The relationship between caregivers' behaviors and resistant behaviors of persons living with dementia during personal care in long-term care facilities: A lag sequential analysis.

Many older adults living with dementia exhibit resistant behaviors. Person-centered care is the gold standard of care; however, the sequential relationship between resistant and caregiving behaviors has not been identified. This study examined the sequential relationship between caregiving and care-resistant behaviors and analyzed 68 videos of personal care encounters of 21 residents living in four long-term care facilities. The videos were coded focusing on two sequences of behavior: residents' resistant behaviors and caregivers' behaviors. Lag sequential analysis was conducted using initial-response behavior pairs (resident-caregiver behavior or caregiver-resident behavior pairs). Person-centered care led to less resistant behavior (odds ratio 0.23; 95 % confidence interval 0.16, 0.33), whereas less person-centered care was followed by resistant behaviors (odds ratio 0.42; 95 % confidence interval 0.30, 0.59). A significant sequential association was found between task-centered behavior and resistant behavior. Hence, rigorous efforts are recommended to provide person-centered care through multilevel efforts.

Health Care Team Interventions to Reduce Distress Behaviors in Older Adults: A Systematic Review.

OBJECTIVES: This review examines health care team-focused interventions on managing persistent or recurrent distress behaviors among older adults in long-term residential or inpatient health care settings. METHODS: We searched interventions addressing health care worker (HCW) knowledge and skills related to distress behavior management using Ovid MEDLINE, Elsevier Embase, and Ovid PsycINFO from December 2002 through December 2022. RESULTS: We screened 6,582 articles; 29 randomized trials met inclusion criteria. Three studies on patient-facing HCW interactions (e.g. medication management, diagnosing distress) showed mixed results on agitation; one study found no effect on quality of life. Six HCW-focused studies suggested short-term reduction in distress behaviors. Quality-of-life improvement or decreased antipsychotic use was not evidenced. Among 17 interventions combining HCW-focused and patient-facing activities, 0 showed significant distress reduction, 8 showed significant antipsychotic reduction (OR = 0.79, 95%CI [0.69, 0.91]) and 9 showed quality of life improvements (SMD = 0.71, 95%CI [0.39, 1.04]). One study evaluating HCW, patient-, and environmental-focused intervention activities showed short-term improvement in agitation. CONCLUSIONS AND CLINICAL IMPLICATIONS: Novel health care models combining HCW training and patient management improve patient quality of life, reduce antipsychotic use, and may reduce distress behaviors. Evaluation of intervention's effects on staff burnout and utilization is needed.

Perspectives on Deprescribing in long-term care: qualitative findings from nurses, aides, residents, and proxies.

BACKGROUND: Deprescribing initiatives in the long-term care (LTC) setting are often unsuccessful or not sustained. Prior research has considered how physicians and pharmacists feel about deprescribing, yet little is known about the perspectives of frontline nursing staff and residents. Our aim was to elicit perspectives from LTC nursing staff, patients, and proxies regarding their experiences and preferences for deprescribing in order to inform future deprescribing efforts in LTC. METHODS: This study was a qualitative analysis of interviews with nurses, nurse aides, a nurse practitioner, residents, and proxies (family member and/or responsible party) from three LTC facilities. The research team used semi-structured interviews. Guides were designed to inform an injury prevention intervention. Interviews were recorded and transcribed. A qualitative framework analysis was used to summarize themes related to deprescribing. The full study team reviewed the summary to identify actionable, clinical implications. RESULTS: Twenty-six interviews with 28 participants were completed, including 11 nurse aides, three residents, seven proxies, one nurse practitioner, and six nurses. Three themes emerged that were consistent across facilities: 1) build trust with team members, including residents and proxies; 2) identify motivating factors that lead to resident, proxy, nurse practitioner, and staff acceptance of deprescribing; 3) standardize supportive processes to encourage deprescribing. These themes suggest several actionable steps to improve deprescribing initiatives including: 1) tell stories about successful deprescribing, 2) provide deprescribing education to frontline staff, 3) align medication risk/benefit discussions with what matters most to the resident, 4) standardize deprescribing monitoring protocols, 5) standardize interprofessional team huddles and care plan meetings to include deprescribing conversations, and 6) strengthen non-pharmacologic treatment programs. CONCLUSIONS: By interviewing LTC stakeholders, we identified three important themes regarding successful deprescribing: Trust, Motivating Factors, and Supportive Processes. These themes may translate into actionable steps for clinicians and researchers to improve and sustain person-centered deprescribing initiatives. TRIAL REGISTRATION: NCT04242186.

The interagency care team: A new model to integrate social and medical care for older adults in primary care.

To integrate management of social drivers of health with complex clinical needs of older adults, we connected patients aged 60 and above from primary care practices with a nurse practitioner (NP) led Interagency Care Team (ICT) of geriatrics providers and community partners via electronic consult. The NP conducted a geriatric assessment via telephone, then the team met to determine recommendations. Thirteen primary care practices referred 123 patients (median age = 76) who had high rates of emergency department use and hospitalization (28.9% and 17.4% respectively). Issues commonly identified included medication management (84%), personal safety (72%), disease management (69%), food insecurity (63%), and cognitive decline (53%). Referring providers expressed heightened awareness of older adults' social needs and high satisfaction with the program. The ICT is a scalable model of care that connects older adults with complex care needs to geriatrics expertise and community services through partnerships with primary care providers.

Care Coordination Processes in Transitional Care for Patients With Heart Failure: An Integrative Review Through a Social Network Lens.

BACKGROUND: Transitional care components are well studied, but their coordination has not been systematically reviewed. Viewing transitional care through a social network framework can focus attention on processes leading to information and relationship transferal to ensure continuity and may lead to new strategies to improve transitional care. OBJECTIVE: The aim of this study was to examine care coordination processes in transitional care interventions for older adults with heart failure by integrating a social network analysis approach. METHODS: PubMed, Scopus, and CINAHL were searched to capture transitional care interventions ( a ) involving care coordination for older adults with heart failure transitioning from hospital to home and ( b ) published in the United States from 2010 to 2020. Study characteristics, intervention characteristics, and care coordination processes (ie, participants, interactions among participants, and their characteristics) were extracted. RESULTS: In 17 studies reviewed, the number of individual roles involved in care coordination varied from 3 to 32. Nurses and pharmacists were the most common interventionists. Six studies involved informal caregivers. In-person interactions were most common among individuals within settings; interactions across settings were typically assisted by technology. Despite high variability among the individuals and interactions involved, a common triadic process was found through which interventionists, patients, and primary care providers or outpatient cardiologists aimed to facilitate the transfer of information and care relationships from hospital to community. CONCLUSIONS: High variability in transitional care is likely because the processes are highly relational. Using a network analysis may help uncover the relational structures and processes underlying transitional care to inform intervention development.

A Standardized Positive Physical Approach to Improve Oral Hygiene for Nursing Home Residents With Alzheimer's Disease and Related Dementias.

Residents with Alzheimer's disease and related dementias (ADRD) in nursing homes (NHs) rely on direct care workers (DCWs) to assist with activities of daily living, such as oral hygiene. The current quality improvement project was implemented to evaluate the effectiveness of teaching a standardized positive physical approach to oral hygiene completion for patients with ADRD residing in a NH. A pre-/postintervention evaluation incorporating a video presentation coupled with a hands-on simulation experience showed a statistically significant improvement in DCWs' overall Sense of Competency in Dementia score, as well as all subcategories of the Sense of Competence in Dementia Care Staff survey. In addition, residents' day shift oral hygiene care completion rates increased monthly pre- to postintervention. NHs should consider implementing training that includes hands-on experiences to equip DCWs with the knowledge and skill needed to improve oral hygiene among residents with ADRD. [Journal of Gerontological Nursing, 48(11), 15-20.].

A mixed methods study on the manifestations of behavioural symptoms of dementia among veterans with and without posttraumatic stress disorder.

AIMS: To explore how behavioural symptoms of dementia are manifested among veterans in residential long-term care settings, in the context of personal, interpersonal/social and environmental triggers and how the manifestations differ between veterans with and without posttraumatic stress disorder. DESIGN: Secondary analysis using a mixed methods approach. METHODS: We analysed text data from a stratified random sample of 66 cases derived from the programme evaluation dataset of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention from 2013 to 2016, using framework analysis. The detailed behavioural assessment descriptions in this dataset are consistent with contemporary non-pharmacologic symptom management. Qualitative categories were converted to quantitative variables for two group comparisons. RESULTS: Four patterns emerged linking specific types of triggers and behavioural symptoms: (1) unmet physical needs or emotional distress triggers non-aggressive behaviours; (2) unsolicited direct care approach triggers care refusal, resistance or combativeness; (3) interpersonal interactions interfering with self-direction trigger aggressive behaviours; and (4) uncontrolled stimulation from environments trigger non-aggressive behaviours. The organisational culture of care influenced how staff conceptualised behavioural symptoms. Veterans with co-existing posttraumatic stress disorder and dementia tended to exhibit rejection of care with aggression compared to those with dementia alone. CONCLUSION: Contextualised accounts of behavioural symptoms of dementia revealed symptom heterogeneity, with different clusters of multi-level triggers arising from specific personal, interpersonal and environmental circumstances. Distinct patterns of symptom manifestations between veterans with and without posttraumatic stress disorder suggest a tailored approach is required to meet each veteran's unique biopsychosocial needs. IMPACT: Classifying behavioural symptoms with their triggers rather than solely by behaviours provides important new information for developing person-centred, non-pharmacological interventions to improve outcomes for veterans with dementia. Multi-level interventions should be considered to meet veteran's needs that account for their earlier life history and current life circumstances.

Mealtime caregiving approaches and behavioral symptoms in persons living with dementia: a longitudinal, observational study.

BACKGROUND: Behavioral symptoms during mealtime can prohibit persons living with dementia from obtaining sufficient nutrition. However, little research has examined the relationship between behavioral symptoms and caregiving approaches. This study examines this relationship and further explores which specific caregiver behaviors were related to behavioral symptoms among persons living with dementia. METHODS: A secondary data analysis was performed using 86 mealtime videos from a longitudinal, observational study. The videos were repeatedly taken at months 0, 3, and 6 with 30 persons living with dementia in one of four long-term care facilities. Video coding was performed using coding schemes modified from the Cohen-Mansfield Agitation Inventory for behavioral symptoms and the Person-/Task-Centered Behavior Inventory for caregiving approaches. Coding schemes for behavioral symptoms consisted of four categories: total duration, aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. Caregiving approaches consisted of ten-verbal/seven-nonverbal person-centered behavior codes, four-verbal/four-nonverbal task-centered behavior codes, and no-verbal/no-nonverbal interaction codes. A mixed-effect model was conducted using variables such as demographics, medical information, cognitive status, depression, function, and caregiving approaches as fixed effects, participant as a random effect, and four categories of behavioral symptoms as dependent variables. RESULTS: The total duration of the Cohen-Mansfield Agitation Inventory was associated with no verbal response (ß = 9.09) and task-centered verbal behavior (ß = 8.43), specifically verbal controlling (ß = 7.87). Physically nonaggressive behavior was associated with no verbal response (ß = 9.36). Verbally agitated behavior was associated with task-centered nonverbal behavior (ß = 51.29), and specifically inappropriate touch (ß = 59.05). CONCLUSIONS: Mealtime is indispensable to dementia care for ensuring adequate nutrition and promoting personhood. Our findings revealed caregivers' task-centered behaviors and no interaction were related to behavioral symptoms of persons living with dementia. When caregivers encounter behavioral symptoms during mealtime, it is recommended to avoid no response and task-centered behaviors, especially verbal controlling and inappropriate touch, and to promote person-centered behaviors.

Nursing home residents' perspectives on their social relationships.

AIMS AND OBJECTIVES: To explore nursing home residents' perspectives on their relationships with other residents, family members and staff. BACKGROUND: The cultivation of social relationships is central to promoting well-being in nursing homes, as these relationships allow residents, family members and staff to be valued as unique persons and empowered as partners in care. Few studies have examined how nursing home residents perceive the relationships in their social networks, both within and beyond the facility. DESIGN: Qualitative secondary analysis. METHODS: We analysed individual and group interviews obtained during "stakeholder engagement sessions" with cognitively intact residents (N = 11 sessions; N = 13 participants) from two nursing homes in North Carolina. The interviews were conducted as part of a larger study on person-directed care planning. We integrated thematic and narrative analytic approaches to guide the analysis of interview data, using a three-cycle coding approach. The COREQ checklist was followed. RESULTS: Four broad themes emerged from this analysis: (a) peer relationships foster a sense of belonging, purpose, achievement and significance; (b) residents' relationships with family members support a sense of belonging, continuity and significance; (c) mutual respect and reciprocity between residents and nursing home staff promote a sense of belonging and significance; and (d) organisational factors pose barriers to forging meaningful relationships. Each type of relationship-peer, family and staff-made distinctive contributions residents' psychosocial well-being. CONCLUSION: Recognising the diverse roles of different actors from residents' social networks raises questions for future research to optimise the distinctive contributions of network members that promote residents' psychosocial well-being. RELEVANCE TO CLINICAL PRACTICE: This study highlights the need for nursing home staff to understand how residents' social relationships influence residents' psychosocial outcomes. Staff training programmes are needed to support residents' rights and to dispel inaccurate interpretations of regulations that threaten sustained meaningful relationships.

Neurocognitive and psychiatric comorbidities of posttraumatic stress disorder among older veterans: A systematic review.

OBJECTIVES: Posttraumatic stress disorder (PTSD) is associated with neurocognitive and psychiatric comorbidities, and older adults experience comorbid illnesses disproportionately. Little is known about the comorbidities of PTSD among older veterans. This systematic review examines the prevalence, incidence, and patterns of neurocognitive and psychiatric comorbidities of PTSD among older veterans and explores the factors associated with these comorbidities. METHODS: A systematic literature review was performed using PubMed, CINAHL, and PsycINFO databases. The search was limited to peer-reviewed articles published in English from January 1980 to October 2018. Eligible studies examined the comorbid neurocognitive and psychiatric disorders of PTSD among veterans aged 60 and older. RESULTS: Twenty-four studies met the criteria for inclusion. The risk for dementia was higher in veterans with PTSD than those without PTSD; hazard ratios ranged from 1.21 to 1.77. Depressive disorder was the most prevalent psychiatric comorbidity with estimates ranging from 33% to 52.3%, followed by generalized anxiety disorder (14%-15%) and substance use disorders (1.9%-11.3%). Factors consistently associated with PTSD comorbidities included age, combat-related exposures, clinical conditions, and health-related and psychosocial outcomes. CONCLUSIONS: Despite heterogeneity in research designs and methodological limitations, this review highlights the need to consider comorbid neurocognitive and psychiatric disorders among older veterans with PTSD in order to individualize care approaches. Future research should incorporate factors associated with neurocognitive and psychiatric comorbidities of PTSD into study designs that can help improve prediction of comorbidity and generate evidence for developing and implementing tailored treatments in older veterans.

Dementia caregiver interventions in Chinese people: A systematic review.

AIMS: The aim of this systematic review was to examine the characteristics and the efficacy of dementia caregiving interventions among the Chinese population. BACKGROUND: In recent years, an increasing number of dementia caregiving interventions have been developed for Chinese older adults living in Asia that aim to reduce caregivers' burden, depression and distress, and enhance quality of life. Little is known, however, on the nature and the efficacy of these interventions. DESIGN: Systematic review with narrative summary. DATA SOURCES: We searched four databases for studies published in English between 1 January 1994-30 December 2017. Nineteen studies reported in 23 articles were included in the final analysis. REVIEW METHODS: We used a set of criteria from the Cochrane Collaboration tool to assess for the risk of bias across studies. RESULTS: We found that interventions varied in length, frequency, approach, and content, making comparisons across studies challenging. Caregivers' burden, depression, and distress were improved among most included studies. All studies that examined quality of life of caregivers (N = 6) showed improvement. Most of the interventions showed beneficial effects on care recipients' behavioural symptoms, agitation, and depression; cognitive function, however, failed to improve. CONCLUSION: Although the review found mixed results on intervention outcomes, the majority of interventions showed a potential to improve the health and well-being of dementia caregivers and care recipients. This review provides suggestions for future dementia caregiving research in the Chinese population, such as inclusion of relevant theoretical frameworks and more rigorous research designs.

Emotional Expression of Persons with Dementia: An Integrative Review with Implications for Evidence-Based Practice.

BACKGROUND: The ability to express emotion typically is preserved longer than language and cognitive function in persons living with dementia. Emotional expression may be an important indicator of underlying individual needs and feelings and may therefore facilitate person-centered care. AIMS: This review aimed to examine how emotional expression has been described, measured, and utilized in empirical studies. METHODS: The design of this study was an integrative literature review. A systematic search was conducted through electronic databases using defined search terms. Articles published up to March 2018 were included. The method proposed by Whittemore and Knafl was used for data synthesis and review integration. Quality appraisal of the selected articles was evaluated by the Mixed Methods Assessment Tool. RESULTS: Most of the articles used feeling-related terms without specific definitions. Less frequently, terms such as affect, emotion, and mood were defined. Although these terms were used interchangeably in the articles, affect, which was defined as expressed emotion in general, was a comprehensive term to encompass other terms. Measurement of emotional expression was performed using observational methods, with direct observation or video recording using a hand-held camera. In both cases, observed emotion was coded with diverse methods or tools. In studies, the emotional expression was utilized as (a) an outcome to demonstrate the effect of interventions, (b) a factor to show relationship with other variables, or (c) an observed value itself. LINKING EVIDENCE TO ACTION: This review provides insights about measurement options for emotional expressions among persons with dementia in long-term care. Long-term care staff should pay attention to emotional expression of persons with dementia to understand underlying unmet needs. Development of adequate measurement of emotional expression could facilitate development of emotion-oriented intervention program to improve psychological well-being and the behavioral and functional health of persons living with dementia.

Technology-based cognitive training and rehabilitation interventions for individuals with mild cognitive impairment: a systematic review.

BACKGROUND: Individuals with mild cognitive impairment (MCI) are at heightened risk of developing dementia. Rapid advances in computing technology have enabled researchers to conduct cognitive training and rehabilitation interventions with the assistance of technology. This systematic review aims to evaluate the effects of technology-based cognitive training or rehabilitation interventions to improve cognitive function among individuals with MCI. METHODS: We conducted a systematic review using the following criteria: individuals with MCI, empirical studies, and evaluated a technology-based cognitive training or rehabilitation intervention. Twenty-six articles met the criteria. RESULTS: Studies were characterized by considerable variation in study design, intervention content, and technologies applied. The major types of technologies applied included computerized software, tablets, gaming consoles, and virtual reality. Use of technology to adjust the difficulties of tasks based on participants' performance was an important feature. Technology-based cognitive training and rehabilitation interventions had significant effect on global cognitive function in 8 out of 22 studies; 8 out of 18 studies found positive effects on attention, 9 out of 16 studies on executive function, and 16 out of 19 studies on memory. Some cognitive interventions improved non-cognitive symptoms such as anxiety, depression, and ADLs. CONCLUSION: Technology-based cognitive training and rehabilitation interventions show promise, but the findings were inconsistent due to the variations in study design. Future studies should consider using more consistent methodologies. Appropriate control groups should be designed to understand the additional benefits of cognitive training and rehabilitation delivered with the assistance of technology.

Improving Oral Hygiene for Veterans With Dementia in Residential Long-term Care.

Oral hygiene care is neglected in long-term care (LTC) due to patient-, staff-, and systems-level barriers. A dementia-specific oral hygiene program, implemented and evaluated in a Department of Veterans Affairs LTC unit, addressed barriers to oral care at multiple levels. Improved staff competency, access to oral care supplies, and standardized documentation systems were accompanied by reduced oral plaque and gingivitis, demonstrating the feasibility and benefits of direct care staff providing improved oral hygiene in LTC.

Implementation of Individualized Music in Long-Term Care: Application of the PARiHS Framework.

The need to provide evidence-based, person-centered care for long-term care (LTC) residents, which often include individuals with dementia, has led to a surge of interest in the implementation of individualized music (IM) programs. An exploratory study was conducted over a 6-month period using the Promoting Action on Research in Health Systems (PARiHS) framework to examine the implementation of an IM program with 19 residents in a LTC facility. All residents using IM had the device available at the end of the program, and 53% received IM at least two times per week. Qualitative analysis of stakeholder interviews with six staff members and three residents after using the PARiHS framework as an implementation guide revealed two themes: Overcoming Resistance to Innovation and Person-Centered Care Through IM. Identification of barriers and facilitators through the PARiHS elements of evidence, context, and facilitation supported the IM implementation process and should enable its replication in other facilities. [Journal of Gerontological Nursing, 44(8), 29-38.].

A pilot-feasibility study of measuring emotional expression during oral care.

This study explored the feasibility of measuring emotional responses to oral care among individuals with dementia living in residential long-term care (LTC). Eleven residents with dementia were recruited from a U.S. Department of Veterans Affairs LTC unit and were observed eight times before, during, and after oral care episodes. Study participants showed a trend toward more positive emotional expressions during and after oral care (mean ± SD: 6.49 ± 1.57 and 6.27 ± 1.20 respectively) than before oral care (6.15 ± 0.86) at the margin of statistical significance (p = .08). Negative emotional expression increased among participants during oral care, from 0.22 ± .35 expressions per minute to 0.60 ± .65 expressions per minute, but returned to baseline after oral care (p < .01). Future studies with more representative samples are needed to more fully examine emotional responses to different types of care, adjusting for potential confounders, and to determine whether residents' emotional responses influence staff members' provision of care.

Management Team Perceptions of Risks and Strategies for Preventing Falls Among Short-Stay Patients in Nursing Homes.

We sought to understand strategies reported by members of the nursing home management team used to prevent falls in short-stay nursing home patients. Using Donabedian's model of structure, process, and outcomes, we interviewed 16 managers from 4 nursing homes in central North Carolina. Nursing home managers identified specific barriers to fall prevention among short-stay patients including rapid changes in functional and cognitive status, staff unfamiliarity with short-stay patient needs and patterns, and policies impacting care. Few interventions for reducing falls among short-stay patients were used at the structure level (eg, specialized units, workload ratio, and staffing consistency); however, many process-level interventions were used (eg, patient education on problem solving, self-care/mobility, and safety). We described several barriers to fall prevention among short-stay patients in nursing homes. From these descriptions, we propose three interventions that might reduce falls for short-stay patients and could be tested in future research: (1) clustering short-stay patients within a physical location to permit higher staff-patient ratios and enhanced surveillance, (2) population-based prevention interventions to supplement existing individually tailored prevention strategies (eg, toileting schedules, medication review for all), and (3) transitional care interventions that transmit key information from hospitals to nursing homes.

Improving Management of Behavioral and Psychological Symptoms of Dementia in Acute Care: Evidence and Lessons Learned From Across the Care Spectrum.

As the prevalence of Alzheimer disease and related dementias increases, dementia-related behavioral symptoms present growing threats to care quality and safety of older adults across care settings. Behavioral and psychological symptoms of dementia (BPSD) such as agitation, aggression, and resistance to care occur in nearly all individuals over the course of their illness. In inpatient care settings, if not appropriately treated, BPSD can result in care complications, increased length of stay, dissatisfaction with care, and caregiver stress and injury. Although evidence-based, nonpharmacological approaches to treating BPSD exist, their implementation into acute care has been thwarted by limited nursing staff expertise in behavioral health, and a lack of consistent approaches to integrate behavioral health expertise into medically focused inpatient care settings. This article describes the core components of one evidence-based approach to integrating behavioral health expertise into dementia care. This approach, called STAR-VA, was implemented in Veterans' Health Administration community living centers (nursing homes). It has demonstrated effectiveness in reducing the severity and frequency of BPSD, while improving staff knowledge and skills in caring for people with dementia. The potential for adapting this approach in acute care settings is discussed, along with key lessons learned regarding opportunities for nursing leadership to ensure consistent implementation and sustainability.

Pain and psychological well-being among people with dementia in long-term care.

OBJECTIVE: To examine the relationship between self-reported pain and psychological well-being of people with dementia (PWD) living in residential long-term care as indicated by displays of observed emotional expression over the daytime period. DESIGN: Secondary analysis using repeated measures of self-report and observational data. SETTING AND SUBJECTS: A total of 177 PWD were included from 17 nursing homes and six assisted living facilities in Michigan and Pennsylvania. METHODS: Negative emotional expression was used as an indicator of reduced psychological well-being. Pain was assessed through PWD's response to a question about presence of pain obtained at each observation. Cognitive impairment was assessed using the Mini-Mental Status Examination. Linear mixed models were used that accounted for correlation of negative emotional expression measurements over time for each participant and between participants within the same facility. RESULTS: Among 171 participants who were able to express their pain, 44% of PWD reported pain once or more during the daytime period. Severity of cognitive impairment was related to expression of negative emotion. PWD with pain displayed more negative emotional expression than PWD without pain. CONCLUSIONS: Routine pain assessment is feasible among PWD with moderate to severe dementia and positive report of pain is associated with greater observed negative emotional expression, an indicator of reduced psychological well-being. Improving pain management holds potential for enhancing psychological well-being among PWD living in residential long-term care.