Reducing care-resistant behaviors during oral hygiene in persons with dementia

Rita A Jablonski, Ann Kolanowski, Barbara Therrien, Ellen K Mahoney, Cathy Kassab, Douglas L Leslie, Rita A Jablonski, Ann Kolanowski, Barbara Therrien, Ellen K Mahoney, Cathy Kassab, Douglas L Leslie

Abstract

Background: Nursing home residents with dementia are often dependent on others for mouth care, yet will react with care-resistant behavior when receiving assistance. The oral health of these elders deteriorates in the absence of daily oral hygiene, predisposing them to harmful systemic problems such as pneumonia, hyperglycemia, cardiac disease, and cerebral vascular accidents. The purpose of this study is to determine whether care-resistant behaviors can be reduced, and oral health improved, through the application of an intervention based on the neurobiological principles of threat perception and fear response. The intervention, called Managing Oral Hygiene Using Threat Reduction, combines best mouth care practices with a constellation of behavioral techniques that reduce threat perception and thereby prevent or de-escalate care-resistant behaviors.

Methods/design: Using a randomized repeated measures design, 80 elders with dementia from 5 different nursing homes will be randomized at the individual level to the experimental group, which will receive the intervention, or to the control group, which will receive standard mouth care from research team members who receive training in the proper methods for providing mouth care but no training in resistance recognition or prevention/mediation. Oral health assessments and care-resistant behavior measurements will be obtained during a 7-day observation period and a 21-day intervention period. Individual growth models using multilevel analysis will be used to estimate the efficacy of the intervention for reducing care-resistant behaviors in persons with dementia, and to estimate the overall efficacy of the intervention using oral health outcomes. Activity-based costing methods will be used to determine the cost of the proposed intervention.

Discussion: At the conclusion of this study, the research team anticipates having a proven intervention that prevents and reduces care-resistant within the context of mouth care. Long-term objectives include testing the effect of the intervention on systemic illnesses among persons with dementia; examining the transferability of this intervention to other activities of daily living; and disseminating threat reduction interventions to nursing home staff, which may radically change the manner in which care is provided to persons with dementia.

Trial registration: ClinicalTrials.gov: NCT01363258.

References

    1. Bagramian RA, Heller RP. Dental health assessment of a population of nursing home residents. J Gerontol. 1977;32(2):168–174.
    1. Kiyak HA, Grayston MN, Crinean CL. Oral health problems and needs of nursing home residents. Community Dent Oral Epidemiol. 1993;21(1):49–52. doi: 10.1111/j.1600-0528.1993.tb00719.x.
    1. Frenkel H, Harvey I, Newcombe RG. Improving oral health in institutionalised elderly people by educating caregivers: a randomised controlled trial. Community Dent Oral Epidemiol. 2001;29(4):289–297. doi: 10.1034/j.1600-0528.2001.290408.x.
    1. Murray PE, Ede-Nichols D, Garcia-Godoy F. Oral health in Florida nursing homes. Int J Dent Hyg. 2006;4(4):198–203. doi: 10.1111/j.1601-5037.2006.00212.x.
    1. Cohen-Mansfield J. The underdetection of pain of dental etiology in persons with dementia. Am J Alzheimers Dis Other Demen. 2002;17(4):249–253. doi: 10.1177/153331750201700404.
    1. Dey AN. Characteristics of elderly nursing home residents: data from the 1995 National Nursing Home Survey. Adv Data. 1997;2(289):1–8.
    1. Shay K, Ship JA. The importance of oral health in the older patient. J Am Geriatr Soc. 1995;43(12):1414–1422.
    1. Chai J, Chu FC, Chow TW, Shum NC, Hui WW. Influence of dental status on nutritional status of geriatric patients in a convalescent and rehabilitation hospital. Int J Prosthodont. 2006;19(3):244–249.
    1. Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis. 2005;40(1):1–6. doi: 10.1086/426023.
    1. Promsudthi A, Pimapansri S, Deerochanawong C, Kanchanavasita W. The effect of periodontal therapy on uncontolled type2 diabetes mellitus in older subjects. Oral Dis. 2005;11:293–298. doi: 10.1111/j.1601-0825.2005.01119.x.
    1. Bakhshandeh S, Murtomaa H, Mofid R, Vehkalahti MM, Suomalainen K. Periodontal treatment needs of diabetic adults. J Clin Periodontol. 2007;34(1):53–57. doi: 10.1111/j.1600-051X.2006.01028.x.
    1. Desvarieux M, Demmer RT, Rundek T, Boden-Albala B, Jacobs DR, Papapanou PN, Sacco RL. Relationship Between Periodontal Disease, Tooth Loss, and Carotid Artery Plaque: The Oral Infections and Vascular Disease Epidemiology Study. Stroke. 2003. pp. 2120–2125.
    1. Desvarieux M, Demmer RT, Rundek T, Boden-Albala B, Jacobs DR, Sacco RL, Papapanou PN. Periodontal microbiota and carotid intima-media thickness: the Oral Infections and Vascular Disease Epidemiology Study (INVEST) Circulation. 2005;111(5):576–582. doi: 10.1161/01.CIR.0000154582.37101.15.
    1. Kurihara N, Inoue Y, Sugano N, Umeda M, Hauang Y, Ishikawa I. Oral Bacteria are a possible risk factor for valvular incompetence in primary varicose veins. Eur J Vasc Endovasc Surg. 2007;34:102–106. doi: 10.1016/j.ejvs.2007.02.010.
    1. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 Overview. National Center for Health Statistics, Vital Health Statistics; 2009.
    1. Mahoney EK, Hurley AC, Volicer L, Bell M, Gianotis P, Hartshorn M, Lane P, Lesperance R, MacDonald S, Novakoff L. et al.Development and testing of the Resistiveness to Care Scale. Res Nurs Health. 1999;22(1):27–38. doi: 10.1002/(SICI)1098-240X(199902)22:1<27::AID-NUR4>;2-T.
    1. Kambhu PP, Levy SM. Oral hygiene care levels in Iowa intermediate care facilities. Spec Care Dentist. 1993;13(5):209–214. doi: 10.1111/j.1754-4505.1993.tb01498.x.
    1. Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. J Adv Nurs. 1996;24(3):552–560. doi: 10.1046/j.1365-2648.1996.22416.x.
    1. Pyle MA, Jasinevicius TR, Sawyer DR, Madsen J. Nursing home executive directors' perception of oral care in long-term care facilities. Spec Care Dentist. 2005;25(2):111–117. doi: 10.1111/j.1754-4505.2005.tb01420.x.
    1. Algase DL, Beck C, Kolanowski A, Whall A, Berent S, Richards K, Beattie E. Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. Am J Alzheimers Dis Other Demen. 1996;11(6):10–19. doi: 10.1177/153331759601100603.
    1. Kolanowski AM, Whall AL. Toward holistic theory-based intervention for dementia behavior. Holist Nurs Pract. 2000;14(2):67–76.
    1. Whall A. Developing Needed Interventions from the Need-Driven Dementia-Compromised Behavior Model. J Gerontol Nurs. 2002;28(10):5.
    1. Volicer L, Bass EA, Luther SL. Agitation and resistiveness to care are two separate behavioral syndromes of dementia. J Am Med Dir Assoc. 2007;8:527–532. doi: 10.1016/j.jamda.2007.05.005.
    1. Beck C, Heacock P, Mercer SO, Walls RC, Rapp CG, Vogelpohl TS. Improving dressing behavior in cognitively impaired nursing home residents. Nurs Res. 1997;46(3):126–132. doi: 10.1097/00006199-199705000-00002.
    1. Frenkel HF. Behind the screens: care staff observations on delivery of oral health care in nursing homes. Gerodontology. 1999;16(2):75–80. doi: 10.1111/j.1741-2358.1999.00075.x.
    1. Chalmers JM, Levy SM, Buckwalter KC, Ettinger RL, Kambhu PP. Factors influencing nurses' aides provision of oral care for nursing facility residents. Spec Care Dentist. 1996;16(2):71–79. doi: 10.1111/j.1754-4505.1996.tb00837.x.
    1. Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc. 2006;54(1):138–143. doi: 10.1111/j.1532-5415.2005.00565.x.
    1. Jablonski RA, Therrien B, Kolanowski A. No more fighting and biting during mouth care: Applying the theoretical constructs of threat perception to clinical practice. Research & Theory for Nursing Practice. 2011. in press .
    1. LeDoux J. The emotional brain, fear, and the amygdala. Cell Mol Neurobiol. 2003;23(4-5):727–738.
    1. Maren S. Building and burying fear memories in the brain. Neuroscientist. 2005;11(1):89–99. doi: 10.1177/1073858404269232.
    1. Ohman A. The role of the amygdala in human fear: automatic detection of threat. Psychoneuroendocrinology. 2005;30(10):953–958. doi: 10.1016/j.psyneuen.2005.03.019.
    1. LeDoux J. The emotional brain, fear, and the amygdala. Cellular and molecular neurobiology. 2003;23(4-5):727–738.
    1. Corcoran KA, Desmond TJ, Frey KA, Maren S. Hippocampal inactivation disrupts the acquisition and contextual encoding of fear extinction. J Neurosci. 2005;25(39):8978–8987. doi: 10.1523/JNEUROSCI.2246-05.2005.
    1. Henry JD, Thompson C, Ruffman T, Leslie F, Withall A, Sachdev P, Brodaty H. Threat perception in mild cognitive impairment and early dementia. J Gerontol B Psychol Sci Soc Sci. 2009;64B(5):603–607. doi: 10.1093/geronb/gbp064.
    1. Jablonski RA, Therrien B, Mahoney EK, Kolanowski A, Gabello M, Brock A. An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist. 2011;31(3):77–87. doi: 10.1111/j.1754-4505.2011.00190.x.
    1. Chalmers J, Pearson A. Oral hygiene care for residents with dementia: a literature review. J Adv Nurs. 2005;52(4):410–419. doi: 10.1111/j.1365-2648.2005.03605.x.
    1. Oral health topics: dentures.
    1. Oral Health Topics: Cleaning your teeth and gums.
    1. Gil-Montoya JA, de Mello AL, Cardenas CB, Lopez IG. Oral health protocol for the dependent institutionalized elderly. Geriatr Nurs. 2006;27(2):95–101. doi: 10.1016/j.gerinurse.2005.12.003.
    1. Chalmers J, Johnson V, Tang JH, Titler MG. Evidence-based protocol: oral hygiene care for functionally dependent and cognitively impaired older adults. J Gerontol Nurs. 2004;30(11):5–12.
    1. Mahoney EK, Hurley AC, Volicer L. Instruction Manual for the Resistiveness to Care Scale (RTC-DAT) Boston, MA: Boston College School of Nursing; 1999.
    1. Chalmers JM. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Spec Care Dentist. 2000;20(4):147–154. doi: 10.1111/j.1754-4505.2000.tb01152.x.
    1. Williams KN, Herman R, Gajewski B, Wilson K. Elderspeak communication: impact on dementia care. Am J Alzheimers Dis Other Demen. 2009;24(1):11–20. doi: 10.1177/1533317508318472.
    1. Herman R, Williams KN. Elderspeak's influence on resistiveness to care: Focus on behavioral events. Am J Alzheimers Dis Other Demen. 2009;24(5):417–423. doi: 10.1177/1533317509341949.
    1. Burgener SC, Jirovec M, Murrell L, Barton D. Caregiver and environmental variables related to difficult behaviors in institutionalized, demented elderly persons. J Gerontol. 1992;47(4):P242–249.
    1. Bosker RJ, Snijders TAB, Guldemond H. PINT (Power IN Two-Level Designs): Estimating Standard Errors of Regression Coefficients in Hierarchical Linear Models for Power Calculations. User's Manual, Version 1.6. 1999.
    1. Snijders TAB, Bosker RJ. Standard errors and sample sizes in two-level research. Journal of Educational Statistics. 1993;18(3):237–260.
    1. Snijders TAB, Bosker RJ. Multilevel Analysis. London: Sage Publications; 1999.
    1. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State:" A practical method for grading the congitive state of patients for the clinician. Journal of Psychiatric Research. 1975. pp. 189–198.
    1. Resnick B, Rogers V, Galik E, Gruber-Baldini AL. Measuring restorative care provided by nursing assistants: reliability and validity of the Restorative Care Behavior Checklist. Nursing research. 2007;56(6):387–398. doi: 10.1097/.
    1. Buckwalter KC, Grey M, Bowers B, McCarthy AM, Gross D, Funk M, Beck C. Intervention research in highly unstable environments. Research in nursing & health. 2009;32(1):110–121. doi: 10.1002/nur.20309.
    1. Rantz MJ, Hicks L, Petroski GF, Madsen RW, Mehr DR, Conn V, Zwygart-Staffacher M, Maas M. Stability and sensitivity of nursing home quality indicators. The journals of gerontology. 2004;59(1):79–82.
    1. Kolanowski A, Buettner L, Moeller J. Treatment fidelity plan for an activity intervention designed for persons with dementia. Am J Alzheimers Dis Other Demen. 2006;21(5):326–332. doi: 10.1177/1533317506291074.
    1. Mahoney EK, Hurley AC, Volicer L, Bell M, Gianotis P, Hartshorn M, Lane P, Lesperance R, MacDonald S, Novakoff L. et al.Development and testing of the Resistiveness to Care Scale. Research in Nursing and Health. 1999;22(1):27–38. doi: 10.1002/(SICI)1098-240X(199902)22:1<27::AID-NUR4>;2-T.
    1. Kayser-Jones J, Bird WF, Paul SM, Long L, Schell ES. An Instrument to assess the oral health status of nursing home residents. The Gerantologist. 1995;35(6):814–824. doi: 10.1093/geront/35.6.814.
    1. Chalmers JM, King PL, Spencer AJ, Wright FA, Carter KD. The oral health assessment tool--validity and reliability. AustDentJ. 2005;50(3):191–199.
    1. Beck C, Heacock P, Mercer SO, Walls RC, Rapp CG, Vogelpohl TS. Improving dressing behavior in cognitively impaired nursing home residents. Nursing research. 1997;46(3):126–132. doi: 10.1097/00006199-199705000-00002.
    1. Sonn U. Longitudinal studies of dependence in daily life activities among elderly persons. Scand J Rehabil Med Suppl. 1996;34:1–35.
    1. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the Index of ADL: A standardized measure of biological and psychosocial function. JAMA. 1963;185:94–919.
    1. Volicer L, Bass EA, Luther SL. Agitation and Resistiveness to Care are two separate behavioral syndromes of dementia. J Am Med Dir Assoc. 2007;8:527–532. doi: 10.1016/j.jamda.2007.05.005.
    1. Reisberg B, Ferris S, De Leon M, Crook T. The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry. 1982;139:1136–1139.
    1. Maas M, Buckwalter K. Final report: Phase II nursing Evaluation Research: Alzheimer's Care Unit [R01 NR01689 - NCNR] Rockville, MD: National Institutes of Health; 1990.
    1. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of chronic diseases. 1987;40(5):373–383. doi: 10.1016/0021-9681(87)90171-8.
    1. Bryk AS, Raudenbush SW. Hierarchical Linear Models. London: Sage Publications; 1992.
    1. Bryk AS, Raudenbush SW. Application of Hierarchical Linear Models to Assessing Change. Psychological Bulletin. 1987;101(1):147–158.
    1. Goldstein H. Multilevel Statistical Models. 2. London: Edward Arnold; 1995.
    1. Goldstein H. In: Multilevel Analysis of Educational Data. Bock RD, editor. New York: Academic Press; 1989. Models for Multilevel Response Variables with an Application to Growth Curves; pp. 107–125.
    1. Raudenbush SW. In: The Analysis of Change. Gottman JM, editor. Mahwah, NJ: Lawrence Eribaum Associates; 1995. Hierarchical Linear Models to Study the Effects of Social Context on Development; pp. 165–201.
    1. Hox JJ, Kreft IGG. Multilevel Analysis Methods. Sociological Methods and Research. 1994;22(3):283–299. doi: 10.1177/0049124194022003001.
    1. Lee VE, Bryk AS. A Multilevel Model of the Social Distribution of High School Achievement. Sociology of Education. 1989;62(July):172–192.
    1. Berry AM, Davidson PM, Masters J, Rolls K. Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. Am J Crit Care. 2007;16(6):552–562. quiz 563.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere