Eilon Caspi

Physician outpatient contacts and hospitalizations among cognitively impaired elderly

This study examined how physician contacts and hospitalizations vary in relation to cognitive function level among community‐residing older adults.

Developing a Research Agenda on Resident-to-Resident Aggression: Recommendations From a Consensus Conference

This article provides an overview of the development of a research agenda on resident-to-resident aggression (RRA) in long-term care facilities by an expert panel of researchers and practitioners. A 1-day consensus-building workshop using a modified Delphi approach was held to gain consensus on nomenclature and an operational definition for RRA, to identify RRA research priorities, and to develop a roadmap for future research on these priorities. Among the six identified terms in the literature, RRA was selected. The top five priorities were: (a) developing/assessing RRA environmental interventions; (b) identification of the environmental factors triggering RRA; (c) incidence/prevalence of RRA; (d) developing/assessing staff RRA education interventions; and (e) identification of RRA perpetrator and victim characteristics. Given the significant harm RRA poses for long-term care residents, this meeting is an important milestone, as it is the first organized effort to mobilize knowledge on this under-studied topic at the research, clinical, and policy levels.

Aggressive behaviors between residents with dementia in an assisted living residence.

Aggressive behavior between residents with dementia in long-term care residences is a concerning but understudied phenomenon. The goal of the study was to identify the circumstances, sequence of events, and triggers that lead to these behaviors. I collected the data during 10 months in two special care units of an assisted living residence. I used participant observation as the primary data collection strategy, complemented by review of clinical records and semi-structured interviews with care staff and managers. As the analytic framework, I used Grounded Theory informed by Miles and Huberman’s approach. In a substantial number of the reported 85 incidents, I identified observable early warning signs; in the majority, I identified observable causes or triggers prior to the aggressive acts. The majority of incidents were situational-reactive (circumstance-driven) and therefore potentially modifiable. Twelve effective staff prevention strategies were identified. I suggest incorporating the study findings into care staff training programs.

Wayfinding difficulties among elders with dementia in an assisted living residence

The concerning phenomena of spatial disorientation and wayfinding difficulties among elders with Alzheimer’s disease or a related dementia in assisted living residences are understudied. This qualitative study aimed to identify the types of wayfinding difficulties as experienced by residents with memory-loss in two special care units of an assisted living residence. The data collection period included participant observation complemented by semi-structured interviews with care staff and managers and review of clinical records. A wide spectrum of wayfinding difficulties was identified as experienced by six residents. The residents experienced difficulties reaching several destinations on the units. The implications of the findings to practice, architectural design, and policy are discussed.

Global Activity Motivation and Activities of Older People

Measures of global motivation to be active might help to explain the overall activity patterns late in life that, in turn, might help us to better understand the nature of successful and productive aging. We report on a study in which we developed a measure of global activity motivation and examined its relationship to four activities: working, volunteering, exercising, and taking classes. An opportunity sample of 193 persons age 55 and older from eastern Massachusetts responded to a self-administered questionnaire on types of activity and motivations for engaging in these activities. The data show that a four-item global activity motivation measure is present and that it is positively associated with participation in a count of the four activities and two of the specific activities: working and volunteering. This analysis demonstrates that global activity motivation is helpful in understanding patterns of activity among older people beyond the contribution of motivation for specific activities. We offer suggestions on how activity organizers can make use of the global activity motivation concept to encourage older people to engage in activities.

Time for change: persons with dementia and "behavioral expressions," not "behavior symptoms".

To the Editor: Several studies have shown that the majority of behavioral expressions (such as aggressive behaviors and resistance to care) among long term care residents with dementia are caused or triggered by an observable event in the social or physical environment).1e3 The guidelines for treatment of agitation in dementia are consistent with these findings: “Agitation may also emerge as a primary feature of a dementia syndrome, although in themajority of cases an explanation will be found in an examination of the patient’s interactions with his environment.”4 In addition, previous research indicates that a large portion of behavioral expressions among persons with dementia is caused by unmet physiological, psychological, and social needs.5,6 The clinical importance of the aforementioned findings and experts’ opinion relates to the fact that understanding the “meaning of the sequence of events”7 and situational triggers leading to behavioral expressions2 and meeting the underlying needs are the primary keys to their prevention. Based on these research findings and experts’ opinions, it is suggested that the use of the term “behavioral symptoms” among persons with dementia should be considered as potentially inaccurate and misleading. This term is frequently used in dementia care settings, the gerontological literature, and the Minimum Data Set 3.0 (Section EeBehaviors). The time has come to examine the problematic nature of this term and consideration should be given to replace it with a more suitable one. Using the word “symptoms” could imply that these behaviors are an inevitable and direct consequence of dementia, which in the majority of situations is not the case. Specifically, there is a great variability in the behavioral manifestations across individuals with dementia as well as within individuals over time. In addition, research has shown that the level of cognitive functioning accounts for only a small percentage of variance in behaviors, which suggests that other factors may play a larger role than cognitive impairment in predicting behaviors.8 In accordance, a study9 in 53 dementia special care units has found a substantial variability (0%‒38%) in the levels of agitated behaviors across units. Specifically, the quality of the physical environment and the amount and quality of the interactions between staff and residents (including staff attitudes toward residents) were found to exert strong influences on unit agitation levels. Perceiving behaviors as symptoms reflects and perpetuates the deterministic biomedical view of dementia that tends to place the origins of behavioral expressions inside the person with dementia and/or her/his brain pathology. Lyman,10 in her article Bringing the social back: A critique of the biomedicalization of dementia states, “Caregivers who interact daily with persons with dementia often attribute most of the person’s behavior to the presumed clinical condition.” This author explains that “the problem with this misperception is that “many of the ‘behavior problems’ associated with dementia may be traced to problems in the caregiving relationship, which are overlooked if the behavior is attributed to the disease. The medicalization of dementia shifts attention from problems in the social situation of caregiving to locate problems in the pathology and misbehavior of the person with dementia.” Attributing the ‘behavior problems’ predominantly to the disease runs the risk of excess disability and in certain situations use of blame-the-victim approach. As explained by Sabat,11 “From strict medical/technical approach, behavior problems have been viewed generally as caused by brain pathology alone and, as a result have been deemed to be symptoms of the disease, rather than reactions to the social milieu in which the afflicted person lives.” The term “behavior symptoms” as it is currently used in practice, the literature, and in the Minimum Data Set 3.0 should be replaced by more suitable terms. The following terms, as reported in the literature, are suggested as candidates as they more accurately reflect the origins and true nature of these behaviors in persons with dementia. These include expressive behaviors,12 reactive behaviors,13 and responsive behaviors.14 These terms reflect and provide further support for a recent experts’ recommendation for using the term “behavioral expressions” as outlined in the White Paper of the National Dementia Initiative.15 The recent national initiative of the Centers for Medicare and Medicaid Services to reduce the excessive and inappropriate use and negative consequences of antipsychotic medications in nursing homes further highlights the need to ensure that practitioners and researchers will use accurate terminology e one that reflects personalizedpractices that recognizeandsupport thewholeperson.15 One potentially problematic consequence of classifying behavioral expressions as symptoms is that when such classification is made it may be more likely that interdisciplinary care teams and researchers will look for the solutions for these “symptoms” in pharmacologic treatment. This, while the first line of treatment for behavioral expressions and aggressive behaviors (that do not present immediate danger to the resident or others) inpersonswith dementia consists of nonpharmacologic interventions.4

MDS 3.0: a giant step forward, but what about items on resident-to-resident aggression?

Aminimumweekly frequency of concurrent training (1 session per week of strength training and 1 session per week of cycle endurance training) may be an efficient stimulus in elderly in early phases of training; For concurrent-training protocols in which both strength and endurance training are performed on the same day, the strength gains may be optimized with strength training before endurance intrasession exercise sequence; Endurance parameters also may be optimized when strength exercises are performed before endurance exercises in each session, because greater changes in the neuromuscular system result in enhanced endurance capacity. Concurrent strengthand endurance-training prescription should include high-speed muscle contractions in the strength-training program, as skeletal muscle power has been strongly associated with the functional capacity of this population.

Deaths as a Result of Resident-to-Resident Altercations in Dementia in Long-Term Care Homes: A Need for Research, Policy, and Prevention

The preceding quotations are from a study by the author of this editorial.1 A growing number of studies in the past decade examined the public health problem of resident-to-resident altercations (RRA) in long-term care (LTC) homes.1e14 These studies identified key characteristics/typologies and causes and triggers of this form of behavioral expression as well as staff-reported strategies to address it. One groundbreaking study examined physical injuries due to episodes of RRA.4 The vast majority of these studies have been conducted in nursing homes, whereas 2 studies were conducted in assisted living residences, 1 among cognitively intact residents15 and 1 among older residents with dementia.1 The prevalence of episodes of RRA has recently been identified in a rigorous study among 2011 residents (average age 84 years) in 10 nursing homes.16 Two other encouraging developments pertaining to this underrecognized behavioral phenomenon include the development and evaluation of the first instrument for measuring episodes of RRA17 and the first staff training program in recognition and prevention of these behaviors (this training program demonstrated fivefold increase in staff recognition of these episodes after the training).18 In addition, at least 3 reviews of the literature have been recently published on RRA in LTC homes.19e21 Furthermore, the first Blog dedicated to prevention of episodes of RRA in dementia was launched in April 2012 and consists of hundreds of free resources on this form of behavior.22 One of the major gaps in research on episodes of RRA in dementia in LTC homes is the fact that virtually no studies examined deaths as

Does Self-Neglect Occur Among Older Adults With Dementia When Unsupervised in Assisted Living? An Exploratory, Observational Study

The phenomenon of older adults with dementia who develop behavioral expressions when they are unsupervised in assisted living residences is understudied. This qualitative study aimed to bridge this gap in the literature by focusing on 12 residents in various stages of dementia. Grounded Theory was followed to guide data collection and analysis. Data were collected in two special care units of an assisted living residence for 10 months. Participant observation was the primary data collection strategy. Semistructured interviews with staff and managers and review of clinical records augmented the observation data. While unsupervised, residents exhibited a wide spectrum of negative emotional states, behavioral expressions, functional difficulties, wayfinding difficulties, serious hygiene problems, and safety risks. More than half of the identified incidents represented self-neglectful behaviors. The study highlights the need for enhanced supervision and targeted interventions for residents with dementia who are susceptible to self-neglect.

Motives That Bridge Diverse Activities of Older People

We report on the results of a pilot study to measure global motives that may help explain patterns of activities of older people. We hypothesize that there may be multiple motives, each of which helps explain participation in more than one activity. We describe the development of a set of conceptually based measures. We then report on the results of a pilot survey conducted in eastern Massachusetts that explored the relationship between the motives and a diverse set of activities. We identified seven distinct motives: seek challenge, avoid frustration, need income, seek mental stimulation, sociable, contentment, and altruism. We found that the motives help to explain overall activity level and participation in specific activities.