Best Practices in Nursing: Developing and Implementing Positive Outcomes when Dealing with Negative Behaviors in Dementia Patients

by Lyn Yorgensen
Alzheimer’s Care Quarterly is a peer-reviewed journal designed for health care professionals which provides information on dementia care practices which can be used in any setting. Author Carly R. Hellen (BS, OTR/L, Nursing Home Services Director, Rush Alzheimer’s Disease Center, Chicago, Illinois) focuses on developing hands-on care strategies and behavioral refocusing interventions allowing Alzheimer’s patients to be treated with dignity and respect.

“I was always looking for a way to ‘connect’ with my care receivers”, says Hellen (Hellen, 2004, para. 2). The author’s approach includes sensory bridging which provides a sensory connection by having the person with dementia hold an item in his or her hand that is similar to the one the caregiver is using to provide care. For example, as the caregiver attempts to comb the resident’s hair he becomes angry and pushes the caregiver away. The caregiver then provides the resident with his own comb to hold, in his hand which gives him something to see and feel, allowing the caregiver to complete the task, the resident now feels he had a part in the task. The author provides many useful care and refocusing strategies along with examples on how to implement each one. The article is particularly useful for the nurse responsible for the care of Alzheimer’s patients and has provided much information for the research topic.

Gleeson, M., & Timmins, F. (2004). Touch: A fundamental aspect of communication with older people experiencing dementia. Nursing Older People, 16 (2), 18. Retrieved July 18, 2007 from Academic Search Premier database.
Nursing Older People is published by the Royal College of Nursing and is
designed particularly for health professionals who work with older people in
any setting. Author Madeline Gleeson RPN, RGN, BNS is the Clinical
Placement Coordinator at Saint Patrick’s Hospital in Dublin Ireland. Co-
author Fiona Timmons RGN, BNS, RNT, FNRCSI, NFESC, MSC is a lecturer at
Trinity College in Dublin Ireland. The authors did an extensive literature
review to explore the use of touch with dementia patients. From the results
of their research three particular aspects of touch emerged: “Physical
touch as an aspect of nursing care, the effect of touch, and the use of touch
with those clients with a diagnosis of dementia” (Gleeson, 2004, para. 4).
Research revealed that task-oriented touch or necessary touch is more
common with nurses working with the elderly than other age group. It was
found that non-necessary touch by a nurse gave patients a sense of safety.
Plus, it provided comfort that helped to keep them calm. In one study,
patients who had poor nutritional intake increased their caloric intake
when they were given a gentle touch and spoken to as they ate. Other
studies revealed that the effect of expressive verbalization (EPT/V) such as a
hand massage reduced anxiety and negative behavior in dementia patients.
Overall, the authors concluded that those in long term care are often
deprived of touch. However, nurses are in a unique position to provide this
vulnerable group of older adults the comfort provided by a simple pat on the
hand or touch on the shoulder. This article provided insight relating to the
importance of touch and provided much information for the research topic.

Ragneskog, H., Gerdner, L., Josefsson, K., & Kihlgren, M. (1998). Probable reasons for expressed agitation in persons with dementia. Clinical Nursing Research 7(189), 2. Retrieved January 20, 2005 from Expanded Academic ASAP database.
Clinical Nursing Research is an international journal published by SAGE
Publications and is designed for practicing nurses to provide information on
clinical research for discussion and professional enrichment. Author Hans
Ragneskog R.N., Dipl. Nurse Ed. is a lecturer in nursing at The Gokteborg
University College of Caring Sciences, Goteborg, Sweden. Co-author Linda
Gerdner R.N., M.A., is a doctoral candidate at the University of Iowa, Karin
Josefsson, R.N., Dipl. Nurse Ed., M.S., is a research assistant at Orebro
Medical Center Hospital, Orebro, Sweden, and Mona Kihlgren, R.N., Ph.D., is
a senior lecturer Orebro Medical Center Hospital, Orebro, Sweden. This
study was conducted at a nursing home in Sweden where dementia patients
were videotaped to help identify possible causes of agitation. As the data
was analyzed it revealed that agitation was often a used as a means of
communication. According to the authors the most common causes
for agitation were, “discomfort, a wish to be served immediately, conflicts
between patients or with nursing staff, reactions to environmental noises or
sounds, and invasion of personal space” (Ragneskog, 1998, para. 1). The
article presented relevant reasons for the need to assess and identify
possible causes for agitation and thereby implement interventions for
prevention of agitated episodes. Therefore, the article provided useful
information for the research topic.

Van Weert, J. et al (2006). Nursing assistants’ behaviour during morning
care: effects of the implementation of snoezelen, integrated in 24-
hour dementia care. Journal of Advanced Nursing, 53(6), 656. Retrieved July 18, 2007 from Academic Search Premier database.
The Journal of Advanced Nursing is a scientific, international, peer-reviewed journal which focuses on the advancement of evidence-based nursing through the publishing of scholarly research. Researchers, Julia C. M. Van Weert (NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Bienke M. Janssen. (NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Alexandra M. Van Dulmen (Research Coordinator, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Peter M. M.Spreeuwenberg (Statistician, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Jozien M. Bensing (Professor in Health Psychology, Director, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), and Miel W. Ribbe (professor in Nursing Home Medicine, Department of Nursing Home Medicine, University Medical Center/EMGO Institute, Amsterdam, The Netherlands). conducted research at six Dutch nursing homes in twelve different wards using a person-centered approach which incorporated multisensory stimulation techniques known as Snoezelen (Van Weert et al, 2006). Researchers defined a sensory stimulus as “the explicit use of visual, auditory, tactile, olfactory or gustatory stimuli to make contact with the resident and/or elicit a response from the resident” (Van Weert et al, 2006 para. 14). The focus was on improving the quality of caregiver behavior by training nursing assistants to integrate multisensory stimulation in morning care. The study revealed that the positive behaviors exhibited toward the residents by the CNAs “resulted in the improved levels of well-being for nursing home residents suffering from dementia” (Van Weert et al, 2006, para. 37). This article proved valuable for the information that it provided regarding the positive impact multisensory therapy has in dementia care.

Best Practices in Nursing: Developing and Implementing Positive Outcomes when Dealing with Negative Behaviors in Dementia Patients
Nurses that work in specialized care units with dementia patients face some particularly unique situations. Due to the disease process, these individuals are no longer able to express their needs appropriately. In addition, they may misunderstand the actions of others who are trying to help them. As a result, those that suffer from dementia sometimes exhibit behaviors that can put themselves and other at risk. The role of the nurse is to look at all factors that may contribute to negative behaviors, implement strategies, and provide caregiver training that can lead to positive outcomes.
In 1998 a study was conducted by a group of researchers at a nursing home in Sweden where dementia patients were videotaped, to help identify possible causes of agitation (Ragneskog et al, 1998). As the data was analyzed, it revealed that agitation was often used as a means of communication. According to researchers, the most common causes of agitation were, “discomfort, a wish to be served immediately, conflicts between patients or with nursing staff, reactions to environmental noises or sounds, and invasion of personal space” (Ragneskog et al, 1998, para. 29). Since dementia patients are often unable to verbalize their feelings or needs, recognizing and identifying causes for agitated behavior is essential for developing a plan of care and implementing interventions, so that their needs can be met and quality of life improved.
Meeting the communication needs of those with dementia may be one of the key elements in alleviating the expression of negative behaviors. One method developed by Carly Hellen, Nursing Home Services Director at Rush Alzheimer’s Disease Center in Chicago, Illinois focuses on developing hands-on care strategies and behavioral refocusing interventions. This strategy allows Alzheimer’s patients to be treated with dignity and respect (Hellen, 2004). “I was always looking for a way to ‘connect” with my care receivers”, says Hellen (Hellen, para. 2). Her approach includes sensory bridging, which provides a sensory connection by having the person with dementia hold an article in his or her hand that is similar to the one the caregiver is using to provide care. For example, as the caregiver attempts to comb the resident’s hair he becomes angry and pushes the caregiver away. The caregiver then provides the resident with his own comb, which gives him something to see and feel, thus allowing the caregiver to complete the task, the resident now feels he had a part in the task and helps maintain his sense of independence and control.
Touch is another method that has proven successful, in reducing anxiety and negative behavior. Gleeson and Timmons (Gleeson, 2004) in their extensive literature review found that three particular aspects of touch emerged: “Physical touch as an aspect of nursing care, the effects of touch and the use of touch with those clients with a diagnosis of dementia”. (Gleeson, 2004, para. 4) Research revealed that task-oriented touch or necessary touch is more common with nurses working with the elderly than any other age group. It was found that non-necessary touch by a nurse gave patients a sense of safety. In addition, it provided comfort that helped keep them calm. One study showed that patients who had poor nutritional intake increased their caloric intake when they were given a gentle touch and spoken to as they ate. Other studies revealed that the effect of expressive verbalization (EPT/V), such as hand massage, reduced anxiety and negative behavior in dementia patients. Overall, the authors concluded that those in long term care are often deprived of touch. Fortunately, nurses are in a unique position to provide this vulnerable group of older adults the comfort provided by a simple pat on the hand or touch on the shoulder.
Todd Hutlock, assistant editor at Nursing Homes, reports on Project RELATE – Research and Education for Living with Alzheimer’s Disease: Therapeutic Eldercare. The study took place in 2001 at a SNF in Grand Rapids, Michigan and “set out to investigate whether specialized training and person-centered approach for caregivers can lead to improved quality of life for residents” (Hutlock, 2004, para.1). The team headed by Iris Boethcher, MD, CMD, began by developing training sessions for the CNAs. Each week for five weeks, the certified nursing assistants were trained in the following areas: practical information about residents with dementia, communication techniques, beginning and sustaining life activities specific to the individual, and assisting residents with need-driven or agitated behavior. According to Dr. Boethcher, the primary focus of the training was “empowering CNAs to approach the residents with dementia as people as opposed to demented people. The focus is on the person and not the disease” (Hutlock, 2004, para 12). Also, nurses attended sessions on how to mentor the CNAs. Their four training sessions incorporated strategies in helping the CNAs develop observations skills, provide feedback, and set goals. The training yielded positive results as reported by Dr. Boethcher, “We saw a trend toward reduced agitated behaviors and also a reduction in depressive symptoms. We also saw a trend toward families noticing that the care was different, which also translates into improved and favorable” (Hutlock, 2004, para. 13). In addition, three months after the training ended, they discovered that “caregivers also expressed a more positive attitude toward their jobs and improved relationships with supervisors” (Hutlock, 2004, para. 14). In retrospect, the person-centered care method focuses not only on the residents but on the caregivers as well. The emphasis on caregiver training validates the role of the caregiver and respects the vital part that they play in the lives of their residents. This translates in to decreased episodes of agitation and improved quality of life for the residents.
Researchers in the Netherlands took the person-centered approach a step further and incorporated multisensory stimulation techniques known as Snoezelen in their study (Van Weert et al, 2006). Researchers defined a sensory stimulus as “the explicit use of visual, auditory, tactile, olfactory or gustatory stimuli to make contact with the resident and/or elicit a response from the resident” (Van Weert et al, 2006 para. 14). The focus was on improving the quality of caregiver behavior by training nursing assistants to integrate multisensory stimulation in morning care. Research was done at six Dutch nursing homes, in twelve different wards. The nursing assistants in the experimental group received four days of ‘snoezelen’ training. Those in the control group did not receive any additional training (Van Weert et al, 2006, para.8).
Several methods of sensory stimulation were used by the CNAs when providing morning care. For example, caregivers engaged the residents in conversation centering on the care they were providing and had the residents smell soap, body lotions, or aftershaves. Tactile stimulation was encouraged, by having the residents feel the “heat of the water or the softness towels, clothes and cuddly animals” (Van Weert et al, 2006 para. 28).
The results of the study revealed that the use of multisensory stimulation in dementia care produced positive changes in CNAs. The Snoezelen-trained CNAs “showed a statistically significant increase in the total number of verbal utterances (more social conversation, agreement, talking about sensory stimuli, information and autonomy” (Van Weert et al, 2006, para. 33). It was also noted that they demonstrated affective touch, looked and smiled at the residents more often. The study concluded that the positive behaviors exhibited toward the residents by the CNAs also “resulted in the improved levels of well-being for nursing home residents suffering from dementia” (Van Weert et al, 2006, para. 37).
Clearly, research supports the importance of providing caregiver training which focuses on the well being of the individual rather than the disease. Learning to communicate by demonstrating person-centered care, touch, and multisensory stimulation techniques provide methods for CNAs to connect with their residents and see them as people rather than behavior problems. As a result, this produces decreased episodes of agitation and positive outcomes for those with dementia.

References
Gleeson, M. & Timmins, F. (2004). Touch: A fundamental aspect of communication with older people experiencing dementia. Nursing Older People, 16 (2), 18. Retrieved July 18, 2007 from Academic Search Premier database.
Hellen, C.R. (2004). Enabling success: Hands-on care strategies and behavioral refocusing interventions. Alzheimer’s Care Quarterly, 5 (2), 178. Retrieved July 18, 2007 from Academic Search Premier database.
Hutlock, T. (2004). Project Relate: Managing the person with Alzheimer’s disease. Nursing Homes, 53(4), 60. Retrieved July 18, 2007 from Academic Search Premier database.
Ragneskog, H., Gerdner, L., Josefsson, K., & Kihlgren, M. (1998). Probable reasons for expressed agitation in persons with dementia. Clinical Nursing Research, 7(2), 189. Retrieved January 20, 2005 from Expanded Academic ASAP database.
Van Weert, J. et al (2006). Nursing assistants’ behaviour during morning
care: effects of the implementation of snoezelen, integrated in 24-
hour dementia care. Journal of Advanced Nursing, 53(6), 656. Retrieved July 18, 2007 from Academic Search Premier database.


Intervention 1: Overcoming Barriers to communication
Disadvantage 1: Knowledge Deficit Related to Lack of Training
Beck, C., Ortigara, A., Mercer, S., & Shue, V (1999). Enabling and empowering certified nursing
assistants for quality dementia care. International Journal of Geriatric Psychiatry, 14, 197
Retrieved October 24, from Academic Search Premier database.
The International Journal of Geriatric Psychiatry, is devoted to communicate the results of original research in the causes, treatment and care of all forms of mental disorders which affect the geriatric population. The Journal is designed for psychiatrists, psychologists, social scientists, nurses and others engaged in therapeutic professions, as well as other researchers. The authors are professors from the University of Arkansas and include a director from the Rush Alzheimer’s Disease Center in Chicago. The article addresses issues regarding barriers to dementia care and providing a framework for training.
In contrast, not all long term care facilities are as enlightened as the previously mentions communities. Most CNAs nationwide have high school education or less and work for a little more that minimum wage (Beck et al, 1999, para. 3). Beck states that CNAs have, “a tremendous impact on residents’ quality of life, but significant barriers limits their care giving effectiveness. These barriers include poor pay, minimal long-term benefits and insufficient training”.
Training is the key to providing quality care and improving communication between resident and caregiver. Federal regulations require a minimum of twelve hours of training before working with residents and at least twelve hours of in-service each year. Regulations also require dementia training for those CNAs working with dementia residents but do not specify the amount of training required (Beck et al, 1999, para. 22).
Disadvantage 2: Knowledge Deficit Related to Using Lying to Gain Compliance
James, I. et al (2006). Lying to people with dementia: developing ethical guidelines for care
settings. International Journal of Geriatric Psychiatry, 21, 800-801. Retrieved October 24,
from Academic Search Premier database.
The International Journal of Geriatric Psychiatry, is devoted to communicate the results of original research in the causes, treatment and care of all forms of mental disorders which affect the geriatric population. The Journal is designed for psychiatrists, psychologists, social scientists, nurses and others engaged in therapeutic professions, as well as other researchers. The authors are from the University of Newcastle, Newcastle upon Tyne, UK and Newcastle General Hospital, Newcastle upon Tyne, UK. The article focuses on the unethical use of manipulation and lying when dealing with dementia patients.
Building a bridge work for communication among caregivers and their residents is essential to developing a trusting relationship. However, Ian James reports in his article, Lying to people with dementia: developing ethical guidelines for care settings, that a questionnaire was given to staff concerning lying to residents in a care setting. Upon completion of the survey it was found “that staff working in a dementia day care setting used a variety of responses to maintain a patient’s safety, including benign manipulation, lying and pretending”. However, staff members also stated that there were problems associated with lying such as: increased confusion due to lack of consistency of the lies being told, developing mistrust between residents and staff, causing tension and confusion with family members (James et al, 2006, para.5).
Intervention 2: Person Centered Care
Disadvantage 1: Socioeconomic barriers to care
Mor, V. et al (2004). Driven to tiers: socioeconomic and racial disparities in the quality of nursing
Home care. Milbank Quarterly, 82(2), 227-256. Retrieved October 24, 2007 from
Academic Search Premier database.
Milbank Quarterly, is an academic journal which contains scholarly articles regarding issues in health and heath care policy for clinicians and policy makers. The authors from both Brown and Temple Universities, report on the two tiered system of care in long term care facilities. The article focuses on the lower tier which consists mainly of Medicaid residents and facilities that have very limited resources.
Not all long term care facilities have the resources to provide innovative care strategies that can lead to a better quality of life for their residents. Facilities that are highly dependent on Medicaid as a source of income have the most difficulty securing the resources needed to provide good-quality care (Mor et al, 2004, para. 2). It was also noted that for profit Medicaid facilities had fewer RNs and CNAs per resident. Medicaid dependent facilities also had a higher incidence of restraint use, use of antipsycotics, and inadequate pain control (Mor et al, 2004, para. 18). As a result, many of the facilities that are Medicaid dependent do not have the financial resources or staffing needed to develop specialized programs to decrease incidents of negative behavior.
Disadvantage 2: Discrimination and Quality of Care
Smith, D. et al (2007). Separate and unequal: racial segregation and disparities in quality
across U.S. nursing homes. Health Affairs, 16(5), 1448-1458. Retrieved
October 24, 2007 from Academic Search Premier database.
Health Affairs, is an academic journal which is committed to the exploration of policy issues in the domestic and international health arenas. It contains papers from industry, labor, government and academe. Plus, it contains book reviews. The authors are all professors from Brown and Temple Universities. In the article the authors note racial segregation in nursing homes and the differences in quality of care.
Private pay long term care facilities are the ideal setting for both dementia or non-dementia residents who need assistance with ADLs. However, not everyone is financial able to afford such accommodations and the quality of care that they provide. This is most evident among the black population. In the study conducted by Smith et al, it was noted that black nursing home residents were more likely to be in a facility with higher total weighed deficiencies and were even more likely to be in nursing homes with cited deficiencies that caused actual harm or put them in immediate jeopardy, “that was subsequently terminated from Medicare and Medicaid participation” (Smith et al, 2007, para.6). It is evident that disparities in treatment and care are directly related to the quality of the facility.

References

Beck, C., Ortigara, A., Mercer, S., & Shue, V (1999). Enabling and empowering certified nursing
assistants for quality dementia care. International Journal of Geriatric Psychiatry, 14, 197.
Retrieved October 24, from Academic Search Premier database.
James, I. et al (2006). Lying to people with dementia: developing ethical guidelines for care
settings. International Journal of Geriatric Psychiatry, 21, 800-801. Retrieved October 24,
from Academic Search Premier database.
Mor, V. et al (2004). Driven to tiers: socioeconomic and racial disparities in the quality of nursing
Home care. Milbank Quarterly, 82(2), 227-256. Retrieved October 24, 2007 from
Academic Search Premier database.
Smith, D. et al (2007). Separate and unequal: racial segregation and disparities in quality
across U.S. nursing homes. Health Affairs, 16(5), 1448-1458. Retrieved
October 24, 2007 from Academic Search Premier database.
Best Periodical Articles
Hellen, C.R. (2004). Enabling success: Hands-on care strategies and behavioral refocusing interventions. Alzheimer’s Care Quarterly, 5 (2), 178. Retrieved July 18, 2007 from Academic Search Premier database.