Feasibility of testing a coaching training intervention for CNAs in nursing homes.

The study aim was to describe the feasibility of conducting a coaching training intervention on use of level of assistance strategies for Certified Nursing Assistants (CNAs) in nursing homes. CNAs received either traditional or coaching training. Feasibility of coaching training was evaluated by determining: acceptability, through use of a Post-Intervention Evaluation Form; fidelity, by adherence to protocol; recruitment and retention, by ease of obtaining the sample and retention rates; and ability to randomize within each home without contamination. CNAs' mean satisfaction score of the coach training was high (4.5 out of 5). Eighteen of 22 comments on the evaluation form were positive. At least six dyads were recruited within the 60-day benchmark in each home. CNA and resident retention rates were 89.47% and 85%, respectively. Eighty-nine percent of intervention group CNAs shared study information, demonstrating contamination. The coaching training intervention is feasible. Findings revealed areas to improve the intervention.

Using an Interactive Video Simulator to Improve Certified Nursing Assistants' Dressing Assistance and Nursing Home Residents' Dressing Performance: A Pilot Study.

This pilot study examined the initial effects and estimated effect size of a computer-based simulation education program on certified nursing assistants' level of assistance when dressing nursing home residents with dementia and on residents' dressing performance. Nine dyads, assigned to either the experimental or control group, completed the study. Both groups received a traditional 1-hour education module delivered by a research assistant. The experimental group was then instructed to undertake an additional 2-hour intervention using a video simulator that enabled nursing assistants to practice level of assistance skills. The appropriateness of dressing assistance from nursing assistants and residents' dressing performance was measured before and 6 weeks after the intervention. The results showed that the two groups did not significantly differ in either appropriate levels of dressing assistance (P = .42) or residents' dressing performance (P = .38). A lack of effort by some assistants to properly assist residents and low statistical power may explain the lack of significance. The effect sizes of the experimental intervention on appropriate levels of dressing assistance and resident dressing performance were 0.69 and 0.89, respectively. Incorporating a strategy to improve motivation should be considered in future studies.

Pilot Testing a Coaching Intervention to Improve Certified Nursing Assistants' Dressing of Nursing Home Residents.

The purpose of the current study was to identify initial effects of a coaching training intervention using Level of Assistance (LoA) strategies compared with traditional lecture techniques on the appropriateness of LoA use by certified nursing assistants (CNAs) and independence of dressing of nursing home residents with dementia. Seventeen CNA-resident dyads participated in this pilot randomized controlled trial (RCT). Control and experimental group CNAs received a 25-minute traditional lecture. Experimental group CNAs also underwent three coaching sessions over 4 weeks. There were significant between-group differences in the percentage of dyads who had improved scores for appropriateness of LoA use and dressing independence from pretest to posttest (experimental: n = 9, 100%; control: n = 8, 50%; p = 0.029). However, there were no statistically significant median differences between groups in appropriateness of LoA use by CNAs and resident dressing independence scores. There were significant within-group median improvements in appropriateness of LoA use (p = 0.004) and independence of dressing scores (p = 0.004) between pretest and posttest in the experimental group, but not in the control group. This initial pilot RCT supports coach training as a method to improve appropriate use of LoA strategies by CNAs and independence of resident dressing. [Res Gerontol Nurs. 2017; 10(6):267-276.].

Experimental Comparison of Efficacy for Three Handfeeding Techniques in Dementia.

BACKGROUND: Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake. OBJECTIVES: To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH). DESIGN: A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences. SETTING AND PARTICIPANTS: 30 residents living with advanced dementia in 11 U.S. NHs. MEASUREMENTS: Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale. INTERVENTION: Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days. RESULTS: Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8). CONCLUSION: All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.

A supplemental report to a randomized cluster trial of a 20-week Sun-style Tai Chi for osteoarthritic knee pain in elders with cognitive impairment.

OBJECTIVE: This was a secondary data analysis of a cluster-randomized clinical trial that tested the efficacy of a 20-week Sun-style Tai Chi (TC) program in reducing pain in community-dwelling elders with cognitive impairment and knee osteoarthritis (OA). The study also examined whether elders' level of cognitive function was related to the outcomes of the TC program. METHOD: Elders (N=55) were recruited from 8 study sites. Each site was randomly assigned to participate in either a 20-week TC or an education program. Verbal report of pain was measured by a Verbal Descriptor Scale (VDS) at weeks 1, 5, 9, 13, 17 and 21 (designated as times 1-6). Pain behaviors and analgesic intake were also recorded at times 1-6. RESULTS: At post-test, scores on the VDS and observed pain behaviors were significantly better in the TC group than in the control group (p=0.008-0.048). The beneficial effects of TC were not associated with cognitive ability. CONCLUSION: These results suggest that TC can be used as an adjunct to pharmacological intervention to relieve OA pain in elders with cognitive impairment. TRIAL REGISTRATION: Clinical Trial.gov NCT01528566.

Putting Residents First: Strategies Developed by CNAs to Prevent and Manage Resident-to-Resident Violence in Nursing Homes.

PURPOSE OF THE STUDY: Resident-to-resident violence (RRV) in nursing homes (NHs) is common and threatens the safety and quality of life of both residents and caregivers. The purpose of this portion of a larger qualitative study was to explore strategies developed by certified nurses' assistants (CNAs) to prevent and manage RRV in NHs. DESIGN AND METHODS: Semistructured interviews were used to collect data. Data were analyzed utilizing content analysis and constant comparison. RESULTS: Analysis revealed one overriding theme, "Putting Residents First" which the CNAs described as a conscious effort to put themselves or a beloved family member in the place of the resident while administering care. Within this theme, there were three related subthemes: (a) Knowing the Residents, (b) Keeping Residents Safe, and (c) Spending Quality Time. IMPLICATIONS: Together, these themes suggest that the formulation of strategies for decreasing and managing RRV was influenced significantly by the ability of the CNAs to empathize with the residents for whom they were caring. The results indicate that in the absence of evidence-based interventions, CNAs have developed their own strategies for the management and prevention of RRV. These strategies may provide a foundation for the development and testing of interventions aimed at preventing and managing RRV in NHs.

Feasibility of a web-based dementia feeding skills training program for nursing home staff.

Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.

Diagnostic accuracy of behavioral, activity, ferritin, and clinical indicators of restless legs syndrome.

STUDY OBJECTIVES: Lack of a valid diagnostic measure of restless legs syndrome (RLS) for persons with dementia, who do not have the cognitive ability to report complex symptoms, impedes RLS treatment and research in this population. The aim of this study was to determine the sensitivity and specificity of a combination of indicators for identifying RLS that could eventually be used to diagnose RLS in persons with dementia. DESIGN: 3-day, prospective instrument validation. SETTING: Sleep laboratory. PARTICIPANTS: Cognitively intact, 107 with RLS, 105 without RLS. INTERVENTIONS: N/A. MEASUREMENTS: Serial 20-min observations with a new measure, the Behavioral Indicators Test-Restless Legs (BIT-RL); leg movements with 3 nights of the Periodic Activity Monitor-Restless Legs (PAM-RL); ferritin; sleep history; clinical data; polysomnography; Hopkins Telephone Diagnostic Interview of RLS Symptoms. RESULTS: The best-fitting diagnostic model for identifying RLS included previous history of iron deficiency (odds ratio [OR] 7.30), leg discomfort (OR 6.47), daytime fatigue (OR 6.15), difficulty falling asleep (OR 3.25), RLS family history (OR 2.60), BIT-RL (OR 1.49), and absence of diabetes (OR 0.27), with sensitivity 78%, specificity 79%, and 77% correctly classified. This model retained its predictive accuracy even with co-morbid sleep apnea. CONCLUSIONS: When compared to those without RLS, persons with RLS have observable behaviors, such as rubbing the legs, that differentiate them, but the behaviors have no circadian and activity-related variability. The final model of clinical and sleep historical data and observation for RLS behaviors using the BIT-RL had good diagnostic accuracy.

Building a state coalition for nursing home excellence.

PURPOSE OF THE STUDY: This article describes the successful evolution of a state coalition for nursing home excellence that brought together organizations that had once worked in silos to improve the quality of care through the implementation of culture change for Arkansas' 240 nursing homes with 27,700 residents. DESIGN AND METHODS: The Coalition was established in 2004 when stakeholders were invited to participate in a retreat to explore how they could come together with a common goal to improve the care of older Arkansans. These stakeholders were encouraged to bring their organization's perspectives to the Coalition and determine ways to work with others. The continuous refinement of the Coalition's activities involved revisiting goals of the Coalition, assessing the need for other stakeholders, identifying gaps and overlaps in quality and culture change programming, and providing feedback to Coalition members. RESULTS: The Coalition stakeholders had the leadership to articulate and mobilize others around a common vision of improving quality of care in nursing homes through culture change. Over time, the Coalition members developed a willingness to share resources and to speak as one voice. IMPLICATIONS: Stakeholders from diverse organizations and governing bodies can come together to complement each other's work and collaborate on programs to build a better system of care for the frail and elderly persons across a state. The success of this statewide effort lends support for policies that encourage regional coalitions of providers to improve care.

Key neuropsychiatric symptoms in common dementias: prevalence and implications for caregivers, clinicians, and health systems.

The purpose of this study was to compare neuropsychiatric symptoms (NPS) among people with common dementias and equip interdisciplinary clinicians and health services planners with large-sample data necessary to plan care for patients and families. We analyzed selected variables from baseline assessments of older adults with dementia of one or more etiologies (N = 3,768) from the National Alzheimer's Coordinating Center data repository. Dementias included Alzheimer's disease (AD), Lewy body dementia (DLB), behavioral variant frontotemporal dementia (bvFTD), and vascular dementia (VaD). We compared the prevalence of four NPS clusters (agitation/aggression, depression/dysphoria, anxiety, irritability/lability) across dementia etiologies and stages using logistic regression and AD as the reference group. NPS profiles differed significantly across dementia types and stages. Compared with primary AD, DLB was associated with greater odds of depression/dysphoria (OR = 1.68, 95% confidence interval [CI] 1.28, 2.20) and anxiety (OR = 1.80, 95% CI 1.37, 2.36), with similar findings when DLB was diagnosed in combination with AD (depression/dysphoria: OR = 1.79, 95% CI 1.11, 2.89; anxiety: OR = 1.88, 95% CI 1.17, 3.02). Primary bvFTD was associated with greater odds of agitation/aggression (OR = 1.59, 95% CI 1.17, 2.18). The prevalence of anxiety and irritability/lability was highest in moderate stages of dementia, and agitation/aggression was most prevalent in severe dementia. Differential diagnosis and staging of dementias and inclusion of single and overlapping etiologies is important for planning and implementing appropriate strategies to anticipate, report, and intervene with key NPS that complicate home and health care.

Resident-to-resident violence triggers in nursing homes.

Certified nurses' assistants (CNAs) employed by a rural nursing home in Northeast Arkansas described their perceptions of resident-to-resident violence in order to provide insight on factors, including unmet needs, that may trigger the phenomenon. Semistructured interviews were conducted with 11 CNAs. Data were analyzed using content analysis and constant comparison. Two categories of triggers emerged from the data-active and passive. Active triggers involved the actions of other residents that were intrusive in nature, such as wandering into a residents' personal space, taking a resident's belongings, and so forth. Passive triggers did not involve the actions of residents but related to the internal and external environment of the residents. Examples were factors such as boredom, competition for attention and communication difficulties. Results indicate that there are factors, including unmet needs within the nursing home environment that may be identified and altered to prevent violence between residents.

A randomized trial of a community-based cognitive intervention for obese senior adults.

OBJECTIVE: To determine whether a cognitive intervention delivered by lay health educators (LHEs) in senior centers was effective in improving cognition in obese older adults. METHODS: This cluster randomized trial was conducted in 16 senior centers from which 228 senior adults were recruited. The centers were randomized to either the cognitive intervention or a control, weight-loss intervention. The primary outcome variable, cognitive function, was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). RESULTS: Analyses of RBANS indices as continuous variables did not indicate significant differences between arms. However, after adjusting for baseline delayed memory, gender, and baseline body mass index, seniors in the cognitive intervention arm had a 2.7 times higher odds of a reliable improvement (clinically significant) in delayed memory from baseline as compared to those in the control intervention (95% CI, 1.3-5.6, p = .011). The intervention effect was not significant for the proportion showing reliable improvement in immediate memory or in attention. Attendance at the 12-session program was high with an average of 83% (67%-92%) sessions attended and 87% of participants in the cognitive arm indicating they would recommend the program. DISCUSSION: Cognitive interventions can be effectively delivered in the community by LHEs.

A pilot cluster-randomized trial of a 20-week Tai Chi program in elders with cognitive impairment and osteoarthritic knee: effects on pain and other health outcomes.

CONTEXT: Because Tai Chi (TC) is beneficial to elders without cognitive impairment (CI), it also may benefit elders with CI. But elders with CI have generally been excluded from TC studies because many measurement tools require verbal reports that some elders with CI are unable to provide. OBJECTIVES: To test the efficacy of a TC program in improving pain and other health outcomes in community-dwelling elders with knee osteoarthritis (OA) and CI. METHODS: This pilot cluster-randomized trial was conducted between January 2008 and June 2010 (ClinicalTrials.gov Identifier: NCT01528566). The TC group attended Sun style TC classes, three sessions a week for 20 weeks; the control group attended classes providing health and cultural information for the same length of time. Measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, physical function and stiffness subscales; the Get Up and Go test; the Sit-to-Stand test; and the Mini-Mental State Examination (MMSE), administered at baseline, every four weeks during the intervention and at the end of the study (post-test). RESULTS: Eight sites participated in either the TC group (four sites, 28 participants) or control group (four sites, 27 participants). The WOMAC pain (P = 0.006) and stiffness scores (P = 0.010) differed significantly between the two groups at post-test, whereas differences between the two groups in the WOMAC physical function score (P = 0.071) and the MMSE (P = 0.096) showed borderline significance at the post-test. WOMAC pain (P = 0.001), physical function (P = 0.021), and stiffness (P ≤ 0.001) scores improved significantly more over time in the TC group than in controls. No adverse events were found in either group. CONCLUSION: Practicing TC can be efficacious in reducing pain and stiffness in elders with knee OA and CI.

Feasibility of providing computer activities for nursing home residents with dementia.

INTRODUCTION: Nursing home residents with dementia need cognitively stimulating and enjoyable activities, and computer technology offers them a means of engaging in such activities. This study therefore examined the feasibility of providing a 12-week computer activity program (CAP) for nursing homes residents with dementia. METHODS: Fourteen participants completed the CAP, and 462 observational logs of CAP sessions were analyzed. RESULTS: On average, participants completed 33 sessions amounting to 936.5 minutes over 12 weeks. Participants with mild and moderate dementia preferred playing a cognitively challenging game such as solitaire, while those with severe dementia enjoyed watching slideshows with music. CONCLUSION: The findings suggest that it is important to match computer activities to interests and cognitive ability in order to increase participation and satisfaction of NH residents with dementia.

Advancing Alzheimer's disease diagnosis, treatment, and care: recommendations from the Ware Invitational Summit.

To address the pending public health crisis due to Alzheimer's disease (AD) and related neurodegenerative disorders, the Marian S. Ware Alzheimer Program at the University of Pennsylvania held a meeting entitled "State of the Science Conference on the Advancement of Alzheimer's Diagnosis, Treatment and Care," on June 21-22, 2012. The meeting comprised four workgroups focusing on Biomarkers; Clinical Care and Health Services Research; Drug Development; and Health Economics, Policy, and Ethics. The workgroups shared, discussed, and compiled an integrated set of priorities, recommendations, and action plans, which are presented in this article.

Victim or initiator? Certified nursing assistants' perceptions of resident characteristics that contribute to resident-to-resident violence in nursing homes.

The purpose of this portion of a larger qualitative study was to explore certified nursing assistants' (CNAs) perceptions of the characteristics of both the victims and initiators of resident-to-resident violence (RRV) to identify resident characteristics that influence development of RRV. Findings gained from semi-structured interviews revealed that CNAs perceive initiators of RRV to be "more with it" and to have "strong personalities," a "short fuse," and "life history" that make them prone to inflict harm on other residents. CNAs described victims of RRV using phrases such as, "they don't know," "can't communicate," and "gets around good." The results also revealed that, in some situations, residents who were usually even tempered might strike out with violence if exposed to triggers over time. This study provides the first detailed description of nursing home residents who initiate violence against other residents. Knowledge gained from this study may be useful in generating models of RRV-a precursor to developing interventions for its prevention.