Louis D. Burgio

Purpose: Agitation frequently accompanies cognitive decline among nursing home residents. This study used cross-sectional and longitudinal (up to 18 months) methods to examine agitation among profoundly and moderately impaired residents using both staff report and direct observation methods. Design and Methods: The study included participants (N = 78) from a larger study who completed either 12 or 18 months of data collection. There were four measurement points, each separated by 6-month intervals. We recorded agitation using two measures: (a) the computer-assisted behavioral observation system (CABOS) and (b) the staff-completed Nursing Home Behavior Problem Scale. We used longitudinal hierarchical linear modeling to capture the dynamic nature of behavior change as a function of individual resident characteristics and time. Results: The profoundly cognitively impaired residents (M Mini-Mental State Examination [MMSE] score = 1.7) displayed more agitation than the moderately impaired group (M MMSE score = 15.4) at Epoch 1 (cross-sectional analyses). Longitudinal analysis found a significant linear and quadratic trend only with the profoundly impaired residents using the CABOS. These residents showed slight improvements in agitation up to 12 months, with agitation increasing significantly from 12 to 18 months. Implications: With nursing homes receiving an increasing number of profoundly cognitively impaired residents, these results have potential cost and policy implications. Measuring agitation over time by using both staff report and observation measures presents various problems, and we present an alternative measure that may help to avoid these difficulties.

Purpose: The purpose of this study was to compare a variety of resident and staff outcomes across two types of staffing patterns, permanent and rotating assignment, and work shift. Although studies have examined these staffing patterns as part of multicomponent intervention packages, few studies have examined the isolated effects of staffing pattern by using an experimental design. Design and Methods: A between-groups comparison design was used to compare residents and certified nursing assistants (CNAs) from four nursing homes; two self-identified as using permanent assignment (PA) staffing and two as using rotating assignment (RA) staffing. Measures yielded data on verbal interaction among residents and staff, resident disruptive behavior, and specific aspects of resident–staff behavior during care routines. Other assessments included resident personal appearance and hygiene, expressed affect, and CNAs' job satisfaction, burnout, absenteeism, and turnover rates. A treatment fidelity check was conducted to confirm PA and RA staffing patterns. Results: Staffing patterns were significantly different between self-identified PA and RA nursing homes. Residents in PA nursing homes and on morning shifts received significantly higher ratings of personal appearance and hygiene. Rates of expressed sadness and interest among residents differed by staffing patterns and shift. However, these differences do not appear to be clinically significant. Although absenteeism was higher in PA nursing homes, these CNAs reported greater job satisfaction than CNAs from RA nursing homes. As expected, evening shifts across nursing homes had significantly higher turnover rates and significantly more resident disruptive behavior. Implications: Quality-of-care outcomes were similar among the two types of nursing homes, despite significantly different staffing patterns. Though staff permanency rates in PA nursing homes (50%) were twice that of RA nursing homes (26%), more research is needed to determine feasibility of higher rates of staff permanency (i.e., > 50%) and effects on resident and CNA outcomes.

Confirmatory factor analysis of the Revised Memory and Behavior Problems Checklist--Nursing Home (RMBPC) replicated the factor structure of the community-based RMBPC (L. Teri et al., 1992). The reliability of the total score was high as indexed by estimates of internal consistency (alpha = .95), test-retest reliability (r = .86), and interrater reliability between 2 interviewers (r = .88). Notably, the interrater reliability between 2 independent certified nursing assistants (CNAs) regarding residents' behavior problem frequency was more modest (r = .46), possibly reflecting the degree to which resident behaviors capture individual CNA's attention. This may have implications for the interpretation of data from the Minimum Data Set. CNAs reported moderately severe burden associated with behavior problems in 47% of residents under their care.

Purpose: We developed manual-guided, replicable interventions based on common needs and cultural preferences of White and African American family caregivers (CGs) of individuals with dementia, and we evaluated these interventions after a 6-month follow-up. Design and Methods: We randomly assigned White (n = 70) and African American (n = 48) CGs of individuals with dementia to either a skills training condition or a minimal support control condition. Results: The degree of treatment implementation was methodically assessed, and findings demonstrated that both interventions were delivered according to protocol and were well received by CGs. CGs in both groups reported decreasing levels of problem behaviors and appraisals of behavioral bother, and increased satisfaction with leisure activities over time. On a measure of appraisal of distress related to behavior problems, White CGs showed more improvement in the minimal support control condition, and African American CGs showed the greatest improvements in the skills training condition. Spouse and nonspouse CGs also showed differential responses to intervention. Implications: Brief manual-guided interventions can be effective with White and African American CGs, and greater attention should be paid to possible differential responses to interventions by race and relationship to care recipient.

Agitation in nursing home residents presents a serious challenge to caregivers and may place residents at risk for harm. Understanding the etiology of agitation can assist clinicians in developing nonpharmacologic interventions for preventing and treating this problem. The purpose of this study was to examine independent and common predictors of resident agitation with structural equation modeling. Agitation was measured with both a standardized staff report rating scale and direct behavioral observation. No indirect or mediating effects were found. Cognitive impairment, vision and hearing impairment, and gender were found to be independent predictors of agitation as measured by direct behavioral observation. Only cognitive impairment was found to be predictive of agitation as measured by the standardized staff report scale. An unexpected finding was that vision impairment appeared to exert a protective effect for agitation in these severely cognitively impaired residents. The clinical implications of these findings are discussed as well as the relative merits of the two methods of measuring agitation.

Purpose: To examine the efficacy of a comprehensive behavior management skills training program for improving certified nursing assistants' (CNA) skill performance in the nursing home, to assess the effectiveness of a staff motivational system for maintaining newly acquired behavior management skills for a 6-month period, and to evaluate any resulting effects on resident agitation. Design and Methods: This study used a randomized clinical trial of 88 residents with behavior disturbances and 106 CNAs who cared for them in two urban nursing homes. After CNAs received 4 weeks of behavior management training, supervisory nursing staff implemented formal staff management (FSM), designed to maintain training effects over time. The supervisory staff used conventional staff management (CSM, usual supervisory routine) on control units. We completed behavioral observations and paper-and-pen assessments at baseline and repeated them during a 4-week post-intervention phase and at 3- and 6-month follow-ups. Results: During the immediate post-training phase, both the FSM and CSM groups improved five out of seven communication skills and the ability to delay physical assistance during care routines. Although CNAs showed a reduction in the use of ineffective behavior management strategies, they did not increase their use of effective behavioral strategies. Follow-up assessments suggested that the FSM system was more effective than CSM for maintaining and even improving communication skills over time. Resident agitation was reduced during care interactions and maintained at follow-up. Implications: The behavior management skills training program improved CNAs' ability to interact with behaviorally disturbed nursing home residents and produced sustained reductions in agitation. The FSM system was more effective for maintaining communication skills 6 months after training.

Purpose: In published dementia caregiver intervention research, there is widespread failure to measure the level at which treatment was implemented as intended, thereby introducing threats to internal and external validity. The purpose of this article is to discuss the importance of inducing and assessing treatment implementation (TI) strategies in caregiving trials and to propose Lichstein's TI model as a potential guide. Design and Methods: The efforts of a large cooperative research study of caregiving interventions, Resources for Enhancing Alzheimer's Caregiver Health (REACH), illustrates induction and assessment of the three components of TI: delivery, receipt, and enactment. Results: The approaches taken in REACH vary with the intervention protocols and include using treatment manuals, training and certification of interventionists, and continuous monitoring of actual imple-mentation. Implications: Investigation and description of treatment process variables allows researchers to understand which aspects of the intervention are responsible for therapeutic change, potentially resulting in development of more efficacious and efficient interventions.

Purpose: We examined the effects of communication skills training and the use of memory books by certified nursing assistants (CNAs) on verbal interactions between CNAs (n = 64) and nursing home residents (n = 67) during care routines. Design and Methods: CNAs were taught to use communication skills and memory books during their interactions with residents with moderate cognitive impairments and intact communication abilities. A staff motivational system was used to encourage performance and maintenance of these skills. Formal measures of treatment implementation were included. Results:Results were compared with those for participants on no-treatment control units. Trained CNAs talked more, used positive statements more frequently, and tended to increase the number of specific instructions given to residents. Changes in staff behavior did not result in an increase in total time giving care to residents. Maintenance of CNA behavior change was found 2 months after research staff exited the facility. Although an increase was found in positive verbal interactions between CNAs and residents on intervention units, other changes in resident communication were absent. Implications: Nursing staff can be trained to improve and maintain communication skills during care without increasing the amount of time delivering care. The methodological advantages of including measures to assess treatment implementation are discussed.

This paper provides a selective review of behavioral intervention research aimed at successfully decreasing dementia-related challenging behaviors in nursing homes. The authors include separate discussions of behavioral excesses (disruptive vocalization, wandering, physical and verbal aggression) and deficits (excess dependency, therapeutic activities, social interaction/communication). Descriptions of interventions used to address each behavior problem are followed by methodological evaluations of the research. Discussions are augmented by inclusion of the authors' ongoing intervention research. The paper concludes with a description of a comprehensive program for teaching behavior management skills to nurse aides and a motivational system for maintaining the performance of these skills over the long term.