Specialized Dementia Unit Research Articles

PW01-86 - Are men from mars and women from venus in subjects with cognitive impairment?

IntroductionNeuropsychiatric symptoms are common in subjects with cognitive impairment (mild cognitive impairment and dementia). It is also widely known that there are many cognitive differences between men and women. The aim of this study is to describe the neuropsychiatric profile of elderly subjects visited in a dementia unit and to estimate the gender differences in this sample.MethodsWe conducted a retrospective study in a sample of outpatients visited for the first time in a specialized dementia unit during 2008. The clinical and socio-demographic characteristics were compiled through a structured interview and neuropsychiatric tests. Yesavage scale was used for depression assessment and psychiatric symptoms were evaluated using NPI-Q test.Results144 subjects were analyzed, 72.2% were women (n=104) and 27.8% were men (n=40). Mean age at diagnosis was 79.15 +/− 6.58 years. Mean score in Yesavage was higher in women (4.34) than in men (3.9) although not statistically significant. Male subjects showed greater anxiety and aggressiveness than women (p< 0.05) analyzed with NPI-Q. Prior to the first assessment interview 73.6% of the subjects had used psychiatric drugs: women were found to take more SSRI (12,5% vs 5%) while men were using more benzodiazepines (22,5% vs 14,4%) although not statistically significant.ConclusionsWe have found that anxiety and aggressiveness defines male neuropsychiatric profile in our sample. More results pointed towards other different features defining genders although not statistically significant. Further studies, with larger samples and more exhaustive assessment, are needed to determine sex differences in subjects with cognitive impairment.

Color Discrimination Performance in Patients with Alzheimer’s Disease

Background/Aims: Visual deficits are frequent in Alzheimer’s disease (AD), yet little is known about the nature of these disturbances. The aim of the present study was to investigate color discrimination in patients with AD to determine whether impairment of this visual function is a cognitive or perceptive/sensory disturbance. Methods: A cross-sectional clinical study was conducted in a specialized dementia unit on 20 patients with mild/moderate AD and 21 age-matched normal controls. Color discrimination was measured by the Farnsworth-Munsell 100 hue test. Cognitive functioning was measured with the Mini-Mental State Examination (MMSE) and a comprehensive battery of neuropsychological tests. The scores obtained on the color discrimination test were compared between AD patients and controls adjusting for global and domain-specific cognitive performance. Results: Color discrimination performance was inversely related to MMSE score. AD patients had a higher number of errors in color discrimination than controls (mean ± SD total error score: 442.4 ± 84.5 vs. 304.1 ± 45.9). This trend persisted even after adjustment for MMSE score and cognitive performance on specific cognitive domains. Conclusions: A specific reduction of color discrimination capacity is present in AD patients. This deficit does not solely depend upon cognitive impairment, and involvement of the primary visual cortex and/or retinal ganglionar cells may be contributory.

High Efficacy for Hip Protectors in the Prevention of Hip Fractures Among Elderly People With Dementia

To evaluate the efficacy of hip protectors (HP) in preventing hip fractures (HF) in patients with dementia. A case-control study. Four specialized dementia units. 206 physically independent patients with dementia. Beginning in January 2004, following the recommendation of the Israeli Ministry of Health, we recommended the use of HP (Hip Saver-nursing home type) to each family/guardian of all patients in these departments. The rate of falls and HF per falls in patients with and without HP. We achieved patient compliance of 70% to 80% for wearing the HP 24 hours a day; 106 patients were permanently wearing HP for a total period of 1905 months. Of those, subgroup B of 63 patients had been monitored prior to January 2004, before HP were introduced. One hundred patients of the same departments have never used HP; together with the months of follow-up before January 2004 in subgroup B, the follow-up period in patients not wearing HP, reached a total of 3136 months. There was no statistical difference between patients with/without HP regarding age, gender, comorbidities, routine laboratory findings, and medications. The rate of falls was not significantly different in patients with and without HP. However, there was a significant difference in the rate of hip fractures (HF): in patients not wearing HP there were 323 falls resulting in 14 HF, and in patients wearing HP, 260 falls but only 2 HF (4.3% versus 0.8%, respectively, P = .007, chi-square test, 95% confidence interval 1.3-24.6, NNT = 28). When appropriately introduced and used, hip protectors have high efficacy in preventing hip fractures in long-term care patients with dementia. The medical, social, and economic beneficial outcomes are substantial.

Dementia and Assisted Living

This article presents an overview of what is known about dementia services in assisted living settings and suggests areas for future research. We undertook a search of Medline, the Journals of Gerontology, and The Gerontologist. We then organized publications dealing with the target subject into 10 topic areas and reviewed them. The article describes the demographic characteristics of cognitively impaired residents in assisted living and related residential settings in the United States, the services they receive, and process and structural elements both in specialized dementia units and in integrated assisted living settings. Finally, we review the literature on methodological issues regarding research in this area. It is important to generate research on processes as well as outcomes, such as dignity, individualized and pleasurable experiences, and freedom from pain and discomfort. We make recommendations for both content areas that would benefit from further research as well as methodological approaches that will yield important information in this field.

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.

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.

A Special Dementia Unit (Hostel): Review of the First Eleven Years Operation

The aim of this review was to study the outcome of residents in a Special Dementia Unit (SDU) in the form of a hostel for 36 people during the first eleven years of operation. The participants were one hundred and seventy one residents admitted for permanent care during that period. The median length of stay in the hostel was 2.3 years. By the end of the period 113 residents (83 percent of those who had completed their time in the hostel) had been transferred to nursing homes. The average survival time after admission to the hostel was 4.7 years. In order to accommodate those who had been transferred from the SDU about the same number of hostel places were needed in nursing homes. We concluded that admission to an SDU hostel for selected people with dementia is more appropriate and less costly than direct admission to a nursing home, notwithstanding the need for subsequent nursing care for the majority. Adequate subsidy should be provided by the Commonwealth Government so that voluntary associations are encouraged to set up SDU hostels for this purpose. Nursing homes should be run in association with these hostels.

Special Dementia Unit as hostel: a residential care development in Australia

As with many other aspects of health care, specialization has become a feature of residential care. In addition to well-aged units and nursing homes there are two categories of hostel care for older people in Australia. An account is given of the development of the Special Dementia Unit (SDU) in the form of a hostel. The advantages and disadvantages of this facility are mentioned. A close association of geriatric and psychogeriatric services with nursing homes and hostels is necessary to achieve a regional service as well as further development in the several components of institutional care.

Understanding the Behaviour of People in Special Dementia Units: the Contribution of Rating Scales

The aim of this study was to investigate the contribution that rating scales can make to the understanding of the behaviour of people with dementia in a residential unit The participants were thirty eight residents in a Special Dementia Unit (SDU) organised as a hostel. Scores were recorded at staff meetings for the following scales: Crichton Royal Behavioural Rating Scale (CRBRS), Confusion Rating (CR), Barthel Index (BI), Cohen‐Mansfield Agitation Inventory (CMAI) and the Mini Mental State Examination (MMSE). It was found that the CRBRS and the CR provide a useful reference to mental and physical disabilities. Scores from the CMAI recorded the type, the frequency and the number of agitated behaviours displayed by individual residents. The majority of agitated behaviours belonged to the physically non‐aggressive category. Information from these scores was combined to construct residents' profiles. We concluded that the CRBRS, the CR and the CMAI can provide information about residents, both as individuals and as a group, which can assist in the understanding of behaviour and in the evaluation of the function of an SDU.

Watsonʼs theory of caring: A model for implementation in practice

Jean Watson's theory of human caring in nursing is introduced as an innovative approach to improving care for residents in a special dementia unit. The rationale for theory-based nursing practice includes implementation projects of caring theory that have increased job satisfaction among staff, shortened hospital length of stay, and reduced health care costs. Specific examples of ways that Watson's model can be applied in typical nurse-client situations are presented. Implementation strategies with creative visual aids are included, and research tools for the evaluation of outcomes are described.

RATING SCALES IN RESIDENTIAL CARE FOR ELDERLY PEOPLE: THE CRICHTON ROYAL BEHAVIOURAL RATING SCALE

ABSTRACTThe Purpose of the study was to consider the merits of the Crichton Royal Behavioural Rating Scale (CRBRS) with respect to its use in selection, monitoring progress and predicting the outcome of residents in institutions.Participants were residents in a special dementia unit (SDU) in the form of a hostel, a standard hostel and a nursing home for sufferers with severe dementia.Method: scores were recorded over a period of five years in the SDU and intermittently in the other two institutions.Results demonstrated the range of scores of residents on admission to the SDU and their changes in behavioural function over five years. The probability of retention in the SDU was greater for residents admitted with scores in the lower ranges. Differences in the three institutions were demonstrated in both range and level of behavioural function. Comparison with the Resident Classification Index (RCI) suggested that the CRBRS has superior discrimination concerning behavioural function.Conclusions: the regular use of rating scales in institutions for elderly people should be mandatory. The CRBRS is useful in the selection of residents and in monitoring outcome but it cannot substitute for conventional methods of diagnosis and assessment.

Caregiver and environmental variables related to difficult behaviors in institutionalized, demented elderly persons.

This study describes the relationship between caregiver and elder behavior in institutionalized, cognitively impaired, elderly persons. A repeated-measures design was used to observe interactive behaviors between caregivers and demented elders within three caregiving situations (dressing, toileting, and bathing) and an interpersonal contact in two long-term care facilities. During observations, the caregiver's behaviors were rated using the Interaction Behavior Measure and Health Professional's-Geriatric Patient Behavior Rating scale, whereas the elder's behaviors were rated using a modified version of the Interaction Behavior Measure. The study included 116 subjects (58 elders and 58 caregivers), with each unique caregiver/elder pair being observed in the four situations. All elder behaviors varied according to situation type, with the most difficult elder behaviors occurring during bathing. Ten of the 12 caregiver behaviors included in the analysis varied by situation type. Significant relationships were systematically found between the caregiver's relaxed and smiling behavior and the elder's calm/functional behaviors, r = .42 (dressing) to r = .46 (toileting) for caregiver relaxed behavior and r = .34 (bathing) to r = .58 (dressing) for smiling. The elder's behavior did not vary by type of nursing unit (special dementia unit or general nursing unit), or interruptions to the interaction.

Behavioral and Cognitive Outcomes of SCU Care

This study compared 12 residents of a dementia special care unit (SCU) and 8 residents of a segregated but not specialized dementia unit in another nursing home, to test the impact of specialized care on longitudinal (13-15 months) change in behavior and cognition. The SCU model included specialized elements in activities, staff selection and training, physical environment, and family involvement. Longitudinal results indicated no superior outcomes on the SCU. Possible interpretations discussed include limited benefit of SCU care over segregated but nonenriched care, methodological limitations of the current study, distinctions between individualized and programmatic behavior modification approaches, and the need to examine quality of life as a SCU outcome.

Physical and Pharmacologic Restraint of Nursing Home Patients With Dementia

This case-control study of 31 specialized dementia units and 32 traditional units in five states investigated use of physical and pharmacologic restraints among 625 patients with the diagnosis of dementia. Physical restraints were observed in use on 18.1% of dementia unit patients and on 51.6% of comparison unit patients who were out of bed during the day (adjusted odds ratio, 0.283;95% confidence interval, 0.129 to 0.619). Pharmacologic restraints were routinely given to 45.3% of dementia unit patients and 43.4% of comparison unit patients (adjusted odds ratio, 0.950; 95% confidence interval, 0.611 to 1.477). We used multivariate logistic regression to identify residence in a nonspecialized nursing home unit, nonambulatory status, transfer dependency, mental status impairment, hip fracture history, and a high nursing staff-to-patient ratio, which we found to be independent predictors of physical restraint use. Physically abusive behavior, severe mental status impairment, and frequent family visitation were found to be significant predictors of pharmacologic restraint use, while advanced patient age, large nursing home size, and patient nonambulatory status were protective against such use. These results support the conclusion that physical and pharmacologic restraint constitute separate treatment modalities with different risk factors for use, and indicate that specialized dementia units are successful in reducing the use of physical but not pharmacologic restraints.

Establishment and impact of a dementia unit within the nursing home.

Thirty-two demented, elderly residents of a nursing home were admitted to a specially designed dementia unit. Each patient was assessed three times: prior to admission, and at four and 12 months after admission to the unit. Patients were evaluated using a modified version of a previously published assessment scale as well as with a standardized New York State numerical rating system. There was an increased level of functioning in both mental and emotional status and basic functions of daily living at both four (P less than or equal to 0.001) and 12 months (P less than or equal to 0.005). The improvement in scores was maintained over a prolonged time period, despite the expectation of progression of the dementing process. There was no change noted on the New York State assessment. Our data suggest that a select group of demented elderly can benefit from being placed on a specialized dementia unit.