Agitation and use of restraint in nursing home residents with dementia. Prevalence, correlates and the effects of care staff training
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Background: Dementia is one of the most prevalent syndromes in the elderly population, and over half of people with dementia live in long-term care homes. 80% of residents in nursing homes have dementia, the majority with severe functional impairments and complex needs. Agitation and other behavioural changes are common, with severe consequences for their functioning and quality of life, including use of restraint and use of psychotropic drugs. To preserve the personal control, dignity and quality of life of these vulnerable individuals, as long as possible, is an important goal of our society. Few studies have explored the relationship between agitation and factors such as stress in care staff and working conditions, and there is little evidence whether education and guidance in care staff can improve agitation and reduce use of restraint and psychotropic drugs. Objective: The objective of this thesis was to study the relationship between agitation and use of restraint, carer burden, organizational and psychosocial factors and whether agitation and use of restraint could be reduced by means of a novel care staff training. Methods: Descriptive, cross-sectional surveys were conducted to analyse the prevalence of agitation in nursing home residents, and to study correlates of health and well-being in care staff. Residents and care staff from four nursing homes in Rogaland County were included. In addition, data from nursing homes in England and Austria were used. Two cluster-randomized controlled trials were conducted to study the effect of a novel care staff training program; Relation Related Care (RRC). Data on agitation and use of restraint and antipsychotics were collected immediately before and after the 6- month intervention period by a research nurse, blinded for study hypothesis. In the second study, an additional follow-up assessment was conducted 6 months after completion of the intervention. Standardized measures were used: Clinical Dementia rating Scale (CDR), Functional Assessment rating Scale (FAST) and the Global Deterioration Scale (GDS) were used to rate severity of dementia. Two rating scales were used to score agitation; Brief Agitation Rating Scale (BARS) and Cohen-Mansfield Agitation Inventory (CMAI). Frequency of use of restraint was determined by a standardized interview, where all use of restraint during the last seven days was recorded. Three scales measured health and well being in care staff: Perceived Stress Scale (PSS), Psychological Distress (HSCL-10) and Subjective health complaints (SHC). Organizational and Psychosocial factors were measured by General Nordic Questionnaire for Psychosocial and Social Factors at Work (QPSNordic). Results: We found that 75.4% of the residents with dementia exhibited at least one agitated behaviour at least weekly and 65.3% several times a week. The six most common agitated behaviours were repetitious sentences or questions, complaining, cursing, pacing, negativism and general restlessness. However, agitation in the Norwegian nursing homes was less common than in nursing homes in UK and Austria. The level of agitation differed between countries, with higher CMAI scores in the Austrian nursing home compared to UK and Norwegian nursing homes. Similarly, the use of psychotropic drugs differed significantly between the homes, with a higher proportion on antipsychotic drugs in UK and Austrian compared to Norwegian nursing homes. Organizational and psychosocial factors, in particular those related to the organizational structure of the nursing home were associated with all three measures of health and well-being in care staff. Leadership, mastery and control of work were the three organizational and psychosocial factors which significantly explained the variance in care staff health and well being. In contrast, agitation in residents was not significantly associated with any of the measures of health and well being in care staff. In the first intervention study, the proportion of restraint declined with 54% in the treatment group and increased with 18% in the control group. This difference was significant. In contrast, agitation did not differ between the groups. In the second study, the intervention led to both reduced severity of agitation and reduction in restraint, which was evident by a much smaller increase in the intervention group compared to the control group. The improvement of agitation continued 6 months after the completion of the intervention, indicating that sustained improvement of agitation can be achieved by means of staff training. The effect on restraint use however, seemed to be short-lived, suggesting that continuous supervision is needed to achieve sustained reduction of the use of restraint. Conclusion: Agitation is common in residents with dementia in Norwegian nursing homes. There is a need to explore factors contributing to agitation, in order to understand and manage it effectively and to avoid misdiagnose of symptoms, reduce inappropriate use of drugs and restraint, and thereby improving the conditions and quality of life for residents with dementia in nursing homes. Our findings from the intervention studies suggests that by lowering the care staff – resident ratio and by providing additional education, guidance and support, improved care of residents can be achieved.
Paper I: International Journal of Geriatric Psychiatry 20(6), Testad, I.; Aasland, A. M.; Aarsland, D., The effect of staff training on the use of restraint in dementia. A single-blind randomized controlled trial, pp. 587-590. Copyright 2005 John Wiley & Sons. Full text not available in BORA due to publisher restrictions. The published version is available at: http://dx.doi.org/10.1002/gps.1329Paper II: International Journal of Geriatric Psychiatry 22(9), Testad, I.; Aasland, A. M.; Aarsland, D., Prevalence and correlates of disruptive behaviour in patients in Norwegian nursing homes, pp. 916-921. Copyright 2007 John Wiley & Sons. Full text not available in BORA due to publisher restrictions. The published version is available at: http://dx.doi.org/10.1002/gps.1766Paper III: International Journal of Geriatric Psychiatry 25(7), Testad, I.; Auer, S.; Mittelman, M.; Ballard, C.; Fossey, J.; Donabauer, Y.; Aarsland, D., Nursing home structure and association with agitation and use of psychotropic drugs in nursing home residents in three countries: Norway, Austria and England, pp. 725-731. Copyright 2009 John Wiley & Sons. Full text not available in BORA due to publisher restrictions. The published article is available at: http://dx.doi.org/10.1002/gps.2414Paper IV: International Journal of Geriatric Psychiatry 25(8), Testad, I.; Mikkelsen, A.; Ballard, C.; Aarsland, D., Health and well being in care staff and it’s relation to organizational and psychosocial factors, care staff and resident factors in nursing homes. Published as: Health and well-being in care staff and their relations to organizational and psychosocial factors, care staff and resident factors in nursing homes, pp. 789-797. Copyright 2009 John Wiley & Sons. Full text not available in BORA due to publisher restrictions. The published version is available at: http://dx.doi.org/10.1002/gps.2419Paper V: Journal of Clinical Psychiatry 71(1), Testad, I.; Ballard, C.; Bronnick, K.; Aarsland, D., The effect of staff training on agitation and use of restraint in nursing home residents with dementia: a single-blind randomized controlled trial, pp. 80-86. Copyright 2010 Physicians Postgraduate Press. Full text not available in BORA due to publisher restrictions. The published version is available at: http://dx.doi.org/10.4088/JCP.09m05486oli