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The aim in this study was to identify specific aspects of care that increased satisfaction of family members of Greek and Italian residents with dementia in mainstream or ethno-specific aged care facilities in Australia. Relatives of 83 aged care residents with Greek or Italian backgrounds who were also cognitively impaired were interviewed. They rated their satisfaction with the facility and suggested improvements regarding the care provided. Family members with relatives in ethno-specific care were more satisfied, in terms of the facility’s ability to meet the resident’s language and cultural needs, social/leisure activities, and the food provided. The presence of a bilingual staff member and greater perceived reduction in family caregiver stress upon admission were associated with higher satisfaction. Results implicate the role of activities programs, catering, resident interaction, supporting caregivers upon admission, and bilingual staff members to increase family satisfaction, with the potential to improve the care provided to residents in mainstream care. [ Journal of Gerontological Nursing, 40 (4), 54–63.]

Behavior and psychological symptoms of dementia are common in residential care facilities. These symptoms not only detract from the quality of life of the resident with dementia, but they can be disruptive to the unit and result in harm to staff and other residents. With the trend away from pharmacological management, other creative psychosocial-environmental strategies are being explored. One innovative approach involves the use of the club concept, where selected agitated residents spend a portion of the day in a separate structured environment. This program combines trained staff and tailored activities that optimize mental stimulation, functional independence, and self-esteem. Benefits include reduced incidents of aggressive behaviors and use of psychoactive medications, as well as enhanced quality of life. Not only do the participants benefit from time spent in this specialized setting, but the therapeutic milieu of the facility is also enhanced. Further evaluation of such strategies is needed to quantify the benefits of targeted behavioral interventions for those with cognitive impairment. [ Journal of Gerontological Nursing, 39 (10), 46–51.]

Older adults with severe cognitive impairment have trouble responding to questions about their osteoarthritis knee or hip pain, which makes pain management difficult. Therefore, the Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders (PBOICIE) was developed as an alternative. This article reports the development and psychometric testing of the PBOICIE in three studies. The 6-item PBOICIE was not associated with the Verbal Descriptor Scale but was significantly associated with Keefe’s method for observing pain behaviors in patients with knee osteoarthritis, with r= 0.36 to 0.55, indicating good concurrent validity. The 6-item PBOICIE was able to discriminate older adults’ pain behaviors before and after administration of an analgesic agent (2.9 ± 1.89 versus 1.97 ± 1.98; p < 0.001). This study has shown that multifaceted pain assessments are needed in older adults with osteoarthritis knee or hip pain, as the observed behaviors did not parallel but added information to verbal report.

The purpose of this study is to clarify the perspectives of physicians and nurses in the medical decision-making process at the time of status change events in nursing home residents. The decision-making processes studied involved 28 cognitively impaired nursing home residents in a large suburban nursing home. In interviews, the authors ascertained the personal opinions of physicians and the nurses related to the status change event and the decision-making process using the Medical Decision-Making During a Status Change Event Questionnaire. Nurses reported a greater degree of familiarity with the family’s and resident’s wishes than did physicians. Physicians reported considering more treatment options and choosing more treatments for residents than nurses. Both physicians and nurses reported that the physicians had a major role in decision-making and that nurses did not, yet the gap in reported roles was greater based on physicians’ reports in comparison to nurse reports. In a third of the reported cases, physicians and nurses disagreed about whether advance directives had been followed. These findings reflect a division of roles and perspectives of nurses versus physicians in the medical decision-making process. This study demonstrates the ability of the questionnaire to reveal several key differences in perceptions of care. This information could be useful in developing forums for communication among the professionals to enhance mutual understanding.

This study examined pain experiences and treatment for older adults in long-term care or rehabilitation settings 3 weeks after surgical repair of a hip fracture. Pain report and pain treatment for cognitively intact residents were compared with cognitively impaired residents. Two thirds of all participants reported pain. Most rated pain as slight or mild in severity. Pain report was similar for cognitively impaired and intact participants. Pain was reported as severe or worse by 17% of the residents. Nursing care pians documented comfort as a goal for fewer than half the participants. Almost 40% (n ~ 23) of the participants were receiving no pain medication 3 weeks postoperatively, five of these rated their pain as moderate or severe. Pain documentation, including effective nonpharmacological treatments, needs to be improved for cognitively impaired and intact older adults who are recovering from hip fracture surgery.

Dementia may cause a barrier to communication; therefore, behavioral indicators and familiarity with patients are valuable in assessing and treating pain in this population.

Realizing the Presence of Pain in Cognitively Impaired Older Adults

Caregivers contribute to loss of functional performance and dependency in cognitively impaired persons when they "do for," that is, dress the person instead of supporting independence in dressing. Persons with dementia have functional reserves that can be activated when caregivers use levels of assistance, standard, and problem-oriented strategies to support the person's cognitive and physical deficits. Use of these strategies requires less than one minute of additional caregiver time and leads to positive outcomes for the person and the caregiver.

1. Cognitively impaired elderly patients often become aggressive toward caregivers who are providing assistance with bathing and grooming, but caregivers can learn methods to prevent or reduce some of the aggression. 2. The R.E.S.P.E.C.T. model describes key practices caregivers can use to better meet patient needs and reduce aggression, increasing their understanding and skill. 3. In addition to training, observation of performance and consultation are important steps in enabling caregivers to apply and maintain their skills.

1. The person with Alzheimer's disease experiences multiple losses and transitions. The need for therapeutic interventions that preserve integrity, generate and maintain positive self-esteem, and enhance well-being is imperative. Reminiscence may be an appropriate nursing intervention to the cognitively impaired elderly. 2. The advantage of reminiscence as an intervention for the person with Alzheimer's disease is that the intervention focuses on remote memory; therefore, short-term memory becomes less important to both the participant and facilitator in the reminiscing activity. Props, such as photo albums and retrieval cues, may have to be used to stimulate the reminiscing activity. 3. Kovach's preliminary model of reminiscence, along with the observation of positive and negative affect as indicators of well-being, provide a framework for examining reminiscence as a supportive intervention with three individuals at different stages of Alzheimer's disease.

1. Nurses working with confused older adults in clinical settings need improved communication techniques. 2. Reality orientation is commonly used in nursing homes with disoriented persons; experienced nurses, however, often find it meets with withdrawal, vegetation or increasing hostility. 3. Validation strategies are communication techniques which are specifically matched to a particular stage of confusion. 4. When validation techniques are appropriately matched to confusional stage the effectiveness of the intervention can be significantly improved.

1. Persons with altered cognition are more prone to display inappropriate behaviors because of decreased ability to accurately interpret environmental cues, and increased frustration in combination with reduced inhibition. 2. Disruptive and agitated behaviors are commonly associated with the provision of assistance with activities of daily living, particularly bathing and dressing. 3. A preventive approach intended to reduce the occurrence of distress and disruptive behaviors in cognitively impaired residents during showering and bathing respects long-standing routines and preferences of the patient.

1. Alzheimer's disease (AD) is the fourth leading cause of death of older persons. Families frequently turn to nursing homes to provide the care that they are unable to provide during the later stages of the disease. 2. Sloane and Mathew concluded that special care units resulted in better care based on appearance, little difference in weight loss, similar range of services to traditional units, higher amount of interaction with residents more often out of their room, greater mobility, fewer medications, less physical restraint, and similar use of chemical restraints. 3. Alzheimer's disease does not affect an individual only; it affects a family. Effective programming includes the family. From the initial contact with the institution through placement on the special care unit--and often beyond the death of the resident--families are supported by the staff.

1. Cognitive changes may be similar in people with Alzheimer's disease, but each person loses abilities differently, and each individual responds differently to interventions. 2. Assessment of cognitive function is needed in order to design appropriate interventions that will be specific in facilitating independence in cognitively impaired elders. 3. Research findings suggest that functional ability in cognitively impaired elders can be maximized by assessing cognitive abilities and using this information to tailor specific interventions that will facilitate independence.

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.

Continence improves from 44.7% dryness at baseline to 54.7% at the end of treatment, an improvement of 22%, or about one incontinent episode per day. Urinary incontinence is improved in cognitively impaired residents by augmenting the prompted voiding procedure with a bellpad. Bladder behavior changes with behavioral treatment strategies, because the volume voided into an appropriate receptacle increased an average of 26 mL per 2 hours. Reimbursement policies should not exclude treatment of the severely cognitively impaired nor the immobile in nursing homes.

In demented persons, activities of daily living skills may deteriorate more quickly than their cognitive decline warrants because caregivers do not allow them to perform ADLs to the full extent of their abilities. Caregiver actions that promote independent behaviors were used with subjects in home and nursing home settings. Four of five home subjects showed decreased caregiver assistance and increased ability to dress more independently. Although nursing home subjects did not show a decrease in caregiver assistance, observation showed that some nursing home caregivers did incorporate behavioral strategies, suggesting potential clinical efficacy of the strategies.

Rehabilitative interventions must be based on remaining cognitive and physical abilities while recognizing the presence of disabilities. Rehabilitation goals should be to provide the least restrictive environment using the least restrictive intervention, thus promoting independence. The use of behavioral strategies that support remaining abilities and compensate for cognitive deficits is recommended as a rehabilitative approach. The behavioral approach requires an assessment of the ADL steps, the range of activities a person is able to complete, and the kinds of caregiver assistance needed.

Changes in mental status are often the first indication of changes in psychophysiological functioning of the older person. A brief and accurate mental status assessment is an essential part of a complete geriatric assessment. The MMSE, SPMSQ, CCSE, or NCSE may be used to aid in assessing the mental status of the cognitively impaired older person. Further testing and the reporting of results of mental status assessments among varying older populations is needed to build on the current level of knowledge of mental status assessment of the cognitively impaired older person.

The morale of cognitively impaired elderly has not been systematically studied as this group has been excluded in most studies of well-being. This study showed that most cognitively impaired persons who retain verbal skills were able to respond to a verbally administered assessment using the Philadelphia Geriatric Center Morale Scale. Support for the reliability and validity of measurement of morale in cognitively impaired elderly using the Philadelphia Geriatric Center Morale Scale was reported. Ratings of the morale of cognitively impaired persons by family members were significantly associated with self-report by elders, but tended to be lower.