Nursing Home Behavior Research Articles

Measuring Effects of Nondrug Interventions on Behaviors: Music & Memory Pilot Study.

Most people with Alzheimer disease and related dementias will experience agitated and/or aggressive behaviors during the later stages of the disease. These behaviors cause significant stress for people living with dementia and their caregivers, including nursing home (NH) staff. Addressing these behaviors without the use of chemical restraints is a growing focus of policy makers and professional organizations. Unfortunately, evidence for nonpharmacological strategies for addressing dementia-related behaviors is lacking. Six-month, preintervention-postintervention pilot study. US NHs (n = 4). Residents with advanced dementia (n = 45). Music & Memory, an individualized music program in which the music a resident preferred when she/he was young is delivered at early signs of agitation, using a personal music player. Dementia-related behaviors for the same residents were measured three ways: (1) observationally using the Agitation Behavior Mapping Instrument (ABMI); (2) staff report using the Cohen-Mansfield Agitation Inventory (CMAI); and (3) administratively using the Minimum Data Set-Aggressive Behavior Scale (MDS-ABS). ABMI score was 4.1 (SD = 3.0) preintervention while not listening to the music, 4.4 (SD = 2.3) postintervention while not listening to the music, and 1.6 (SD = 1.5) postintervention while listening to music (P < .01). CMAI score was 61.2 (SD = 16.3) preintervention and 51.2 (SD = 16.1) postintervention (P < .01). MDS-ABS score was 0.8 (SD = 1.6) preintervention and 0.7 (SD = 1.4) postintervention (P = .59). Direct observations were most likely to capture behavioral responses, followed by staff interviews. Nursing-home based, pragmatic trials that rely solely on available administrative data may fail to detect effects of nonpharmaceutical interventions on behaviors. Findings are relevant to evaluations of nonpharmaceutical strategies for addressing behaviors in NHs, and will inform a large, National Institute on Aging-funded pragmatic trial beginning spring 2019. J Am Geriatr Soc 67:2134-2138, 2019.

Factorial structure of the French version of the Nursing Home Behavior Problem Scale

Several measuring devices are available to assess specific behavioural problems of dementia patients residing in nursing homes but only a few have been translated and validated in French. This study's main objective was to determine the factorial structure of the French version of the Nursing Home Behavior Problem Scale (NHBPS) with people suffering from dementia. A secondary objective was to document the variables associated with the global score of the NHBPS and the underlying dimensions of the instrument. Participants (n = 155) were diagnosed with dementia and resided in three nursing homes and a hospital's long-term care unit. The presence of behavioural problems and other characteristics were assessed by two nurses. A factor analysis revealed five key dimensions in the francophone version of the questionnaire. Several variables were associated with the total score of the NHBPS and its five underlying dimensions. Although the factorial solution of the French version of the NHBPS is similar to the English versions, our results also show differences that may depend on methodological characteristics.

Relationship between delirium and behavioral symptoms of dementia

Persons with dementia frequently present behavioral and psychological symptoms as well as delirium. However, the association between these has received little attention from researchers and current knowledge in this area is limited. The purpose of this study was to examine the relation between delirium and behavioral symptoms of dementia (BSD). Participants were 155 persons with a diagnosis of dementia, 109 (70.3%) of whom were found delirious according to the Confusion Assessment Method. BSD were assessed using the Nursing Home Behavior Problem Scale. Participants with delirium presented significantly more BSD than participants without delirium. More specifically, they presented more wandering/trying to leave, sleep problems, and irrational behavior after controlling for cognitive problems and use of antipsychotics and benzodiazepines. Most relationships between participant characteristics and BSD did not differ according to the presence or absence of delirium, but some variables, notably sleep problems, were more strongly associated to BSD in persons with delirium. Although correlates of BSD in persons with delirium superimposed on dementia are generally similar to those in persons with dementia alone, delirium is associated with a higher level of BSD. Results of this study have practical implications for the detection of delirium superimposed on dementia, the management of behavioral disturbances in patients with delirium, and caregiver burden.

A long-term care center interdisciplinary education program for antipsychotic use in dementia: program update five years later

While antipsychotic (AP) medications are frequently used in long-term care, current evidence suggests that the risks may offset the benefits, necessitating periodic reassessment of their use. The aims of this present study were: (1) to assess rates of AP use five years after our first intervention to determine the long-term impact; and (2) to implement an updated AP reduction educational intervention program at the same center five years later in order to determine whether AP use could be further reduced. Participants were residents with dementia receiving AP medication. The educational program component included separate lectures on pharmacologic and non-pharmacologic treatment of behavioral and psychological symptoms of dementia (BPSD). Completion of the Nursing Home Behavior Problems Scale (NHBPS), physician interviews concerning AP treatment plans for subjects with dementia, and AP administration and dose assessment occurred both at baseline and again between four to five months after the educational program. Of 308 long-term residents with dementia, 53 (17.2%) were receiving regular APs, primarily for agitation, aggressivity, other behavioral problems and psychosis. Of these, six died and one was transferred, leaving 46 participants. At five months, ten (21.7%) residents were no longer receiving APs and seven (15.2%) were on a lower dose; thus, 17 (37.0%) were either discontinued or on a lower dose. There was no worsening of NHBPS scores. Despite the low prevalence (17.2%) of AP users at the beginning of the current study compared to that observed five years prior (30.5%), it is still possible to further decrease the proportion of users.

Nursing Home Price and Quality Responses to Publicly Reported Quality Information

To assess whether the release of Nursing Home Compare (NHC) data affected self-pay per diem prices and quality of care. Primary data sources are the Annual Survey of Wisconsin Nursing Homes for 2001-2003, Online Survey and Certification Reporting System, NHC, and Area Resource File. We estimated fixed effects models with robust standard errors of per diem self-pay charge and quality before and after NHC. After NHC, low-quality nursing homes raised their prices by a small but significant amount and decreased their use of restraints but did not reduce pressure sores. Mid-level and high-quality nursing homes did not significantly increase self-pay prices after NHC nor consistently change quality. Our findings suggest that the release of quality information affected nursing home behavior, especially pricing and quality decisions among low-quality facilities. Policy makers should continue to monitor quality and prices for self-pay residents and scrutinize low-quality homes over time to see whether they are on a pathway to improve quality. In addition, policy makers should not expect public reporting to result in quick fixes to nursing home quality problems.

A Longitudinal Examination of Agitation and Resident Characteristics in the Nursing Home

Agitation frequently accompanies cognitive decline among nursing home residents. This study used cross-sectional and longitudinal (up to 18 months) methods to examine agitation among profoundly and moderately impaired residents using both staff report and direct observation methods. The study included participants (N = 78) from a larger study who completed either 12 or 18 months of data collection. There were four measurement points, each separated by 6-month intervals. We recorded agitation using two measures: (a) the computer-assisted behavioral observation system (CABOS) and (b) the staff-completed Nursing Home Behavior Problem Scale. We used longitudinal hierarchical linear modeling to capture the dynamic nature of behavior change as a function of individual resident characteristics and time. The profoundly cognitively impaired residents (M Mini-Mental State Examination [MMSE] score = 1.7) displayed more agitation than the moderately impaired group (M MMSE score = 15.4) at Epoch 1 (cross-sectional analyses). Longitudinal analysis found a significant linear and quadratic trend only with the profoundly impaired residents using the CABOS. These residents showed slight improvements in agitation up to 12 months, with agitation increasing significantly from 12 to 18 months. With nursing homes receiving an increasing number of profoundly cognitively impaired residents, these results have potential cost and policy implications. Measuring agitation over time by using both staff report and observation measures presents various problems, and we present an alternative measure that may help to avoid these difficulties.

Medicare payment changes and nursing home quality: effects on long-stay residents

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.

Resident dog in the Alzheimer's special care unit.

Behavioral disturbances are a commonfeature of Alzheimer's disease (AD). Prior studies have demonstrated a significant reduction in agitation behaviors during short-term exposure to a dog on an Alzheimer's special care unit (SCU)for persons with AD. The purpose of this study was to determine the effect over time of a resident dog on problem behaviors of persons with AD in an SCU. A within-participants repeated-measures design was used for this study. The Nursing Home Behavior Problem Scale was used to document behaviors (on days and evenings) I week before and 4 weeks after placement of the dog. Participants on the day shift exhibited significantly fewer problem behaviors across the 4 weeks of the study (F[1, 80] = 7.69, p < .05). No significant change in behaviors occurred on the evening shift. Thefindings support the long-term therapeutic effects of dogs for persons residing in Alheimer's SCUs.

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.

Determinants for the use of psychotropics among nursing home residents.

To characterise the prescription pattern of psychotropics in Danish nursing homes and to identify diagnostic, behavioural, cognitive and performance characteristics associated with prevalent psychotropic drug use. Prescribed daily medication was recorded from nurses' files. Based on the Anatomical Therapeutical Chemical (ATC) classification index, psychotropics were categorised into neuroleptics, benzodiazepines and antidepressants. Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. One hundred and eighteen staff members were interviewed about the residents's Activities of Daily Living (ADL), behavioural problems (Nursing Home Behavior Problem Scale), orientation, communication skills and if the resident had any psychiatric disorder. Multiple logistic regression was used to select the items that determined the use of psychotropics. Fifty-six percent of the residents received a psychotropic, 21% received neuroleptics, 38% received benzodiazepines and 24% received antidepressants. In the multivariate analysis, staff assessment of the resident's mental health was a determinant for the use of all types of specific psychotropics, whereas a GMS-AGECAT diagnosis only determined the use of neuroleptics. Behavioural problems were a determinant for the use of neuroleptics and the use of benzodiazepines irrespective of the psychiatric diagnosis of the resident. Use of antidepressants was associated with male gender and increasing age. Staff perceptions of psychiatric morbidity and norms have a greater impact on the prescription of psychotropics than standardised clinical criteria.

Organizational Form and Nursing Home Behavior

The authors identify differences in performance among for-profit, nonprofit, and government-owned nursing homes in Minnesota. They investigate whether homes of diverse ownership types distribute their surpluses differently, if those differences narrow over time, and if the various ownership types react differently to changes in the regulatory environment. Government-owned and nonprofit homes spend more per resident day for nursing care costs than do independent for-profit homes. Chain affiliation is important in explaining persistent spending differences. There is an agency problem: Nursing homes belonging to chains behave differently from their independent counterparts. Secular non-profits belonging to national chains spend less of their surplus on nursing care costs after regulations allowed more of this form of spending to be recouped in rates charged to the residents. The secular firms affiliated with national chains spend less on nursing care than the control group. As the predicted surpluses of for-profit chains increase, the owners’ compensation falls.

Haloperidol vs. Alprazolam for Disruptive Behavior in the Nursing Home.

Nursing home personnel must often manage the disruptive behaviors of elderly cognitively impaired patients. This double-blind, crossover study compared the effects of a neuroleptic and a benzodiazepine, two drug classes commonly used for this purpose. The subjects …

Geropsychiatric restraint use.

To investigate predictors and reasons for restraint use with geropsychiatric patients. A prospective, correlational study. The geriatric unit of an acute-care psychiatric hospital. Twenty-one staff nurses and 131 patients admitted consecutively over a period of 6 months. Disruptive behaviors were measured with the Nursing Home Behavior Problem Scale (NHBPS), cognitive function was measured with the Mini-Mental State Examination (MMSE), mobility was measured with a Functional Mobility Screen (FMS), and reasons for restraint use were obtained with a questionnaire completed by nurses. Patients with a diagnosis of dementia, impaired mobility, or behavioral problems were more likely to be restrained. The most frequent reasons given by staff for restraint use were an unsteady gait and a risk of falling. The incidence of restraint use was 27.1%. The use of restraint with geropsychiatric patients may be more common than previously reported and requires further investigation.

Subacute care, Medicare benefits, and nursing home behavior.

Two policy changes in 1988, one administrative and one legislative, allowed greater Medicare coverage of subacute care in skilled nursing facilities (SNFs). The Medicare Catastrophic Coverage Act (MCCA) of 1988, in conjunction with an administrative directive, or transmittal, from the Health Care Financing Administration (HCFA), changed the Medicare SNF benefit structure substantially. In this study, we specified a simultaneous equation system to explain the effects of the benefit changes on Medicare use. The results suggest that the two policy changes increased Medicare use in Pennsylvania SNFs substantially; however, the increase was associated with facility and case mix characteristics, which suggest that the increase was largely attributable to reclassification of current patients from other payer categories, Medicaid and self-pay, rather than new admissions. The effects of the MCCA and the HCFA transmittal on increased Medicare use were unanticipated and have important implications for the way in which subacute care is defined and financed in future benefit discussions.

Effects of antipsychotic withdrawal in elderly nursing home residents.

To study the effects of antipsychotic withdrawal in elderly nursing home residents. Longitudinal prospective study. 12 community nursing homes that participated in a randomized controlled trial of an educational program designed to reduce antipsychotic use. 271 residents receiving antipsychotics at baseline and remaining in the home for approximately 6 months thereafter. These were placed into two groups: those with continued use of antipsychotics at follow-up (n = 207) and those with drug discontinued (n = 64). Change between baseline and follow-up for several standard measurements. These included behavior problems, as reported by both regular care providers (Nursing Home Behavior Problem Scale) or a blinded study rater (items from the Brief Psychiatric Rating Scale), observer-rated psychiatric symptoms (subset of the Brief Psychiatric Rating Scale), and other standard tests of function (Activities of Daily Living, Mini-Mental State Examination, Geriatric Depression Scale, and Abnormal Involuntary Movements Scale). The frequency of behavior problems did not increase in residents with antipsychotics discontinued. For these residents, observer-rated psychiatric symptoms decreased by 21% (P = 0.003), which resulted from a 27% decrease in adverse affective symptoms (P = 0.0002). Residents with drug discontinued had no deterioration in any of the measures of function. In this sample, nursing home residents whose antipsychotics were discontinued had significantly improved affect and no discernable adverse effects.

Bedside assessment of executive cognitive impairment: the executive interview.

This study is a pilot validation of the Executive Interview (EXIT), a novel instrument designed to assess executive cognitive function (ECF) at the bedside. Inter-rater reliability testing and validation using inter-group comparisons across levels of care and measures of cognition and behavior. Forty elderly subjects randomly selected across four levels of care. Settings ranged from independent living apartments to designated Alzheimer's Special Care units in a single 537-bed retirement community. The EXIT: a 10-minute, 25-item interview scored from 0-50 (higher scores = greater executive dyscontrol) was administered by a physician. Subjects were also administered the Mini-Mental State Exam (MMSE) and traditional tests of "frontal" executive function by a neuropsychologist, and the Nursing Home Behavior Problem Scale (NHBPS) by Licensed Vocational Nurses. Interrater reliability was high (r = .90). EXIT scores correlated well with other measures of ECF. The interview discriminated among residents at each level of care. In contrast, the MMSE did not discriminate apartment-dwelling from residential care residents, or residential care from nursing home residents. The EXIT was highly correlated with disruptive behaviors as measured by the NHBPS (r = .79). These preliminary findings suggest that the EXIT is a valid and reliable instrument for the assessment of executive impairment at the bedside. It correlates well with level of care and problem behavior. It discriminates residents at earlier stages of cognitive impairment than the MMSE.

The Nursing Home Behavior Problem Scale

Nursing home patients frequently have serious disturbances of behavior that can lead to use of chemical or physical restraints. To support research into better management of these problems, we developed the Nursing Home Behavior Problem Scale (NHBPS), a 29-item inventory of serious behavior problems designed to be completed by nurses and nursing assistants. NHBPS scores were obtained for two samples of nursing home residents: 431 in Tennessee and 122 in Texas. The interrater correlation was .754 in the Tennessee sample and .827 in the Texas sample. The NHBPS had a correlation of -.747 with the NOSIE scale and .911 with the CMAI. There was a pronounced association of increased NHBPS scores with mental impairment and use of sedative drugs or restraints. These data suggest the NHBPS is a useful research instrument for measuring serious behavior problems in nursing home residents.

Effect of an Incontinence Training Program on Nursing Home Staff's Knowledge, Attitudes, and Behavior

To test a behavioral approach for urinary incontinence (UI), 166 staff in four nursing homes participated in a quasi-experimental study that measured knowledge and attitudes about UI and compliance with toileting protocols. The intervention group (N = 96) showed a slight increase in knowledge; their attitudes remained positive over the four testing times. Compliance with the more critical component of the toileting protocol was only 72%, although evidence existed that the protocol reduced UI. Results are discussed in terms of the sociocultural environment of nursing homes.

Case-Mix Payment for Nursing Home Care: Lessons from Maryland

Even before Medicare adopted case-based payments for hospitals, some state Medicaid programs employed case-mix payment systems for nursing home care. Their purpose was less to promote cost containment than to improve access to nursing homes for the most costly patients. This paper evaluates one such system, adopted by the state of Maryland in 1983 as part of an overall reimbursement reform. Using data on nursing home patient characteristics, costs, and staffing, as well as interviews with officials and various providers of care, the article shows that Maryland's system was successful in shifting nursing home service away from light-care and toward heavy-care patients. Furthermore, the shift occurred without inducing readily measurable declines in quality of care and with little additional administrative cost (partly because the state built its case-mix system on preexisting patient review activities). Although states could learn from and improve upon Maryland's experience--most notably in offering incentives to improve quality of care and in targeting community care on the light-care patients that nursing homes become less willing to serve--Maryland demonstrates that case-mix payment can change nursing home behavior in desired directions without substantial negative consequences.

How nursing homes behave: A multi-equation model of nursing home behavior

This paper estimates a multi-equation model of nursing home behavior using the 1973 NCHS National Nursing Home Survey for data. The paper investigates empirically the effects of public reimbursement and regulatory policies, as well as other exogenous factors, on the following dependent variables: (1) average operating cost; (2) nursing hours per patient-day; (3) an index of rehabilitation-type services; (4) the occupancy rate; (5) the mix of public and private patients; and (6) the rate charged to private patients. The results dramatize the importance of endogeneity concerns in nursing home behavior. Rate setting and many regulations are shown empirically to have unintended and often undesired consequences on cost and other policy criteria of interest. While there has been anecdotal evidence of such system-wide interdependencies, this study affirms that such possibilities must be taken seriously. Rational nursing home regulation cannot proceed apart from a comprehensive understanding of the nursing home behavioral environment.