Nikki L. Hill

Agreeableness and activity engagement in nursing home residents with dementia.

Residents with dementia are the least likely to be engaged in the nursing home and often spend most of their time doing nothing at all. However, resident participation in meaningful activities is important to promote both physical and psychological health. Tailoring activities to individual functional abilities and personality preferences improves both the time and level of participation. This pilot study used an analysis of covariance procedure to test the relationship between the personality trait of agreeableness and engagement when activities are ideally tailored to ability and interest. No significant difference was found between the high and low agreeableness groups, indicating that residents were more engaged when activities were individually tailored, regardless of their agreeableness level. Although low agreeableness may pose a challenge when implementing activities for people with dementia, the results of this study suggest that tailoring activities to functional ability and interest may overcome the effects.

“Wish we would have known that!” Communication Breakdown Impedes Person-Centered Care

PURPOSE To understand how nursing home staff obtain information needed for implementing person-centered care (PCC) to residents with dementia who exhibit behavioral and psychological symptoms of dementia (BPSD), and how they communicate this information to other staff. Barriers to PCC and information exchange were also explored. DESIGN AND METHODS Participants were 59 staff from two nursing homes. Focus group methodology captured discussions in eight 1-hr sessions. Sessions were audiotaped and transcribed. Data were analyzed using qualitative content analysis to provide a comprehensive summary of real world context of implementing PCC. RESULTS To deliver PCC staff identified a need for access to psychosocial/medical history of the resident and knowledge of strategies families used for managing BPSD in the past. However, resident information is not routinely shared with all staff and written documentation systems for communicating resident-specific information do not support the time-pressured work pattern of certified nursing assistants (CNAs). Word-of-mouth was considered more reliable and expedient than educational sessions. CNAs described themselves as visual learners who prefer educational programs addressing individual resident emergent behaviors and programs that are scheduled at dedicated times. IMPLICATIONS To improve PCC the flow of information exchange requires: inclusion of all staff, particularly CNAs; systems of communication that consider the time and resource constraints of nursing homes; development of educational programs for BPSD that are responsive to staff learning styles; administrative investment in nursing leadership to effect these changes; and reimbursement approaches to encourage culture change investments.

Managing delirium in the acute care setting: a pilot focus group study

BACKGROUND Delirium frequently occurs in hospitalised older adults leading to poor outcomes and frequent adverse events. Proper recognition and management of delirium by acute care nurses can minimise the effects of negative sequelae associated with delirium. AIM This pilot study used focus group methodology to: (i) describe acute care nurses experience and knowledge regarding assessment and management of delirium in hospitalised older adults; (ii) illustrate potential facilitators and barriers to non-drug management of delirium; and (iii) to explicate the use of non-drug interventions by acute care nurses to manage delirium in hospitalised older adults. DESIGN Qualitative, pilot study. METHODS A total of 16 nurse participants, working on medical, surgical and orthopaedic units from one acute care hospital participated in two focus groups. RESULTS Main themes included the following: confusion is normal; our duty is to protect; and finding a balance. Nurses were able to identify non-pharmacological interventions for delirium and facilitators and barriers to using these in clinical practice. CONCLUSIONS Findings from this pilot study illustrate the need for regular assessment of cognitive status in hospitalised older adults and nursing staff education regarding the use of non-pharmacological management of delirium. Based on their experience, nurses have a wealth of ideas for managing delirium. Areas for future research and policy are also highlighted. IMPLICATIONS FOR PRACTICE More research is needed on how to improve delirium management by acute care nurses to increase the efficacy and use of non-pharmacological interventions in the management of delirium in hospitalised older adults. To translate these findings into practice, nursing care needs to be guided by evidence-based guidelines to implement non-pharmacological strategies in the acute care setting.

The Triple Challenge of Recruiting Older Adults With Dementia and High Medical Acuity in Skilled Nursing Facilities

PURPOSE To describe strategies, culled from experience, for responding to several recruitment challenges in an ongoing randomized clinical trial of delirium in persons with dementia. ORGANIZING CONSTRUCT Delirium in people with dementia is common across all cultures. Little research supports the use of specific interventions for delirium. Recruitment of an adequate sample is critical to the validity of findings from intervention studies that form the foundation for evidence-based practice. METHODS The trial referenced in this article tests the efficacy of cognitive stimulation for resolving delirium in people with dementia. Participants are recruited at the time of admission to one of eight community-based skilled nursing facilities (SNFs). Eligible participants are 65 years of age or older and community dwelling, and have a diagnosis of dementia and delirium. Recruitment challenges and strategies were identified during weekly team meetings over a 2-year period. FINDINGS Recruitment challenges include factors in the external and internal environment and the participants and their families. Strategies that address these challenges include early site evaluation and strong communication approaches with staff, participants, and families. CONCLUSIONS The recruitment of an adequate sample of acutely ill older adults with dementia in SNFs can pose a challenge to investigators and threaten the validity of findings. Recruitment strategies that help improve the validity of future studies are described. CLINICAL RELEVANCE Worldwide, over 100 million people will have dementia by 2050, placing them at increased risk for delirium. Recruitment strategies that improve the quality of nursing research and, by extension, the care and prevention of delirium in older adults with dementia during rehabilitation in SNFs are greatly needed.

What it takes: perspectives from developing nurse scientists.

The need for nurse scientists has never been greater, given the complexity of health problems facing our world and the rising cost of providing care to prevent and treat them. The development of nurse researchers is critical to preserve and advance the scientific foundation of the discipline. In this article, two successful doctoral students present their personal views about the cognitive and behavioral transformation they experienced during their program of study, highlighting what they believe to be important resources that enhance doctoral education and sharing how they overcame the challenges encountered. The framework of transformational leadership is used to highlight important aspects of their development as nurse scientists. Action steps for attracting a greater number of nurses to a career in science are recommended.

Community-based non-pharmacological interventions delivered by family caregivers reduce behavioural and psychological symptoms of dementia

Implications for practice and research: Non-pharmacological interventions (NPIs) should be the first line of treatment for the behavioural and psychological symptoms of dementia (BPSD). Multicomponent NPIs tailored to individual and caregiver needs can reduce BPSD in community settings. Current instruments that measure BPSD lack precision, diluting the observed effect of NPIs; more precise outcome measures are needed. Quality-of-life indicators may be more sensitive measures of NPI benefits than reduction in negative behaviours.

Anticholinergic Exposure during Rehabilitation: Cognitive and Physical Function Outcomes in Patients with Delirium Superimposed on Dementia

OBJECTIVES We examined the association between anticholinergic medication exposure and subsequent cognitive and physical function in patients with delirium superimposed on dementia during rehabilitation. We also examined length of stay and discharge disposition by anticholinergic medication exposure. DESIGN In this secondary analysis we used control group data from an ongoing randomized clinical trial. SETTING/PARTICIPANTS Participants with delirium and dementia were enrolled at admission to post-acute care. These 99 participants had a mean age of 86.11 (±6.83) years; 67.6% were women; 98% were Caucasian; and 33% were positive for at least one APOE e4 allele. MEASURES We obtained daily measures of cognitive and physical function using: Digit Span; memory, orientation and attention items from the Montreal Cognitive Assessment; CLOX; the Confusion Assessment Method; and the Barthel Index. Anticholinergic medication exposure was measured weekly using the Anticholinergic Cognitive Burden Scale. RESULTS Using multilevel models for time we found that greater use of clinically relevant anticholinergic medications in the previous week reduced cognitive and physical function, as measured by Digit Span Backwards and the Barthel index, in the current week. There was no effect of anticholinergic medication use on delirium severity, and APOE status did not moderate any outcomes. Greater use of clinically relevant anticholinergic medications was related to longer length of stay but not discharge disposition. CONCLUSIONS For vulnerable older adults, anticholinergic exposure represents a potentially modifiable risk factor for poor attention, working memory, physical function, and greater length of stay during rehabilitation.

Factors associated with sustained attention during an activity intervention in persons with dementia.

Background/Aims: Are the noncognitive factors of self-reported mood and personality related to sustained attention in nursing home residents with dementia during an activity intervention? Methods: Intervention data from a randomized clinical trial were used to address the aim of this project. Subjects were 128 nursing home residents who were assessed for mood, personality, behavioral indicators of attention, time on task and number of disengagements during an activity intervention. Results: More positive self-reported mood was associated with greater behavioral displays of attention during activities, greater time spent engaged in the activities and less disengagement. Conclusion: To our knowledge, this is the first study to report on the association of mood, personality and sustained attention in nursing home residents with dementia. While the findings are preliminary, they can be used to inform the design of future research.

Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial

To determine whether cognitively stimulating activities would reduce duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care.

The Model of Care Partner Engagement: Use in delirium management

Care partner engagement is a central tenant of person-centered care. Despite widespread interest in transforming current health care delivery to a more person-centered system, little is known about effective strategies for engaging care partners. The Model of Care Partner Engagement is introduced and described as an evidence-informed framework that nurses can use to guide the development of care partnerships. The case of hospitalized older adults with cognitive impairment and delirium is used to illustrate implementation of the model. Care partner engagement is integral to national efforts that promote affordable, equitable, high quality care and is a growing expectation of older adults and their families.