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Improving documentation of aggressive behavior in nursing home residents.

1. Although 66% of the 1.3 million elderly nursing home residents in the US exhibit aggressive tendencies, research indicates that caregivers underdocument aggressive incidents. As a result, the extent of aggression is unknown. 2. This study found that LPNs reported the largest percentage (41%) of the 51 documented aggressive incidents, which reportedly occurred most frequently in the bathroom (49% of the time) between 5 AM and noon (86% of the time). Most aggressive residents (55.1%) never had visitors. 3. This study concludes that nursing practice would benefit from a consistent definition of aggression, an easy-to-use clinical instrument to collect data on aggression, and caregiver education programs on assessing aggression.

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Development of instruments to assess assaultive behavior in nursing homes.

The use of psychometric techniques is not usually considered in the development of non-scale tools. In the development of these tools, both content validation and inter-rater reliability were assessed in an effort to produce better quality tools than would have occurred otherwise. The procedure employing content experts for content validation followed the usual protocol for both of the tools. In each case, valuable information about the tools was obtained, in addition to data supporting the content validity of the tools. The development of vignettes for the inter-rater assessment would probably not have occurred if the authors were not familiar with the different techniques for assessing inter-rater reliability. The only way data concerning inter-rater reliability could be obtained was by having each respondent view the same stimuli. Creating vignettes was the best way to accomplish this goal in a cost-effective manner. The additional data obtained from the respondents also provided invaluable information for the development of the tools. This pilot study was conducted to assess all aspects of the tools in the nursing home setting. Clarity of items and usability of the tools were major considerations. Because NAs were involved in the pilot study, both readability by most NAs and clarity of the items in the revised tool were assured. Considerable time was spent assessing these tools, but the completed tools are evidence that the time was well spent. The use of psychometric techniques resulted in objective evidence that led to quality improvement decisions. The revised tools have the potential for use in obtaining quality data for research projects, in policy development by an agency, and for training agency personnel.

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Suicidal behavior in the nursing home and a postsuicide intervention.

The suicidal elderly patient in the nursing home has been the focus of inadequate attention. Given the longer life expectancy, we can project that the nursing home as a context of end-life care will be utilized by increasing numbers of elderly. This article presents a case of a suicide in a nursing home and a review of the relevant current literature. A mental health consultation to the administration and staff of the nursing home following the suicide is presented as an effective way to promote healing and limit adverse sequelae. In addition, a view of the concept of institutional care to the elderly is discussed. Relocation to a nursing home as a catalyst for suicidal behavior and the notion of "goodness of fit" as it applies to resident adaptation to the nursing home is posited. A continuum of suicidality is proposed. Suicidal ideation and Intentional Life Threatening Behaviors (ILTBs) are described as adapting to the context of the nursing home, and examples are offered. The article concludes with a model of suicide probability in the nursing home resident.

Activities of Daily Living↗

Prenatal protein malnutrition and home orientation in the rat.

Home orienting behavior was studied during the first 11 days of life in prenatally protein-malnourished and well-nourished rat pups, both groups having been reared by well-nourished mothers since birth. On all days of testing, mean weights were compromised in the prenatally malnourished pups relative to their well-nourished age controls (body weight deficit = 19-29%). Eye opening was also significantly delayed in the malnourished group. On the test of homing behavior, malnourished pups were significantly impaired in their ability to locate the nest on days 9 and 11. The effect was not related to activity levels of the pups, which were generally similar in the two nutritional groups. Thus, prenatal malnutrition disturbs the development of the homing response in the early postnatal period.

Animals↗

Management of geriatric incontinence in nursing homes.

A behavioral management system designed to reduce urinary incontinence was evaluated in two nursing homes with a pretest-posttest control group design with repeated measures. The primary components of the system were prompting and contingent social approval/disapproval which required approximately 2.5 minutes per patient per hour to administer. The frequency of correct toileting for experimental subjects increased by approximately 45%. The experimental groups were significantly different from the control groups on both incontinence and correct toileting measures. The results are discussed in view of the management issues inherent in nursing home settings.

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Radial arm maze behavior in mice when a return to the home cage serves as the reinforcer.

Male ddY mice were housed in a cage with an eight arm radial maze apparatus for 6 h a day. A water bottle was placed at the central platform. The end of each arm ran to the home cage through a guillotine door (G). Food was placed at the home cage. During the housing in the apparatus, one G was raised and the remaining seven G were lowered. The raised G was changed every 45 min in random order. Mice housed in this apparatus learned efficient strategy to return the home cage by trial and error. When they chose the arm in which the G was lowered on their way to the home cage from the platform, they returned to the platform, then chose a different arm until they were able to enter the home cage. The mice housed in this apparatus mastered the radial maze task on the 7th day. When scopolamine (SCO) was injected, SCO butylbromide had no effect on performance, but SCO hydrobromide (0.2 and 0.4 mg/kg) impaired working memory, dose dependently. These results show that the apparatus is useful for ease in estimating working memory in mice without the use of severe food or water deprivation.

Animals↗

Dose-response effect of mother-infant clinical home visiting on aggressive behavior problems in kindergarten.

OBJECTIVE: The objective of this follow-up study was to assess the long-term effects of clinical infant home-visiting services on child outcomes at school entry. METHOD: Participants were 63 five-year-olds from low-income families, half of whom were referred to parent-infant home-visiting services during the first 18 months of life due to concerns about the caretaking environment. Families received between 0 and 18 months of weekly home visits based on infant age at entry into the study. At age 5, children were rated by teachers on the Preschool Behavior Questionnaire for behavior problems in the classroom and by parents both on the Simmons Behavior Checklist for behavior problems at home and on the Achenbach Social Competence Items for positive play behaviors with friends. RESULTS: With initial family risk status and child gender controlled, teacher-rated hostile behavior problems decreased in dose-response relation to the duration of early home-visiting services, which accounted for 15% of the variance in child hostile behavior. Parents' reports of positive play behaviors were positively linearly related to service duration. Parents' reports of behavior problems were less reliably related to service duration than teacher reports. CONCLUSIONS: Early home-visiting services reduced the incidence of aggressive behavior problems among socially at-risk children for up to 3.5 years after the end of services.

Aggression↗

Risk of behavior problems among nursing home residents in the United States.

This study identified personal risk factors associated with behavior problems among nursing home residents using data based on a national survey of nursing home residents. Data are based on the Institutional Population Component of the 1987 National Medical Expenditure Survey and include nursing home residents living in licensed facilities on January 1, 1987. Multiple regression analyses were conducted to examine characteristics of residents that place them at risk of behavior problems. Independent variables include physical functioning, sensory impairment, cognitive impairment, psychiatric diagnoses, and demographics. Eleven behavior problems grouped into four categories based on factor analysis serve as dependent variables: wandering/safety, aggressive behaviors, collecting behaviors, and delusions/hallucinations. Risk factors emerging as predictors included sex (male), cognitive impairment, ADL dependency, incontinence, psychiatric history, receptive communication, walking, and difficulty seeing. Risk factors differ by type of behavior problem. Results suggest a multiple etiology in which biological, psychological, and sociocultural factors all play a role in generating behavior problems in the long-term care setting.

Activities of Daily Living↗

Fimbria-fornix lesions disrupt the dead reckoning (homing) component of exploratory behavior in mice.

Exploration is the primary way in which rodents gather information about their spatial surroundings. Thus, spatial theories propose that damage to the hippocampus, a structure thought to play a fundamental role in spatial behavior, should disrupt exploration. Exploration in rats is organized. The animals create home bases that are central to exploratory excursions and returns, and hippocampal formation damage alters the organization of exploration by disrupting returns. Mice do not appear to readily establish home bases in novel environments, thus, for this species, it is more difficult to establish the contribution of the hippocampus to exploration. The purpose of the present study was threefold: develop a task in which mice center their exploration from a home base, determine whether the exploratory behavior is organized, and evaluate the role of fimbria-fornix lesions on exploration. Mice were given a novel exploratory task in which their nesting material was placed on a large circular table. Video records of control and fimbria-fornix mice were made in both light and dark (infrared light) conditions. Exploration patterns (outward trips, stops, and homeward trips) were reconstructed from the video records. Control mice centered their activity on their bedding, from which they made circuitous outward trips marked by many stops, and periodic direct returns. The bedding-centered behavior and outward trips of the fimbria-fornix mice were similar to those of the control mice, but significantly fewer direct return trips occurred. The direct homeward trips observed under light and dark conditions were consistent with a dead-reckoning strategy, in which an animal computes its present position and homeward trajectory from self-movement cues generated on the outward trip. Because the fimbria-fornix lesions disrupted the homeward component of exploratory trips, we conclude that the fimbria-fornix may contribute to dead reckoning in mice. The results also show that the home-bedding methodology facilitates the establishment of a home base by mice, thus providing a useful methodology for studies with mice.

Animals↗

Long-term efficacy of olanzapine in the control of psychotic and behavioral symptoms in nursing home patients with Alzheimer's dementia.

BACKGROUND: Psychotic symptoms and behavioral disturbances are a leading cause of institutionalization in elderly patients with Alzheimer's disease (AD). OBJECTIVES: Elderly nursing home patients (n=105) with possible or probable AD were entered into a multicenter study to determine the long-term efficacy and safety of olanzapine in treatment of psychotic symptoms and behavioral disturbances due to AD. METHODS: Following a double-blind, 6-week exposure to fixed-dose olanzapine (5, 10, or 15 mg/d), patients entered an additional 18-week, open-label, flexible-dose treatment. Baseline was defined from the start of the extension phase. RESULTS: Patients improved significantly on the primary efficacy measure, defined a priori, which consisted of the sum of the Agitation/Aggression, Delusions, and Hallucinations items ('Core':) of the NPI/NH. Olanzapine also significantly improved scores for the NPI/NH total and the Core item-associated Occupational Disruptiveness of the NPI/NH, as well as the BPRS total and CGI Severity-of-Alzheimer's scores. Barnes Akathasia scores improved significantly from baseline, while Simpson-Angus and AIMS scores were not significantly changed. Treatment-emergent symptoms included somnolence, accidental injury, and rash. No significant changes were seen in ECGs, including QT(c) interval, nor in weight or vital signs, including orthostasis. CONCLUSIONS: Low-dose olanzapine appears to be effective and well tolerated for treatment of behavioral disturbances and psychotic symptoms due to AD in elderly patients.

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Transfer of therapeutic effects from institution to home: faith, hope, and behavior modification.

Effective transfer of therapeutic results from institutional to home settings is a demanding problem facing family therapists. The issues involved and one approach to their solution are examined through the case of a 10-year-old boy hospitalized for severe antisocial behavior. Once results were obtained in an institutional setting, the therapeutic program there was faded out and concurrently faded into the home. Three- and 12-month follow-ups revealed continued improvement.

Behavior Therapy↗

Five-year follow-up study of nursing home residents using the behavioral rating scale.

We followed up 109 elderly nursing home residents for 5 years using the modified Stockton Geriatric Rating Scale (SGRS). They were divided into 3 groups according to their walking ability, prolonged bedrest, walking with aids and walking by themselves. The scores of physical disability and apathy and the total score were in direct proportion to the degree of walking ability, and the score of communication failure of prolonged bedrest was significantly higher than those of other 2 states in the initial examination. The percentage of mortality of prolonged bedrest was significantly higher than those of other 2 groups. Physical disabilities of all the groups had deteriorated during the follow-up period, but only communication failure of walking with aids and the total score of walking by themselves had aggravated. It is considered that using of the behavioral rating scale such as the modified SGRS is conformative in caring of the elderly.

Activities of Daily Living↗