The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial

OBJECTIVES: To examine the effect of integrated emotion-oriented care on nursing home residents with dementia and nursing assistants. DESIGN: A multi-site randomized clinical trial with matched groups, and measurements at baseline and after seven months. SETTING: Sixteen psychogeriatric wards in fourteen nursing homes in the Netherlands. PARTICIPANTS: One hundred and forty-six elderly residents with the diagnosis dementia of the Alzheimer (DAT) type, mixed DAT and vascular dementia, and dementia syndrome (NAO) and 99 nursing assistants. INTERVENTIONS: Integrated emotion-oriented care and usual care. MESUREMENTS: Demented elderly: Behaviour and mood related to adaptation to the illness and the institutionalization. Nursing assistants: General health as measured by feelings of stress, stress reactions, feeling of competence and illness. RESULTS: Positive effects in favour of the integrated emotion-oriented care were found in mild to moderately demented residents on two adaptive tasks: maintaining an emotional balance (less anxiety) and preserving a positive self-image (less dissatisfaction). In the trained group of nursing assistants fewer stress reactions were found only in those who perceived improvement in their emotion-oriented care skills after training. CONCLUSION: Emotion-oriented care is more effective with regard to the emotional adaptation in nursing homes of persons with a mild to moderate dementia. For the severely demented elderly we did not find this surplus value. This outcome is of clinical importance for elderly persons with dementia who are cared for in nursing homes. With respect to the nursing assistants it is concluded that emotion-oriented care has a positive influence on stress reactions in some of them.     

Strain in nursing care of people with dementia: nurses' experience in Australia, Sweden and United Kingdom

OBJECTIVES: The aim of this study was to explore nurses' experience of strain in dementia care. METHOD: Focus groups were held with 35 nurses in Sweden, Australia and UK, who care for people with dementia. The discussions were tape-recorded and analysed using qualitative content analysis. RESULTS: The nurses described the complexity of their situation and referred to environmental factors such as 'the system', community attitudes, other staff, residents' family members and also their own family. With regard to caring for people with dementia, three main sources of strain could be identified: Being unable to reach; Trying to protect; and Having to balance competing needs. CONCLUSION: The nurses' experience could be understood as a desire to do the best for the people in their care by trying to alleviate their suffering and enhance their quality of life. When they did not have the resources, opportunity or ability to do this, it caused strain.     

Disturbed behaviour in dementia sufferers: A comparison of three nursing home settings

In order to determine whether a specialist psychogeriatric nursing home was fulfilling its intended role of caring for the most behaviourally disturbed dementia sufferers, 24 of its demented residents were compared with 28 demented individuals discharged from a psychiatric unit to ordinary nursing homes and 30 mobile dementia sufferers in nursing home wards of a geriatric centre. Those in the psychogeriatric nursing home showed more disturbed behaviours than those in the other two settings. Scores on the Rating Scale for Aggressive Behaviour in the Elderly were compared with degree of cognitive impairment for the first time in the literature and showed no correlation with degree of cognitive impairment for the first time in the literature and showed no correlation with congnitive performance.     

Assessment of dementia in nursing home residents by nurses and assistants: criteria validity and determinants.

OBJECTIVES: To describe the criterion validity of nursing home staff's assessment of organic disorder compared with ICD-10 criteria, and to identify determinants of staff assessment of organic disorder. METHOD: Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. Nursing staff members were interviewed about the residents' activities of Daily Living, behavioural problems, orientation in surroundings and communication skills, and asked if the resident had an organic disorder. Multiple logistic regression was used to select the items that most strongly determined staff assessment of organic disorder. RESULTS: Sixty-two per cent of the residents were diagnosed by GMS-AGECAT as having organic disorder, 78% of these were correctly identified by the staff. Whether analysed among residents with or without organic disorder, or in the total group of residents, the staff assessment of the presence of organic disorder depended on a limited set of behavioural characteristics of the resident, namely 'going to the toilet in inappropriate places', 'saying things that do not make sense' and impairment in orientation. CONCLUSIONS: Staff comprehension of organic disorder resulted in over- as well as under-labelling of residents, a tendency that will affect communication with medical personnel and may lead to inadequate or wrong medical treatment and to negative performance as well as negative role expectations in everyday life in nursing homes.     

Factors influencing quality of life for people with dementia: a qualitative perspective

Objectives: An exploration and understanding of quality of life (QOL) can help to enhance understanding and respect for people with dementia and assist in improving care and treatment of this population. This study sought to understand the factors that influence QOL for people living with dementia in long-term care (LTC), including an understanding of how they perceived they were valued.

Methods: In-depth interviews were conducted with 32 older people with dementia from one service provider and across four large care settings, in two Australian states.

Results: While these residents were either satisfied or dissatisfied with elements of their life, the factors influencing a positive QOL were related to their relationship with family and other people, and ‘things’ such as needing some control over their life and, more importantly, needing to contribute to their community. Participants reported feeling of little use and therefore of limited value to society.

Conclusion: This study proposes a need to understand how relationships might be maintained and strengthened following a move into LTC and highlights the importance of control and its influence on feeling valued.     

Alcohol abuse: a source of reversible functional disability among residents of a VA nursing home

The prevalence of psychiatric disorders was determined in a sample of 196 VA nursing home residents who were interviewed using the modified Schedule for Affective Disorders and Schizophrenia (mSADS). Of the 160 subjects for whom data were available, 86% had a diagnosis of at least one psychiatric disorder. The prevalence of clinically significant cognitive impairment was 60.6% and of major depression 13.8%. Of 110 residents for whom alcohol histories were obtained, 32 (29%) had a lifetime diagnosis of alcohol abuse. The degree of impairment in activities of daily living improved significantly from the time of admission to the time of the evaluation (average 1.4 years) among those who were recently abusing alcohol compared to those who formerly abused alcohol and those who never abused alcohol. The effect is clinically as well as statistically significant and has the potential benefit of reducing caregiver burden and health care costs for the elderly. © 1997 John Wiley & Sons, Ltd.     

“I couldn’t change the past; the answer wasn’t there”: A case study on the subjective construction of psychotherapeutic change of a patient with a Borderline Personality Disorder diagnosis and her therapist

Background: Qualitative research has provided knowledge about the subjective experiences of therapists and patients regarding the psychotherapy process and its results. Only few studies have attempted to integrate both perspectives, considering the influence of a patient’s characteristics and diagnosis in the construction of this experience. Aim: To identify aspects of psychotherapy that contribute to therapeutic change based on the experience of a patient and her therapist, and to construct an integrated comprehension of the change process of a patient with Borderline Personality Disorder. Method: A single case was used to carry out a qualitative analysis of follow-up interviews of the participants of a long-term psychotherapy. Two qualitative approaches were combined into a model entitled “Discovery-Oriented Biographical Analysis” to reconstruct an integrated narrative. Results: This method yielded an integrated narrative organized into four “chapters” that reflect the subjective construction of both the patient’s and the therapist’s experience of psychotherapy in terms of meaning. Discussion: The understanding of psychotherapy as a multilevel process, in which different themes occur and develop simultaneously, is discussed. From this perspective, psychotherapy can be characterized as a process that involves the recovery of trust in others through corrective emotional experiences and the construction of a shared implicit relational knowledge.

Clinical or methodological significance of this article: Research on the subjective experiences of psychotherapy must consider both patient and therapist as privileged but always complementary witnesses of their interaction. In addition, it should be noted that the experience of studying this biographical reconstruction generates a space where research and practice converge. The analysis of participants’ narratives provides fascinating windows into their perceptions of psychotherapy and the process of change (Safran, 2013); here, the researcher is not merely a advantaged observer or a good summarizer: He/she has the chance to imbue the psychotherapy with a new meaning by connecting it with a common set of knowledge and a body of socially shared experience.     

Characteristics of double care demanding patients in a mental health care setting and a nursing home setting: results from the SpeCIMeN study

Background: Older patients suffering from a combination of psychiatric disorders and physical illnesses and/or dementia are called Double Care Demanding patients (DCDs). Special wards for DCDs within Dutch nursing homes (NHs) and mental health care institutions (MHCIs) offer a unique opportunity to obtain insight into the characteristics and needs of this challenging population.

Methods: This observational cross-sectional study collected data from 163 DCDs admitted to either a NH or a MHCI providing specialized care for DCDs. Similarities and differences between both DCD groups are described.

Results: Neuropsychiatric symptoms were highly prevalent in all DCDs but significantly more in MHCI-DCDs. Cognitive disorders were far more present in NH-DCDs, while MHCI-DCDs often suffered from multiple psychiatric disorders. The severity of comorbidities and care dependency were equally high among all DCDs. NH-DCDs expressed more satisfaction in overall quality of life.

Conclusions: The institutionalized elderly DCD population is very heterogeneous. Specific care arrangements are necessary because the severity of a patient's physical illness and the level of functional impairment seem to be equally important as the patient's behavioural, psychiatric and social problems. Further research should assess the adequacy of the setting assignment and the professional skills needed to provide adequate care for elderly DCDs.     

From a 'state mental hospital' to new homes in the city: longitudinal research into the use of intramural facilities by long-stay care-dependent psychiatric clients in Amsterdam

In 1986, the traditional psychiatric hospital where 70% of Amsterdam's intramural¹ treatment took place, was closed down. The progress of two groups of long-stay patients was followed by longitudinal cohort research for five years after their transferral to new small-scale facilities in Amsterdam. The ADL-functioning of the most severely handicapped clients improved and their psychiatric symptoms decreased, while no improvement was seen in the functioning of the more independent and less handicapped clients. Now, thirteen years after closure of the old hospital, the use of the psychiatric facilities by these clients is being evaluated. This evaluation makes clear that the improvement of the severely disabled patients depends on the intensity of care given. Apparently, the improvement in the new facilities is no guarantee for a further development into a less care-intensive environment. The less handicapped and more independent clients, however, could more easily be transferred to less care-intensive facilities.     

Prediction of first episode of clinical depression in patients newly admitted to a medical long-term care facility: Findings from a prospective study

A cohort of 104 patients newly admitted to a medical long-term care facility was studied over 1 year for evolution of depression. Seven variables that were associated with level of depression were used in discriminant function analyses. Results showed that the variables had about 90% accuracy in predicting depressed versus non-depressed groups with good sensitivity and specificity. The variables measured: coping with admission; life satisfaction at admission; affective and non-affective symptoms at admission; clinical health status after admission; friends in hospital after admission; and changes in affective symptoms after admission before the onset of depression.     

Incidence of depression in a medical long-term care facility: Findings from a restricted sample of new admissions

The prevalence rate of depression in medical long-term care facilities is high but varies over a large range. One source of variation may be differences in the underlying incidence rates. A cohort of 104 new admissions was followed for one year and showed and incidence rate of approximately 14%. This rate is comparable to the only other published study and suggests that incidence rates may be more uniform than expected from the range of prevalence reports.     

Burdens and difficulties experienced by caregivers of children and adolescents with schizophrenia-spectrum disorders: a qualitative study

Aim: The purpose of this qualitative study was to investigate the burdens and difficulties associated with the experience of caring for youth with schizophrenia‐spectrum disorders. Methods: Ten caregivers participated in a modified version of the Knowledge about Schizophrenia Illness interview. Results: The most common areas of general difficulties reported by caregivers were emotional burdens and the everyday practical demands and sacrifices required in caring for their dependents. Results also suggested high levels of burden for caregivers concerning difficulties with mental health services. Conclusion: Additional work is needed to learn more about the challenges that caregivers of youth with schizophrenia‐spectrum disorders are facing, as well as to develop empirically based strategies for helping these caregivers and their dependents.