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Creating a Therapeutic Psychosocial Environment in Dementia Care: A Preliminary Framework

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Abstract

Research in dementia care during the past few years has focused on identifying and designing therapeutic physical environments while the psychosocial environment has remained a largely unexplored domain. More recently, discussions regarding the effect of the social environment on individuals with dementia have increased in the literature. Nevertheless, the authors suggest the term "social environment" does not adequately represent the critical psychological and emotional effect social interaction has on individuals with cognitive impairment. Through an examination of the literature, three conceptual frameworks, and clinical observations of several special care units (SCUs), the authors suggest that the psychosocial environment is the most important element of institutional dementia care. A preliminary conceptualization is offered which identifies the elements necessary to facilitate a supportive psychosocial environment in long-term care. The potential benefits of implementing such a model include preservation of personhood, simple recognition of remaining abilities and a decreased focus on disabilities, and reduction of pharmacologic therapy for disruptive behavior resulting in overall improvement in quality of life.

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... Florence Nightingale is recognized as the first nurse theorist to focus on the environment's role in nursing. She stated that the main function of nursing is to aid the body's own means of recovery by enhancing the therapeutic function of the environment {Nightmgale, 1969;Weiss & Lonnquist, 2000). In the more recent caring literature, theorists such as Rogers (1970) and Watson (1985) have focused on the interrelationship between human be-ings and their environment. ...
... In line with previous literature, this article highlights the philosophy of care as being of importance for both the physical environment and people's doing and being in the environment. One application of these findings is that an evaluation of the environment needs to include the philosophy of care as one dimension (e.g., Kayser-Jones, 1991;Werezak & Morgan, 2003). ...
Article
This article presents the findings of a study that aimed to describe what constitutes therapeutic environments and interpret what it means to be in such environments for older adults. Interview and observational data collected in Swedish health care contexts were subjected to qualitative content analysis. The findings describe therapeutic environments as being constituted by three interacting and interwoven categories: the physical environment, people's doing and being in the environment, and an organizational philosophy of care. The findings are interpreted in light of the existential philosophy of home as a concept, a place, and an existential experience, highlighting that therapeutic environments can support existential at-homeness among patients. The findings of this study can contribute to nursing practice by providing a conceptual basis for reflecting on and evaluating how the physical environment, staff's doing and being, and the organizational philosophy of care cooperate to support well-being among older adults living in long-term care facilities.
... Psychosocial environments that support well-being can comprise the establishment and use of a person-centred philosophy; adequate staffi ng; the promotion of a calm, safe, and welcoming environment; and the adoption of person-directed policies and procedures. 64,65 Non-institutional practices and the provision of activities have also been shown to have a positive eff ect on behaviour and social interaction, 66 whereas taskoriented practices and adherence to routines are barriers to quality dementia care. 67 The psychosocial environment is also associated with the prevalence of behavioural symptoms and the use of physical restraints and psychotropic medication in people with dementia. ...
... The published work on person-centred care for people with severe AD comprises a large number of articles that are based on clinical experiences, personal opinions, and anecdotal evidence; however, there are few theoretically and empirically rigorous studies. 7, 22,28,65,83 The clinical eff ects of person-centred care as established by interventions and outcome studies are also, to some extent, still lacking. 19,20,23,24,25,33,44 The methodological limitations of published studies that evaluate interventions include small sample sizes, a lack of control groups, the inclusion of confounders, interventions with many components, and great variation in the types and stages of dementia in the participants. ...
Article
When caring for people with severe Alzheimer's disease (AD), the concept of the person being central is increasingly advocated in clinical practice and academia as an approach to deliver high-quality care. The aim of person-centred care, which emanates from phenomological perspectives on AD, is to acknowledge the personhood of people with AD in all aspects of their care. It generally includes the recognition that the personality of the person with AD is increasingly concealed rather than lost; personalisation of the person's care and their environment; offering shared decision-making; interpretation of behaviour from the viewpoint of the person; and prioritising the relationship as much as the care tasks. However, questions remain about how to provide, measure, and explore clinical outcomes of person-centred care. In this Review, we summarise the current knowledge about person-centred care for people with severe AD and highlight the areas in need of further research.
... Previous studies have described that personcenteredness emanates from an interaction between the physical environment, the people in that environment, and the organizational philosophy of care. 44,57 It has also been suggested that a person-centered psychosocial climate is perceived as a caring environment that facilitates subjective well-being and existential experiences of at-homeness for patients and relatives. 57,58 This task of creating and maintaining caring environments to facilitate healing and well-being has been central to nursing theory across time and contexts. ...
... 44,57 It has also been suggested that a person-centered psychosocial climate is perceived as a caring environment that facilitates subjective well-being and existential experiences of at-homeness for patients and relatives. 57,58 This task of creating and maintaining caring environments to facilitate healing and well-being has been central to nursing theory across time and contexts. The importance of caring environments has been described most explicitly by Florence Nightingale, Martha Rogers, and Jean Watson. ...
Article
To optimize family-centered care and the staff working environment, the physical care environment should be designed to meet the needs of the infants, their families, and staff. It is important to evaluate the effects of a purpose-built neonatal ward on staff perceptions of job strain, the psychosocial climate, and the appropriateness of the physical environment. This study collected information from staff at a neonatal intensive care unit (NICU), before and after the ward was relocated to a new NICU. Effects were measured using the following variables: job strain, person-centered climate and appropriateness-of-the-physical-environment questionnaires. Data were analyzed using repeated-measures generalized estimating equations and factor analysis. After staff began to work in the new NICU, their job strain significantly increased. At the 2-year follow-up, staff stress levels had returned to preintervention levels. Participating staff perceived the purpose-built neonatal ward as being a significantly more appropriate physical environment for family-centered care of the infants and their families. The staff also perceived the psychosocial climate of the new NICU as significantly more person-centered in terms of having a more homey, comfortable, and everyday ambience and thus experienced as being more supportive. An NICU built according to recommended standards optimized the physical care environment for family-centered care and increased the staff working climate.
... The design of the PCRs is based on the goal of maintaining functioning of the residents, cognitively, behaviorally, and physically. Werezak and Morgan ( 2003 ) concluded there is a body of evidence that supports the importance and adequacy of the physical environment in the care of clients with dementia. Similarly, Morgan, Stewart, D'Arcy, and Werezak ( 2004 ) reported that residents in SDCUs, which were designed based on best practices of a psychosocial model of dementia care, demonstrated positive effects on functioning. ...
... The staffi ng model for the PCR is based on a psychosocial model of care and incorporates licensed professional staff and unregulated health care providers (patient care attendants), mostly the latter. Werezak and Morgan ( 2003 ) have recommended an appropriate staffi ng model for a psychosocial model of care. They suggest staffi ng levels that permit the operationalization of the philosophy of care promoting the well-being of the residents. ...
Article
Full-text available
RÉSUMÉ Cette étude phénoménologique et herméneutique a donné un aperçu des expériences des membres des familles des résidents qui ont été diagnostiqués d’une démence légère à modérée et qui ont été déménagés de leur institution de soins dans une résidence medicalisée unique. Des entrevues semi-dirigées ont été realisées avec 10 membres de la famille, dont six thèmes ont émergé : (a) la communication en cours, (b) de secours et de contentement, (c) des activités significatives, (d) un environnement amélioré, (e) le fonctionnement amélioré, et (f) le personnel engagé. Ces résultats ont des implications importantes pour la prestation des soins et la planification des programmes futurs dans les soins aux résidents ayant des besoins spéciaux. Surtout, nous pouvons conclure que les résultats axés sur le client des soins produit des résultats positifs pour les résidents et les membres des familles.
... Therapeutic Psychosocial Environment Framework (TPEF) by Bell (2015) defines five elements (i.e., psychosocial environment; physical environment & staffing; allocation of funding; policies & procedures; and organisational philosophy) for the quality of life of private construction's firms. Meanwhile, a study conducted by Werezak & Morgan (2003), further identified psychosocial environment could be divided into five (5) factors. These are job characteristic; role in the organisation; social aspects; job prospects; and organisational factors. ...
... The combination of both ideas is presented in Figure 1. (Bell, 2015;Werezak & Morgan, 2003). ...
Article
Full-text available
In the last decade, both natural and man-made disaster events in Malaysia bring hindrance to construction firms’ operations. Disaster events causing stress, anxiety and depression among people which leads to lose of working days. This research reports on psychosocial environment factors to private construction firms in the event of disaster. A semi-structured interviews were conducted among six (6) construction firms and the data were analysed using content analysis. The findings revealed that three (3) psychosocial environment factors (i.e., job characteristics; role in organisations; and social aspects) affected by man-made disasters; while job prospect and organisational factors distressed by natural disasters. Keywords: Man-made Disaster; Natural Disaster; Private Construction Firms; Psychosocial Environment Factors eISSN 2398-4279 © 2018. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. https://doi.org/10.21834/ajqol.v3i11.130
... Florence Nightingale is recognized as the first nurse theorist to focus on the environment's role in nursing. She stated that the main function of nursing is to aid the body's own means of recovery by enhancing the therapeutic function of the environment {Nightmgale, 1969;Weiss & Lonnquist, 2000). In the more recent caring literature, theorists such as Rogers (1970) and Watson (1985) have focused on the interrelationship between human be-ings and their environment. ...
... In line with previous literature, this article highlights the philosophy of care as being of importance for both the physical environment and people's doing and being in the environment. One application of these findings is that an evaluation of the environment needs to include the philosophy of care as one dimension (e.g., Kayser-Jones, 1991;Werezak & Morgan, 2003). ...
Article
This article presents the findings of a study that aimed to describe what constitutes therapeutic environments and interpret what it means to be in such environments for older adults. Interview and observational data collected in Swedish health care contexts were subjected to qualitative content analysis. The findings describe therapeutic environments as being constituted by three interacting and interwoven categories: the physical environment, people's doing and being in the environment, and an organizational philosophy of care. The findings are interpreted in light of the existential philosophy of home as a concept, a place, and an existential experience, highlighting that therapeutic environments can support existential at-homeness among patients. The findings of this study can contribute to nursing practice by providing a conceptual basis for reflecting on and evaluating how the physical environment, staffs doing and being, and the organizational philosophy of care cooperate to support well-being among older adults living in long-term care facilities.
... The importance of the physical environment in long-term care facilities has mainly been explored from the perspective of persons with dementia (Day et al. 2000, Calkins 2009, Landmark et al. 2009). Several aspects of institutional environments supporting persons with dementia have been described, such as small and homelike environments, environments which makes it easy for residents to get his or her bearings and safe environments with a balanced stimuli levelneither monotonous nor bewildering (Werezak & Morgan 2003, Bergland & Kirkevold 2011. 'Smallgroup' environments are often described as an essential characteristic of 'good design' of institutions for persons with dementia (Day et al. 2000, Calkins 2009), although Lai et al. (2009) have shown that results from studies of special care units are conflicting. ...
Article
Aims and objectivesTo assess the content validity and reliability of the Person-centred Climate Questionnaire-Patient version in long-term care facilities, to describe residents' perceptions of the extent to which their ward climate was person-centred and to explore whether person-centredness was associated with facility and resident characteristics, such as facility and ward size, having a sensory garden and having a primary caregiver.Background The importance of the physical environment to persons with dementia has been investigated. However, research is lacking regarding the extent to which mentally lucid residents experience their physical and psycho-social ward climate as person-centred and the factors influencing their experience.DesignCross-sectional survey design.Methods The Person-centred Climate Questionnaire–Patient version was translated into Norwegian with forward and backward translation. The content validity index for scales was assessed. The Person-centred Climate Questionnaire –Patient version was completed by 145 mentally lucid residents in 17 Norwegian long-term care facilities. Reliability was assessed by Cronbach's α and item–total correlations. Test–retest reliability was assessed by paired samples t-test and Spearman's correlation. To explore differences based on facility and resident characteristics, independent-samples t-test and one-way anova were used.ResultsThe content validity index for scales was satisfactory. The Person-centred Climate Questionnaire–Patient version was internally consistent and had satisfactory test–retest reliability. The climate was experienced as highly person-centred. No significant differences were found, except that residents in larger facilities experienced the climate as more person-centred in relation to everyday activities (subscale 2) than residents in smaller facilities.Conclusion The Norwegian version of the Person-centred Climate Questionnaire–Patient version can be regarded as reliable in a long-term care facility context. Perceived degree of person-centredness was not associated with facility or resident characteristics, such as the number of residents, having a sensory garden or knowing that one has a primary caregiver.Relevance to clinical practiceA person-centred climate can be attained in different kinds of long-term care facilities.
... The importance of the surrounding environment for patients' experiences of nursing care is well described in the literature, for example the influence of nature and the physical environment on interaction, well-being and reduction of important for the well-being of people with dementia (Werezak & Morgan 2003). The aim of this study was to explore the psychosocial climate and its influence on the well-being of people with dementia in a psycho-geriatric unit. ...
Article
Aims and objectives: This article present findings from a study aiming to explore the psychosocial climate and its influence on the well-being of people with dementia in a psycho-geriatric hospital unit. Background: Environmental influence in dementia is well explored in relation to the physical environment; however, few studies have explored the psychosocial environment and its influence on well-being. Design: The study had a grounded theory design. Methods: Participant observations were conducted in a psycho-geriatric ward for assessment and treatment of people with dementia in Sweden (n = 36 hours). Data were collected and analysed in a dialectical fashion using the principles of grounded theory methodology. Results: The basic social process that best accounted for the variation in the psychosocial climate and well-being of patients at the unit was 'staff presence or absence', conceptualised as the core category. Three categories emerged in relation to the core category; 'sharing place and moment', 'sharing place but not moment' and 'sharing neither place nor moment'. Conclusions: Staff were catalysts for the psychosocial climate and when being present and engaged they could create a climate interpreted as at-homeness which supported patient well-being. When being absent, the climate quickly became anxious and this facilitated patient ill-being. To provide quality care for people with dementia staff need to be aware of their role in setting the emotional tone of the psychosocial climate and also that this emotional tone significantly influences patient well-being. Relevance to clinical practice: The findings are clinically relevant and can be operationalised and applied in clinical practice. Awareness of the intimate connection between staff presence and absence, the psychosocial climate and patient well-being highlights an ethical responsibility to question: routines that promote staff absence; a culture of merely 'doing for'; and nursing tasks which involve a minimum of staff-patient interaction. The findings have implications for managers as well as for clinical staff.
... The importance of the psychosocial environment in institutional dementia care cannot be understated (Werezak & Morgan, 2003). Research indicates that residents who suffer from dementia are less likely to interact socially (Kolanowski et al, 2002), are more susceptible to depression (Meeks & Depp, 2002;Teri & Logsdon, 2000), and are increasingly unable to learn new tasks. ...
Article
Full-text available
Many older individuals have cohort-specific knowledge that may not be known by young caregivers. By providing familiar information, using Montessori principles that key into the remaining abilities of those with dementia, it is possible for the younger caregivers to successfully facilitate satisfying, interactive programs. Forty activity directors and staff, age 25–50, in long-term care settings interacted with residents age 56–100 in groups of 10 or more in both an activity intervention and standard activities. The younger caregivers indicated positive responses to the activity intervention and demonstrated increases in positive attitudes toward cognitively impaired, elderly residents, which was due to the intervention that provides the structure and materials to overcome both the skills gap and intergenerational knowledge gap for those staff that have them.
... Previous studies indicate that the extent to which the psychosocial climate of care settings is perceived as being person-centred is experienced as an indicator of caring environments that can cater for the psychosocial needs of patients and staff and facilitate well-being and existential experiences of at-homeness (Werezak & Morgan 2003, Edvardsson et al. 2005. Grand nursing theorists such as Florence Nightingale, Martha Rogers and Jean Watson have all described the interconnectedness of people and their environments, and they have argued for the centrality of nursing to create caring environments that supports healing (Nightingale 1969, Rogers 1970, Watson 1979. ...
Article
This study aimed to establish reliability and cut-off scores for the person-centred climate questionnaire - staff version (PCQ-S) in residential aged care. A number of tools have emerged recently to measure person-centredness, and these need psychometric evaluation and cut-off scores to enhance utilisation and interpretation. A cross-sectional survey design was employed in a Swedish sample of residential aged care staff (n = 1237). Psychometric evaluation using Cronbach's alpha and item-total correlation was used, together with establishing cut-off scores based on quartile scores. The PCQ-S had satisfactory psychometric properties and the following total scale cut-off scores for unit person-centredness were suggested: ≤49 ('well below average'), 50-56 ('below average'), 57-62 ('above average') and ≥63 ('well above average'). These cut-off scores were clinically meaningful as they separated the sample into four groups in which staff in more person-centred units reported significantly higher work satisfaction, social support and less stress of conscience. The PCQ-S has reliability in residential aged care samples, and cut-off scores are provided that provide important fundaments for comparative studies and aggregation of data to explore person-centredness care further. The study enables managers with ways to measure, interpret and compare levels of person-centredness between units and facilities for research, practice development and/or benchmarking purposes.
... The conceptual framework for this study is derived from the gerontological discourse surrounding personhood and person-centred care (Brooker, 2004: Brooker & Surr, 2005Crisp, 1999;Downs, 2000;Kitwood, 1993Kitwood, , 1997Kitwood & Bredin, 1992;Li & Orleans, 2002;Sabat, 1998;Sabat & Harre, 1992;Touhy, 2003;Werezak & Morgan, 2003;Woods 1999Woods , 2001. It explores the related body of research on self. ...
... Many health care reformers (IOM, 1986;Wunderlich et al., 1996;Miller & Mor, 2006;IOM, 2001) and proponents of culture change (Kitwood, 1997;Thomas, 1996;Jones, 1996;Fabiano, 2002;Thomas & Johansson, 2003) argue that improving living conditions for PCH residents must equally focus on improving the work environment for workers. Unfortunately, in the rush to create home-like environments the overwhelming focus is on the physical environment, often at the expense of the social context (Taft, Delaney, Seman & Stansell, 1993), in particular resident and staff relationships which are critical for dementia care (Mace, 1989;Lyman, 1989;Werezak & Morgan, 2003). Rantz and Flesner (2004) found that for HCAs, after extensive physical renovations in the study facility, RCC meant increased workload without additional resources, and more varied tasks but less time with residents. ...
... Kitwood challenged the practice of seeing individuals with dementia primarily through a biomedical lens where the illness comes fi rst and explored the ways in which persons with dementia remain persons fi rst, with dementia second. Personhood is a principle which suggests that even those with extreme limitations ought to be viewed as whole persons experiencing contentment, self-worth, self-esteem, purposefulness, peacefulness, and spirituality (Coker, 1998 ;Sikma, 2006 ;Touhy, 2004 ;Werezak & Morgan, 2003 ). ...
... While the physical designs of environments often receive most attention, the social environment and operational policies are more important than the physical design [67]. The systematic review of Bradshaw, Playford, Riazi [68] found that residents did not define a homelike environment by specific physical features but by: connection with others; participation in meaningful tasks; decision making and choice; staff knowing and respecting each individual's life history; and non-rushed and non-forced staff routines. ...
Article
Full-text available
Objectives: Despite an abundance of research acknowledging the value of interactive occupation and social engagement for older people, and the limits to these imposed by many residential settings, there is a lack of research which measures and analyzes these concepts. This research provides a method for measuring, analysing and monitoring interactive occupation and social engagement levels of residents in a secure residential setting for older people with mental health problems and dementia. It proposes suggestions for changes to improve the well-being of residents in residential settings. Method: In this case study design, the Assessment Tool for Occupational and Social Engagement (ATOSE) provided a 'whole room' time sampling technique to observe resident and staff interactive occupation and social engagement within the communal sitting room over a five-week period. Researchers made contemporaneous notes to supplement the ATOSE data and to contextualise the observations. Results: Residents in the sitting room were passive, sedentary, and unengaged for 82.73% of their time. Staff, who were busy and active 98.84% of their time in the sitting room, spent 43.39% of this time in activities which did not directly engage the residents. The physical, social and occupational environments did not support interactive occupation or social engagement. Conclusions: The ATOSE assessment tool, in combination with narrative data, provides a clear measurement and analysis of interactive occupation and social engagement in this and other residential settings. Suggestions for change include a focus on the physical, social, occupational, and sensory environments and the culture of care throughout the organization.
... In this body of literature, creating and maintaining caring environments to facilitate healing and well-being has for long been conceptualized as central to nursing due to the interconnectedness of people, health and their environments described by nursing theorists, such as Florence Nightingale, Martha Rogers and Jean Watson. Previous studies have conceptualized that the extent to which the psychosocial ward environment is perceived as being person-centred originates from an interaction between the physical environment, people's 'doing and being' in the environment and the organizational philosophy of care (Werezak & Morgan 2003, Edvardsson et al. 2005. It seems that in the pursuit of high-quality nursing care, providing environmental dimensions such as cleanliness, positive distractions and a general welcoming and homely ...
Article
Full-text available
Patient experiences of caring and person-centredness are associated with perceived nursing care quality. Abstract Aims. To explore the extent to which patient ratings of perceived caring and person-centredness are associated with perceived nursing care quality in an acute hospital sample of inpatients. Background. Self-reported patient experiences have had limited attention in
... The combination of both ideas is presented in Figure 1. (Bell, 2015;Werezak & Morgan, 2003) Hence, the objective of this paper is to investigate psychosocial environment factors in the event of disasters to private construction firms. The purpose is to explore the effect of quality of life (in long term care) among employees in construction firms and their workers during disaster occurrences. ...
Article
Full-text available
In the last decade, both natural and man-made disaster events in Malaysia bring hindrance to construction firms’ operations. Disaster events causing stress, anxiety and depression among people which leads to lose of working days. This research reports on psychosocial environment factors to private construction firms in the event of disaster. A semi-structured interviews were conducted among six (6) construction firms and the data were analysed using content analysis. The findings revealed that three (3) psychosocial environment factors (i.e., job characteristics; role in organisations; and social aspects) affected by man-made disasters; while job prospect and organisational factors distressed by natural disasters.
... In this body of literature, creating and maintaining caring environments to facilitate healing and well-being has for long been conceptualized as central to nursing due to the interconnectedness of people, health and their environments described by nursing theorists, such as Florence Nightingale, Martha Rogers and Jean Watson. Previous studies have conceptualized that the extent to which the psychosocial ward environment is perceived as being person-centred originates from an interaction between the physical environment, people's 'doing and being' in the environment and the organizational philosophy of care (Werezak & Morgan 2003, Edvardsson et al. 2005. It seems that in the pursuit of high-quality nursing care, providing environmental dimensions such as cleanliness, positive distractions and a general welcoming and homely ...
Article
AimsTo explore the extent to which patient ratings of perceived caring and person-centredness are associated with perceived nursing care quality in an acute hospital sample of inpatients. Background Self-reported patient experiences have had limited attention in conceptualizations of healthcare quality as described in policy and national standards, as well as in health and nursing care practice. The impact of central nursing concepts such as caring and person-centredness on patient ratings of nursing care quality is largely unknown. DesignA descriptive non-experimental correlational design was used to collect and analyse data from a sample of Australian acute hospital inpatients (n=210) in December 2012. Methods The study collected self-report patient data through a study survey including demographic data and the Caring Behaviours Inventory, the Person-centred Climate Questionnaire, the SF-36 and the Distress thermometer. Descriptive statistics together with Pearson correlation and hierarchical linear regression were used. FindingsPerceived caring behaviours of staff and the person-centredness of wards were significantly associated with nursing care quality as evidenced by Pearson correlations being significant and exceeding the pre-set cut-off of r>0 5. Staff caring behaviours and ward person-centredness also accounted for more than half of the total variance in perceived nursing care quality as evidenced by the final regression model. Knowledgeable and communicable staff, timeliness of assistance and environmental support stood out as most significantly related to patient perceived nursing care quality. Conclusions Patient experiences of caring and person-centredness seem to have an influential role in the extent to which patients experience the quality of nursing care. Knowledgeable and communicable staff, timeliness of assistance and environmental support stand out as most significantly related to patient-perceived nursing care quality.
... Kitwood challenged the practice of seeing individuals with dementia primarily through a biomedical lens where the illness comes fi rst and explored the ways in which persons with dementia remain persons fi rst, with dementia second. Personhood is a principle which suggests that even those with extreme limitations ought to be viewed as whole persons experiencing contentment, self-worth, self-esteem, purposefulness, peacefulness, and spirituality (Coker, 1998 ;Sikma, 2006 ;Touhy, 2004 ;Werezak & Morgan, 2003 ). ...
Article
RÉSUMÉ En 2010, 500 000 Canadiens étaient atteint d’une maladie liée à une démence. On estime que le nombre des malades va doubler en environ 25 ans. Pour cause de ce groupe démographique croissant, la démence de plus en plus (le plus souvent causée par la maladie d’Alzheimer) exercera un impact significatif sur notre communauté vieillissante et ses soignants. La démence est associée à des comportements difficiles tels que l’agitation, l’errance et l’agression. Les prestataires de soins doivent trouver des stratégies novatrices afin de faciliter la qualité de vie pour cette population; d’ailleurs, de telles stratégies doivent valoriser l’individu. Les robots socialement engagés – conçu spécifiquement à la communication et aux fins thérapeutiques – fournir un moyen d’atteindre cet objectif. Cet article décrit une étude dans laquelle Paro (un bébé phoque robotique) a été utilisé dans le cadre d’un programme de formation d’été pour étudiants. Les conclusions préliminaires suggèrent que l’integration des robots socialement engagés peuvent se révéler comme utiles cliniquement en milieux de soins de longue durée.
... The importance of the surrounding environment for patients' experiences of nursing care is well described in the literature, for example the influence of nature and the physical environment on interaction, well-being and reduction of important for the well-being of people with dementia (Werezak & Morgan 2003). The aim of this study was to explore the psychosocial climate and its influence on the well-being of people with dementia in a psycho-geriatric unit. ...
Article
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Major renovations were carried out in occupied dementia care units at the Lodge at Broadmead, Victoria, British Columbia. A 32-bed lodge was divided into two, requiring the relocation of three sets of doors. Home-like kitchens and living and dining rooms were built and furnished in each unit. A silent resident call system was installed. Nursing stations were moved off the unit. Murals added atmosphere and camouflaged exit doors. The process, while challenging, was successful due to comprehensive planning, careful phasing, the contractor's daily presence, the education of construction workers about residents, constant communication among key people and cooperation of lodge staff. Preliminary results are positive.
Article
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This paper describes an ethnographic study that sought to gain knowledge of the occupational patterns of persons with dementia in a care home and how the residents perceived the group activities in which they participated. The residents' ages ranged from 82 to 92 years. They were seven women and one man. Both participant observation and interviews were used to collect data. Data analysis resulted in an ethnographic story organised around two key themes: (1) the occupational patterns of the residents, and (2) the residents' perceptions of the activities offered. In this story residents appeared passive, playing the role of guests in the care home. Residents were dependent on staff to engage in daily occupations. Interviews revealed that residents perceived participation in activities as important to their mental and physical health and an advantage of living in the care home.
Article
Agitation is exhibited by most nursing home residents with dementia and is a risk factor for poor health outcomes. Identifying the antecedents of agitation is essential for appropriate treatment because interventions require well-defined targets. This study explored relationships between level of social interaction (high vs. low), the premorbid personality trait of extraversion, and agitation using baseline data from a clinical trial that tested the efficacy of activity interventions for agitation. Most residents exhibited at least one agitated behavior over the 332 observation days. Agitation was significantly greater under high social interaction as compared with low social interaction (P < .0001) regardless of the extraversion score.
Article
Elder abuse and neglect can be detected only through awareness, healthy suspicion, and knowledge of risk factors. A detailed and well-documented medical history, including information from the medical records, patient, family, and caregivers, and a comprehensive physical examination are necessary to identify and document signs of abuse and neglect. Suspected cases must be reported to adult protective services or other appropriate law enforcement agencies. Elder abuse and neglect is a result of the dynamic interaction between personal, family, social and cultural values, priorities, and goals. Therefore, attention must be given to those factors that, although they do not cause abuse, contribute to its likelihood. In NHs, these risk factors include behavioral problems of the resident, staff caregiver burden, staff burnout, and staff ageism. In home care, risk factors include the personality problems of the family caregiver (more than overall caregiver burden), the characteristics of paid home care workers, and the psychosocial problems of the patient (eg, isolation, psychiatric illnesses, and poor social support). By its nature, abuse and neglect is person driven and preventable. Thus, patient and caregiver education and other interventions targeted toward risk factors or types of abuse or neglect play an invaluable role in preventing elder abuse and mistreatment.
Article
Dementia care has been trapped in a "trial and error" type of practice due to difficulty understanding the needs of older adults with severe dementia. Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) can be quite difficult for residential staff. However, some experienced care workers succeed in establishing effective relationships. The goal of this study was to: 1) develop a process to identify needs behind BPSD; 2) find solutions using a team approach; and 3) apply the results to educate new workers. The KJ method was employed to reach decision-making about best practices in residential dementia care. This qualitative method is used to organize group data collected in the field and is based on understanding complex situations. A group process of 12 Japanese care workers experienced in understanding and responding to the "repeated appeal to return home" of residents in nursing care facilities is highlighted along with an illustrative case example. The workgroup met over two years. The study revealed five steps in understanding the needs behind the appeal, which include: (1) Listen to the voice and go with the flow of the behavior; (2) Learn about the inner experience; (3) Learn about the contextual environment of "here and now" situations; (4) Reflect on the care environment; and (5) Find the keyword. This needs identification process has application to other cultural contexts. The implications of this study for practitioners who work with people with dementia in residential settings will be discussed.
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Mental illness is prevalent among nursing home residents, but staff are not well trained to deal with it. This research evaluated an Internet mental illness training program designed for certified direct care workers, ie, nurse aides (NAs). Pilot research was also conducted to explore effects and acceptance of the same program with a sample of licensed health professionals (LHPs). Trial 1: Pre-post randomized treatment and control design for NAs; Trial 2: Quasi-experimental pre-post within-subjects design for LHPs. Both studies were conducted on the Internet. Trial 1: n = 70 NAs; Trial 2: n = 16 LHPs. Internet-based behavioral skills training and knowledge building, using video modeling with mastery learning instructional design. Video situations testing and assessment of psychosocial constructs associated with behavior change; follow-up interviews with a sample of treatment NAs. Trial 1: Multivariate analysis of covariance analysis showed positive results (P = .003) for knowledge, attitudes, self-efficacy, and behavioral intention, with medium-large effect sizes. The training was well received by the users. Trial 2: Paired t tests showed significant effects on 5 of 6 outcome measures, with medium-large effect sizes, and it was well received by the LHP sample. Internet training can be an effective approach to help staff work with residents with mental illness. In this research, it showed significant positive effects and was well received by NAs and by LHPs.
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Nightingale saw the art of nursing as providing an environment in which patients were offered the best conditions for nature to act upon them. However, we still have limited research-based understandings of care settings experienced as supportive by patients, significant others and staff. The aim of this study was to construct a theoretical understanding of processes contributing to supportive care settings. The authors used grounded theory design and the constant comparative method to analyse theoretically sampled interview and observational data from three different contexts of care. The tentative theory conceptualizes supportive care settings as sensing an atmosphere of ease, and five categories were recognized: experiencing welcoming; recognizing oneself in the environment; creating and maintaining social relations; experiencing a willingness to serve; and experiencing safety. Having one's expectations of the environment exceeded was a mediating factor in sensing an atmosphere of ease. Sensing an atmosphere of ease facilitated experiences of being able to locate oneself in familiar and safe surroundings; being able to follow one's own rhythm; being seen, acknowledged and cared about; and having possibilities of benefiting from beauty and contacts with others.
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To explore the impact of personal attributes, environmental attributes, and the presentation of 9 categories of stimuli on agitation in nursing home residents with dementia. Participants in this randomized, controlled, observational cross-sectional study were 193 residents of 7 nursing homes, all with a diagnosis of dementia, for whom we obtained data pertaining to cognitive functioning (via the Mini-Mental State Examination), performance of activities of daily living (Minimum Data Set), and role-identity/activities of past interest (Self-Identity Questionnaire). Environmental attributes (eg, noise, lighting) and direct observations of agitation (primary outcome) were recorded via the Agitation Behavior Mapping Inventory. Engagement was measured using the Observational Measurement of Engagement. Both agitation and engagement were assessed for each stimulus (including a control condition). Univariate findings (ie, for 1 explanatory variable at a time) showed agitation to be related to several personal attributes--ie, female gender was related to verbal agitation (P < .0001); low cognitive function was related to total, verbal, and physical agitation (P < .001 for each); low performance of activities of daily living was significantly related to all types of agitation (P < .01 for total agitation and P < .05 for each type of agitation); and unclear speech was significantly related to total agitation (P < .01). Eight of the 9 stimulus categories were significantly related to decreased levels of agitation, with ORs ranging from 0.37 (live human stimuli, P < .001) to 0.79 (inanimate social stimuli, P < .05). Higher levels of engagement were related to lower levels of agitation (P < .001 for total agitation). In the multivariate analyses, higher cognitive function (P < .001), male gender (P < .05), level of engagement with stimuli (eg, duration of engagement for 3 minutes or longer, P < .05), and all 9 stimulus categories, with the exception of music, were independently predictive of lower levels of agitation (P < .001). The finding that both type of stimuli and engagement level with the stimuli were significant predictors of agitation underscores the importance of engagement as a determinant of agitation levels.
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This research evaluated an individualized Internet training designed to teach nurse aides (NAs) strategies to prevent or, if necessary, react to resident aggression in ways that are safe for the resident as well as the caregiver. A randomized treatment and control design was implemented, with baseline, 1-, and 2-month assessments for 158 NAs. The training involved 2 weekly visits. The Internet intervention was a behaviorally focused and video-based training that included content on skills for safely dealing with physical aggression. Measures included video situation testing and assessment of psychosocial constructs associated with behavior change. Analysis of covariance showed positive results for knowledge, attitudes, self-efficacy, and empathy, with medium-large effect sizes maintained after 2 months. The training was well received by participants. Internet training is a viable approach to shape appropriate NA reactions to aggressive resident behaviors. This format has future potential because it offers fidelity of presentation and automated documentation, with minimal supervision.
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The pathogenic mechanisms by which physical exercise influences atherosclerotic lesion formation remain poorly understood. Because vigorous physical training increases oxidative stress, this study tested the hypothesis that graduated and moderate physical exercise together with metabolic intervention (l-arginine and antioxidants) may contribute to increased vascular protection. Exercise training in mice was induced by graduated swimming. In hypercholesterolemic male mice on an atherogenic high-cholesterol diet, graduated and moderate exercise lowered plasma cholesterol and decreased atherosclerotic lesions compared with sedentary control mice. Antioxidants (1.0% vitamin E added to the chow and 0.05% vitamin C added to the drinking water) and l-arginine (6% in drinking water) supplementation to exercising hypercholesterolemic mice further and synergistically reduced atherosclerosis compared with untreated exercised mice. Arterial oxidation-specific epitopes and systemic oxidative stress were reduced by metabolic intervention. Graduated chronic exercise elicited an increase in production of nitric oxide through increased endothelial nitric oxide synthase expression and ameliorated scavenger activities. Thus, metabolic intervention with l-arginine and antioxidants together with graduated and moderate exercise training reduce atherosclerotic lesion formation. • catalase • nitric oxide synthase • vitamin E • oxidative stress • low-density lipoprotein
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Objective: The objective of this review is to outline a comprehensive set of possible design interventions focusing on spatial and environmental design factors influencing positive social interaction, which is one of the key aspects of quality of life (QoL) in long-term care facilities (LTCFs). Methods: This systematic literature review synthesized research evidence from seven databases (after the year 2000) spanning medical and health literature, environmental psychology, architecture, interior design, and evidence-based design literature. Results: The key spatial design characteristics of the facilities shown to affect positive social interaction were as follows: (a) The Physical Environment and Setting; (b) Accessibility, Legibility, and Layout; (c) Social Environment and Network; and (d) Staff–Resident Ratio and Care Philosophy. Conclusion: Several critical spatial design features of the facilities were identified. Spatial design interventions could influence the design decisions for future care facilities and provide designers the guidelines that are generalizable regardless of geographic location of the LTCF.
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Physical and verbal assaults by residents on care staff are not uncommon in long-term residential care facilities (LTCs). This research evaluated an Internet training designed to teach nurse aides (NAs) strategies to work with aggressive resident behaviors. Six LTCs were randomized in an immediate treatment (IT) and delayed treatment (DT) design, and NAs were recruited in each (IT: n = 58; DT; n = 45). The treatment involved 2 weekly visits to the online training. Hard copy assessments collected participant responses at baseline (T1), 8 weeks (T2), and at 16 weeks (T3). The DT group viewed the program after T2. Hierarchical linear models showed significant group differences at T2 in knowledge, and these levels were maintained at T3. The number of aggressive incidents reported per day by the IT group were nonsignificant at T2 but decreased significantly from T1 to T3 with a large effect size. The program was well received by users. These results suggest that the Internet training was an effective tool to reduce assaults in LTCs, and training effects may improve over time as NAs gain experience using the techniques.
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Licensed care staff working in long-term care facilities may be poorly prepared to work with residents with mental illness. This research reports on the program evaluation of Caring Skills: Working with Mental Illness, a training program delivered on the Internet. It was tested with a randomized treatment-control design, with an eight-week follow-up. The training provided video-based behavioral skills and knowledge training. Measures included video situations testing and assessment of psycho-social constructs including empathy and stigmatization. ANCOVA analysis at 4-weeks posttest showed significant positive effects with medium-large effect sizes, which were largely maintained at the 8-week follow-up. The training was well-received by the users.
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Background: The physical and psychosocial environments in nursing homes influence the residents’ everyday life as well as their well-being and thriving. The staff’s perceptions of and relationships with the residents are crucially important to quality care. Quality care is described often as person-centred. Few measurement tools exist that focus on person-centred care in nursing homes. Objective: The aim of this study was to evaluate the psychometric properties of the Norwegian version of the Person-centred Climate Questionnaire–Staff version (PCQ-S). Design: This study had a cross-sectional survey design. Participants and Settings: Two hundred and nine healthcare and support staff in five nursing homes in the eastern part of Norway. Methods: The Swedish PCQ-S was translated into Norwegian with forward and backward translation. The relevance of the items included in the questionnaire was assessed by an expert panel of 10 nursing home care staff, because the questionnaire has not been used in this context previously. A psychometric evaluation using statistical estimates of validity and reliability was performed. The discriminatory capacity of the questionnaire was also tested. Results: The content validity index was satisfactory (0.78). The PCQ-S showed high internal consistency reliability in that Cronbach’s α was satisfactory for the total scale (0.92) and the three subscales (0.81, 0.89 and 0.87). The test–retest reliability was also satisfactory as evident from a Spearman’s correlation coefficient of 0.76 (p < 0.01) between the total PCQ scores at test and retest. The Norwegian version retained the original factor structure of the Swedish version. Conclusion: As the psychometric evaluation showed satisfactory validity and reliability scores, this study supports the Norwegian version of the PCQ-S when applied to a sample of nursing home staff.
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This critical constructionist case study of ‘Leonard,’ a man with frontotemporal dementia living on a special care unit predominantly populated by people with Alzheimer’s Disease and related dementias, explores how healthy others’ perceptions of the prevailing physical and psychosocial environment were influenced by Leonard’s behaviour which, in turn, was influenced by people’s perceptions of him as a ‘problem.’ Data were obtained through participant observations, individual interviews with staff and residents, and focus groups with family members and nursing staff. Leonard’s ‘needs-driven dementia compromised’ behaviours are not recognized as such by many of the healthy others with whom he co-creates his psychosocial environment; rather he is constructed as deviant, which undermines his selfhood as well as his quality of life. Education of staff and family members as well as broad organizational change is needed to address the issues underlying the problems for which Leonard is blamed but instead arise largely from the environment within which Leonard is situated.
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Internet training courses for nurse aides (NAs) in long-term care facilities (LTCs) have been shown to be effective. Little is known, however, about Internet training effects on NAs in a non-research context, or about continued utilization of an available training programme. In this research, a replication study was conducted with the Internet training programme Caring Skills: Working with Mental Illness. Three LTCs provided the training to all NAs, each within a 1-month interval scheduled during consecutive months. Supervisors were interviewed subsequently about their experiences organizing and supervising the training. Participants in all three LTCs showed positive pre-post-tests effects with large effect sizes on situational knowledge and self-efficacy, and knowledge about mental illness. Users rated the programme highly, and they indicated that it would improve quality of their resident care. Supervisors praised the training, and they said NAs were using recommended training behaviours. Although available to all staff, nursing and other staff made little use of the training in subsequent months. Training for NAs on the Internet thus appears feasible, and it is perceived to be beneficial for resident care. Plans for continued utilization and dissemination of best practices to other staff, however, should be integrated when planning for staff training on the Internet.
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Die ständige Zunahme des Anteils demenziell erkrankter Bewohner stellt die Einrichtungen der stationären Altenpflege vor große Probleme. Die Betreuung und Pflege demenziell erkrankter Menschen unterscheidet sich wesentlich von der Pflege lediglich somatisch pflegebedürftiger Menschen. Verhaltensauffälligkeiten der demenziell Erkrankten, wie z. B. das Eintreten in fremde Zimmer, ein veränderter Tag-Nacht-Rhythmus, motorische Unruhe und Schwierigkeiten bei der Kommunikation erzeugen vielfach Reibungspunkte und Konflikte mit anderen Bewohnern. Dies führt im Alltag wiederholt zu Unverständnis, Ärger und Ablehnung. Daher bedarf es eines besonderen Betreuungs- und Pflegeansatzes für demenziell Erkrankte (Kuratorium Deutsche Altershilfe, 2000; Lind, 2000; Wood u.a. 2005).
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This study used a two-round modified Delphi technique with a questionnaire survey in order to reach a consensus for the questionnaire; the survey was conducted from September to December 2009. The six indicators for the environmental quality of long-term care institutions in Taiwan are (1) indoor environmental quality, (2) safety equipment for the prevention and management of disasters occurring in residents’ daily lives, (3) provision for assistive devices for residents’ daily use, (4) provision for privacy and individualized space, (5) provision for comfortable and decorated indoor environments, and (6) provision for social interaction space. The scale included 34 items with an acceptable number of panel members and acceptable construct validity. Panel members all highly approved of Indicators 1, 2, and 6. Although they approved of Indicator 3, they suggested that caregivers at institutions should replace the functions of living assistive devices. They approved of Indicator 5; however, they questioned the method for providing comfortable and decorated environments. They approved of Indicator 4; however, they suggested that private space need not be provided in the living room of the institution. In terms of long-term care institution environments in Taiwan, Indicators 1, 2, and 6 were important for protecting residents’ physical and psychological well-being and improving their social interactions. Indicator 3, although important, could be directly replaced by caregivers. Indicator 5 required more implementation methods, while Indicator 4, the living room of the institution, was considered unnecessary.
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This article presents evidence for the efficacy of psychosocial interventions for people with dementia and their carers. The evidence base is not yet robust enough to clearly suggest which interventions are most suited for which environment. However, from our literature review there appears to be reason to use music therapy, aromatherapy, life story work, animal-assisted therapy and post-diagnosis/carer support work. We focus on both the traditional outcome measures of behavioural and psychological symptoms of dementia (BPSD) and the more difficult to measure, but equally important, person-centred outcomes of nonpharmacological interventions, as their properties are distinctly different from those of pharmacological agents. Learning Objectives • Be aware of the range of psychosocial interventions. • Have a better understanding of the possible outcomes from given interventions. • Be aware of the paradigm shift from managing BPSD to a person-centred approach that focuses on the patient's well-being and quality of life.
Chapter
Health-care professionals in the field of geriatrics are well aware that behavioral and psychiatric symptoms are extremely common in persons with dementia. Over the past decade, there has been a growing interest in the development and use of nonpharmacologic treatment approaches to addressing dementia-related behavioral problems. This chapter provides an overview of the use of nonpharmacologic interventions in treating behavioral problems associated with common types of dementia. Most dementia-related behavioral problems are linked to confusion, delirium, medication-induced delirium, pain, environmental factors, and the intrusive aspects of caregiving. Models of nonpharmacologic treatments include good care/comfort care, unmet needs, environmental intervention, learning theory, antecedent control, family and caregiving education and training, and psychosocial and individualized therapies.
Chapter
Organic mental disorders, in contrast to functional (i.e., psychological) disorders, have historically been defined as mental disorders that can be attributed to biological pathology. Disorders that were classified as organic mental disorders in previous editions of the DSM have been divided into three separate sections in the DSM-IV: (1) Delirium, Dementia, and Amnestic and Other Cognitive Disorders; (2) Mental Disorders Due to a General Medical Condition; and (3) Substance-Related Disorders. Organic mental disorders may be classified as either acute or chronic based on duration, abruptness on onset, and defining symptoms. Proper assessment and diagnosis of organic disorders is essential, as leaving them untreated may lead to further deterioration or premature death. The majority of organic disorders are maintained by the underlying biological cause, and therefore require medical treatment to ameliorate the condition. However, a biopsychosocial approach to treatment is required to address all symptoms, particularly as organic disorders often have affective and relational consequences as well. Psychotherapy and cognitive rehabilitation strategies have been shown to be effective with a variety of acute and chronic organic disorders. Although therapeutic interventions with chronic degenerative conditions, such as Alzheimer’s dementia, cannot produce permanent change, they can optimize the person’s functioning and increase quality of life. In other cases, such as moderately severe amnesia, memory functions that have been compromised may be recovered through neuro-rehabilitation. Each individual (i.e., case) is unique and depends not only on the physical factors involved but also on personal, relational, and contextual features. Thus, clinicians that practice with this heterogeneous population need considerable knowledge and clinical experience which should include competence in geropsychology and neuropsychology as well as rehabilitative and psychotherapeutic procedures.
Chapter
Staff training and development in caring for the client with dementia includes organizational development, evaluation of job descriptions, competencies, programs available, as well as whether to develop training programs in a face-to-face or online learning environment. Utilization of adult learning principles to achieve just-in-time training and daily huddles will assist in offering frequent reminders of principles of the formal educational program. © Springer International Publishing AG 2017. All rights reserved.
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Although individualized care for persons with dementia in long-term care institutions has become accepted as best practice, there have not been easy-to-use, multi-item reliable measures of the concept for scientific research or for administrative use. Following review of the literature, consultation with experts in the field, and direct observation within long-term care facilities, three domains of individualized care (knowing the person/resident, resident autonomy and choice, communication — staff-to-staff and staff-to-resident) were chosen as appropriate for the development of multi-item paper-and-pencil staff completion scales. These scales are presented in this article, including, where appropriate, shorter scales derived from factor analyses. The findings suggest that these domains of individualized care lend themselves to brief multi-item measures and that not all conceptual domains of individualized care co-occur in practice. Further, supplemental staff training in individualized care practice may be warranted.
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Direct assessment of quality of life (QoL) of persons with dementia has largely been ignored due to logistical, conceptual and practical issues. This article presents a disease-specific conceptual framework of QoL for dementia. Based on this conceptualization, a 29-item instrument designed to assess QoL by direct interview with dementia patients was developed and tested on 99 participants. The data show that the instrument is reliable and shows evidence of validity. Nearly all participants (96%) were able to respond to questions appropriately. Thus, persons with mild to moderate dementia can be considered good informants of their own subjective states, paving the way to consider patient responses rather than proxy measures as the gold standard for assessing QoL for persons with dementia.
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Older people experience sensory, cognitive, and social deficits that adversely affect their interaction with the environment. Design of institutions for the elderly resident should be prosthetic to ensure that environments optimally accommodate the functioning of the residents. The sensory and cognitive state of the residents should be considered in every facility. This review discusses how sensory and cognitive changes in aging affect orientation and wayfinding as well as how the physical aspects of the environment can accommodate these changes to reduce confusion and disorientation. Environmental features that promote social interaction are reviewed. Because the environmental needs and unique characteristics of the cognitively impaired resident differs from that of the nonimpaired resident, special issues in the design of facilities for demented residents are reviewed. Conclusions are offered with regard to research needs and applied problems.
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The authors evaluated participation in activity programs in a prospective study of 198 new nursing home admissions. Both on admission and after 1 year, approximately 50% of patients were not participating in activities. Nonparticipation was associated with greater cognitive and functional impairment and the use of restraints and neuroleptics. Over the year, activity status changed for approximately 50% of patients in relation to these factors. These findings indicate current limitations in nursing home activity programs and suggest that participation is a dynamic process influenced by identifiable clinical variables. Revision of activity programs is necessary to meet OBRA regulations to improve the quality of patients' lives.
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The consideration of disease-specific quality of life (QoL) for persons with dementia has, until recently, been mostly ignored. Definitions have been inconsistent, conceptual models scarce and due to methodological concerns, measurement has been problematic. This paper presents a conceptual model of disease-specific QoL for dementia and psychometric data on the Dementia Quality of Life Instrument (D-QoL) (a patient-administered instrument based on this framework). QoL is defined as an individuals' subjective experience and evaluation of their life circumstances. QoL is shaped by subjective and objective determinants; four context domains (dementia signs and symptoms, comorbid illness, physical and social environment, individual characteristics) as well as functioning and behavioral variables. Five domains of QoL are presented; aesthetics, positive affect, negative affect, self-esteem and feelings of belonging. The D-QoL was found to adequately assess these domains with five scales having internal consistencies ranging from .67 to .89 and interscale correlations ranging from .09 to .67, thus providing a valuable new tool for assessing QoL in dementia.
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Estimates of the prevalence of disruptive behavior in the nursing home are presented based upon a representative sample of nursing home residents from intermediate care and skilled nursing facilities (ICF and SNF) in Rhode Island. Results indicate that 26.4% of residents had engaged in some form of disruptive behavior within two weeks prior to assessment. Abusiveness (physical and verbal) and noisiness were identified as the most prevalent behavior types (11.6% and 10.2%, respectively). Given the similarity of Rhode Island nursing home residents to nursing home residents nationally, these estimates may be considered as estimates for the national nursing home population. Older residents and those with greater physical and cognitive impairments were more likely to exhibit behavior problems. Although disruptive behavior seems to be associated with the dementing process, cognitively intact residents also demonstrated these behaviors. These findings suggest that an etiology of disruptive behavior should include both physiological as well as social and psychological factors.
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As we become more deeply concerned with the care of people with Alzheimer's disease and related disorders, it becomes increasingly clear that design is not just an incidental concern, but is integral to a well balanced program for this population. It is gratifying that over the last few years attention has begun to focus on the basic issues of quality of care. We have only begun to examine the potential of the physical surroundings in preventing and dealing with the loss of function-vision, hearing, mobility, social behavior and mental competence. It is, at the same time, equally disheartening that many involved in institutional care still seek only to meet minimum code requirements without responding to care, care management and the residence itself. The facilities themselves look dismal and depressing and perhaps more importantly, do not function much better. The average facility may have a ”decorated“ lobby, but design that is both functional and attractive is the exception. Often buildings are renovated or ”designed“ without architectural or professional design input. These ”design efforts“ are characterized by the inclusion of super graphics, the cosmetic approach of bright colors and the inclusion of grab bars and handrails. It is my view that incorporating environmental design into the quality of care and care management programs can greatly enhance these programs to the benefit of both the cognitively impaired and the staff.
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Autonomy and independence have recently become important issues for the elderly, but have not been applied to Alzheimer's disease patients. This project explores pertinent autonomy for the cognitively disabled by studying exit door behaviors. A specially designed environment satisfied safety and health concerns and enabled residents to have free access to the outdoors during daylight hours. Twenty two residents in early to advanced stages of the disease participated in the project. The results indicate that the number of agitated behaviors in five categories decreased under the unlocked door condition.
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To manage the care of residents with dementia, many long-term care facilities have created special care units designed to meet the unique needs of this group. This article describes results of the qualitative component of a larger research project examining environment-behavior relationships in dementia care settings. The study includes 18 in-depth interviews that were conducted with 9 staff and 9 family members of special care unit (SCU) residents. Thematic analysis was conducted using grounded theory techniques. Although participants described residents 'needs in relation to both the physical and social environments, the latter was perceived to have more impact on quality of life andfunctional ability. This article focuses on five areas of need, identified by participants, in relation to the social environment: stimulation and meaningful activity, human contact, safety and supervision, individualized care, andflexibility.
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1. Aggressive behavior in elders with dementia occurs most often during personal care. It is often a response to invasion of private space and may be prevented or reduced by interpersonal approaches that reflect a set of individualized goals for the resident. 2. Five resident goals for preventing or reducing aggressive behavior are to feel safe, to feel physically comfortable, to experience a sense of control, to experience optimal stress, and to experience pleasure. 3. These goals provide a framework for humane care that respects the personhood of the individual and minimizes the need for psychotropic medications and physical restraints.
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It is alarming that a basic need such as fluids and nutrition can be so neglected when caring for elderly patients. Dennis & Prescott (1985) found when asking nurses around the country to describe good nursing practice that dietary concerns were not commonly identified as an activity comprising good nursing. Kayser-Jones (1981) found, when comparing the quality of care in a Scottish and an American institution, that the greatest difference between the two facilities was the environment. In the Scottish institution, the environment was patient centered while, in the American institution, little attempt was made to consider the needs of the elderly residents (Andreasen, 1985). To provide quality care to the elderly, the nurse must be involved in all aspects of the environment--the physical, the organizational, the personal, and the psychosocial milieu. While all components are important, the nurse's involvement in the organizational aspects of long-term care facilities is essential for quality nursing care. Florence Nightingale emphasized that the nature of the hospital authority (e.g., policy issues) was critical. "For unless an understanding is come to on this point, the very existence of good nursing is an impossibility" (Nightingale, 1859, 1980). There are many environmental factors that will promote well being for the institutionalized elderly, such as color, lighting, the physical arrangement of furniture, personal belongings, the administrative philosophy, and the absence of irritating noises. Nothing, however, is more important than the characteristics of the nursing staff. Human relationships--the bond between nurse and patient--are more important than the physical surroundings. Nurses must be involved in planning an environment that will promote and enhance the nurse-patient relationship. Furthermore, we must emphasize the value of the nurse-patient contact and be involved in the design of facilities and the development of policies that will increase this contact and promote the development and maintenance of a strong nurse-patient bond.
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Common nursing concerns and patient needs within the physical, emotional, cognitive, and social dimensions are addressed. Nursing interventions that help the patients maintain the maximum level of independence for as long as possible are suggested.
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The environment plays an essential role in the functioning and care of older persons, particularly those with Alzheimer's disease. This article describes the characteristics of the environment that affect the functioning of persons with Alzheimer's disease and the interaction between the person and environment. Assessment and interventions based on environmental characteristics and person-environment interaction are identified.
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Describes a program designed to enhance self-esteem, relaxation, vitality, and exercise (SERVE) in a 127-bed intermediate-care facility for the elderly in which about 50–60% of residents have cognitive impairment. The SERVE program is based on the concept that there are reversible aspects of dementia (i.e., chronic brain syndrome, organic brain syndrome, Alzheimer's disease, and/or multi-infarct disease). One of the concepts underlying the approach is a belief that many of the behavioral symptoms evolve from patients' responses to the environment and their personal awareness of cognitive deficits. Fear and anxiety are normal emotions when a patient feels confused and disoriented much of the time. Components of the program include a simple stretching and range-of-motion exercise segment, a vitality/fun component, a walking segment, and a relaxation segment. The goal of the program is to help participants achieve a sense of order in their disoriented world and to know success. Results with 2 groups of patients have been mixed, with dramatic, modest, or no improvement for individuals. The positive change in staff attitude is also noted. (34 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This formal research study tested the effect of highly individualized psycho-social, medical, and behavioral diagnosis and treatment of the excess disabilities of mentally-impaired (moderate to severe CBS) institutionalized elderly women. The project achieved significant positive improvement in the conditions toward which treatments were specifically directed. However, generalized improvement in other aspects of functioning did not occur. The results encourage therapeutic optimism and support the importance of identifying and utilizing the individual's unique traits, personality, history, and current potential strengths.
Article
1. While the physical and recreational environments have been shown to be important to the mental health of the long-term care resident, human relationships and social contact have been described as being far more important in determining quality of life. 2. This study identified two new findings as contributing to quality of life--caring for oneself and the importance of helping others. 3. Failure to accurately assess a resident's ability to provide self-care may lead to excess disability, a situation in which a resident may become more functionally disabled, in part, due to the staff performing more care than is actually needed.
Article
Data from a longitudinal clinical trial funded by the National Institute of Aging, testing the effects of staff education and consultation on restraint reduction in nursing homes, were used to examine disturbing behaviors in institutionalized elders and to identify related environmental and personal characteristics. Subjects were 586 residents from three well-matched nursing homes. Kayser-Jone's (1989) model on environment and quality of life in long-term care institutions served as the organizing framework. Data on disturbing behaviors from the Psychogeriatric Dependency Rating Scale were factor analyzed. Three factors, Agitated Psychomotor Behaviors, Aggressive Interpersonal Communication, and Expressive Difficulty, emerged from the principal factor analysis and accounted for 35% of the variance. The Kayser-Jones model partially explained Agitated Psychomotor Behavior (R2 = .22). A model comparison approach indicated that the addition of an organizational variable, staff mix, significantly increased the amount of variance explained over and above that contributed by the personal variables.
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1. In dementia care, the full spectrum of interventions in a therapeutic milieu provides for safety, structure, support, involvement, and validation. 2. A safe environment accommodates wandering and compensates for physical and cognitive impairments. A therapeutic milieu provides for both physical and psychologic safety. 3. Two components of structure include the design of the physical environment and the schedule of activities. 4. The central element that defines quality in a therapeutic milieu is the dimension of interpersonal relationships.
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The patient perspective has been largely ignored in studies of Alzheimer's disease. The person with dementia is often relegated to the status of object rather than legitimate contributor to the research process and much can be gained from a systematic study of patients' views regarding their illness and care. We examine the status of dementia patients in three research areas and identify research challenges and opportunities that may substantially increase our understanding of dementia.
Article
1. Cognitively impaired elders uniquely express their individuality (expressed selfness) despite the effects of the dementing process. 2. Recognizing and attending to expressed selfness has implications for planning nursing care both to meet specific needs and to support existing characteristics and behaviors. 3. With the multiple losses encountered in dementia, supporting expressed selfness accessible to the individual can enhance the quality of the individual's living experience.
Article
In this article, a psychosocial model of dementia care is presented from a social constructionist perspective, contrasted to the medical model, and illustrated with data from a qualitative study. In findings reported in this article, family and professional caregivers described social and psychological approaches that portray elements of specialized dementia care provided within a therapeutic social environment.
Article
To determine the point prevalence of agitated behaviors in a representative sample of Alzheimer's disease Special Care Units, and to determine the extent to which agitation is associated with aspects of the treatment environment. A cross-sectional study in which nonparticipant observers recorded 3723 observations of resident behaviors in 53 Alzheimer's disease Special Care Units. Observational data were gathered on the physical environment and staff treatment in these settings, and resident characteristics were extracted from a data base developed in the study states by the Health Care Financing Agency. Analyses studied the association between aspects of the staff and physical environment and resident agitation levels, controlling for resident cognitive and functional status. Special Care Units in nursing homes in Kansas, Maine, Mississippi, and South Dakota. All residents and staff of the participating units. Eight specific agitated behaviors and two indexes of resident agitation were measured by direct observation by research assistants on three to four data collection walk-throughs in each of the study facilities. The most common agitated behaviors noted were repetitive mannerisms (4.5% of resident observations) and non-loud verbal excess (3.8%). Wandering, which frequently reflects agitation, was noted in 6.5% of resident observations. The proportion of residents exhibiting an agitated behavior varied from none in some units to 38% in one unit. Independent correlates of low unit agitation levels included favorable scores on measures of the physical environment and of staff treatment activities, low rates of physical restraint use, a high proportion of residents in bed during the day, small unit size, low levels of resident functional dependency, and fewer numbers of comorbid conditions. While the prevalence of agitation tends to increase as Alzheimer's disease progresses, modifiable treatment factors appear to have a strong influence on the prevalence of agitation. Both physical design and staff treatment appear to influence agitation rates, as do some measures consistent with a low stimulus approach to Alzheimer's care.
Article
To manage the care of increasing numbers of residents with dementia, many long-term care facilities have created special care units (SCUs) designed to meet the unique needs of this group. This article describes results of the qualitative component of a larger research project examining environment-behavior relationships in dementia care settings. Eighteen indepth interviews were conducted with 9 staff and 9 family members of SCU residents. Thematic analysis was conducted using grounded theory techniques. Participants described residents' needs in relation to both the physical and social environments. This article focuses on the five areas of need identified by participants in relation to the physical environment: safety, homelike setting, optimal stimulation, cues, and options for privacy and social interaction.
Article
Some foundations are laid for a social-psychological theory of dementia care. Central to this is a conceptualisation of personhood, in which both subjectivity and intersubjectivity are fully recognised. Evidence is brought forward concerning relative well-being even in those who are, from a cognitive standpoint, severely demented. In the light of this it is argued that the key psychological task in dementia care is that of keeping the sufferer's personhood in being. This requires us to see personhood in social rather than individual terms.
Article
The purpose of this review is to identify and explore the emerging attention being paid to the individual in dementia research. Following a brief introduction, the review will examine literature which recognises three aspects of the person with dementia: the individual's sense of self; the person's rights; and the value to be gained from a concern with the perspectives of people with dementia. To date the medical model has dominated dementia research. This model tends to reduce the person with dementia to his/her neurobiology or neuropsychology (Cotrell and Schulz 1993). The experience and manifestation of dementia has been attributed solely to the disease process, with a consequent neglect of the psychosocial context surrounding the individual (Lyman 1989). Research on the psychosocial aspects of dementia has concentrated on family carers. Keady (1996) provides a useful categorisation of this research into the following topics: gender and coping style; marital relationships and the impact of dementia; access to information and services; participation in and effectiveness of support groups; adjustment and circumstances surrounding admission into care; and perception of own health needs. No literature focuses on people with dementia.
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