Multisensory environments for leisure: promoting well-being in nursing home residents with dementia

Multisensory environments such as Snoezelen^® rooms are becoming increasingly popular in health care facilities for older individuals. There is limited reliable evidence of the benefits of such innovations, and the effect they have on residents, caregivers, and visitors in these facilities. This two-stage project examined how effective two types of multisensory environments were in improving the well-being of older individuals with dementia. The two multisensory environments were a Snoezelen room and a landscaped garden. These environments were compared to the experience of the normal living environment. The observed response of 24 residents with dementia in a nursing home was measured during time spent in the Snoezelen room, in the garden, and in the living room. In the second part of the project, face-to-face interviews were conducted with six caregivers and six visitors to obtain their responses to the multisensory environments. These interviews identified the components of the environments most used and enjoyed by residents and the ways in which they could be improved to maximize well-being.

Clinical usefulness and feasibility of using Reality Orientation with patients who have dementia in acute care settings

Reality Orientation (RO) was developed as a strategy to assist people with dementia to improve their orientation and everyday function. Although its efficacy has been extensively studied in long-term care facilities, its effectiveness has rarely been examined in acute care settings. The aim of this review was to examine the studies cited in systematic reviews of RO to determine the potential clinical usefulness and the feasibility of using RO in acute care settings. Based on this information, the authors make recommendations for future research in this area. The feasibility of implementing RO in acute care poses challenges because of the short time a patient is in hospital and their ability to participate given their acute medical condition. Although the efficacy and feasibility of using RO in acute care settings have not been sufficiently examined, its potential to improve care should not be ignored. A comprehensive and rigorous study is necessary to investigate the usefulness of RO in the acute care setting and to help establish clinical guidelines for dementia care in the context of acute care nursing.

Effectiveness of staff training programs to manage behavioural problems of dementia

Purpose : Behavioural problems among older people with dementia are a major concern in nursing homes. This study was designed to evaluate the effectiveness of staff training programs on both staff and residents.
Methodology : Two programs (standard dementia care, individualised behaviour therapy) were compared to a control condition. A total of 90 staff and 113 aged care residents participated in the study.
Findings: The results demonstrated an improvement in the self-efficacy of staff who received either training program at post-intervention, and at three- and six-month follow-up. Facility managers also rated an improvement in the performance of staff who received behaviour therapy at post-intervention and at follow-up. There were no changes in behaviours or quality of life for residents in any group.
Implications: Staff education programs may not assist in the management of behavioural symptoms of dementia, but can improve staff attitudes. Other explanations and suggestions for future research are discussed.

An individualized psychosocial approach for "treatment resistant" behavioral symptoms of dementia among aged care residents

Background: Behavioral symptoms of dementia are common among residents in mainstream aged care settings, and have a substantial impact on residents and professional caregivers. This study evaluated the impact of individualized psychosocial interventions for behavioral symptoms through a small preliminary study.
Method: Interventions were delivered to a patient group of 31 psychogeriatric aged care residents who presented with behavioral symptoms of dementia that had failed to respond to pharmacological treatment approaches. Outcome data on severity of behaviors, health service utilization and staff burden of care were collected.
Results: A modest but significant reduction in staff ratings of the severity of aggressive and verbally agitated behavioral symptoms was found, with an associated reduction in their perceptions of the burden of caring for these patients. Reduced behavioral disturbance was associated with a reduction in the requirement for primary care consultations, and all participants were able to continue to reside in mainstream aged care facilities, despite an increase in the severity of dementia.
Conclusions: This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.

Effectiveness of staff training programs for behavioral problems among older people with dementia

This paper reviewed studies on staff training programs to address the behavioral problems associated with dementia among older people in residential care. The papers were classified according to whether or not the studies included a control group in the research design. The results of the review demonstrate that there has been a wide range of psychosocial and educational interventions to reduce behavioral problems among older people with dementia, with inconsistent results being obtained. However, many of these studies suffer from problems in their research design that make it difficult to evaluate their effectiveness. Problems in conducting research in the nursing home setting are highlighted, and suggestions for future research in this area are discussed.

Psychoeducational approaches to managing behavioural symptoms of dementia

Behavioural symptoms of dementia, such as wandering, aggression, and restlessness, are commonly manifested by residents of long-term residential facilities, and are associated with a range of negative outcomes. This paper reviews the literature on the efficacy of psychoeducation programs to improve the skills of residential care staff in managing these symptoms. The benefits and limitations of this approach are illustrated through presentation of case studies from clinical practice, with a focus on organisational and motivational factors. Preliminary data from a psychoeducation program delivered by an Aged Persons Mental Health Team are presented. Recommendations are made for future research and practice.

Managing behavioural symptoms of dementia : Effectiveness of staff education and peer support

This study was designed to investigate the impact of staff education on the behaviour and quality of life of residents with dementia and on staff members' attitudes about working with people with dementia and level of burnout. Staff from three aged care facilities participated in the study (n = 52). These facilities were randomly assigned to one of two intervention groups or a control group. Staff assigned to the intervention groups received an eight-week behaviourally-based programme. Staff from one aged care facility also participated in a peer support group designed to reinforce educational material and facilitate positive changes among staff members. Behavioural symptoms displayed by residents (n = 76) in each of the facilities were also assessed. Assessments were conducted at pre-intervention, post-intervention, three- and six-month follow-up. The results of this study indicated that education or peer support was not associated with an improvement in resident behaviour or quality of life. Education or peer support also did not impact on staff members' level of burnout. There was, however, a change in staff members' attitudes about working with people with dementia. Possible explanations for these findings and implication for further research are considered.

Death and late-stage dementia in institutions : a cultural analysis

The first purpose of this study was to describe the deaths of fifteen nursing home residents with late-stage dementia. The devastating effect of dementia on a person has been called a ‘living death’ (Woods, 1989). The caring which occurs when someone is going through this process in a nursing home was recorded and analysed. In analysing this act of caring, the second purpose was to look for the origins of the structures and the sources of pressure that shaped the context and therefore helped determine the behaviour of the various groups under observation. These groups were residents and their relatives, the staff of the nursing home and the treating doctors. Before commencing observations and carrying out this study, an understanding needed to be developed of: the condition of dementia as it is perceived by health professionals and presented in the media; the institutions in which the majority of people with dementia end their days; the background and conditions of the staff who nurse in them; the models of care that guide and determine policies; and the conceptions of life and death which underpin relevant laws and moral standpoints. Accordingly, in part 1. chapter 1 the history, causes, pathology and effects of dementing conditions are examined. Relevant medical and lay literature including media influences are examined which pertain to the subject of death and dementia and nursing home care. The history of this institutional care is briefly examined together with the growth of the discipline of gerontological nursing. Chapter 2 discusses some of the effects of this history on present day care and the concept of emotional work being carried out within the present day aged care public policy regulations. The moral arguments surrounding illness and dying in Australian society today are briefly discussed. Chapter 3 describes the conceptual framework for the study, the ethnographic method that has been employed and an outline of critical theory as the basis for analysis. The chapter concludes by recounting the practical steps taken to arrange the field work, secure the consent of participants, record data and gather documents, and outlines the ethical considerations given to the undertaking of the study. Chapter 4 describes the context in which the study took place and the first tentative exploration of the culture from an etic perspective. Part 2 describes the death trajectories observed and raises some questions about alternative strategies that may have been considered within a different paradigm of caring. In chapter 5 the death trajectories of each of the fifteen residents in the study are described, each written with a particular emphasis to illustrate aspects of the culture of care that emerged through thematic analysis. Observations, comments and feelings from staff and family are wound in and around these case studies. Chapter 6 looks more closely at the impact of policy and institutional pressure on the milieu in which these deaths took place. Part 3 draws conclusions from the observations and makes suggestions for emancipatory change as viewed from the author's standpoint of critical ethnographic analysis. In the final chapter an argument is presented for policy change that leads a movement towards palliative care practices for people with late-stage dementia. Approaches to implementation of palliative care will need to take account of any expression by the resident such as an advanced directive, indicating a preferred approach to treatment in the period prior to death; a need for a better understanding of such issues as the significance of body breakdown, the manifestations of pain and electrolyte imbalances; the surrounding ethical complexities and shift in public opinion, and perhaps, most of ail, the culture of the institutions in which this dying will take place. A definition of late-stage dementia which might be used in determining patterns of care is set out. A discussion about changes in practice which relate lo communication with treating doctors, the administering of antibiotics, the relief of pain, the mobilisation of residents and the provision of food and water takes place in light of the evidence found. The discussion of these issues is raised in the form of debate. Each aspect needs more rigorous analysis and information so that evidence-based practice, rather than care which is value-laden and emotional, can be used when treatment decisions are made for people with late-stage dementia.

Staff education to manage behavioural symptoms of dementia

The thesis investigated strategies for managing behavioural symptoms of dementia in nursing homes which involved developing and implementing an eight week education program. Results demonstrated that staff education can be associated with positive outcomes for staff members, while education alone is insufficient to change residents' behaviour. The portfolio investigated grief relating to loss of health through four case studies. Attachment theory, dual processing model and meaning reconstruction model were found to be clinically useful for both bereavement--related losses and health-related losses.

An evaluation of a national program to implement the cornell scale for depression in dementia into routine practice in aged care facilities

Background: Screening tools have been recommended for use in aged care to improve the detection and treatment of depression. This study aimed to evaluate the impact of a program for the routine implementation of the Cornell Scale for Depression in Dementia in Australian facilities, to determine whether use of the instrument by nurses led to further monitoring of depressive symptoms, medical referral, and changes in treatments prescribed for depression.
Methods: A file review was completed for 412 participants out of a total of 867 older people (47.5%) who resided in ten aged care facilities. The review examined Cornell Scale assessment data, medication charts, medical history, nursing progress notes, and resident care plans. Nursing staff who administered the Cornell Scale to each participant were also interviewed, and ten facilitymanagers took part in an interview to determine barriers to the effective implementation of the instrument.
Results: The Cornell Scale had been administered to 46.8% of the sample in the previous 12 months, with 25% of these participants scoring 9–13 and 27% scoring 14 and above. Less than one third of the residents with high scores were monitored by the staff following the assessment. Only 18% of residents with high scores were referred for further assessment of depression, while 10% received a treatment change.
Conclusions: The absence of a protocol for responding to high Cornell Scale scores limited the potential of this program to result in widespread improved treatment of depressed older people. The use of the Cornell Scale by aged care nurses with limited training raised concern.

Transdermal estrogen patches for aggressive behavior in male patients with dementia : a randomized, controlled trial

Objectives: To investigate the efficacy and tolerability of transdermal estrogen patches for the adjunctive treatment of aggressive behavior in male patients with advanced dementia. Methods: The study was designed as an 8-week, randomized, controlled trial in acute aged psychiatry inpatient units and specialized nursing homes in Melbourne, Australia, between 1998 and 1999. The participants were 27 men with established dementia, identified as displaying aggressive behavior not responding to treatment for at least 2 weeks prior to referral. The instruments used to measure aggressive behavior were the Rating Scale for Aggressive Behavior in the Elderly (RAGE), the Cornell Scale for Depression in Dementia (CSDD) and the Mini-mental State Examination (MMSE). Physical examination was performed and biochemistry and serum hormone concentrations were measured at baseline and at 8 weeks. Concomitant psychotropic medication use was recorded and analyzed. Results: There was no significant difference in aggressive behavior at 8 weeks, but significant “rebound” in aggressive behavior (change in scores between week 8 and week 10, p<0.009) and benzodiazepine use in the estrogen group (p<0.03), following removal of the patches. Only behavioral items of the CSDD improved in the experimental group (p=0.031). The use of patches was associated with a significant rise in serum estrogen (p<0.001) but not with a significant decrease in serum testosterone (p=0.077). There were no adverse effects associated with their use. Conclusions: The use of transdermal estrogen yielding up to 100μg per day was not associated with discernable improvement in aggressive behavior in men with advanced dementia. Small subject numbers, multiple variables and a lack of statistical power impair interpretation of these results. However, the tolerability and apparent rebound effect on removal of patches indicate the need for larger studies in this area.