had a statistically significant indirect effect on rejection of care via interpersonal triggers only in veterans with PTSD (β = 0.09, p = .009). Functional status had a statistically significant direct effect on aggression only in the PTSD group (β = 0.28, p = .044). ConclusionsOur study identified similar and distinct patterns of relationships among background factors, interpersonal triggers, and rejection of care and aggression between veterans with dementia with and without PTSD. The indirect effect of depression on care rejection via interpersonal triggers has implications for developing targeted interventions that focus on interpersonal triggers for veterans with dementia with PTSD who have greater depressive symptoms. This study underscores the importance of an enhanced focus on trauma-informed care for veterans with dementia and PTSD.

Factors Associated With Behavioral and Psychological Symptoms of Dementia: Prospective Observational Study Using Actigraphy.

BackgroundAlthough disclosing the predictors of different behavioral and psychological symptoms of dementia (BPSD) is the first step in developing person-centered interventions, current understanding is limited, as it considers BPSD as a homogenous construct. This fails to account for their heterogeneity and hinders development of interventions that address the underlying causes of the target BPSD subsyndromes. Moreover, understanding the influence of proximal factors—circadian rhythm–related factors (ie, sleep and activity levels) and physical and psychosocial unmet needs states—on BPSD subsyndromes is limited, due to the challenges of obtaining objective and/or continuous time-varying measures.ObjectiveThe aim of this study was to explore factors associated with BPSD subsyndromes among community-dwelling older adults with dementia, considering sets of background and proximal factors (ie, actigraphy-measured sleep and physical activity levels and diary-based caregiver-perceived symptom triggers), guided by the need-driven dementia-compromised behavior model.MethodsA prospective observational study design was employed. Study participants included 145 older adults with dementia living at home. The mean age at baseline was 81.2 (SD 6.01) years and the sample consisted of 86 (59.3%) women. BPSD were measured with a BPSD diary kept by caregivers and were categorized into seven subsyndromes. Independent variables consisted of background characteristics and proximal factors (ie, sleep and physical activity levels measured using actigraphy and caregiver-reported contributing factors assessed using a BPSD diary). Generalized linear mixed models (GLMMs) were used to examine the factors that predicted the occurrence of BPSD subsyndromes. We compared the models based on the Akaike information criterion, the Bayesian information criterion, and likelihood ratio testing.ResultsCompared to the GLMMs with only background factors, the addition of actigraphy and diary-based data improved model fit for every BPSD subsyndrome. The number of hours of nighttime sleep was a predictor of the next day’s sleep and nighttime behaviors (odds ratio [OR] 0.9, 95% CI 0.8-1.0; P=.005), and the amount of energy expenditure was a predictor for euphoria or elation (OR 0.02, 95% CI 0.0-0.5; P=.02). All subsyndromes, except for euphoria or elation, were significantly associated with hunger or thirst and urination or bowel movements, and all BPSD subsyndromes showed an association with environmental change. Age, marital status, premorbid personality, and taking sedatives were predictors of specific BPSD subsyndromes.ConclusionsBPSD are clinically heterogeneous, and their occurrence can be predicted by different contributing factors. Our results for various BPSD suggest a critical window for timely intervention and care planning. Findings from this study will help devise symptom-targeted and individualized interventions to prevent and manage BPSD and facilitate personalized dementia care.

Rejection of Care and Aggression among Older Veterans with Dementia: The Influence of Background Factors and Interpersonal Triggers

ObjectivesTo test relationships among background factors, interpersonal triggers, rejection of care, and aggression among veterans living with dementia in residential long-term care settings, based on the need-driven dementia-compromised behavior model. DesignA mixed methods secondary analysis of program evaluation data from the Staff Training in Assisted Living Residences-Veterans Health Administration intervention implemented by the US Department of Veterans Affairs healthcare system. Setting and ParticipantsIn total, 315 older veterans who participated in the 2013‒2016 Staff Training in Assisted Living Residences-Veterans Health Administration program at 76 Community Living Centers (Veterans Affairs-operated nursing homes). MethodsText data that captured the interdisciplinary team observations of distressed behaviors of concern and their circumstances were coded into categorical variables and then combined with existing quantitative data to test hypothesized relationships using structural equation modeling. ResultsRejection of care was directly affected by interpersonal triggers (β = 0.32, P < .005) and background factors such as depression (β = 0.29, P < .018), anxiety (β = −0.18, P < .023), and cognitive status (β = 0.10, P < .049). Depression also had an indirect effect on rejection of care through interpersonal triggers (α × β = 0.13 × 0.32 = 0.04, P < .012). Aggression was directly affected by both interpersonal triggers (β = 0.19, P < .009) and functional status (β = 0.17, P < .011). Both function (α × β = 0.12 × 0.19 = 0.02, P < .035) and depression (α × β = 0.13 × 0.19 = 0.03, P < .005) had indirect effects on aggression through interpersonal triggers. Conclusions and ImplicationsInterpersonal triggers influenced rejection of care and aggression in veterans with dementia. Background factors such as depression and severity of functional impairment increased the likelihood of these symptoms. Study findings emphasize the importance of developing and implementing interventions that improve interpersonal relationships and developing targeted interventions for those with depressive symptoms.

Influencing factors of psychological and behavioral symptoms among dementia patients in old-age care instituions

Objective To explore the influencing factors of psychological and behavioral symptoms among dementia patients in old-age care institutions in China along with taking the need-driven dementia-compromised behavior (NDB) model as the theoretical framework. Methods From July to August 2013, 687 elderly people from four public old-age care institutions in Zhejiang Province and 246 dementia patients enrolled in. Assessment was carried out with the Mini-Mental State Examination (MMSE) , Clinical Dementia Rating (CDR) , Neuropsychiatric Inventory-Questionnaire (NPI-Q) , Chinese version of Pain Assessment Scale for Patients with Advanced Dementia (C-PAINAD) . Results Among the 246 patients with dementia, 233 had at least one mental behavioral symptom in the past 1 month, accounting for 94.7%, of which sleep/night behavior was the most common, accounting for 59.3%; followed by abnormal motor behavior (46.7%) , irritability/emotional lability (44.3%) and depression (43.5%) . Multiple linear regression on influencing factors of psychological and behavioral symptoms among dementia patients in old-age care institutions based on NDB model showed that the background factors were activity of daily living and CDR (P<0.05) , the proximal factors included having or not having entrance guard, frequency of family visit and having or not having spouse (P<0.05) . Conclusions Psychological and behavioral symptoms are hints of demands among dementia patients. If an appropriate response is given, the symptom will be reduced. Caregivers should provide corresponding care according to proximal factors and background factors so as to decrease the incidence of psychological and behavioral symptoms. Key words: Dementia; Aged; Psychological and behavioral symptoms; Need-driven dementia-compromised behavior model; Old-age care instituions

Does Pain Mediate or Moderate the Effect of Cognitive Impairment on Aggression in Nursing Home Residents with Dementia?

The purpose of this study was to investigate if pain mediates or moderates the relationship between cognitive impairment and aggressive behaviors in nursing home residents with dementia based on the Need-driven Dementia-compromised Behavior model. This was a secondary analysis of the Minimum Data Set assessment data on long-term care from the state of Florida during calendar year 2009. The data used in this study was the first comprehensive assessment data from residents with dementia (N = 56,577) in Medicare-certified or Medicaid-certified nursing homes. Path analysis using a series of hierarchical regression analyses and two-way analysis of variance was used to evaluate the mediating and moderating effect of pain on the relationship between the level of cognitive impairment and aggression. Results indicated that pain did not mediate the relationship between cognition and aggressive behaviors, but there was evidence of a significant moderating effect of pain only for residents with severe cognitive impairment. Only among the residents with severe cognitive impairment, those with pain had significantly more frequent aggressive behaviors than those without pain. A change in the frequency of aggressive behaviors in severely cognitively impaired residents should signal the possibility that the person is experiencing pain. Accurate but simple pain assessment in this population including these behavioral changes should be developed further, and pain should be well controlled to reduce these problematic behaviors.

A Randomized Clinical Trial of Theory-Based Activities for the Behavioral Symptoms of Dementia in Nursing Home Residents

To test the main and interactive effects of activities derived from the Need-Driven Dementia-Compromised Behavior model for responding to behavioral symptoms in nursing home residents. Randomized double-blind clinical trial. Nine community-based nursing homes. One hundred twenty-eight cognitively impaired residents randomly assigned to activities adjusted to functional level (FL) (n=32), personality style of interest (PSI) (n=33), functional level and personality style of interest (FL+PSI) (n=31), or active control (AC) (n=32). Three weeks of activities provided twice daily. Agitation, passivity, engagement, affect, and mood assessed from video recordings and real-time observations during baseline, intervention, random times outside of intervention, and 1 week after intervention. All treatments improved outcomes during intervention except mood, which worsened under AC. During intervention the PSI group demonstrated greater engagement, alertness, and attention than the other groups; the FL+PSI group demonstrated greater pleasure. During random times, engagement returned to baseline levels except in the FL group in which it decreased. There was also less agitation and passivity in groups with a component adjusted to PSI. One week after the intervention, mood, anxiety, and passivity improved over baseline; significantly less pleasure was displayed after withdrawal of treatment. The hypothesis that activities adjusted to FL+PSI would improve behavioral outcomes to a greater extent than partially adjusted or nonadjusted activities was partially supported. PSI is a critical component of individualized activity prescription.

Factors associated with problematic vocalizations in nursing home residents with dementia.

Problematic vocalizations (PVs) are the most frequent and persistent disruptive behaviors exhibited by nursing home residents with dementia. Understanding factors associated with these behaviors are important to prevent or reduce them. We used the Need-Driven Dementia-Compromised Behavior model to identify the characteristics of persons with dementia who are likely to display nonaggressive and aggressive PVs and the conditions under which these behaviors are likely to occur and persist. This multisite descriptive study included 138 residents of 17 nursing homes, and approximately half had a history of PVs. Background data were gathered through interviews, chart reviews, and administration of physical and neuropsychological assessments. Proximal data were obtained from observations and videotapes. When the 2 subscales of the Verbal Behavior Scale were used as the dependent variables, agreeableness and conscientiousness, positive affect, and discomfort were associated with nonaggressive vocalizations, and general health state (GHS), age, and negative and positive affect were associated with aggressive vocalizations. When the verbally agitated (nonaggressive) section of the Cohen-Mansfield Agitation Inventory was the dependent variable, the background factors of gender, agreeableness, GHS, and age remained predictors, as did the proximal factors of affect and discomfort. We identified 5 background factors and 3 proximal factors as risk factors for PVs in persons with dementia, with variation between nonaggressive or aggressive PVs. These data provide direction for caregiving for persons with dementia and design of interventions to prevent or reduce PVs.

Predictors of need-driven behaviors in nursing home residents with dementia and associated certified nursing assistant burden

Objective: We examined predictors of staff-reported need-driven behaviors and resistiveness to care in nursing home residents with dementia and predictors of certified nursing assistant (CNA) burden related to both constructs. Background and proximal factors from the need-driven dementia-compromised behavior model [Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K., et al. (1996). Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer's Disease, 5, 10–19] were examined as potential predictors of need-driven behaviors (NDBs) and resistiveness to care and CNA burden. Method: We used secondary data analysis of prospective data from 10 nursing homes in Birmingham, Alabama. One-hundred and sixty-one residents (83.43 ± 8.56 years) with mini mental state examination (MMSE) score = 6.41 (± 6.66) were assessed via chart review, resident surveys, and surveys of CNAs. Results: Multiple regression models revealed that cognitive functioning, activities of daily living functioning, race, gender, and CNA-reported weekly resident pain intensity were associated with resident NDBs. Regression models also revealed that weekly pain intensity and medical comorbidity were associated with CNA burden associated with the resident NDBs. However, we were unable to explain a significant amount of variance in the resistiveness to care or CNA burden associated with resistiveness to care. Discussion: Results underscore the role of pain in both resident NDBs and associated CNA burden. Future research should focus on predictors of resident resistiveness to care and the relation of pain assessment and management practices to CNA burden. Moreover, interventions to improve resident care should seek to include CNAs in institutional pain assessment and management processes.

Emotional Intervention Strategies for Dementia-Related Behavior

Behavioral disturbances of elders with dementia are prevalent. Yet the science guiding development and testing of effective intervention strategies is limited by rudimentary and often-conflicting theories. Using a theory-synthesis approach conducted within the perspective of the need-driven dementia-compromised behavior model, this article presents the locomoting responses to environment in elders with dementia (LRE-EWD) model. This new model, based on empirical and theoretical evidence, integrates the role of emotion with that of cognition in explicating a person-environment dynamic supporting wandering and other dementia-related disturbances. Included is evidence of the theory's testability and elaboration of its implications. The LRE-EWD model resolves conflicting views and evidence from current research on environmental interventions for behavior disturbances and opens new avenues to advance this field of study and practice.

Assisted Living Nursing Practice: The Language of Dementia: Theories and Interventions

The person with dementia uses behavior to communicate, but their behavior is altered by the combination of neurological damage and impairment, altered interpersonal relationships and reactions of others, and the individual's loss or weakening of their lifelong defenses or coping mechanisms. This article discusses the routes by which behavior can be understood and describes a constellation of needs of a person with dementia that has a unique fit with person-centered care. Three evidence-based models (theories) and interventions specific to dementia behaviors are discussed: the Need-Driven Dementia-Compromised Behavior Model, the Progressively Lowered Stress Threshold Model, and the utilization of self-identity roles. Montessori-based activities are another approach to person-centered dementia care that respect, as do the models, the dignity, worthiness and interests of the person afflicted with dementia. The models discussed in this article all seek to improve the quality of life of the person with dementia. Other than those at the profound end stage of dementia, most sufferers can communicate feelings. Subjective quality of life must be determined based on the self-report of the person suffering with dementia so that treatment interventions and effectiveness are grounded in that person's reality.

Special Section—Behavioral symptoms of dementia:their measurement and intervention. Validation of the Algase Wandering Scale (Version 2) in across cultural sample

This study examined the psychometric properties of an expanded version of the Algase Wandering Scale (Version 2) (AWS-V2) in a cross-cultural sample. A cross-sectional survey design was used. Study subjects were 172 English-speaking persons with dementia (PWD) from long-term care facilities in the USA, Canada, and Australia. Two or more facility staff rated each subject on the AWS-V2. Demographic and cognitive data (MMSE) were also obtained. Staff provided information on their own knowledge of the subject and of dementia. Separate factor analyses on data from two samples of raters each explained greater than 66% of the variance in AWS-V2 scores and validated four (persistent walking, navigational deficit, eloping behavior, and shadowing) of five factors in the original scale. Items added to create the AWS-V2 strengthened the shadowing subscale, failed to improve the routinized walking subscale, and added a factor, attention shifting as compared to the original AWS. Evidence for validity was found in significant correlations and ANOVAs between the AWS-V2 and most subscales with a single item indicator of wandering and with the MMSE. Evidence of reliability was shown by internal consistency of the AWS-V2 (0.87, 0.88) and its subscales (range 0.88 to 0.66), with Kappa for individual items (17 of 27 greater than 0.4), and ANOVAs comparing ratings across rater groups (nurses, nurse aids, and other staff). Analyses support validity and reliability of the AWS-V2 overall and for persistent walking, spatial disorientation, and eloping behavior subscales. The AWS-V2 and its subscales are an appropriate way to measure wandering as conceptualized within the Need-driven Dementia-compromised Behavior Model in studies of English-speaking subjects. Suggestions for further strengthening the scale and for extending its use to clinical applications are described.

Special Section—Behavioral symptoms of dementia: their measurement and intervention. Caregiver interventions for passive behaviors in dementia: links to the NDB model

Passive behavior (PB) in persons with Alzheimer's disease (PWAD) has been overlooked despite recognition that it occurs on a daily basis and is often resistant to interventions. The purpose of this study was to describe how the experience of passivity was for the caregiver and the PWAD, factors that precipitated PB, caregiver responses that promoted engagement, and caregiver responses that intensified PB, as well as activities initiated by caregivers over the past month that reduced passivity in the person with dementia (PWD). Fifty caregivers of community-dwelling persons with mild (n = 15), moderate (n = 16), and severe (n = 19) Alzheimer's disease participated in a semi-structured interview. Data were analyzed using Colaizzi's Phenomenological Thematic Extraction and descriptive statistics. Caregivers identified decreased levels of activity, decreased verbalization, withdrawal, less socialization, and decreased interest in activities as examples of PBs. For caregivers, the experience of coping with PBs engendered frustration with their loved ones’ cognitive deterioration, difficulty in watching and accepting loss of function, fatigue, sadness, and using coping skills. Paradoxically, both being alone and increased environmental stimuli precipitated PB. Feelings of helplessness and loss of control by the person also caused PB. The most successful interventions to promote engagement were: giving cues and assistance, initiating the task, giving guidance, and providing enjoyable activities. Responses that hindered engagement included: ‘correcting’ or putting stress on the person, rushing activities, and repeating directions. Faith, humor, patience, and contact with friends and family were identified as positive approaches. Caregiver interventions demonstrated synchrony with selected background and proximal variables in the Need-driven Dementia-compromised Behavior (NDB) model.

Theory-based intervention for dementia behaviors: A within-person analysis over time

The historic "black-box" approach to treatment effectiveness research has hampered the development of effective activity interventions for persons with dementia. The purpose of this case study is to test the effectiveness of activities derived from the Need-Driven Dementia-Compromised Behavior Model. Activities that matched skill level and personality style of interest resulted in a pattern of greater time on task (p =.0012), participation (p =.004), and positive mood (p =.0001) and fewer dementia-related behaviors (p =.009) compared with activities matched to skill level only. Practitioners may improve behavioral outcomes for persons with dementia by prescribing activities based on an assessment of skill level and style of interest.

The Way We Were

Cognitively impaired older adults often exhibit behaviors such as hitting, screaming and wandering. The cause of these behaviors is complex and includes psychosocial factors such as past personality and life experiences. This paper presents a method for assessing psychosocial history that is derived from the Need-driven Dementia-compromised Behavior Model. The use of these data for designing activities that respond to dementia-related behaviors is illustrated.

A taxonomy of passive behaviors in people with Alzheimer's disease.

To construct a taxonomy of passive behaviors for understanding people with Alzheimer's disease. Passive behaviors are those associated with decreased motor movements, decreasing interactions with the environment, and feelings of apathy and listlessness. Little is known about behaviors associated with passivity, and these behaviors have not been categorized. Taxonomy construction. Passive behaviors in people with Alzheimer's disease were conceptualized as disturbing behaviors, patterns of personality change, and negative symptoms. The taxonomy was developed using critical reviews of 15 empirical studies published 1985 through 1998. Procedures included listing behaviors; clustering behaviors into inductively derived groupings; conducting an expert panel-review, making revisions, and conducting a second review; establishing global and category-by-category reliability using Cohen's Kappa. The nonhierarchic, natural taxonomy indicated five categories of behaviors associated with passivity in Alzheimer's disease: diminutions of cognition, psychomotor activity, emotions, interactions with people, and interactions with the environment. Analysis indicated substantial agreement beyond chance and showed statistically significant agreement among the six nurse-expert rates. Areas of synchrony between the taxonomy and the Need-Driven Dementia Compromised Behavior Model were identified. This taxonomy of passive behaviors in patients with Alzheimer's disease showed empirical rigor and compatibility with a middle-range theory and can be viewed as a sensitizing analytic scheme to guide future practice, research, and theory development.

Toward holistic theory-based intervention for dementia behavior.

Four million Americans suffer from some form of dementia. Over 50% of these individuals exhibit behaviors that are perceived as "disturbing" by family and caregivers. The Need-driven Dementia-compromised Behavior Model was developed by a group of nurse researchers to study and understand these behaviors. The model changes the view of dementia behaviors as "disturbing" to that of behavior as signifying potentially understandable needs. This article reviews the model and demonstrates how interventions derived from the model can be used to respond to dementia behaviors in a holistic fashion.

An overview of the need-driven dementia-compromised behavior model.

An overview of the need-driven dementia-compromised behavior model.