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Correspondence: Please address correspondence to Malaz Boustani, MD, MPH, Regenstrief Institute, Inc., and Indiana University Center for Aging Research, 1050 Wishard Blvd. RG 6, Indianapolis, IN 46202-2872. E-mail: mboustani{at}regenstrief.org
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Abstract |
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Key Words: Agitation • Assisted Living • Residential Care • Nursing Homes
BSRD result from an interplay between host (resident), agent (caregiver), and environmental (setting) factors (Cohen-Mansfield, 2001). The majority of studies have evaluated only host characteristics and identified increased age, being male, functional impairment, moderate to severe cognitive deficit, greater comorbidity, pain, psychosis, and depressed mood as potential precipitants for BSRD (Brodaty, et al, 2001; Cohen-Mansfield, 2001; Gruber-Baldini et al, 2004). Evidence for caregiver and environmental factors is scattered (Roth, Stevens, Burgio, & Burgio, 2002; Sloane, Mitchell, Preisser, et al., 1998). This study begins to shed light on the relationship of caregiver and environmental factors to BSRD. We first describe the provision of care for behavioral symptoms for RC/AL and nursing home residents with dementia, such as care-provider assessment and management of symptoms. Second, we identify potential environmental and caregiver characteristics that play a role in BSRD, independent of the resident's cognitive and functional status.
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Methods |
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Measures
The Dementia Care project assessed BSRD with the short form of the Cohen-Mansfield Agitation Inventory (CMAI), which has adequate validity and reliability (Cohen-Mansfield, 1995). The 14-item CMAI identifies the frequency (on a 5-point scale) of behavior symptoms during the previous 2 weeks based on interviews with the supervisor familiar with the resident. The CMAI includes three subtypes of behaviors: aggressive (4 items), physically nonaggressive (5 items), and verbal (5 items). A frequency of at least once a week on any of the 14 items was used to indicate the presence of behavioral symptoms. The CMAI is one of the most commonly used instruments to measure BSRD in epidemiological studies.
BSRD care provision
For each resident, the supervisor also reported whether BSRD were perceived to be currently present (her or his own perception of a moderate level of BSRD), how BSRD were assessed and treated, and, if detected, how successful treatment was considered to be.
Resident demographics (age, gender, race, and presence of 11 comorbid medical conditions) and facility information (facility type, size, and profit status) were collected through interviews with the supervisor and the administrator. Cognitive status was based on the Mini-Mental State Examination (MMSE) via interviews with the resident (Folstein, Folstein, & McHugh, 1975) or the Minimum Data Set Cognition Scale (MDS-COGS) via interviews with the supervisor (Hartmaier, Sloane, Guess, & Koch, 1994), if the MMSE was unavailable (N = 51). MMSE cutpoints for mild, moderate, severe, and very severe were 
18, 11–17, 3–10, and 0–2; respective MDS-COGS cutpoints were 0–1, 2–3, 5–8, and 9–10. Depression, functional status, and pain were assessed by interviews with the supervisor using the Cornell Scale for Depression in Dementia (CSD-D; Alexopoulos, 1988), the Minimum Data Set Activity of Daily Living scale (MDS-ADL; Morris, Fries, & Morris, 1999), and the Philadelphia Geriatric Center Pain Intensity Scale (Parmelee, 1994). Care providers assessed activity involvement with the Albert Patient Activity scale (Albert et al., 1996). Mobility and food and fluid intake were measured via direct observation (Williams et al., 2005, this issue) and the Structured Meal Observation (Reed, Zimmerman, Sloane, Williams, & Boustani, 2005, this issue). Medication use (all regular prescription and nonprescription medications administered at least 4 of the past 7 days) was recorded from residents' medication records and coded using American Hospital Formulary Service system criteria (McEvoy, 2001). Medications included neuroleptics, antidepressants, hypnotics, and cholinesterase inhibitors (ChEIs). Care provider characteristics, including dementia-sensitive attitudes toward residents, work stress, and satisfaction working with this population were assessed by interviews with the care provider using the Approaches to Dementia Care scale (Lintern, Woods, & Phair, 2000), the Work Stressors Inventory (Schaefer & Moos, 1996) and the Staff Satisfaction scale (Åström, Nilsson, Norberg, & Winblad, 1990). The physical environment was assessed using the Special Care Unit Environmental Quality Scale (SCUEQS) and the Assisted Living Environmental Quality Scale (ALEQS; Sloane et al., 2002).
Analyses
We computed simple descriptive statistics separately for RC/AL and nursing homes. We did statistical comparison of these characteristics based on score statistic p values from generalized estimating equations (GEE; Diggle, Heagerty, Liang, & Zeger, 2002) applied to linear or logistic models and an exchangeable correlation structure, with facilities specified as clusters. Similarly, we computed descriptive statistics for those for whom the supervisor reported BSRD compared to those with no BSRD. We estimated odds ratios and 95% confidence intervals using separate binary logistic regression models for each characteristic, controlling for clustering using GEE empirical standard error estimates and exchangeable correlation. We estimated adjusted odds ratios, controlling for resident age in years, gender, non-White race, cognitive impairment, comorbidity, and functional status. Finally, to ensure that the factors associated with supervisor report of BSRD did not differ between nursing homes and RC/AL facilities, we tested a setting-by-characteristic interaction term in each multivariable logistic regression model.
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Results |
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Characteristics Associated With BSRD in Long-Term Care
As shown in Table 2, BSRD were more common among those with more cognitive impairment and with depression but less common among immobile residents; also, BSRD were associated with pain in nursing homes only. The odds of having BSRD did not differ by facility type, size, or ownership but were higher when residents were assessed by professionals or with standardized measures and were being treated for BSRD. Examining the relationship between staff training and BSRD, residents living in facilities with a higher percentage of supervisors trained in treating and managing BSRD were less likely to display BSRD (OR 0.28; 95% CI 0.15–0.53), but the odds of having BSRD were significantly elevated for residents whose most involved staff felt adequately trained to assess BSRD (OR 2.63; 95% CI 1.14, 6.04). Finally, in evaluating the care provider characteristics that might impact BSRD, our study found that staff sensitive attitudes toward dementia care (Lintern Approaches to Dementia Care scale), staff work stress (Schaefer Work Stressors Inventory), and staff satisfaction (Åström Satisfaction scale) were not related to the prevalence of BSRD.
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Discussion |
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Not surprisingly, residents with BSRD were more likely to have had formal assessment and management of BSRD and to be perceived by staff to have more BSRD; that is, treatment was a likely response to their BSRD. However, despite recognition and treatment, current management methods are insufficient in responding to the need of dementia residents with BSRD. We found no association between BSRD and facility characteristics such as type, size, ownership, and physical environment. Although residents in facilities in which more supervisory staff were trained to detect and treat BSRD were less likely to display BSRD, we found no association between BSRD and direct care provider approaches to dementia care, work stress, and satisfaction. Further, individual staff members who felt adequately trained to assess BSRD were more likely to report BSRD in their residents, which may reflect their enhanced ability to recognize these symptoms. While power may have been insufficient to detect weak associations between BSRD and care provider (and environmental) factors, the impact of these factors is clearly minimal in the presence of cognitive deficit, depressed mood, and immobility.
One caveat to the findings reported herein is that they are limited by their cross-sectional nature. Also, they relied on caregiver ratings. However, while such measures are subjective, this type of rating may be more valid than observation because it captures rare but clinically relevant BSRD (Cohen-Mansfield, 1995).
In conclusion, long-term care facilities, including nursing homes and RC/AL, are working to meet the needs of residents with BSRD. Based on our findings of the association between BSRD and two modifiable factors (resident depression and staff training), developing a program that includes depression detection and management, as well as staff training in BSRD management, may be a valuable next step to improve the care of long-term care residents with BSRD.
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Footnotes |
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1 Regenstrief Institute, Inc., and Indiana University Center for Aging Research, Indianapolis.
2 Cecil G. Sheps Center for Health Services Research and the School of Social Work, University of North Carolina at Chapel Hill.
3 Cecil G. Sheps Center for Health Services Research and the Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill.
4 Division of Gerontology, Department of Epidemiology & Preventive Medicine, University of Maryland, School of Medicine, Baltimore.
5 Department of Psychiatry, University of North Carolina at Chapel Hill.
6 Alzheimer's Association, National Office, Chicago IL.
7 Cecil G. Sheps Center for Health Services Research and the Department of Family Medicine, University of North Carolina at Chapel Hill.
Decision Editor: Richard Schulz, PhD
Received for publication June 28, 2004. Accepted for publication September 24, 2004.
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This article has been cited by other articles:
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  M. Smith, K. C. Buckwalter, H. Kang, V. Ellingrod, and S. K. Schultz Dementia-Specific Assisted Living: Clinical Factors and Psychotropic Medication Use Journal of the American Psychiatric Nurses Association, March 1, 2008; 14(1): 39 - 49. [Abstract] [PDF]
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 I. D Maidment, C. G Fox, M. Boustani, J. Rodriguez, R. C Brown, and C. L Katona Efficacy of Memantine on Behavioral and Psychological Symptoms Related to Dementia: A Systematic Meta-Analysis Ann. Pharmacother., January 1, 2008; 42(1): 32 - 38. [Abstract] [Full Text] [PDF]
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