Dementia in Nursing Homes (eBook)

Sandra Schüssler completed her training as a psychiatric-mental health nurse and acquired a Bachelor’s, Master’s and PhD degree in Nursing Science at the Medical University of Graz, Austria. She is currently the Debuty Head of the Institute of Nursing Science, Medical University of Graz, Austria. Sandra Schüssler is author and reviewer in several national and international journals. Her research area is dementia in view of care dependency and nursing care problems (e.g. incontinence, physical restraints, malnutrition) in nursing homes. Christa Lohrmann is a nurse and obtained a MA of nursing education from the Humboldt-University in Berlin, Germany, and a PhD from Charité-Universitätsmedizin, Berlin, Germany. She is a Professor of Nursing Science and Head of Department of the Institute of Nursing Science, Medical University of Graz, Austria, She is fellow of the European Academy of Nursing Science. Her research topics focused among others on care dependency and nursing care problems in older adults.

Contents 5
1: Introduction 7
References 10
2: Meaningful Activities 11
2.1 Introduction 12
2.2 Impact of Inactivity 12
2.3 Life in a Care Home 13
2.4 What Makes Activity Meaningful? 15
2.5 Providing Meaningful Activity 15
2.5.1 The Individual’s Life Story 17
2.5.2 Measuring Capacity for Activity: The Pool Activity Level (PAL) Instrument 17
2.6 Impact of the Environment on Activity Provision 18
2.6.1 Physical Environment 18
2.6.2 Social and Organisational Environment 19
2.7 Successful Activity Provision 20
2.7.1 Reducing Challenging Behaviour 20
2.8 Interventions 21
References 23
3: Patient-/Person-Centered Care 27
3.1 Introduction 27
3.2 Background 28
3.3 Implementation 29
3.4 PCC Models/Frameworks 29
3.5 Current Research Evidence About PCC 30
3.5.1 Effects of PCC on Persons with Dementia 30
3.5.2 Effects of PCC on Formal/Professional Caregivers of Persons with Dementia 31
3.5.3 Effects of the Physical Environment on the Provision of PCC 31
3.6 Conclusion 32
3.7 Resources 32
References 32
4: Psychosocial Interventions 34
4.1 Section A: Coping with Dementia – Integrated Emotion-­Oriented Care for Nursing Home Residents 35
4.1.1 The Adaptation-Coping Model 35
4.1.2 Integrated Emotion-Oriented Care 37
4.1.2.1 Phases of Ego-Experience and Perceptions 38
4.1.2.2 Care Needs and Care Objectives 39
4.1.2.3 Methods in the Different Phases of Dementia and Phases of Ego-Experience 39
4.1.2.4 Care in the Phase of Threatened Ego-Experience 40
4.1.2.5 Care in the Phase of Wandering Ego-Experience 41
4.1.2.6 Care in the Phase of Hidden Ego-Experience 42
4.1.2.7 Care in the Phase of Sunken Ego-Experience 43
4.1.3 How Integrated Emotion-Oriented Care Can Influence Adaptation 43
4.1.3.1 Integrated Emotion-Oriented Care and Cognitive Adaptation 43
Coping with the Own Invalidity 43
Developing an Adequate Care Relationship with the Staff 44
4.1.3.2 Integrated Emotion-Oriented Care and Emotional Adaptation 46
Maintaining an Emotional Balance 46
Maintaining a Positive Self-Image 46
Preparing for an Uncertain Future 48
4.1.3.3 Integrated Emotion-Oriented Care and Social Adaptation 49
Coping with the Nursing Home Environment 49
Developing and Maintaining Social Relationships 50
4.1.4 Finally 51
4.2 Section B: Implementing Psychosocial Interventions 52
4.2.1 Introduction 52
4.2.2 Building Trust 52
4.2.3 Enhancing Integrity Through Reminisces and Self-Reflection 53
4.2.4 Multigenerational Programs 54
4.2.5 Summary 55
References 55
Section A: Coping with Dementia: Integrated Emotion-Oriented Care for Nursing Home Residents 55
Section B: Implementing Psychosocial Interventions 57
5: Challenging Behavior in Nursing Home Residents with Dementia 59
5.1 Introduction 60
5.2 Getting Grips on Challenging Behavior 60
5.2.1 Definition 60
5.2.2 Detection 61
5.2.3 Analysis 61
5.2.3.1 Unmet Needs 62
5.2.3.2 Progressively Lowered Stress Threshold 62
5.2.3.3 Model of Functional Analysis 63
5.2.3.4 Combining Several Views: The Biopsychosocial Model 64
Biological Factors 64
Psychological Factors 64
Social Factors 64
5.3 Treatment 64
5.3.1 Treatment of Physical Factors 65
5.3.2 Functional Analysis-Based Interventions 65
5.3.3 Music Therapy 66
5.3.4 Training Staff 66
5.3.5 Sensory Interventions 66
5.3.6 Pharmacological Interventions for Challenging Behavior 66
5.3.6.1 Symptoms of Psychosis (Hallucinations/Delusions) Agitation/Aggression
5.3.6.2 Depression or Depressive Symptoms 67
5.3.6.3 Anxiety or Anxiety Symptoms 68
5.4 Evaluation 68
5.5 Requirements to Get Grips on Challenging Behavior in the NH 68
References 69
6: Inclusion and Support of Family Members in Nursing Homes 71
6.1 Family Involvement in Nursing Homes 71
6.2 Dilemmas in Care Practice 73
6.2.1 Attitude and Role Conflict 73
6.2.2 Communication 74
6.2.3 Organization 76
6.3 Good Practice Programs Building Partnerships 76
References 79
7: Pain in Dementia 81
7.1 A Brief Explanation on Pain 81
7.2 Presence of Pain in Dementia 82
7.3 Assessing Pain in Dementia 83
7.3.1 Self-Report of Pain 84
7.3.2 Behavioral Assessment of Pain 85
7.4 Management of Pain in Older People 87
7.5 Future Directions 88
References 89
8: Staff Training and Education 92
8.1 Introduction 92
8.2 Philosophy, Mission, and Values 93
8.3 Long-Term Care Facilities and Resources 94
8.4 Models of Care 96
8.5 Staff Educational Needs Assessment 97
8.6 Coordination of Training for Dementia Care 98
8.7 Dementia-Specific Competencies 98
8.8 Formal Training 101
8.9 Ongoing Inservice 102
8.10 Self-Instruction Modules 103
8.11 Resources 104
References 105
9: Communication in Dementia 108
9.1 Communication in Dementia 109
9.2 Verbal and Non-verbal Communication 109
9.3 The Consequences of Poor Communication in Dementia 110
9.4 Possible Barriers to Communication in Dementia 111
9.4.1 Barriers in the Physical and Sociocultural Environment 111
9.4.2 Physiological Impact of the Disease on Understanding and Communication 112
9.4.3 Different Realities: Understanding the Person Affected by Dementia 114
9.5 The Benefits of Positive Communication 114
9.5.1 Truth or Lies? The Value of Therapeutic Deception 114
9.5.2 The Value of Reorientation Strategies 115
9.6 Positive Communication: Seeking to Meet Underlying Need 116
9.7 Effective Listening 118
9.8 Person-Centred Communication 120
9.8.1 Know the Person 120
9.8.2 Attentive Patience 120
9.8.3 Simplify Choices to Enable Control 121
9.9 Improving Our Practice: The Importance of Reflection 121
References 123
10: Polypharmacy in Nursing Home Residents with Dementia 125
10.1 The Problem of Polypharmacy in Nursing Home Residents with Dementia 126
10.1.1 Polypharmacy and the Risk of Side Effects 126
10.1.2 Inappropriate Drug Use in Nursing Home Residents with Dementia 128
10.2 Prescribing in Dementia Patients: The WHO Six Step 129
10.3 Performing a Medication Review 132
10.4 Decision-Making Based on Evidence-Based Medicine 134
10.5 Screening Tools 135
10.6 The Problem of Stopping Medication 135
References 138
11: Quality of Life of People with Dementia in Nursing Homes 140
11.1 Introduction 141
11.2 Models of Quality of Life for People with Dementia in Nursing Homes 142
11.3 Measuring of Dementia-Specific Quality of Life in Nursing Homes 143
11.3.1 Different Measurement Perspectives 144
11.3.2 Quality of Life Measurements for People with Dementia in Nursing Homes 145
11.3.2.1 AAIQOL (Activity and Affect Indicator Quality of Life) 146
11.3.2.2 CBS-QoL (Cornell-Brown Scale for Quality of Life in Dementia) 146
11.3.2.3 DEMQOL and DEMQOL-Proxy (Dementia Quality of Life Questionnaire) 146
11.3.2.4 H.I.L.DE (Heidelberg Instrument for the Assessment of Quality of Life in Dementia) 147
11.3.2.5 QoL-AD (Quality of Life in Alzheimer’s Disease) 147
11.3.2.6 QoL-AD NH (Quality of Life in Alzheimer’s Disease Nursing Home Version) 147
11.3.2.7 QOLAS (Quality of Life Assessment Schedule) 148
11.3.2.8 ADRQL (Alzheimer Disease-Related Quality of Life) 148
11.3.2.9 DCM (Dementia Care Mapping) 148
11.3.2.10 OQOLD (Observing Quality of Life in Dementia) and OQOLDA (Observed Quality of Life in Dementia Advanced) 148
11.3.2.11 QoL-D (Quality of Life for Dementia) 149
11.3.2.12 QUALID (Quality of Life in Late-Stage Dementia Scale) 149
11.3.2.13 QUALIDEM 149
11.3.2.14 Vienna List 150
11.3.2.15 Selection of the Appropriate Measurement 150
11.4 Factors Associated with Quality of Life of People with Dementia in Nursing Homes 151
11.4.1 Personal Characteristics Not Related to Dementia 151
11.4.2 Personal Factors Related to Dementia 151
11.4.3 Challenging Behavior and Mood 152
11.4.4 Pain 152
11.5 Effectiveness of Non-pharmacological Interventions Targeting Quality of Life of People with Dementia in Nursing Homes 153
11.6 Summary 153
References 154
12: End-of-Life Care and Advance Care Planning in Dementia 159
12.1 Introduction 160
12.2 What Is End-of-Life Care? 160
12.3 Prognostication and Timely Recognition of Dying 162
12.4 Optimal Treatment of Symptoms in People with Dementia 163
12.4.1 The Consequences of Poor Prognostication in Dementia Care 163
12.4.2 Polypharmacy and Inappropriate Interventions at the End of Life 164
12.4.3 The Benefits of Hospice or Specialist Palliative Care Interventions at the End of Life in Dementia 166
12.5 Continuity of Care 168
12.5.1 Hospice Versus Residential Home Deaths 169
12.5.2 Education and Training for Care Home Staff 169
12.6 Communication, Shared Decision Making and Advance Care Planning 170
12.6.1 Engaging in Advance Care Planning Discussions 171
12.6.2 When Is It Best to Initiate Advance Care Planning Discussions? 172
References 175
13: Depression in Nursing Home Residents with Dementia 178
13.1 Introduction 179
13.2 How to Act in Case of Depression in Dementia? 180
13.2.1 Element 1: Stepwise Depression Assessment 180
13.2.2 Element 2: Treatment Strategies 182
13.2.3 Element 3: Monitoring and Evaluation 183
13.2.4 Apathy and Depression 184
13.3 Requirements for Appropriate Treatment of Depression in NH Residents with Dementia 184
References 186
14: Delirium 189
14.1 Introduction 190
14.2 Categorisation of Delirium 190
14.3 Distinguishing Delirium from Dementia 191
14.4 Incidence 192
14.5 Causes 192
14.6 Pathophysiology 193
14.7 Diagnosis 193
14.8 Outcomes 195
14.9 Management of DSD 195
14.9.1 Non-pharmacological Interventions 195
14.9.2 Pharmacological Interventions 196
14.9.2.1 Prevention of Delirium 197
References 198
15: Dementia Care in Nursing Homes Requires a Multidisciplinary Approach 200
15.1 Introduction 201
15.2 The Necessity of Integrated Multidisciplinary Care for Residents with Dementia 201
15.3 Theoretical Aspects of Multidisciplinary Care 203
15.3.1 The Process of Collaboration 203
15.3.2 Collaborative Competences in Daily Practice and Education 204
15.3.3 Quality of Multidisciplinary Care 205
15.4 The Dutch Nursing Home as Interesting Example 207
15.4.1 The Multidisciplinary Care Concept of Dutch Nursing Homes 208
15.4.2 Employing the Multidisciplinary Team in a Setting in which Learning Is Leading 210
15.4.3 Future Developments in Dutch Multidisciplinary Nursing Home Care 212
References 213
16: The Prevention and Reduction of Physical Restraint Use in Long-Term Care 215
16.1 Physical Restraints 216
16.2 Determinants and Consequences of Restraint Use 216
16.3 Approaches Aiming at the Reduction of Physical Restraints 217
16.4 EXBELT 218
16.4.1 Effectiveness of EXBELT 219
16.4.1.1 Restraint Reduction 219
16.4.1.2 Restraint Prevention 220
16.4.1.3 Long-Term Effects 220
16.4.2 Conclusions: Restraint Reduction and Prevention 220
16.5 New Challenges: Physical Restraint Use in the Community 221
References 222
17: Care Dependency 225
17.1 Introduction 226
17.2 Care Dependency: Conceptualization 226
17.2.1 Introduction 226
17.2.2 Data Sources 227
17.2.3 Sociological Perspective 229
17.3 Care Dependency: Operationalization 229
17.3.1 Introduction 229
17.3.2 Frame of Reference 229
17.3.3 Operationalizing Nursing Concepts 230
17.3.4 Developing the Theoretical Definition 230
17.3.5 Specifying Variable Dimensions 232
17.3.6 Identifying Observable Indicators 235
17.3.7 Developing Means for Measuring the Indicators 236
17.4 Care Dependency Scale: Utilization 237
17.4.1 Introduction 237
17.4.2 Instruction for Use in Clinical Practice 237
17.4.3 Clinical Reasoning 238
17.4.4 Care Dependency and Nursing Care Problems 239
17.4.5 Practical Application of the CDS 240
References 241