Coming to grips with challenging behaviour: a cluster randomised controlled trial on the effects of a new care programme for challenging behaviour on burnout, job satisfaction and job demands of care staff on dementia special care units.

BACKGROUND: Caring for people with dementia in dementia special care units is a demanding job. Challenging behaviour is one of the factors influencing the job satisfaction and burnout of care staff. A care programme for the challenging behaviour of nursing home residents with dementia might, next to diminishing the challenging behaviour of residents, improve job satisfaction and reduce the care staff's feelings of burnout. OBJECTIVES: To determine the effects of a care programme for the challenging behaviour of nursing home residents with dementia on the burnout, job satisfaction and job demands of care staff. DESIGN: The care programme was implemented according to a stepped wedge design in which care units were randomly divided over five groups with different time points of starting with implementation. SETTING: 17 Dutch dementia special care units. PARTICIPANTS: Care staff members of the 17 units. INTERVENTION: The care programme consists of an education package and of various structured assessment tools that guide professionals through the multidisciplinary detection, analysis, treatment and evaluation of treatment of challenging behaviour. METHODS: Burnout, job satisfaction and job demands were measured before implementation, halfway through the implementation process and after all the care units had implemented the care programme. Burnout was measured with the Dutch version of the Maslach burnout inventory (UBOS-C, three subscales); job satisfaction and job demands were measured with subscales of the Leiden Quality of Work Questionnaire. Mixed model analyses were used to determine effects. Care staff could not be blinded for the intervention. RESULTS: Of the 1441 questionnaires, 645 were returned (response 45%, 318 control measurements, 327 intervention measurements) by 380 unique care staff members. Significant effects were found on job satisfaction (0.93, 95% CI 0.48-1.38). On the other outcomes, no significant changes in the scores were found. CONCLUSION: Positive effects of using the Grip on Challenging behaviour care programme were found on job satisfaction, without an increase in job demands.

Nurses in distress? An explorative study into the relation between distress and individual neuropsychiatric symptoms of people with dementia in nursing homes.

OBJECTIVES: To optimize care and interventions to improve care, and to reduce staff burden, it is important to have knowledge of the relation between individual neuropsychiatric symptoms and distress of care staff. We therefore explored the relation between frequency and severity of individual neuropsychiatric symptoms and distress of care staff. DESIGN: This is an explorative study with a cross-sectional design. PARTICIPANTS AND SETTING: Care staff was interviewed regarding 432 residents of 17 nursing homes for people with dementia. MEASUREMENTS: Behavioural problems were assessed using the Nursing Home version of the Neuropsychiatric Inventory (NPI-NH) questionnaire. The distress scale of the NPI-NH was used to determine the distress of care staff. RESULTS: Agitation/aggression had the highest mean distress score and was also the most prevalent symptom. Disinhibition and irritability/lability also had high mean distress scores, whereas euphoria/elation, hallucinations and apathy had the lowest mean distress score. The symptom severity of each symptom strongly predicted the distress score, whereas the frequency of the symptoms was a less important factor. CONCLUSIONS: Although some of these findings are in accordance with studies among informal caregivers, there are also notable differences. Apathy caused little distress among care staff. Therefore, care staff might not feel the urgency to explore the causes of this symptom. The findings of this study emphasize the importance of supporting care staff in the management of behavioural problems, especially aggression and apathy.

[The lived-experiences of early-stage dementia and the feared suffering: an explorative survey]. / De beleving van beginnende dementie en het gevreesde lijden.

This qualitative explorative survey aimed at investigating the personal experiences of elderly people with early-stage dementia with regard to their illness and the extent to which they experience their situation as 'suffering'. In the Netherlands insight in this suffering is relevant with regard to ongoing debate on euthanasia and physician assisted death in early dementia. Participants in the study were 24 elderly (mean age 76.3 years) diagnosed with early-stage Alzheimer's disease. The semi-structured interviews were transcribed verbatim, and qualitatively analyzed. The elderly were found to be very capable of sharing experiences about their disease. They indicated not to experience their situation 'as a whole' as one of dreadful suffering. The gradual progression, which is distinctive of Alzheimer's disease, also allows people to adapt and adjust to their changing situation. As a result, the actual experiences of the disease can, in a positive manner, deviate from their anticipatory beliefs. The experiences of the participants appeared less negative than the ideas 'healthy' elderly often have about a life with dementia. The results from this study emphasize the importance of listening to the voices of people with dementia. Communication with elderly with Alzheimer's disease, is in the early stages quite possible and essential for advance care planning to be adjusted to their actual wishes and needs.

[Small-scale group living for elderly with dementia: a clarification]. / Kleinschalig wonen voor ouderen met dementie: een begripsverheldering.

This article discusses the results of a Concept Mapping, held to clarify the concept of small-scale group living for elderly with dementia. Seventeen experts from different backgrounds formulated 91 statements about small-scale group living. These were subsequently depicted on a concept map with two dimensions: care versus living and individual versus context. The statements were then divided into six clusters by hierarchical cluster analysis. Five of these clusters centred around the arrangements of the individual lives of the residents and the collective lives of residents and staff, while only one held statements about the physical characteristics of small-scale group living. Therefore, it can be concluded from this Concept Map that small-scale group living is not so much determined by the physical characteristics but by the organisational features of the care context.

Prevalence and correlates of anxiety among nursing home patients.

BACKGROUND: Very little is known about the prevalence and correlates of anxiety among nursing home patients. The current knowledge is predominantly based on information from population-based studies among elderly. METHODS: Prevalence of anxiety was measured with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) in a sample of 333 nursing home patients of somatic wards of 14 nursing homes in the Netherlands. Participants were over 55 years, had a MMSE-score >14 and were able to communicate sufficiently. Information about demographic, health-related, psychosocial and care-related characteristics was collected in interviews with participants and from attending physicians and nursing home staff. RESULTS: The prevalence of anxiety disorders was 5.7%, of subthreshold anxiety disorders 4.2% and of anxiety symptoms 29.7%. Only health-related characteristics (MMSE-score >23, depression, stroke) were significantly associated with anxiety disorders and subthreshold anxiety disorders. Demographic (>6 years education), health-related (depression, impaired vision, pain) and psychosocial characteristics (a recent negative life event) were significantly associated with anxiety symptoms. No care-related characteristics were associated with anxiety. LIMITATIONS: The study population is a selective one (>55 years, MMSE >15, able to communicate sufficiently). The data were collected cross-sectionally. CONCLUSIONS: Anxiety disorders and anxiety symptoms occur frequently among nursing home patients and are mainly associated with health-related characteristics. Physicians should focus special attention on patients with depression or stroke.

[Anxiety disorders in nursing homes: a literature review of prevalence, course and risk indicators]. / Angststoornissen bij verpleeghuisbewoners: een literatuuronderzoek naar prevalentie, beloop en risico-indicatoren.

Psychiatric disorders such as dementia and depression are highly prevalent in nursing homes. The prevalence of anxiety disorders is less clear. Prevalence, course and risk-indicators of anxiety disorders among nursing home residents were examined, based on a review of the literature. Medline and PsychINFO searches were conducted for 1966-2002. Twelve studies were considered relevant. These differed substantially with respect to study-population, diagnostic instruments and diagnostic criteria that were used and the specific anxiety disorders investigated. The prevalence of anxiety disorders ranged from 0-20%. Only in one study the course of anxiety disorders was investigated. About 60% of the nursing home residents recovered in one year. The most important risk-indicators for anxiety disorders identified were: female sex, depression, lack of social support, poor physical health and functional and cognitive impairments. Generalization of these results to the Dutch nursing home population is restricted by the substantial heterogeneity of the studies. Further studies are required to provide reliable estimates of prevalence, course and risk-indicators of anxiety disorders among nursing home residents using appropriate diagnostic instruments and adjusted diagnostic criteria. This will enhance detection and improve treatment of anxiety disorders among nursing home residents.

Survival in a population-based cohort of dementia patients: predictors and causes of mortality.

OBJECTIVES: To examine predictors of survival time and causes of mortality in a population-based cohort of demented subjects. DESIGN: Longitudinal naturalistic follow-up study. SETTING: A rural area in The Netherlands. PARTICIPANTS: The study population consisted of 102 demented subjects derived from a population-based, two-stage prevalence study of dementia among subjects aged 65 and over. MEASUREMENTS AND ANALYSIS: Survival analysis was performed using the Realized Probability of Dying as a measure of survival time. Adjustment for duration and severity at study entry was employed in all analyses. RESULTS: A substantial excess mortality was present among demented subjects as compared with their non-demented birth cohort. Disorders related to dementia, such as cachexia, dehydration and pneumonia, were major causes of death. Variables related to severity of functional impairment, aphasia and a shorter duration at study entry predicted a shorter survival in the study population.

Prevalence of dementia in a rural Netherlands population and the influence of DSM-III-R and CAMDEX criteria for the prevalence of mild and more severe forms.

To obtain estimates of the prevalence of mild and moderate/severe dementia among people age 65 and over, applying criteria for severity of both DSM-III-R and CAMDEX, a two-stage community-based study was conducted in a rural area of the Netherlands. In the first stage, 2191 subjects (out of the target population of 2655) participated in an interview which included the Mini-Mental State Examination (MMSE). Based on MMSE score, a non-proportional random sample (n=496) was drawn for the second stage. A total of 421 subjects responded and were subsequently examined using the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX). In determining the severity of dementia, criteria of both DSM-III-R and CAMDEX were applied. Overall prevalence for both classification systems was 6.5%. There was a large discrepancy between the two classification systems with regard to the criteria for rating severity. The prevalence of moderate/severe dementia using DSM-III-R criteria was twice as high as the prevalence using CAMDEX criteria. These findings reflect the differences between DSM-III-R and CAMDEX in descriptions of dementia severity. Rating according to CAMDEX predicts institutionalization in specialized nursing homes somewhat better than staging according to DSM-III-R. Both content analysis and institutionalization data suggest that the CAMDEX operationalization of rating severity seems preferable.

Characteristics of non-responders and the impact of non-response on prevalence estimates of dementia.

BACKGROUND: Differential distributions of sociodemographic characteristics and cognitive impairment in responders and non-responders may result in a biased prevalence estimate of dementia based on responders only. METHODS: Responders (n = 2191) to a cross-sectional, two-stage community study were compared with regard to sociodemographic characteristics and cognition with three subgroups of non-responders: (A) subjects who refused to participate (n = 369), (B) subjects who were too ill or who had died prior to the screening (n = 72) and (C) subjects who had moved out of the study region or were not traceable (n = 23). Prevalence estimates specific for age and housing situation in responders and physicians' ratings of cognitive impairment were used to estimate the prevalence of dementia among non-responders. RESULTS: Group A differed from responders in age and housing situation, group B in age, housing and cognition, and group C only in age. Separate prevalence estimates of dementia based on age, housing and cognition yielded figures for group A between 4.9% and 7.2%, for group B between 13.1% and 19.1%, and for group C between 2.6% and 4.2%. Joined with the prevalence rate among responders (6.5%) the best possible point estimate of the prevalence of dementia in the target population lies between 6.4% and 6.9%, i.e. within the 95% confidence interval (CI) of the prevalence among responders (5.4-7.5%). CONCLUSIONS: Although in this study non-response had no important influence on the overall prevalence, the findings among the distinct non-response subgroups point to the importance of describing non-response sociodemographically as well as in terms of the study objective. The authors recommend that non-responders are categorized into distinct groups based on the reason for non-response.

Care services for dementia patients: predictors for service utilization.

AIM: The objective of this study was to examine service utilization figures among a representative sample of demented patients and to determine whether sociodemographic and health-related variables are associated with care utilization. METHOD: The study population was derived from a population-based, two-stage cross-sectional study in The Netherlands and consisted of 102 demented subjects. Four levels of care intensity were used: level 1, no use of professional care; level 2, use of one or more types of professional care by community-dwelling subjects; level 3, residential living in homes for the aged; level 4, long-term care in specialized nursing homes. Sociodemographic variables and variables related to mental and physical health, functional dependency and severity of dementia were studied as determinants of levels of care. RESULTS: Eighty-two per cent of the study subjects used one or more types of formal care and 55% were institutionalized. Multivariate analysis yielded age, severity of dementia, somatic disorders, dependency in terms of ADL and martial status as predictors of higher levels of care. Sets of predictors differed across different care levels. CONCLUSIONS: The findings point to the importance of the social network and the relevance of general medical treatment and an active approach towards decreasing the impact of ADL dependency in demented subjects.

[Usefulness of the 'Mini-Mental State Test'for the diagnosis of dementia; study of criterion validity in a Dutch rural population]. / Bruikbaarheid van de 'Mini-mental state examination' voor het vaststellen van dementie; onderzoek naar de criteriumvaliditeit in een Nederlandse plattelandspopulatie.

OBJECTIVE: To establish the criterion validity of the MMSE for dementia in a community-based population. DESIGN: Descriptive. SETTING: Eight rural general practices and eight adherent institutions for long-term care near Zwolle, the Netherlands. METHODS: In the first (screening) stage, the MMSE was applied, in the second (diagnostic) stage the 'Cambridge examination for mental disorders of the elderly' (CAMDEX) was used. After exclusion of subjects with clinically relevant impairment of hearing and (or) vision, analyses were based on 2151 screened subjects. Based on a non-proportional, stratified randomized sampling procedure using the MMSE score as the stratification variable, 390 of the screened subjects were examined with the CAMDEX. Seventy-seven cases of DSM-III-R dementia were identified. Based on 390 paired observations the relationship between MMSE score and DSM-III-R dementia was modelled by logistic regression. After extrapolation of this relationship to the total screened population, sensitivity and specificity figures were calculated at several cut-offs of the MMSE, and Receiver Operating Characteristic (ROC) curves were constructed for the total population as well as for four subpopulations. (men, women, < 80, > or = 80 years). RESULTS: At the cut-off of 23/24, sensitivity was 0.76 and specificity 0.91 in the total population. However, the criterion validity of the MMSE varied substantially between the four sex-age combinations. Criterion validity was especially poor for women in the younger age range. CONCLUSION: The MMSE has only limited value in clinical practice. Use of uniform cut-offs has to be rejected.

Differences in prevalence of dementia based on community survey and general practitioner recognition.

A study was conducted, which simultaneously used GPs and epidemiological assessment procedures (MMSE, CAMDEX), to identify individuals with DSM-III-R dementia in the same population. In addition, a 1-year follow-up assessment was conducted in patients with a CAMDEX-diagnosis of dementia. In the non-institutionalized group, which was assessed both by the GP and with the epidemiological test battery, the prevalence of dementia according to the GP was 2.2%, whereas the prevalence based on the epidemiological approach amounted to 5.2%. In general CAMDEX-diagnoses of dementia were confirmed at 1-year follow-up, and thus the discrepancy between the two prevalence estimates must be attributed to the low sensitivity of the GPs. Sensitivity of the GP was related to help-seeking behaviour, with low sensitivity in patients with a low contact rate. It was also related to the use of less specific diagnostic labels by the GP (cognitive impairment), and to poor recognition of cognitive impairment in patients who visited their GP.

[Prevalence and severity of the dementia syndrome in homes for the aged and nursing homes. A study in elderly from a rural area near Zwolle]. / Prevalentie en ernst van het dementiesyndroom in bejaardenoorden en verpleeghuizen. Een onderzoek bij ouderen afkomstig van het platteland rondom Zwolle.

In the Netherlands both nursing homes and homes for the aged serve as a residence for demented elderly. Although these institutions differ considerably regarding financing and care facilities, specific functions of each institute concerning demented elderly have not been clearly defined. In order to know to what extent residential facilities serve demented elderly, the prevalence and severity of dementia among residents aged 65 and over was studied as part of a prevalence study among elderly people in a rural area of the Netherlands. The target population existed of all persons aged 65 and over who were registered in eight general practices. Patients who had to leave the practice on account of ill-health and were admitted to nursing homes were included in the study. In a two stage study the MMSE was applied as a screening instrument. Based on MMSE-score a non-proportional stratified random sample was drawn for the second, diagnostic stage, which existed of the CAMDEX. Prevalence estimates for DSM-III-R-dementia were 21% among residents of homes for the aged, 48% among residents of somatic wards of nursing homes and 100% among those admitted to psychogeriatric wards of nursing homes. Severity of dementia was highest among residents of psychogeriatric wards of nursing homes and lowest among those living in homes for the aged. Prevalence of dementia among residents of homes for the aged can be fully attributed to the age-distribution. The high frequency of dementia among residents of somatic nursing home wards can be explained in several ways: First, admission can be necessary due to a combination of dementia and somatic illness.(ABSTRACT TRUNCATED AT 250 WORDS)

[The dementia syndrome in the clinical practice of 15 family physicians. A pilot study of the prevalence in the Zwolle area]. / Het dementiesyndroom in de praktijk van 15 huisartsen. Een oriënterend prevalentie-onderzoek in de regio Zwolle.

A pilot investigation among 15 general practitioners in the region of Zwolle has been carried out in order to obtain an indication as to the prevalence of the dementia syndrome among noninstitutionalized elderly people. According to the general practitioner--on the basis of the Clinical Dementia Rating--4.4% of the population of people of 65 years and older display the symptoms of dementia, a percentage that is low compared with foreign studies. There is a striking difference in the prevalence rate between urban (2.8%) and rural (5.7%) populations. The most obvious explanation for this difference is that in rural areas there is more informal care and a larger degree of tolerance of demented elderly people, which helps prevent institutionalization. This assumption is supported by an identical difference in the admission rate to nursing homes. As a person becomes older, the chance that he/she will suffer from the dementia syndrome increases, although the increase is not a steady one. Despite the well-recognized necessity for thorough medical examination of demented elderly people, it is only carried out to a small degree. The authors argue in favour of more extensive research into the prevalence rate of the dementia syndrome, which will promote policy making with regard to medical practice and the planning of care facilities.