Subsyndromes and symptom clusters: Multilevel factor analysis of behavioral and psychological symptoms of dementia with intensive longitudinal data.

INTRODUCTION: Behavioral and psychological symptoms in dementia (BPSD) are dynamic phenomena with a high amount of intraindividual variability. We applied a multilevel framework to identify subsyndromes (between-person factors) that represent clinically relevant profiles of BPSD and identify symptom clusters (within-person factors) that represent contextually driven daily symptom experiences. METHODS: This study used an intensive longitudinal design in which 68 co-residing family caregivers to persons living with dementia were recruited to proxy report on their care recipient's daily symptom experiences of 23 different BPSD for eight consecutive days (n = 443 diaries). A multilevel exploratory/confirmatory factor analysis was used to account for nested data and separate within-person variances from between-level factor estimates. RESULTS: Exploratory factor analysis identified a 4-between 3-within factor structure based on fit statistics and clinical interpretability. DISCUSSION: This study offers major methodological and conceptual advancements for management of BPSD within Alzheimer's disease and related dementias by introducing two related but distinct concepts of subsyndromes and symptom clusters. HIGHLIGHTS: Because behavioral and psychological symptoms of dementia (BPSD) are dynamic temporal phenomenon, this introduces measurement error into aggregate group-level estimates when trying to create subsyndromes. We propose a multilevel analysis to provide a more valid and reliable estimation by separating out variance due to within-person daily fluctuations. Using a multilevel exploratory factor analysis with intensive longitudinal data, we identified distinct and meaningful groups of BPSD. The four factors at the between-person level represented subsyndromes that are based on how BPSD co-occurred among persons with Alzheimer's disease (AD). These subsyndromes are clinically relevant because they share features of established clinical phenomena and may have similar neurobiological etiologies. We also found three within-person factors representing distinct symptom clusters. They are based on how BPSD clustered together on a given day for an individual with AD and related dementias. These clusters may have shared environmental triggers.

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.].

Maturation of the MOUTh Intervention: From Reducing Threat to Relationship-Centered Care.

The purpose of the current article is to describe a personalized practice originally conceived as a way to prevent and minimize care-resistant behavior to provide mouth care to older adults with dementia. The original intervention, Managing Oral Hygiene Using Threat Reduction Strategies (MOUTh), matured during the clinical trial study into a relationship-centered intervention, with emphasis on developing strategies that support residents' behavioral health and staff involved in care. Relationships that were initially pragmatic (i.e., focused on the task of completing mouth care) developed into more personal and responsive relationships that involved deeper engagement between mouth care providers and nursing home (NH) residents. Mouth care was accomplished and completed in a manner enjoyable to NH residents and mouth care providers. The MOUTh intervention may also concurrently affirm the dignity and personhood of the care recipient because of its emphasis on connecting with older adults.

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.

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.

Revising the Resistiveness to Care Scale.

BACKGROUND AND PURPOSE: The Resistiveness to Care Scale for Dementia of the Alzheimer's Type was developed to quantify care-resistant behavior. The purpose of this article is to explain how the instrument was modified and tested in two clinical studies that examined interventions to improve the oral hygiene of persons with dementia who resist care. METHODS: After pilot testing, the revised instrument (RTC-r) was used in 7 facilities (N = 83 residents). Systematic training procedures were implemented to preserve reliability. RESULTS: Clinical validity was confirmed throughout the pilot and interventional studies. Reliability was assessed using inter-rater reliability, which ranged from 0.87 (p < .001) to 1.0 (p < .001) across 2,328 mouth care observations. CONCLUSIONS: The RTC-r validly and reliably measures care-resistant behavior in persons with dementia.

Getting Grandma Online: Are Tablets the Answer for Increasing Digital Inclusion for Older Adults in the U.S.?

Using information and communication technologies (ICTs) can improve older adults' quality of life. ICT use is associated with decreased feelings of loneliness and depression, along with increased feelings of independence and personal growth. However, limited access and low technological self-efficacy are key reasons why some groups, especially older adults, are excluded from being fully engaged in the digital world. In this study, we focus on older adults' technological self-efficacy, which is related to their actual use of technology and the second level digital divide. Specifically, we examine: 1) how older adults decide to use a new technology, tablet computers; 2) how they conquer the barrier of technological self-efficacy through using tablets; and 3) the impacts of using this new technology in their lives. Twenty-one in-depth interviews were conducted with older adults residing in independent living communities in a medium-sized city in the Deep South region of the United States. Observational and enactive learning played important roles for older adults in using tablets. Seeing others use tablets, getting recommendations from family members, or having tablets given to them were the primary reasons they started to use tablet computers. The ease of use feature of tablets helped solve the problem of lacking technological self-efficacy. Using tablets helped increase a sense of connectedness. Tablet computers may be one way to increase digital inclusion among older adults.

The impact of activity interventions on the well-being of older adults in continuing care communities.

As the U.S. population ages, interventions are needed to ensure quality of life continues as boomers enter assisted and independent living communities (AICs). These transitions can significantly affect quality of life. Activity and continuity theories maintain that participation in discretionary/informal activities is crucial for psychosocial health and well-being (aspects of quality of life). This study evaluates the impacts of participation in discretionary activities on life satisfaction, social isolation, and loneliness, using data from a longitudinal study of older adults in AICs. Older adults who participated in 8 weeks of discretionary activities reported greater life satisfaction and lower levels of social isolation compared with non-participants. Forming alliances and group identities is the key for building new relationships and maintaining relationships in the community. Determining the impact participation in activities has on residents is vital to being able to help develop a more comprehensive understanding of how quality of life can be maintained in AICs.

Attitudes Towards and Limitations to ICT Use in Assisted and Independent Living Communities: Findings from a Specially-Designed Technological Intervention.

While much literature has been devoted to theoretical explanations of the learning processes of older adults and to the methods of teaching best utilized in older populations, less has focused on the education of older adults who reside in assisted and independent living communities (AICs), especially with regards to information and communication technology (ICT) education. The purpose of this study is to determine whether participants' attitudes and views towards computers and the Internet are affected as a result of participating in an eight-week training program designed to enhance computer and Internet use among older adults in such communities. Specifically, we examine if ICT education specially designed for AIC residents results in more positive attitudes towards ICTs and a perceived decrease in factors that may limit or prevent computer and Internet use. We discuss the implications of these results for enhancing the quality of life for older adults in AICs and make recommendations for those seeking to decrease digital inequality among older adults in these communities through their own ICT classes.

You can teach an old dog new tricks: a qualitative analysis of how residents of senior living communities may use the web to overcome spatial and social barriers.

For adults in senior living communities, information and communication technologies (ICTs) can be used to increase and expand communication for a population that is often spatially and socially separated from the general public. Using qualitative observational data from a longitudinal study of the impact of ICT usage on the quality of life among residents in assisted and independent living communities, the authors examine whether ICTs can mitigate the effects of social and spatial barriers. The authors find that ICTs have the potential to allow individuals to transcend social and spatial barriers, providing residents with the ability to maintain and enhance social networks as well as provide a greater sense of connection to the world at large.