Louis D. Burgio

Interventions for Caregivers of Patients with Alzheimer's Disease: A Review and Analysis of Content, Process, and Outcomes:

Current reviews of the caregiver intervention literature have focused primarily on the outcomes of interventions for caregivers and general methodological limitations of individual studies (i.e., sampling and recruitment issues, adequacy of outcome measures, and generalization issues). Little attention has been paid to the specific factors affecting the therapeutic process, including the intensity and integrity of the interventions used. The purpose of this review is to examine closely the content and process of Alzheimers disease (AD) caregiver interventions. We describe the types of interventions currently in use, factors affecting intervention outcomes, and we conclude with specific recommendations for the application of intervention technology and for the documentation of intervention research.

The Effects of Changing Prompted Voiding Schedules in the Treatment of Incontinence in Nursing Home Residents

To determine the effects of different prompted voiding schedules on urinary incontinence on a continence unit (CU) and the maintenance of benefits on normal nursing units.

Direct observation of behavioral disturbances of dementia and their environmental context.

The cognitive domain has long been the focus of clinical and scientific efforts in dementia research. Only recently has behavior, and more specifically behavioral problems, been recognized as a legitimate focus of research. In its summary statement of September 1991, the Alzheimers Association Task Force on Behavior Management noted the following with regarding behavioral disturbances: “(a) the study of assessment and treatment of behavioral problems must develop in its own right as well as complement studies on improving cognition; (b) controlled clinical trials of behavioral treatments of behavioral disturbances are desperately needed; and (c) both standardized rating scales and direct behavioral observations should be used to assess problems and determine treatment efficacy.” [Emphasis added by author.]

SOCIAL WORKERS’ ACCEPTABILITY RATINGS OF BEHAVIORAL TREATMENTS AND PHARMACOTHERAPY FOR THE MANAGEMENT OF GERIATRIC BEHAVIOR PROBLEMS

The purpose of the present study was to obtain treatment acceptability ratings from social workers whose client contacts include a high percentage of persons age 60 or older. Social workers were presented with written scenarios depicting a 75‐year‐old woman with a behavior problem. The client in the case varied by cognitive capacity (nondemented or experiencing dementia), living situation (living with a family caregiver or in a nursing home), and presenting problem (aggression, verbal abuse, or noncompliance). Using Kazdins (1980) Treatment Evaluation Inventory, participants rated three treatments: positive reinforcement, time out from positive reinforcement, and haloperidol. Although ratings for time out varied by presenting problem, the highest acceptability for each type of behavior problem was assigned to the positive reinforcement condition, followed by time out, with the lowest ratings associated with haloperidol.

Acceptability Ratings of Psychotherapeutic Treatments for Elderly Individuals

Adults age 60 and older were presented with written scenarios depicting a 75-year-old woman with a behavioral problem The client in the case varied by cognitive capacity (impaired or intact), behavior problem (physical aggression, verbal disruption, or noncompliance), and living situation (nursing home or family home) Participants rated six types of psychotherapy treat ments with Kazdins Treatment Evaluation Inventory: person-centered therapy, strategic family therapy, transactional analysis, play reading, group therapy, and purposeful activity. All treat ments were considered acceptable by these older respondents; however, person-centered therapy was rated the most acceptable. These treatments were also rated as slightly more acceptable for cognitively intact case clients than for impaired ones. Treatment ratings varied according to the case clients living situation (i.e., nursing home or family home).

Treatment in Residential Settings

Geriatric behavioral disturbances present numerous difficulties for both the staff and the residents of nursing homes and other geriatric long-term care settings. Examples of these problematic behaviors include behavioral excesses, such as agitation, wandering, disruptive vocalization (DV) and physical aggression, and various behavioral deficits. Behavioral deficits, also referred to by geriatric health care professionals as “excess deficits” (Brody, Kleban, Lawton, & Silver-man, 1971), are symptoms of functional incapacity greater than that warranted by actual organic impairment. Such deficits can range from an absence of ambulation when the capability exists to urinary incontinence with no identifiable medical cause. Estimates of the prevalence of disruptive behaviors in nursing homes vary, depending on method of reporting and presence of dementia, but studies have found that between 64% (Zimmer, Watson, & Treat, 1984) and 83% of nursing home residents exhibit disruptive behaviors (Swearer, Drachman, O’Donnell, & Mitchell, 1988). It is further estimated that 73% of demented nursing home residents display at least one, if not several, aberrant behaviors (Cohen-Mansfield, 1986). Consequently, there is great interest among geriatric health care professionals in developing interventions for managing these behaviors.

Aging and Mental Retardation

With the recent growth in the population of older adults, there has been a concomitant increase in the visibility of “special populations” of elders. One “special population” consists of older adults with mental retardation and other developmental disabilities. Although estimates of the size of this population vary, it is expected that by the year 2025 there will be between 400,000 and one million people over the age of 65 with developmental disabilities living in the United States (see Anderson, 1993, for a review of other pertinent statistics). It is believed that older adults with mental retardation constitute a group with special needs beyond those of the general aged population (Newbern & Hargett, 1992). For example, older adults with mental retardation have fewer compensatory abilities than their nonretarded peers to adjust for age-associated declines in functioning (Jenkins, Hildreth, & Hildreth, 1993). As a result, there has been a recent effort by researchers, health care professionals, and other service providers to identify the pertinent characteristics and needs of this special population. This information would help to determine whether existing services for older adults and persons with mental retardation are adequate for meeting their needs.

Behavioral Microanalysis of Helping Interactions Between Mothers and Adult Children with Mental Retardation

Although direct observation has provided much information regarding caregiver-care recipient interactions, our understanding of the applications of this technique remains incomplete. This study expands upon earlier observational work by examining adults with mental retardation (MR) and their family caregivers in the home setting. Specialized computer software was used to conduct real-time observation and recording of interactional styles of maternal caregivers of eight younger (M = 23 years old) and eight older (M = 49 years old) MR adults during two cognitive tasks: block design and card sorting. Differences in the amount and type of assistance provided by the caregiver were examined by coding the occurrence and duration of seven interactional behaviors. The results demonstrated that the caregivers of the younger adults used more positive statements and modeling/gestural prompts, whereas the caregivers of the older adults provided more physical assistance and performed more of the tasks themselves. More importantly, this project provided information regarding interactions between MR adults and their maternal caregivers and demonstrated the utility of computer-assisted data collection technology with a community-based, nondemented population.