Ann Kolanowski

Need-driven dementia-compromised behavior: An alternative view of disruptive behavior

The disruptive behavior of persons with dementia is a problem of considerable clinical interest and growing scientific concern. This paper offers a view of these behaviors as expressions of unmet needs or goals and provides a comprehensive conceptual framework to guide further research and clinical practice. Empiricalfindings and clinical impressions related to wandering, vocalizations and aggression to support and illustrate the framework are presented

Efficacy of Theory-Based Activities for Behavioral Symptoms of Dementia

BackgroundAgitation and passivity are behavioral symptoms exhibited by 90% of nursing home residents with dementia. They account for many poor health outcomes, caregiver burden, and increased costs of long-term care. ObjectivesThis study tested the efficacy of recreational activities derived from the Need-driven Dementia-compromised Behavior (NDB) model: activities matched to skill level only; activities matched to style of interest only; and a combination of both (NDB-derived) for responding to the behavioral symptoms of dementia. MethodsThirty participants were randomly assigned to 1 of 6 possible order-of-condition presentations in this crossover experimental design with repeated measures of dependent variables. Trained research assistants, blind to condition match, implemented each condition for 12 consecutive days. Measures of engagement (time on task and participation), affect, and behavioral symptoms (agitation and passivity) were taken from videotape recordings of each session. Mood was measured with the Dementia Mood Picture Test. The primary analysis method was mixed-model analysis of variance. ResultsSignificantly more time on task, greater participation, more positive affect, and less passivity were found under NDB-derived and matched to interest only treatments compared with the matched to skill level only treatment or baseline. Agitation and negative affect improved under all treatments compared with baseline. There was no significant change in mood. DiscussionThe NDB-derived activities are tailored to meet individual needs and improve behavioral symptoms associated with dementia. These findings help to explain factors that produce behavioral symptoms and the mechanisms that underlie their successful treatment.

A randomized clinical trial of theory-based activities for the behavioral symptoms of dementia in nursing home residents

OBJECTIVES: To test the main and interactive effects of activities derived from the Need‐Driven Dementia‐Compromised Behavior model for responding to behavioral symptoms in nursing home residents.

Methods to Improve Reliability of Video Recorded Behavioral Data

Behavioral observation is a fundamental component of nursing practice and a primary source of clinical research data. The use of video technology in behavioral research offers important advantages to nurse scientists in assessing complex behaviors and relationships between behaviors. The appeal of using this method should be balanced, however, by an informed approach to reliability issues. In this article, we focus on factors that influence reliability, such as the use of sensitizing sessions to minimize participant reactivity and the importance of training protocols for video coders. In addition, we discuss data quality, the selection and use of observational tools, calculating reliability coefficients, and coding considerations for special populations based on our collective experiences across three different populations and settings.

Reframing person-centered nursing care for persons with dementia.

Alzheimer’s dementia manifests in a complex clinical presentation that has been addressed from both biomedical and phenomenological perspectives. Although each of these paradigmatic perspectives has contributed to advancement of the science, neither is adequate for theoretically framing a person-centered approach to nursing care. The need-driven dementia-compromised behavior (NDB) model is discussed as an exemplar of midrange nursing theory that promotes the integration of these paradigmatic views to promote a new level of excellence in person-centered dementia care. Clinical application of the NDB promotes a new level of praxis, or thoughtful action, in the care of persons with dementia.

Factors that relate to activity engagement in nursing home residents

Many nursing home residents are unoccupied and at risk for poor health outcomes because of inactivity. The purpose of this study was to identify characteristics of residents with dementia that predict engagement in activities when activities are implemented under ideal conditions. Data from a clinical trial that tested the efficacy of individually prescribed activities were used to address the study aim. Thirty subjects were videotaped daily for 12 days during 20-minute activity sessions. Measures of engagement (time on task and level of participation) were taken from these videotapes. Univariate logistic regression analyses indicated that cognitive status and physical function explained a significant amount of variance in engagement. Efforts to promote function may facilitate even greater benefits from prescribed activities by improving capacity for engagement.

Evidence supporting nutritional interventions for persons in early stage Alzheimer's disease (AD)

The purpose of this paper is to grade research evidence supporting nutritional interventions for persons with early stage dementias and to report the recommendations of a consensus panel. Thirty four studies were reviewed in the areas of dietary restriction, antioxidants, and Mediterranean diet with strong support from epidemiological studies found in all three areas. The body of evidence to support nutritional interventions in the prevention and treatment of AD is growing and has potential as a treatment modality following translational studies.

Contextual factors associated with disturbing behaviors in institutionalized elders

Data from a longitudinal clinical trial funded by the National Institute of Aging, testing the effects of staff education and consultation on restraint reduction in nursing homes, were used to examine disturbing behaviors in institutionalized elders and to identify related environmental and personal characteristics. Subjects were 586 residents from three well-matched nursing homes. Kayser-Joness (1989) model on environment and quality of life in long-term care institutions served as the organizing framework. Data on disturbing behaviors from the Psychogeriatric Dependency Rating Scale were factor analyzed. Three factors, Agitated Psychomotor Behaviors, Aggressive Interpersonal Communication, and Expressive Difficulty, emerged from the principal factor analysis and accounted for 35% of the variance. The Kayser-Jones model partially explained Agitated Psychomotor Behavior (R2 = .22). A model comparison approach indicated that the addition of an organizational variable, staff mix, significantly increased the amount of variance explained over and above that contributed by the personal variables.

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.

Special Section—Behavioral symptoms of dementia: their measurement and intervention. Editorial: The need-driven dementia-compromised behavior model—a framework for understanding the behavioral symptoms of dementia

By the year 2030, one in every three people on earth will be age 60 or over and at risk for dementia (United Nations, 1999). Currently there is no cure for dementia so many individuals require extensive long-term care, often involving nursing home placement. Today there are approximately 1.5 million nursing home residents in the USA, and these numbers are expected to double by the year 2020 (Feder, Komiar & Niefeld, 2000). Nursing home placement is often precipitated by behavioral symptoms such as agitation and passivity (Haupt & Kurz, 1993). These symptoms are exhibited by 90% of persons with dementia (Cohen-Mansfield, Marx & Rosenthal, 1989; Galynker et al., 1995) and account for many poor health outcomes such as declines in functional status (Harwood et al., 2000), social engagement and physical activity (Wunderlich & Kohler, 2000). Behavioral symptoms not only diminish quality of life, they contribute significantly to long-term care cost (O’Brien, Shompe & Caro, 2000) and are a major source of caregiver burden (Donaldson, Tarrier & Burns, 1997). Unfortunately there are few effective interventions for behavioral symptoms that accompany dementing disorders. Both pharmacological and behavioral interventions have demonstrated modest effects in clinical trials (Teri et al., 2002). At issue is a lack of understanding about the root causes of behavioral symptoms in persons with dementia. In 1996, a group of researchers proposed a model of behavioral symptoms set within a nursing view: the Need-driven Dementia-compromised Behavior (NDB) model (Algase et al., 1996). In the model, individual distinguishing characteristics of the person with dementia and their common human needs, a traditional raison d’etre for nursing practice, are suggested as possible bases for these behaviors. Knowledge of the extent to and manner in which human needs contribute to behavioral symptoms can guide the development of effective interventions. The papers that comprise this special section have all used the NDB model to derive and test interventions for specific behavioral symptoms, or to address methodological issues surrounding the measure of these symptoms. We introduce this group of papers by describing the NDB model and placing it within the context of other theoretical models found within developmental psychology.