Facilitators and barriers for families caring for adults living with Alzheimer's dementia: A qualitative study.

This study investigates the barriers and promoters of caring for older adults living with Alzheimer's Dementia (AD) in families. This was a qualitative study through content analysis (based on the Granheim and Lundman method), and the participants were selected using purposive sampling from the families of older adults living with AD who were receiving care in the community. We used semi-structured interviews to collect data from 32 family members. The validity and reliability of the data were assessed using the Lincoln and Guba criteria. In this study, 70.58% of primary caregivers were women. Caregiving facilitators included "Efficient family," "Capable caregiver," and "Motivated caregiver." Caregiving barriers included "Lacking awareness and knowledge," "Vulnerable family," "Older person with complex/multiple needs," and "Lack of care infrastructures." Training families and caregivers and developing care infrastructures for older adults with AD can help reduce caring barriers in older adults.

Randomised clinical trial: Efficacy of strategies to provide oral hygiene activities to nursing home residents with dementia who resist mouth care.

OBJECTIVES: The purpose of this study was to test the efficacy of MOUTh (Managing Oral Hygiene Using Threat Reduction), a nonpharmacologic, relationship-based intervention vs. control on 2 primary outcomes for nursing home (NH) residents with dementia who resisted mouth care: (i) reduction in the occurrence and intensity of care-resistant behaviours (CRBs) and (ii) improvement in oral health. Two secondary outcomes were also examined: (i) the duration of mouth care and (ii) the completion of oral hygiene activities. BACKGROUND: Persons with dementia who exhibit CRBs are at risk for inadequate mouth care and subsequent systemic illnesses. MATERIALS AND METHODS: The study used a randomised repeated measures design. Recruitment occurred in 9 nursing homes that varied in size, ownership, reimbursement patterns and location. One hundred and one nursing home residents with dementia were randomised at the individual level to experimental (n = 55) or control groups (n = 46). One hundred participants provided data for the analyses. RESULTS: Compared to the control group, persons in the experimental group had twice the odds of allowing mouth care and completing oral hygiene activities; they also allowed longer duration of mouth care (d = 0.56), but showed only small reductions in the intensity of CRBs (d = 0.16) and small differential improvements in oral health (d = 0.18). CONCLUSION: The data suggest that this intervention facilitates mouth care among persons with dementia. The management of refusal behaviour may be a clinically more realistic approach than reducing or eradicating refusals.

Feasibility of Providing Safe Mouth Care and Collecting Oral and Fecal Microbiome Samples from Nursing Home Residents with Dysphagia: Proof of Concept Study.

Individuals with dysphagia who reside in nursing homes often receive inadequate mouth care and experience poor oral health. From a policy perspective, the combination of absent evidence-based mouth care protocols coupled with insufficient dental coverage create a pool of individuals at great risk for preventable infectious illnesses that contribute to high health care costs. The purpose of the current study was to determine (a) the safety of a mouth care protocol tailored for individuals with dysphagia residing in nursing homes without access to suction equipment, and (b) the feasibility of collecting oral and fecal samples for microbiota analyses. The mouth care protocol resulted in improved oral hygiene without aspiration, and oral and fecal samples were safely collected from participants. Policies supporting ongoing testing of evidence-based mouth care protocols for individuals with dysphagia are important to improve quality, demonstrate efficacy, and save health care costs. [Journal of Gerontological Nursing, 43(9), 9-15.].

A nurse developed toolkit for long-term care ombudsmen.

Federal regulations provide all nursing home resident access to third party advocates, known as ombudsmen. The ombudsmen are provided unrestricted access to this vulnerable population for complaint investigation and protection of their federally mandated resident's rights. States autonomously administer their ombudsman programs, allowing latitude in hiring and training practices. The majority of state programs rely on a combination of paid and volunteer staff, with most staff lacking formal healthcare training. In an attempt to educate long-term care ombudsmen on common geriatric clinical diagnoses, a clinical toolkit was developed and ombudsmen employed by Alabama Department of Senior Services agreed to pilot test the toolkit. Results of the pilot test did not show ombudsmen with less experience would find the toolkit more useful. Results revealed that all ombudsmen regardless of length of tenure found the toolkit useful.

The invisible elderly: lesbian, gay, bisexual, and transgender older adults.

More than 2 million older adults identify as lesbian, gay, bisexual, or transgender (LGBT). The purpose of this article is to present an overview of the physical and mental health needs of LGBT older adults to sensitize nurses to the specific needs of this group. Nurses are in a prominent position to create health care environments that will meet the needs of this invisible, and often misunderstood, group of people.

Anosognosia for Hemiplegia and Falls After Stroke: A Prospective Correlational Study.

PURPOSE: The aim of this study was to explore the association between the presence and severity of anosognosia for hemiplegia (AHP) and falls in stroke survivors. DESIGN: A prospective, correlational research design was utilized. METHODS: Primary instrumentation included demographic information and the Visual-Analogue Test for Anosognosia for motor impairment (VATA-m). Correlational and regression analyses were performed between a priori variables. RESULTS: There was no statistically significant relationship found between AHP and falls. An incidental finding included that clinicians erroneously charted that their patients were aware of their physical limitations 100% of the time, which indicates that there is discord between clinicians and patients regarding physical limitations. CONCLUSIONS: Though no statistically significant relationship was found between AHP and falls, the incidental finding of dissonance between the patient and the clinician has important clinical implications. RELEVANCE: The relationship between AHP and stroke rehabilitation outcomes is still not understood, and incorporating part of the VATA-m into patient assessment could improve clinician understanding of patient awareness.

Profile of nursing home residents with dementia who require assistance with mouth care.

The majority of nursing home residents require assistance with activities of daily living, including oral care. Poor oral health is common in the nursing home because residents are not given appropriate assistance to support this aspect of their care. The purpose of this study was to describe the demographic, functional, and behavioral profile of nursing home residents with dementia who require verbal or physical assistance with mouth care. Residents who required verbal support to complete mouth care exhibited higher levels of physical function, higher levels of cognitive functioning in the domains of language and executive function, lower levels of passivity, and higher scores for the personality trait of openness than residents who required physical assistance. Best practices for implementing verbal and physical assistance during mouth care to persons with dementia are presented on the basis of these profiles.

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

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.

Certified Nursing Assistants' Perceived Workplace Violence in Long-Term Care Facilities: A Qualitative Analysis.

BACKGROUND: Certified nursing assistants (CNAs) provide 80% to 90% of direct care and are 23 times more likely to experience aggressive behavior from residents in long-term care (LTC) facilities than in other health care settings. The purpose of this study was to describe CNAs' perceptions of workplace violence while working in LTC facilities. METHODS: Ten CNAs were recruited from five LTC facilities through snowball sampling. A semi-structured interview was conducted with CNAs currently working in LTC facilities in Alabama. Question domains included (a) demographics, (b) residents' behavior, (c) behavior of residents with dementia, (d) experiences of verbal or physical violence from residents, (e) quality of care delivered, (f) coping strategies, (g) administrative support, and (h) training for dementia-related care challenges. The resulting transcripts were thematically analyzed. FINDINGS: CNAs described workplace violence as part of the job. They expressed a lack of administrative support as inadequate communication and a dismissal of violence against them. They regularly experienced racially charged abuse, but the perception of abuse was moderated by the presence or absence of dementia. They described a lack of training and direction to recognize and de-escalate workplace violence. CONCLUSIONS/APPLICATION TO PRACTICE: Workplace violence from residents residing in LTC facilities is an occupational health risk for CNAs. LTC facilities need a multisystem approach to reduce episodes of resident-on-CNA violence. This approach should include comprehensive training to recognize triggers of violent behavior, especially when working with individuals with dementia, as well as administrative support, and mental health resources to address the cumulative and negative consequences of racism.

Missed opportunities: under-detection of trauma in elderly adults involved in motor vehicle crashes.

INTRODUCTION: Geriatric trauma, mainly as a result of motor vehicle crashes (MVCs), has been a persistent and serious problem for those older than 65 years of age. Because of physiological changes and pre-existing disease, older adults present a unique clinical challenge to emergency nurses and staff. "Are older adults involved in MVCs appropriately assessed and treated?" METHODS: A review of the research literature, including 17 articles from 2003 to 2009, on the topic of geriatric trauma, specifically trauma that resulted from MVCs will be explored. RESULTS: Four different areas were discussed: (1) the under-detection of geriatric trauma, (2) prehospital triage guidelines, (3)the injury severity score, and (4) common resultant injuries encountered by older adults. DISCUSSION: Understanding specific patterns of injury in older adults and the geriatric trauma outcomes data is essential to emergency nursing practice. Following this literature review, the emergency nurse will be more comfortable managing the next geriatric patient arriving in the emergency department.

Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants.

UNLABELLED: The purpose of this study was to examine the knowledge, beliefs, and practices of nursing assistants (NAs) providing oral hygiene care to frail elders in nursing homes, with the intent of developing an educational program for NAs. METHODS: The study occurred in two economically and geographically diverse nursing homes. From a sample size of 202 NAs, 106 returned the 19-item Oral Care Survey. RESULTS: The NAs reported satisfactory knowledge regarding the tasks associated with providing mouth care. The NAs believed that tooth loss was a natural consequence of aging. They reported that they provided mouth care less frequently than is optimal but cited challenges such as caring for persons exhibiting care-resistive behaviors, fear of causing pain, and lack of supplies. CONCLUSION: Nurses are in a powerful position to support NAs in providing mouth care by ensuring that they have adequate supplies and knowledge to respond to resistive behaviors.

Description of Process and Content of Online Dementia Coaching for Family Caregivers of Persons with Dementia.

Family caregivers of persons with dementia encounter resistance to care behaviors (RCBs). The purpose of this methods paper was to describe the process and content of six weekly 60-min caregiver coaching sessions delivered synchronously through an online platform to 26 family caregivers of persons with dementia. All session notes were analyzed for process; two coaching sessions from five purposely-selected participants were transcribed and analyzed thematically for content. The six sessions followed an overall pattern. The first session included the most teaching and goal-setting; the coaches also queried the family caregiver about the premorbid personality, work history, and interpersonal attributes of the person with dementia. Sessions two through five were the most active coaching sessions; previously suggested strategies were evaluated and tailored; caregivers also role-played with the coaches and developed scripts designed to curtail RCB. The sixth session served as a review of successful caregiver strategies and concluded the coaching relationship. Four primary content themes emerged in the coaching process: (1) education; (2) caregiver communication; (3) affirmation of the caregiver; and (4) individualized strategies. These four content categories were used throughout the coaching process and were interwoven with each other so that the participant knew why the behavior was occurring, how to verbally address it, how to use a strategy effectively, and affirmation of the result. The coaching process and content demonstrated alignment with person-centered practices and relationship-centered care.

The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders.

The purpose of this article is to review the literature on and discuss how interactions between bio-behavioral aging, nursing home environments, and social forces shaping current health care policies have contributed to oral health disparities in frail and functionally dependent elders who reside in nursing homes. Emerging empirical evidence suggests links between poor oral health with dental plaque deposition and systemic disease, such as nursing home-acquired pneumonia. The majority of nursing home residents lack either the functional ability or the mental capacity to perform their own mouth care and therefore must rely on others to perform mouth care for them. Certified nursing assistants (CNAs), who provide the majority of care activities, were unsure how to provide care to residents who engaged in care-resistive behaviors. The nurses who supervise the CNAs have limited knowledge regarding the provision of mouth care in general, and they specifically lack knowledge regarding the provision of mouth care to elders exhibiting care-resistant behavior. Elders in nursing homes have limited options when paying for dental care; Medicare does not generally cover routine dental care. Medicaid coverage varies widely between individual states; even when coverage exists, low Medicaid reimbursements discourage dentists from accepting Medicaid patients. The strategies needed to reduce these oral health disparities are complicated but not unrealistic. Investigators willing to embrace this cause will have no shortage of opportunities to test methods to improve the delivery of oral care as well as to monitor and reassess these methods.

Care intervention for older adults with Alzheimer's disease and related dementias: effect of family involvement on cognitive and functional outcomes in nursing homes.

The purpose of this quasi-experimental study was to examine the effect of an intervention for caregivers of individuals with Alzheimer's disease and related dementias (ADRD) on nursing home residents' functional and cognitive status. Fourteen special care units (SCUs) in 14 midwestern nursing homes were paired according to size, ownership, and staff turnover. The paired nursing homes were randomly assigned to either experimental or control groups. The intervention consisted of the Family Involvement in Care (FIC) protocol. The FIC intervention was designed to help family caregivers of nursing home residents with dementia negotiate and establish a partnership with the staff caregivers for the care of residents. One hundred sixty-four residents participated in the study, 71 in the control group and 93 in the experimental group. Sixty-three residents were lost to attrition (38%). The experimental group exhibited less global deterioration throughout the study. Inappropriate behavior, cognition, and functional status remained relatively unchanged over time within and between the groups. Increased family involvement did slow global deterioration in individuals with ADRD. The findings of the study show that more factors need to be examined to discover those interventions that preserve functional and cognitive abilities.

Personality as a moderator of cognitive stimulation in older adults at high risk for cognitive decline.

This exploratory study examined the moderating effects of personality traits on cognitive function following a cognitively stimulating individualized activity intervention delivered to individuals at high risk for cognitive decline: those with delirium superimposed on dementia. Data were taken from an ongoing randomized clinical trial with the addition of a personality measure. The results for 71 participants randomized to intervention or control groups are reported. Significant moderating effects of personality traits were found such that participants with higher agreeableness were more likely to have improved delayed recall and those with lower extraversion were more likely to have improved executive function, as a result of the intervention. Lower openness, higher agreeableness, and lower conscientiousness were associated with greater engagement in the intervention. A cognitive stimulation intervention for older adults at high risk for further cognitive decline may be differentially effective based on certain personality traits.

Oral health and hygiene content in nursing fundamentals textbooks.

The purpose of this paper is to describe the quantity and quality of oral hygiene content in a representative sample of before-licensure nursing fundamentals textbooks. Seven textbooks were examined. Quantity was operationalized as the actual page count and percentage of content devoted to oral health and hygiene. Quality of content was operationalized as congruency with best mouth care practices. Best mouth care practices included evidence-based and consensus-based practices as published primarily by the American Dental Association and supported by both published nursing research and review articles specific to mouth care and published dental research and review articles specific to mouth care. Content devoted to oral health and hygiene averaged 0.6%. Although the quality of the content was highly variable, nearly every textbook contained some erroneous or outdated information. The most common areas for inaccuracy included the use of foam sponges for mouth care in dentate persons instead of soft toothbrushes and improper denture removal.

No more fighting and biting during mouth care: applying the theoretical constructs of threat perception to clinical practice.

The purpose of this article is to describe how the neurobiological principles of threat perception and fear response can support clinical approaches to prevent and reduce care-resistant behaviors during mouth care. Nursing home residents who exhibit care-resistant behavior are at risk for poor oral health because daily oral hygiene may not be consistently provided. Poor oral health predisposes these older people to systemic problems such as pneumonia, cerebral vascular accidents, and hyperglycemia. Care-resistant behavior is a fear-evoked response to nurses' unintentionally threatening behavior during mouth care. Nurses can safely and effectively provide mouth care to persons with dementia who resist care by using personalized combinations of 15 threat reduction strategies.

An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study.

The primary purpose of this pilot study was to test the feasibility of an intervention designed to reduce care-resistant behaviors (CRBs) in persons with moderate-to-severe dementia during oral hygiene activities. The intervention, Managing Oral Hygiene Using Threat Reduction (MOUTh), combined best oral hygiene practices with CRB reduction techniques. Oral health was operationalized as the total score obtained from the Oral Health Assessment Tool (OHAT). CRB was measured using a refinement of the Resistiveness to Care Scale. Seven nursing home residents with dementia received twice daily mouth care for 14 days. The baseline OHAT mean score of 7.29 (SD = 1.25) improved to 1.00 (SD = 1.26, p < .001); CRB improved from 2.43 CRBs/minute (SD = 4.26) to 1.09 CRBs/minute (SD = 1.56, t = 1.97, df 41, p= .06). The findings from this pilot study suggest that the MOUTh intervention is feasible and reduced CRBs, thus allowing more effective oral care.