Maha Dakheel-Ali

Engagement in Persons With Dementia: The Concept and Its Measurement

PURPOSE The aim of this article is to delineate the underlying premises of the concept of engagement in persons with dementia and present a new theoretical framework of engagement. SETTING/SUBJECTS The sample included 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. METHODOLOGY The authors describe a model of factors that affect engagement of persons with dementia. Moreover, the authors present the psychometric qualities of an assessment designed to capture the dimensions of engagement (Observational Measurement of Engagement). Finally, the authors detail plans for future research and data analyses that are currently underway. DISCUSSION This article lays the foundation for a new theoretical framework concerning the mechanisms of interactions between persons with cognitive impairment and environmental stimuli. Additionally, the study examines what factors are associated with interest and negative and positive feelings in engagement.

Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli

OBJECTIVES: To assess the relative effect of different types of stimuli on agitated behaviors of nursing home residents with dementia.

Efficacy of nonpharmacologic interventions for agitation in advanced dementia: a randomized, placebo-controlled trial.

BACKGROUND A randomized, placebo-controlled clinical trial was undertaken to determine the efficacy of nonpharmacologic individualized interventions (individualized to address unmet needs such as boredom or pain) in decreasing agitation in persons with dementia. METHOD Agitated nursing home residents with advanced dementia (from 9 nursing homes in 5 locations in Maryland, United States) were randomized into an intervention group (n = 89) and a placebo control group (n = 36). On the basis of data from baseline assessment, a systematic methodology for individualizing nonpharmacologic interventions, Treatment Routes for Exploring Agitation (TREA), was used with the intervention group: an unmet need was hypothesized, a corresponding treatment category was identified, and specifics of the treatment were chosen to fit the persons need, past identity, preferences, and abilities. (Unmet needs were hypothesized based on physician evaluations, structured staff interviews, relative questionnaires, direct observations of agitation with the Agitation Behavior Mapping Instrument [the primary outcome measure] and affect with Lawtons Modified Behavior Stream [the secondary outcome measure], and resident assessments.) TREA interventions were implemented for 2 weeks, and observations of agitation and affect were recorded. The study was conducted from June 2006 until December 2011. RESULTS Relative to a control group, TREA interventions for unmet needs produced statistically significant declines in total (P < .001), physical nonaggressive (P < .001), and verbal agitation (P = .004) and significant increases in pleasure (P < .001) and interest (P < .05). CONCLUSIONS This is the first large randomized controlled trial to demonstrate the efficacy of TREA and one of only a few such trials of nonpharmacologic interventions for agitation in persons with dementia. The translation of these findings into practice is sorely needed and would require structural changes dedicating staff time to observing each agitated resident, determining unmet needs, obtaining appropriate intervention materials, conducting the individualized nonpharmacologic interventions, and evaluating results. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00820859.

The Impact of Different Dog-related Stimuli on Engagement of Persons With Dementia

Objective: To provide further empirical evaluation of the effectiveness of animal-assisted therapy in nursing home residents with dementia. Methods: Participants were 56 residents of 2 suburban Maryland nursing homes and had a diagnosis. Activities of daily living performance was assessed via the minimum data set and cognitive functioning assessed using the Mini-Mental State Examination. Engagement with dog-related stimuli was systematically assessed via the observational measurement of engagement. Results: Mean engagement duration was significantly lower for the small dog. Highest mean engagement duration was found for the puppy video, followed by the real dog and lowest was for the dog-coloring activity. Positive attitudes were found toward the real dogs, robotic dog, the puppy video, and the plush dog. No significant differences were found in engagement duration among our dog-related stimuli. Conclusions: Nursing homes should consider animal-assisted therapy and dog-related stimuli, as they successfully engage residents with dementia.

The impact of past and present preferences on stimulus engagement in nursing home residents with dementia

Objectives: We examined engagement with stimuli in 193 nursing home residents with dementia. We hypothesized that activities and stimuli based on a persons past and current preferences would result in more engagement than other activities/stimuli. Method: The expanded version of the self-identity questionnaire [Cohen-Mansfield, J., Golander, H. & Arheim, G. (2000)] was used to determine participants’ past/present interests (as reported by relatives) in the following areas: art, music, babies, pets, reading, television, and office work. We utilized the observational measurement of engagement (Cohen-Mansfield, J., Dakheel-Ali, M., & Marx, M.S. (2009). Results: Analysis revealed that residents with current interests in music, art, and pets were more engaged by stimuli that reflect these interests than residents without these interests. Conclusion: Our findings demonstrate the utility of determining a persons preferences for stimuli in order to predict responsiveness. Lack of prediction for some stimuli may reflect differences between past preferences and activities that are feasible in the present.

Which unmet needs contribute to behavior problems in persons with advanced dementia

The Unmet Needs Model states that problem behaviors of people with dementia result from unmet needs stemming from a decreased ability to communicate those needs and to provide for oneself. The purpose of this study is to describe the unmet needs of persons with dementia exhibiting behavior problems. Eighty-nine residents with dementia from six Maryland nursing homes were assessed by research assistants and nursing assistants for their unmet needs using multiple assessment tools. Three unmet needs per resident were identified on average, with informants rating boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activity as the most prevalent needs. Discomfort was associated with higher levels of verbally agitated behaviors (e.g., complaining). Based on results and independent ratings of pain, the authors estimate notable under-detection of discomfort and pain by both types of informants. The study demonstrates methodologies for uncovering unmet needs among persons with dementia and highlights the importance of developing programs that address those unmet needs, especially social and activity needs of nursing home residents. The detection of pain, and possibly that of discomfort, may require a different methodology.

Engaging nursing home residents with dementia in activities: The effects of modeling, presentation order, time of day, and setting characteristics

We examined the impact of setting characteristics and presentation effects on engagement with stimuli in a group of 193 nursing home residents with dementia (recruited from a total of seven nursing homes). Engagement was assessed through systematic observations using the Observational Measurement of Engagement (OME), and data pertaining to setting characteristics (background noise, light, and number of persons in proximity) were recorded via the environmental portion of the Agitation Behavior Mapping Inventory (ABMI; Cohen-Mansfield, Werner, & Marx, (1989). An observational study of agitation in agitated nursing home residents. International Psychogeriatrics, 1, 153–165). Results revealed that study participants were engaged more often with moderate levels of sound and in the presence of a small group of people (from four to nine people). As to the presentation effects, multiple presentations of the same stimulus were found to be appropriate for the severely impaired as well as the moderately cognitively impaired. Moreover, modeling of the appropriate behavior significantly increased engagement, with the severely cognitively impaired residents receiving the greatest benefit from modeling. These findings have direct implications for the way in which caregivers could structure the environment in the nursing home and how they could present stimuli to residents in order to optimize engagement in persons with dementia.

What Are the Barriers to Performing Nonpharmacological Interventions for Behavioral Symptoms in the Nursing Home

OBJECTIVE Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms. DESIGN A descriptive study of barriers to intervention delivery in a controlled trial. SETTINGS The study was conducted in six nursing homes in Maryland. PARTICIPANTS Participants were 89 agitated nursing home residents with dementia. INTERVENTION Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined. MEASUREMENTS Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect. RESULTS Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment. CONCLUSION Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery.

The impact of stimuli on affect in persons with dementia.

OBJECTIVE To examine how presentation of different stimuli impacts affect in nursing home residents with dementia. METHOD Participants were 193 residents aged 60 to 101 years from 7 Maryland nursing homes who had a diagnosis of dementia (derived from the medical chart or obtained from the attending physician). Cognitive functioning was assessed via the Mini-Mental State Examination (MMSE), and data pertaining to activities of daily living were obtained through the Minimum Data Set. Affect was assessed using observations of the 5 moods from Lawtons Modified Behavior Stream. Baseline observations of affect were performed for comparisons. During the study, each participant was presented with 25 predetermined engagement stimuli in random order over a period of 3 weeks. Stimuli were categorized as live social, simulated social, manipulative, work/task-related, music, reading, or individualized to the participants self-identity. The dates of data collection were 2005-2007. RESULTS Differences between stimulus categories were significant for pleasure (F(6,144) = 25.137, P < .001) and interest (F(6,144) = 18.792, P < .001) but not for negative affect. Pleasure and interest were highest for the live social category, followed by self-identity and simulated social stimuli for pleasure, and for manipulative stimuli in terms of the effect on interest. The lowest levels of pleasure and interest were observed for music. Participants with higher cognitive function had significantly higher pleasure (F(1,97) = 6.27, P < .05). Although the general trend of the impact of the different categories was similar for different levels of cognitive function, there were significant differences in pleasure in response to specific stimuli (interaction effect: F(6,92) = 2.31, P < .05). Overall, social stimuli have the highest impact on affect in persons with dementia. CONCLUSIONS The findings of the present study are important, as affect is a major indicator of quality of life and this study is the first to systematically examine the impact of specific types of stimuli on affect. As live social stimuli are not always readily available, particularly in busy nursing home environments, simulated social stimuli can serve as an effective substitute, and other stimuli should have a role in the activity tool kit in the nursing home. The relative ranking of stimuli was different for interest and pleasure. The findings demonstrate the differential effect of presentation of different types of stimuli on the affect of persons with dementia, and that, while the impact is greater on persons with higher levels of cognitive function, there is a different effect of varying stimuli even in persons with MMSE scores of 3 or lower. Future research should attempt to ascertain a persons degree of interest in stimuli prior to developing an intervention.

The underlying meaning of stimuli: Impact on engagement of persons with dementia

In a previous article, we discussed a theoretical framework asserting that a combination of stimulus attributes, personal attributes and environmental attributes as well as interactions among these affects engagement with stimuli by persons with dementia [Cohen-Mansfield, J., Dakheel-Ali, M., Marx, M.S., 2009. Engagement in persons with dementia: The concept and its measurement. American Journal of Geriatric Psychiatry 7, 299-307]. Based on this framework, we tested the impact on engagement of the personal meaning of stimuli, specifically examining work-like stimuli, stimuli based on the persons identity, and gender role-based activities. We hypothesized that having such meanings will render stimuli more engaging than stimuli without these meanings. Participants were 193 residents of 7 Maryland nursing homes. All participants had a diagnosis of dementia. Results confirmed the hypotheses, demonstrating that the meaning of the stimulus impacts engagement shown by persons with dementia. Interventions that involve objects or tasks with meaning specific to the person with dementia will be more likely to engage that person. Future research could explore more identity roles as well as other mechanisms affecting engagement.