Staff Reports of Behavioral Expressions of Persons With Dementia in 250 Assisted Living Communities

Debra Dobbs, Sheryl Zimmerman, Paula Carder, Anna S Beeber, Stephanie J Palmertree, Debra Dobbs, Sheryl Zimmerman, Paula Carder, Anna S Beeber, Stephanie J Palmertree

Abstract

Background and objectives: Assisted living (AL) residents with dementia commonly exhibit behavioral expressions (BEs), yet no study has examined how AL staff perceive and respond to BEs in terms of the "ABC" model of antecedents, behaviors, and consequences, or how perceptions relate to organizational characteristics. Understanding staff perceptions may inform interventions.

Research design and methods: A convergent, mixed methods design was used in a study of health care supervisors from 250 AL communities in 7 states who reported 366 cases of resident BEs (one successful and one unsuccessful case). Qualitative analysis identified antecedents, BEs, staff responses, resident outcomes, and disposition (aging in place or discharge). Content analysis identified themes and compared case types. Descriptive statistics examined organizational characteristics associated with identifying antecedents.

Results: One quarter of cases recognized antecedents; slightly more were identified in successful (28%) compared to unsuccessful cases (20%); staff in dementia-only and smaller communities identified antecedents more often. Combativeness and anxiety were the most frequently reported BEs. The majority of both types of cases reported staff responses. Medication management was enacted as a response in 40% of cases compared to psychiatric assessment in 33% of cases.

Discussion and implications: Staff training is indicated to increase AL staff recognition of antecedents; doing so might reduce the use of antipsychotic medications. Psychiatric assessment plays an important role in dementia care in AL and warrants further examination. Results could be helpful for applied behavioral researchers interested in developing ways to improve the identification of antecedents of BEs of persons with dementia.

Keywords: Antecedent–Behaviors–Consequences model; Assisted living; Dementia care; Mixed methods; Staff training for persons with dementia.

© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

References

    1. Algase, D. L., Yao, L., Hong, G. R., Son, G. R., Beattie, E. R., Beck, C., & Whall, A. F. (2007). Initial psychometrics of the ambiance scale: A tool to study person–environment interaction in dementia. Aging & Mental Health, 11(3), 266–272. doi:10.1080/13607860600963604
    1. Beck, C. K., Vogelpohl, T. S., Rasin, J. H., Uriri, J. T., O’Sullivan, P., Walls, R., Phillips, R., & Baldwin, B. (2002). Effects of behavioral interventions on disruptive behavior and affect in demented nursing home residents. Nursing Research, 51(4), 219–228. doi:10.1097/00006199-200207000-00002
    1. Burgio, L. D. & Burgio, K. L. (1986). Behavioral gerontology: Application of behavioral methods to the problems of older adults. Journal of Applied Behavior Analysis, 19(4), 321–28. doi:10.1901/jaba.1986.19-321
    1. Carder, P., O’Keeffe, J., O’Keeffe, C., White, E., & Wiener, J. M. (2016,). State regulatory provisions for residential care settings: An overview of staffing requirements. RTI Press. doi:10.3768/rtipress.2016.op.0030.1607
    1. Caspi E. (2013). Time for change: Persons with dementia and “behavioral expressions,” not “behavior symptoms.” Journal of the American Medical Directors Association, 14, 768–769. doi:10.1016/j.jamda.2013.05.019
    1. Chen, J. C., Borson, S., & Scanlan, J. M. (2000). Stage-specific prevalence of behavioral symptoms in Alzheimer’s disease in a multi-ethnic community sample. American Journal of Geriatric Psychiatry, 8(2), 123–133.
    1. Cho, J. Y., & Lee, E. (2014). Reducing confusion about Grounded Theory and qualitative content analysis: Similarities and differences. The Qualitative Report, 19(32), 1–20.
    1. Creswell, J. W., & Clark, V. L. P. (2018). The nature of mixed methods research. In Creswell J. W. & Clark V. L. P. (Eds.), Designing and conducting mixed methods research (pp. 1–20). SAGE Publications.
    1. Cunningham, C. (2006). Understanding challenging behaviour in patients with dementia. Nursing Standard, 20(47), 42–45.
    1. Dobbs, D., Hobday, J., Roker, R., Kaas, M. J., & Molinari, V. (2018). Certified nursing assistants’ perspectives of the CARES® activities of daily living dementia care program. Applied Nursing Research, 39, 244–248. doi:10.1016/j.apnr.2017.11.016
    1. Fazio, S., Zimmerman, S., Doyle, P. J., Shubeck, E., Carpenter, M., Coram, P., Klinger, J. H., Jackson, L., Pace, D., Kallmyer, B., Pike, J., & Members of the Alzheimer’s Association Dementia Care Provider Rountable. (2020). What is really needed to provide effective, person-centered care for behavioral expressions of dementia? Guidance from the Alzheimer’s Association Dementia Care Provider Roundtable. Journal of the American Medical Directors Association, 21(11), 1582–1586.E1. doi:10.1016/j.jamda.2020.05.017
    1. Gilhooly, K. J., Gilhooly, M. L., Sullivan, M. P., McIntyre, A., Wilson, L., Harding, E., Woodbridge, R., & Crutch, S. (2016). A meta-review of stress, coping and interventions in dementia and dementia caregiving. BMC Geriatrics, 16, 106. doi:10.1186/s12877-016-0280-8
    1. Goga, J. K., Depaolo, A., Khushalani, S., Walters, J. K., Roca, R., Zisselman, M., & Borleis, C. (2017). Lean methodology reduces inappropriate use of antipsychotics for agitation at a psychiatric hospital. The Consultant Pharmacist, 32(1), 54–62. doi:10.4140/TCP.n.2017.54
    1. Hobday, J. V., Savik, K., Smith, S., & Gaugler, J. E. (2010). Feasibility of internet training for care staff of residents with dementia: The CARES program. Journal of Gerontological Nursing, 36(4), 13–21. doi:10.3928/00989134-20100302-01
    1. Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. doi:10.1177/1049732305276687
    1. Ismail, Z., Smith, E. E., Geda, Y., Sultzer, D., Brodaty, H., Smith, G., Aguera-Ortiz, L., Sweet, R., Miller, D., Lyketsos, C. G., & ISTAART Neuropsychiatric Symptoms Professional Interest Area. (2016). Neuropsychiatric symptoms as early manifestations of emergent dementia: Provisional diagnostic criteria for mild behavioral impairment. Alzheimer’s & Dementia, 12(2), 195–202. doi:10.1016/j.jalz.2015.05.017
    1. Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2019). When less is more, but still not enough: Why focusing on limiting antipsychotics in people with dementia is the wrong policy imperative. Journal of the American Medical Directors Association, 20(9), 1074–1079. doi:10.1016/j.jamda.2019.05.022
    1. Karlin, B. E., Teri, L., McGee, J. S., Sutherland, E. S., Asghar-Ali, A., Crocker, S. M., Smith, T. L., Curyto, K., Drexler, M., & Karel, M. J. (2017). STAR-VA intervention for managing challenging behaviors in VA community living center residents with dementia: Manual for STAR-VA behavioral coordinators and nurse champions.U.S. Department of Veterans Affairs.
    1. Karlin, B. E., Visnic, S., McGee, J. S., & Teri, L. (2014). Results from the multisite implementation of STAR-VA: A multicomponent psychosocial intervention for managing challenging dementia-related behaviors of veterans. Psychological Services, 11(2), 200–208. doi:10.1037/a0033683
    1. Kong, E. H. (2005). Agitation in dementia: Concept clarification. Journal of Advanced Nursing, 52(5), 526–536. doi:10.1111/j.1365-2648.2005.03613.x
    1. Logsdon, R. G., Teri, L., McCurry, S. M., Gibbons, L. E., Kukull, W. A., & Larson, E. B. (1998). Wandering: A significant problem among community-residing individuals with Alzheimer’s disease. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 53(5), 294–299. doi:10.1093/geronb/53b.5.p294
    1. Mahoney, E., Volicer, L., & Hurley, A. (2000). Management of challenging behaviors in dementia. Health Professions Press.
    1. McDermott, C. & Gruenewald, D. (2019). Pharmacologic management of agitation in patients with dementia. Current Geriatrics Reports, 8(1), 1–11. doi:10.1007/s13670-019-0269-1
    1. National Center for Health Statistics. (2018). Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2015–2016.
    1. Pleasant, M. L., Molinari, V., Hobday, J. V., Fazio, S., Cullen, N., & Hyer, K. (2017). An evaluation of the CARES® Dementia Basics Program among caregivers. International Psychogeriatrics, 29(1), 45–56. doi:10.1017/S1041610216001526
    1. Rattinger, G. B., Burcu, M., Dutcher, S. K., Chhabra, P. T., Rosenberg, P. B., Simoni-Wastila, L., Franey, C. S., Walker, L. D., & Zuckerman, I. H. (2013). Pharmacotherapeutic management of dementia across settings of care. Journal of the American Geriatrics Society, 61(5), 723–733. doi:10.1111/jgs.12210
    1. Scales, K., Zimmerman, S., & Miller, S. J. (2018). Evidence-based nonpharmacological practices to address behavioral and psychological symptoms of dementia. The Gerontologist, 58(Suppl. 1), S88–S102. doi:10.1093/geront/gnx167
    1. Scientific Software Development. (2018). ATLAS.ti Scientific Software Development GmbH. (Version 8).
    1. Sloane, P. D., Hoeffer, B., Mitchell, C. M., McKenzie, D. A., Barrick, A. L., Rader, J., Stewart, B. J., Talerico, K. A., Rasin, J. H., Zink, R. C., & Koch, G. G. (2004). Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(11), 1795–1804. doi:10.1111/j.1532-5415.2004.52501.x
    1. Smith, M., & Buckwalter, K. (1993). Back to the A–B–C’s: Understanding & responding to behavioral symptoms in dementia. Supportive materials. The John A. Hartford Center of Geriatric Nursing Excellence & College of Nursing, University of Iowa.
    1. Stall, N. M., Kim, S. J., Hardacre, K. A., Shah, P. S., Straus, S. E., Bronskill, S. E., Lix, L. M., Bell, C. M., & Rochon, P. A. (2019). Association of informal caregiver distress with health outcomes of community-dwelling dementia care recipients: A systematic review. Journal of the American Geriatrics Society, 67(3), 609–617. doi:10.1111/jgs.15690
    1. Teri, L. (1994). Behavioral treatment of depression in patients with dementia. Alzheimer Disease and Associated Disorders, 8(Suppl. 3), 66–74.
    1. Teri, L., & Gallagher-Thompson, D. (1991). Cognitive-behavioral interventions for treatment of depression in Alzheimer’s patients. The Gerontologist, 31(3), 413–416. doi:10.1093/geront/31.3.413
    1. Teri, L., Huda, P., Gibbons, L., Young, H., & van Leynseele, J. (2005). STAR: A dementia-specific training program for staff in assisted living residences. The Gerontologist, 45(5), 686–693. doi:10.1093/geront/45.5.686
    1. Teri, L., Logsdon, R. G., Uomoto, J., & McCurry, S. M. (1997). Behavioral treatment of depression in dementia patients: A controlled clinical trial. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 52(4), 159–166. doi:10.1093/geronb/52b.4.p159
    1. Teri, L., McKenzie, G., Logsdon, R. G., McCurry, S. M., Bollin, S., Mead, J., & Menne, H. (2012). Translation of two evidence-based programs for training families to improve care of persons with dementia. The Gerontologist, 52(4), 452–459. doi:10.1093/geront/gnr132
    1. Volicer, L. (2009). Behaviors in advanced dementia. Journal of the American Medical Directors Association, 10(2), 146. doi:10.1016/j.jamda.2008.10.017
    1. Volicer, L. (2018). Behavioral problems and dementia. Clinics in Geriatric Medicine, 34(4), 637–651. doi:10.1016/j.cger.2018.06.009
    1. Volicer L. (2020). Problems with DICE and BPSD. Journal of the American Medical Directors Association, 21(4), 563–564. doi:10.1016/j.jamda.2019.11.031
    1. Volicer, L., & Hurley, A. C. (2003). Management of behavioral symptoms in progressive degenerative dementias. The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 58(9), 837–845. doi:10.1093/gerona/58.9.m837
    1. Zimmerman, S., Cohen, L. W., Reed, D., Gwyther, L. P., Washington, T., Cagle, J. G., Beeber, A. S., & Sloane, P. D. (2013). Comparing families and staff in nursing homes and assisted living: Implications for social work practice. Journal of Gerontological Social Work, 56(6), 535–553. doi:10.1080/01634372.2013.811145
    1. Zimmerman, S., Scales, K., Wiggins, B., Cohen, L. W., & Sloane, P. D. (2015). Addressing antipsychotic use in assisted living residents with dementia. Journal of the American Geriatrics Society, 63(9), 1970–1971. doi:10.1111/jgs.13625
    1. Zimmerman, S., Sloane, P. D., Eckert, J. K., Gruber-Baldini, A. L., Morgan, L. A., Hebel, J. R., Magaziner, J., Stearns, S. C., & Chen, C. K. (2005). How good is assisted living? Findings and implications from an outcomes study. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 60(4), 195–204. doi:10.1093/geronb/60.4.s195
    1. Zimmerman, S., Sloane, P. D., & Reed, D. (2014). Dementia prevalence and care in assisted living. Health Affairs, 33(4), 658–666. doi:10.1377/hlthaff.2013.1255
    1. Zimmerman, S., Sloane, P. D., Ward, K., Wretman, C. J., Stearns, S. C., Poole, P., & Preisser, J. S. (2020). Effectiveness of a Mouth Care Program provided by nursing home staff vs standard care on reducing pneumonia incidence: A cluster randomized trial. JAMA Network Open, 3(6), e204321. doi:10.1001/jamanetworkopen.2020.4321

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