Christine R Kovach

Assessment and treatment of discomfort for people with late-stage dementia

People with dementia have often been excluded from pain studies. However, there is evidence supporting that people with dementia experience frequent pain, often poorly assessed and undertreated, and that the etiology for pain descriptions is poorly documented. The Assessment of Discomfort in Dementia (ADD) Protocol is designed to: a) more accurately assess discomfort in people with dementia who can no longer verbally describe physical pain or affective discomfort; b) more accurately and thoroughly treat physical pain and affective discomfort; and c) decrease inappropriate use of psychotropic medication. The use of the ADD Protocol was studies with a convenience sample of 104 residents of long-term care with end-stage dementia. Use of the ADD Protocol was associated with a significant decrease in discomfort (t = 6.56, p = 0.000). The most frequently seen behavioral symptoms associated with discomfort were tense body language, sad facial expression, fidgeting, perseverant verbalizations, and verbal outburts. The ADD Protocol was also associated with a significant increase in the use of scheduled analgesics and non-pharmacological comfort interventions. The protocol was not associated with an increase in the use of prn analgesics or with prn or scheduled psychotropics. This study has provided some support for the notion that the needs of people with significant dementia can be discerned and treated.

Late-stage dementia and participation in therapeutic activities.

This study examined the participation and behavior of people with late-stage dementia during various therapeutic activities. Subjects were able to actively participate for 10 minutes or less 54% of the time. Caregivers were not responding to meet apparent resident needs 37.5% of the time. Active participation was significantly correlated with having more senses stimulated. In addition, as the length of resting time increased before a scheduled therapy, active participation significantly decreased. Subjects exhibited various behaviors during therapeutic activities. Behaviors were categorized as approaching and withdrawing, relaxing and tensing, mimicking, nonverbal connecting, and verbal connecting.

Planning activities for patients with dementia: a descriptive study of therapeutic activities on special care units

1. Therapeutic activities for people with dementia have been used to prevent behavior problems, relieve boredom, and to maintain or restore holistic health and function. 2. This study found that subjects spent more time actively participating in an activity when they were able to make a cognitive tie between the current activity and an event from their past through reminiscing. 3. Active participation in therapeutic activities was associated with increased daytime napping but was not related to continuous sleep at night.

Promise and Problems in Reminiscence Research

Nurses use reminiscence as an intervention with elderly clients to meet a wide variety of needs. Research on reminiscence has provided some support for benefits of reminiscence in maintaining or improving mood, cognitive functioning, life satisfaction, and self-esteem in the elderly. Weaknesses in reminiscence research have been presented along with suggestions for developing a body of knowledge for nursing regarding reminiscence.

Impacts of a therapeutic environment for dementia care

This study explores the association ofphysical environments with the behaviors and care ofpeople with dementia. In order to have a comparative understanding, environmental settings of a traditional nursing facility and an innovative dementia care unit on the same campus were selected. Behavioral observations were done on 12 residents before and after their move ftrom the traditional facility to the dementia care unit. Resident and staffusage and behaviors in the shared spaces were systematically recorded and analyzed Findings include increased use ofthe activity spaces, increased social interaction among the residents, and more interactive than assistive behavior between the staff and residents

The effects of hospice interventions on behaviors, discomfort, and physical complications of end stage dementia nursing home residents

This project was guided by the question—what is the effect of hospice-oriented care on discomfort, physiological complications, and behaviors associated with dementia for residents of long term care facilities with an end stage dementing illness? Convenience sampling from three long term care facilities was used and 62 residents completed the project. The intervention was implemented through a four pronged approach: • Interdisciplinary development of the intervention strategies for the new hospice households; • Development of the households; • Use of a hospice nurse as a case manager; and • Education of staff A pretest-posttest experimental design with random assignment to groups was used. Two months after the interventions were implemented, there was a statistically significant difference in discomfort levels between the treatment and control groups (t = 3.88, p < .001). Even though the treatment group showed lower scores on the tool that assessed behavior problems, the differences were not large enough to be statistically significant (t = 1.44, p = .155). There was no difference in the number of physical iatrogenic problems between the treatment and control groups (t = .054, p = .957). Staff reaction to the project was positive with staff reporting greater job satisfaction and empathy, and describing a variety of improvements in residents.

FACILITATING CHANGE IN DEMENTIA CARE : STAFF PERCEPTIONS

OBJECTIVES The authors describe factors that facilitate positive changes in dementia care as perceived by long-term care employees. BACKGROUND Creating positive changes in dementia care is a complex undertaking involving multiple variables. The perspectives of long-term care employees may provide important insight and direction for a successful change process. METHODS A convenience sample of 181 long-term care employees utilized a q-sort methodology to provide data for this descriptive study. Results were analyzed using rankings and Spearmans rho correlation coefficient. RESULTS The facility factors most often cited as important for making positive changes in dementia care involved teamwork, administrative support, staff attitude, and knowledge. There was little congruence between facility factors identified as ideal for providing dementia care and those identified as actually evident at the subjects place of employment. Personal characteristics that were identified as most important for facilitating positive changes in dementia care include genuinely liking people with dementia, being flexible, kindness, calmness, and having a positive attitude. The correlations between ideal and real personal factors were higher than for the facility factors. CONCLUSIONS This study supports the idea that the fundamental tenets of good leadership--communication, involvement, and empowerment--are foundational for real change in dementia care to be attained and sustained.

The implementation of the serial trial intervention for pain and challenging behaviour in advanced dementia patients (STA OP!): a clustered randomized controlled trial

BackgroundPain (physical discomfort) and challenging behaviour are highly prevalent in nursing home residents with dementia: at any given time 45-80% of nursing home residents are in pain and up to 80% have challenging behaviour. In the USA Christine Kovach developed the serial trial intervention (STI) and established that this protocol leads to less discomfort and fewer behavioural symptoms in moderate to severe dementia patients. The present study will provide insight into the effects of implementation of the Dutch version of the STI-protocol (STA OP!) in comparison with a control intervention, not only on behavioural symptoms, but also on pain, depression, and quality of life. This article outlines the study protocol.Methods/DesignThe study is a cluster randomized controlled trial in 168 older people (aged >65 years) with mild or moderate dementia living in nursing homes. The clusters, Dutch nursing homes, are randomly assigned to either the intervention condition (training and implementation of the STA OP!-protocol) or the control condition (general training focusing on challenging behaviour and pain, but without the step-wise approach). Measurements take place at baseline, after 3 months (end of the STA OP! training period) and after 6 months.Primary outcome measures are symptoms of challenging behaviour (measured with the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and pain (measure with the Dutch version of the Pain Assessment Checklist for Seniors (PACSLAC-D) and the Minimum Data Set of the Resident Assessment Instrument (MDS-RAI) pain scale). Secondary outcome measures include symptoms of depression (Cornell and MDS-RAI depression scale), Quality of Live (Qualidem), changes in prescriptions of analgesics and psychotropic drugs, and the use of non-pharmacological comfort interventions (e.g. snoezelen, reminiscence therapy).DiscussionThe transfer from the American design to the Dutch design involved several changes due to the different organisation of healthcare systems. Specific strengths and limitations of the study are discussed.Trial registrationNetherlands Trial Register (NTR): NTR1967

Effects of a Stepwise Multidisciplinary Intervention for Challenging Behavior in Advanced Dementia: A Cluster Randomized Controlled Trial.

To assess whether implementation of a stepwise multicomponent intervention (STA OP!) is effective in reducing challenging behavior and depression in nursing home residents with advanced dementia.

The agitation-activity interface of people with dementia in long-term care

The purpose of this study was to examine agitated behaviors of people with dementia relative to time and activity variables. This descriptive study involved a sample of 420 units of 30-minute time periods collected in a longterm care setting. The highest agitation scores occurred during the evening (F = 3.93, p = 0.009). Agitation scores were significantly higher when the same level of activity was sustained for 1.5 hours or longer (p = 0.000). This study suggests that future examination is needed of an intervention to control activity schedules so that there is a balance between sensory-stimulating and sensorycalming activities.