Effects of Behavioral Interventions on Disruptive Behavior and Affect in Demented Nursing Home Residents Essay

behavioural interpolations aptitude ameliorate them and fuck off a decreed erect on nonmigratorys mood ( uphold). Objectives This vignette tried and true ii disturbancesan activities of cursory living and a psychosocial bodily process interventionand a gang of the devil to determine their efficacy in trim troubled airs and improving motivate in breast feeding spot residents with frenzy. Methods The development had 3 word separates (activities of effort slight living, psychosocial bodily function, and a cabal) and dickens take in conclaves (placebo and no intervention).breast feeding assistants engage specifically for this work enacted the interventions under the heed of a victors inclined(p) gerontological clinical support specialist. breast feeding assistants employ at the treat steads save the occurrence of disruptive behaviors. Raters analyzed videotapes enter during the canvass to determine the interventions influence on make believe. Results Findings indicated importantly much confident(p) hit save non reduced disruptive behaviors in word collections comp ared to dominate groups.Conclusions The interpositions did non specifically send for the cistrons that whitethorn ache been triggering disruptive behaviors. treatments much more neverthe diminished constructed than those employed in this study require development to quell disruptive behaviors. Nontargeted interventions qualification step-up demonstrable demand. Treatments that constitute even a brief benefit in act indicate modify quality of rational health as mandated by federal law. Key lyric poem affect Alzheimers disease behavior therapy dementedness nurse home(a)s Nursing look for July/ rarefied 2002 Vol 51, No 4 proximately 1. 3 million older Americans live in breast feeding homes today (Magaziner et al. , 2000). By 2030, with the maturement of the population, the estimated demand for long-term condole with is pas s judgment to more than double (Feder, Komisar, & Niefeld, 2000). Thus, nursing home expenditures could grow from $69 billion in 2000 to $330 billion in 2030 (Shactman & Altman, 2000). About half(prenominal) of new nursing home residents go dementia (Magaziner et al. , 2000). The disease has an impact on quartette major categories of functioning in someones with dementia.These are disruptive behavior (DB), affect, in operation(p) status, and cognition (Cohen-Mansfield, 2000). This article get out reading on the first cardinal categories. luxuriant behavior has received much more vigilance than affect has (Lawton, 1997), perhaps for trinity actors. First, more than half (53. 7%) of nursing home residents demonstrate DB with pugnacity (34. 3%) occurring the rockyly often (Jackson, Spector, & Rabins, 1997). Second, DB threatens the wellbeing of the resident and differents in the environment. Consequences imply (a) stress experienced by early(a) resiCornelia K.Beck, PhD, RN, is Professor, Colleges of Medicine and Nursing, University of Arkansas for medical examination Sciences. Theresa S. Vogelpohl, MNSc, RN, is President, ElderCare Decisions. Joyce H. Rasin, PhD, RN, is harmonise Professor, School of Nursing, University of North Carolina. Johannah Topps Uriri, PhD(c), RN, is Clinical assistant Professor, College of Nursing, University of Arkansas for checkup Sciences. Patricia OSullivan, EdD, is a bankrupt _or_ abettor Professor, Office of Educational Development, University of Arkansas for Medical Sciences.Robert Walls, PhD, is Professor Emeritus, University of Arkansas for Medical Sciences. Regina Phillips, PhD(c), RN, is adjuvant Professor, Nursing Villa Julie College. Beverly Baldwin, PhD, RN, deceased, was Sonya Ziporkin Gershowitz Professor of Gerontological Nursing, University of Maryland. A Note to Readers This article employs a matter of acronyms. Refer to delay 1 to ease reading. 219 220 Effects of lookal hitchs Nursing e xplore July/ high-flown 2002 Vol 51, No 4 card 1.Acronyms Term locomoteivities of day-to-day living digest of variance discernible affect evaluate shield Arkansas Combined exuberant behavior(s) debauched behavior weighing machine licence practical nurse(s) Maryland miniskirt kind status exam Negative optic analogue subdue Nursing home nursing assistant(s) Observable displays of affect scale validating visual analogue scale Project nursing assistant(s) Psychosocial activity search assistant(s) Acronym ADL ANOVA AARS AR CB DB DBS practical nurse MD MMSE NVAS NHNA ODAS PVAS PNA prostate specific antigen RA reductions in targeted behaviors (Gerdner, 2000 Matteson, Linton, Cleary, Barnes, & Lichtenstein, 1997).However, other(a)s report nonsignificant reductions (Teri et al. , 2000), no swap (Churchill, Safaoui, McCabe, & Baun, 1999), or increase behavioural symptoms (Mather, Nemecek, & Oliver, 1997). These studies utilize nursing home caters to collect data, had test sizes below 100, and cadencyd an array of DB with different assessments. Only in the outlast decade do exploreers investigated affect. Compared to studies to reduce DB, out-of-the-way(prenominal) few studies keep up measured interventions using affect as an outcome measure.Studies reported verifying outcomes on affect from such interventions as simulated presence therapy (Camberg et al. , 1999), Montessori- found activities (Orsulic-Jeras, Judge, & Camp, 2000), go on practice nursing (Ryden et al. , 2000), music (Ragneskog, Brane, Karlsson, & Kihlgren, 1996), rocking mince therapy (Watson, Wells, & Cox, 1998), and coddle therapy (Churchill et al. , 1999). The studies on affect employ global measures that relied on observer interpretation, which could regard as compromised objectivity. Theoretical BasesA procedure of conceptual frameworks digest guided intervention query on persons with cognitive impairment (Garand et al. , 2000). The theory-based basis for this study was that case-by-cases dedicate raw material psychosocial of necessity, which, when met, reduce DB (Algase et al. , 1996) (Table 2). The interventions, unmatched focalization on activities of daily living (ADL) and the other focusing on psychosocial activity (prostate specific antigen), and a combination (CB) of the 2, were developed to reach most of the radical psychosocial necessarily that Boettcher (1983) identified.These entangled territoriality, hiding and freedom from unwanted corporeal ravishment chat, opportunity to talk openly with others self-esteem, obligingness from others and freedom from insult or shaming preventative and security, protection from harm autonomy, maneuver all over ones life ad hominem identity, access to individualised periods and identifying material, and cognitive sense, cognisance of surroundings and mental clarity. The section on study groups specifies which interventions were knowing to set up which of necessity. Positive affect usually accompanies interventions that meet basic psychosocial postulate (Lawton, Van Haitsma, & Klapper, 1996).Several researchers and clinicians have suggested that displays of affect may press a window for revealing demented residents removes, preferences, aversions (Lawton, 1994), and responses to daily events (Hurley, Volicer, Mahoney, & Volicer, 1993). The study reported here dents and supply (b) change magnitude falls and injury (c) frugal costs, such as property reproach and provide burn-out, absendeeism, and turnover (d) delirious lack such as social isolation of the resident and (e) use of personal or pharmacologic restraints (Beck, Heithoff, et al. 1997). Third, sooner the Nursing bag Reform Act (Omnibus Budget satisfaction Act, 1987), nursing homes routinely applied physical and chemical restraints to mesh DB with only guarded results (Garand, Buckwalter, & Hall, 2000). However, the Act mandated that residents have the right-hand(a) to be free from restraints imposed for make grow or convenience and not demand to treat the residents medical symptoms. Thus, researchers have tested a big range of behavioral interventions to reduce DB and replace restraints.The Act (1987) also stipulated that all residents are authorise to an environment that cleanses or brinytains the quality of mental health. interferences that promote positive mood or affect fulfill this entitlement. Therefore, this article will report the force outs of an intervention to increase functional status in activities of daily living (Beck, Heacock, et al. , 1997), a psychosocial intervention, and a combination of both(prenominal) on reducing DB and improving affect of nursing home residents with dementia. dining table 2. Basic Psychosocial Needs applicable Literature Literature suggests that behavioral interventions offer promise in man senescence DB.A wide range of modalities and approaches have been tested (a) sensory stimulation (e. g. , music) (b) physical environment adjustments (e. g. , walled garden) (c) psychosocial measures (e. g. , pet therapy) and (d) multimodal strategies. M all studies found significant Territoriality colloquy Self-esteem Safety and security familiarity Personal identity Cognitive understanding Nursing Research July/August 2002 Vol 51, No 4 Effects of behavioural handlings 221 adopt the interpretence by Lawton et al. (1996) that frequent displays of positive affect when basic psychosocial needs are met exponent indicate improved emotional wellbeing. is leg continually and without apparent reason needs re containion. This intervention lasted 4560 minutes a day during dissimilar ADL. PSA Intervention. A PNA also conducted the PSA intervention, which composite 25 standardized mental facultys de write to meet the psychosocial needs for communication, selfesteem, prophylactic and security, personal identity, and cognitive understanding through difference of opinion in thinkingful activity while considering the individuals unique cognitive and physical abilities (Baldwin, Magsamen, Griggs, & Kent, 1992).The intervention was chosen because it (a) provided a systematic plan for the PNA to address whatever(prenominal) of the participants basic psychosocial needs and (b) represented clinical interventions that many long-term care facilities routinely used, alone had not been formalized into a research communications protocol or systematically tested. each module contained quintuplet psychosocial areas of content ( depiction of feelings, expression of thoughts, holding/recall, recreation, and education) and stimulated phoebe bird sensory modalities (verbal, visual, auditory, tactile, and gustative/olfactory).For instance, Activity Module I convoluted life review, communicating ideas visually (identifying and fashioning drawings), clapping to different rhythms, massaging ones face, and eating a snack. Initially, many participants tolerated less than 15 minutes of the activity precisely eventually habituated and participated 30 minutes. CB Intervention. This intercession consisted of both the ADL and PSA interventions and lasted 90 minutes daily. Placebo Control. This heterogeneous a one-to-one interaction among the participant and PNA.It simplenessled for the offspring of the personal attention that the PNA provided to the trine discourse groups. The PNA asked the participant to ask the activity, such as holding a conversation or manicuring nails. It lasted 30 minutes a day. No Intervention Control. This hold back consisted of routine care from a NHNA with no scheduled contact between participants and the PNA. Instruments fast Behavior Scale. The 45- stop disruptive behavior scale (DBS), de sign to construct dozens based on the occurrence and virulence of behaviors, assessed the effect of the interventions on DB (Beck, Heithoff et al. 1997). Gerontological experts (n 29) naturalized content validity, and interrater dependableness tests yielded an interclass correlation coefficient of . 80 (p . 001). Geropsychiatricnursing experts weighted the behaviors using a Q-sort to improve the scales capacity to look to perceived patient disruptiveness. Factor compendium identified quadruple factors (Beck et al. , 1998). deuce corresponded to twophysically aggressive and physically unassertiveof the terzetto categories from the factor compendium of the Cohen-Mansfield tumult archive (Cohen-Mansfield, Marx, & Rosenthal, 1989).The third category of the Inventory was verbally agitated in contrast, the factor psychoanalysis of the DBS produced a third and fourth category literally agitated and vocally aggressive. To obtain a score for the DBS, a educate individual completed a DBS form for any hour of a shift by check- Methods The primary ingest was to conduct a randomized run of the ADL and PSA interventions individually and in combination (CB) for their effect on DB and affect on a large seek of nursing home residents. The experimental design consisted of one-third discourse groups (ADL, PSA, and Combined) and two go groups (placebo and no intervention).Individual residents were assigned to one of the louvre groups at each(prenominal) of seven sites in Arkansas and Maryland, which authorizationled for site differences. To make the practicability of the interventions and assure adherence to the treatment protocols, certified nursing assistants were hired and trained as project nursing assistants (PNA). They implement the interventions MondayFriday for 12 weeks. Afterward, one-calendar calendar month and two-month experience periods occurred. Nursing assistants employed by the nursing homes (NHNA) recorded DB. To measure affect, raters were hired for the study to analyze videotapes take during intervention.Research Subjects The archetype initially consisted of 179 participants. The study design allowed for the detection of an improvement in DB scores on the Di sruptive Behavior Scale (DBS) (Beck, Heithoff et al. , 1997) across eon of at least 1. 6 units with a power of 80%. This power figuring assumed that the repeated measures would be correlated with one another at 0. 60. cellular inclusion criteria were age 65 a dementia diagnosis a Mini psychic Status Exam (MMSE) (Folstein, Folstein, & McHugh, 1975) score of 20 and a report of DB in the antecedent two weeks.To form a more homogeneous group for generalizing findings, elimination criteria were a physical disability that naughtily limited ADL a psychiatric diagnosis and a progressive or revenant medical, metabolic, or neurological condition that tycoon interfere with cognition or behavior. survey Groups ADL Intervention. A PNA used the ADL intervention during bathing, g entertainsing, dressing, and the twelve noon meal based on no-hit protocols that improved functional status in dressing (Beck, Heacock et al. , 1997).It attempted to meet residents psychosocial needs for te rritoriality, communication, autonomy, and self-esteem to promote their sense of safety and security. The intervention also tried to respect participants cognitive and physical abilities by prescribing three types of strategies specific to the individual participant. First, strategies to complete an ADL address specific cognitive deficits. For example, the person with ideo take apraxia needs touch or physical counsel to start movements. Second, standard strategies are behaviors and communication techniques that work for almost everyone with dementia.For example, the caregiver gives a series of one-step commands to guide the resident to put on her shoe. Third, problem-oriented strategies address ill-tempered disabilities such as fine motor impairment, physical limitations, or perseveration. For example, a crush who rubs his hand back and forth on 222 Effects of Behavioral Interventions ing the behaviors that occurred. The score for a behavior was the frequency (08) cartridge clip s the weight. The item scores were summed to obtain each of the four subscale scores. Mini Mental Status Exam. The Mini Mental Status Exam (MMSE) (Folstein et al. 1975) provided a global evaluation of participants cognitive statuses for test subjects for the study. Test-retest reliability of the MMSE is . 82 or better (Folstein et al. ). Cognition is assessed in seven areas, and scores lower than 24 out of 30 indicate dementia. Nursing Research July/August 2002 Vol 51, No 4 Observable Displays of mask Scale. The Observable Displays of advance Scale (ODAS) (Vogelpohl & Beck, 1997), knowing to rate videotaped data, contains 41 behaviors categorized into cardinal subscales of positive and minus facial displays, vocalizations, and consistency movement/ position.Raters indicate presence/absence seizure of each behavior during five 2-minute intervals from a 10minute videotape. piles range from 05 for each item. The range of scores for each scale is facial positive (020), aggres sion during bathing facial forbid (020), vocal positive (045), vocal prejudicial (050), frame could stem from physical positive (030), and body prohibit discomfort or rough (040). Interrater reliabilities (Kappa handling coefficients) for the ODAS range from . 681. 00, and intrarater reliability is . 971. 00.Ten gerontological nursing experts established content validity (Vogelpohl & Beck). Apparent Affect Rating Scale. The Apparent Affect Rating Scale (AARS) (Lawton et al. , 1996) is designed for direct reflection of persons with dementia and contains vi emotive states pleasure, anger, anxiety/fear, sadness, interest, and contentment. (In later work, Lawton, Van Haitsma, Perkinson, & Ruckdeschel 1999 deleted contentment). Each item has a noninclusive list of behaviors that might signal the presence of the affect from which observers infer the affect.The observer assigns a score of 1 to 5 to measure the duration of the behavior. optical analogue Scales. The Positive Visual l atitude Scale (PVAS) and Negative Visual Analogue Scale (NVAS) (Lee & Kieckhefer, 1989 Wewers & Lowe, 1990) are two 10cen dateter lines on set forth pages for rank positive and negative affect. The PVAS has end anchors of no positive affect and a great deal of positive affect. The NVAS has end anchors of no negative affect and a great deal of negative affect. Scores range from 0 to 100. bit The study consisted of six phases (a) preliminary activities, (b) a three-week normalization/desensitization period, (c) a 12-week intervention period, (d) a onemonth followup period, (e) a two-month critique period, and f) a videotape analysis. Preliminary Activities. The institutional review boards at the University of Arkansas for Medical Sciences and the Univer- sity of Maryland approved the research. Each nursing home identified residents with dementia and sent letters informing persons responsible for the residents that researchers would be contacting them.Responsible persons could re turn a signed form if they did not want to participate. free responsible persons received a squall call explaining the study followed by a mailed written description along with two consent forms. Those willing unploughed one consent form for their records and signed and mailed back the other. Screening involved a review of the residents charts, recording their diagnoses, and interviews with the staff to find evidence of DB during the previous two weeks. Each resident took the MMSE to meet inclusion criteria.Within each home, egg-producing(prenominal) residents who passed these screens were randomized to one of the five groups by a drawing, unless males were assigned to the five groups to fit even distribution of their vitiated turn of events. Simultaneously, research staff members were hired and trained. standardization/Desensitization. For the next three weeks, each PNA attach to a NHNA to learn the routines of the facility but did not help care for dominance study parti cipants. A videotape technician determined a camera that was not cartroad in the dining and shower live to desensitize residents and staff to its presence.In addition, nursing home staffs participated in two-hour cooking sessions on the DBS. Throughout the study, a gerontological clinical nurse specialist trained any new NHNA and retrained if behaviors reported on the DBS differed from those she observe during randomized checks. Intervention. During the 12-week intervention period, the first three weeks were considered service line and the last two weeks postintervention. The PNA administered the treatment/s or placebo five years a week. Every day, they asked participants to give their accept and espected any dissents. During weeks 1112 (postintervention), the PNA disposed(p) the participants for their departure by telling them that they were expiration soon. To facilitate data collection, a separate form of the DBS for each of the three eight-hour daily shifts was developed . Eight one-hour blocks accompanied each item of the scale. The NHNA placed a check nock in the block that corresponded to the hour when the NHNA discovered the behavior. The NHNA completed the DBS on all participants during or at the end of a shift.In addition, a technician videotaped participants in the treatment and placebo groups every other week during an interaction with the PNA and no intervention group monthly during an ADL. The technician monitored fix and operation of the camera from outside the room or behind a mantelpiece to respect the participants esotericness. One-Month and Two-Month Follow-up. One month and two months after the research team leave the nursing home, Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 223 esearch assistants (RA) retrained nursing home staffs on the DBS. The NHNA so collected DB data on their shifts MondayFriday for one week. tervention, week 16 as one-month follow-up, and week 20 as two-month follo w-up. Participants with few than six observations at any quantify period were omitted. For each period, a come in DBS score represented an averVideotape Analysis. The videotapes ranged in aloofness from age of the participants data for the three shifts of each day less than five minutes to 40 minutes, depending on the across the five days of the observation week.Therefore, activity and the participants willingness to stand by with sum DBS scores were obtained for baseline (M of weeks the treatment (baseline and train participants tapes 13), intervention (M of weeks 410), postintervention (M tended to be shorter). To standardize the opportunity for of weeks 1112), first follow-up (M of week 16), and secbehaviors to occur, an editor took 10-minute segments ond follow-up (M of week 20). The same purpose from the middle of baseline and last treatment eek tapes yielded subscale scores for physically aggressive, physically and randomized them onto videotapes for rating. Because unaggressive, vocally aggressive, and vocally agitated videotaping occurred to ensure appropriate implementabehaviors for each of the five time periods. tion of interventions, the treatment groups had more A repeated measures analysis of variance (ANOVA) usable videotapes than the bidding groups did. consisted of two between-subjects and one within-subjects A masters prepared gerontological factors.The between-subjects factors nurse specialist intensively trained six were intervention group and state (AR raters on the Observer III Software or MD) to account for regional differSystem (Noldus Information Technolences in scoring DB, and the withinogy, 1993) for direct data foundation and subjects factor represented DBS scores the affect rating scales. The raters for the five different time periods. Each reached . 80 agreement with the speanalysis allowed for scrutiny by intervencialist on practice tapes before they tion group, time period, and state. The Screaming may started ratin g the study videotapes. nalysis of the interaction effect of She monitored reliability for each tape intervention group by time period express pain or monthly, retrained as needed, and rantested the possibleness that the intervenself-stimulation domized the sequence of rating the tions would decrease DB across time in scales. The raters entered the ODAS treatment conditions as compared to and AARS data directly into a com give conditions. The analysis was puter using the Observer. The system repeated five times, once for each suballowed raters to enamor videos repeatscale of the DBS and once for the total edly in authentic time and slow action to score. direct of significance was set at text file behaviors objectively and 0. 05. The researchers believed that the precisely. The raters indicated their small group sizes confirm the liberal perception of the participants positive and negative level of significance. For the videotape analysis, analyses of affect by placing a vertica l mark at several(prenominal) point between covariance occurred for the 14 variables observed from the the two end anchors of the PVAS and NVAS. They videotapes during intervention. The baseline score served marked neutral affect as negative. s a covariate for the final score. While a multivariate analysis would have been desirable, it would have had Intervention virtue The PNA and video camera techniinsufficient power with this number of variables and subcian underwent two weeks of intensive training on general jects. The 14 univariate analyses do hit the ceiling the Type I error aging topics, stress management, information on dementia, rate. and confidentiality/privacy issues. Training also involved instruction on the study interventions, DBS, and research Results protocols.Of the 179 initial participants, 36 did not finish the greatA gerontological clinical nurse specialist viewed treatest excoriation occurred in the no intervention suss out group. ment and placebo videotapes biweekly in a private office to Attrition resulted from death (39%), climb-down of fammonitor PNA compliance with research protocols, provide ilys consent or at nursing home staffs bay (26%), discorrective feedback to PNA, and help PNA recognize and charge (18%), and change in health status/medications meet participants needs as they changed during treatment. hat did not meet inclusion criteria (17%). This left 143 The hap for contamination appeared to be low participants 29 in the ADL, 30 in PSA, 30 in CB, 30 in the because NHNA were supposed(prenominal) to change their care practices placebo, and 24 in the no intervention, but 16 with incomand had little opportunity to observe PNA. Further, NHNA plete data were dropped. Table 3 gives the demographic were blinded to the speculation of the study, the nature of the statistics for the 127 participants with complete data.No interventions, and the participants group assignments, statistically significant demographic differences em erged although they probably could identify the no intervention among the five groups. In short, this sample primarily conparticipants. sisted of elderly, sportsmanlike egg-producing(prenominal)s with severe cognitive impairment. Analysis Reviewers examine for completeness of all data. For the videotape analysis, the final number was 84 The researchers designated intervention weeks 13 as baseparticipants with 168 videotape segments. Most were line, weeks 410 as intervention, weeks 1112 as postin- 224 Effects of Behavioral InterventionsNursing Research July/August 2002 Vol 51, No 4 TABLE 3. Description of the Sample by Intervention Group No Intervention 19 89. 5 78. 9 84. 2 86. 47 (6. 37) 11. 47 (6. 43) ADL Number in group pct female Percent white Percent widowed connote age (SD) M MMSE (SD) 28 78. 6 82. 1 64. 3 82. 29 (8. 40) 11. 44 (7. 69) PSA 29 82. 1 85. 7 66. 7 82. 18 (7. 64) 10. 65 (6. 76) CB 22 81. 8 77. 3 77. 3 82. 82 (9. 81) 7. 91 (5. 41) Placebo 29 75. 9 86. 2 75. 9 86 . 45 (6. 92) 11. 11 (6. 39) tote up 127 81. 0 82. 5 72. 8 83. 64 (7. 97) 10. 55 (6. 64) Note. ADL = activities of daily living PSA = psychosocial activity CB = combination. emale (79%) and widowed (69%) with a mean age of 83 (SD 7. 44). Participants had a mean score of 10 (SD 6. 34) on the MMSE, indicating moderate to severe cognitive impairment. Table 4 displays the means and standard deviations for the DBS boilersuit and the four subscales across the five time periods for the five groups. No significant differences emerged for the intervention-by-time interaction for any of the dependent variables. Thus, the results failed to support the guesswork that the interventions would decrease DB across time in treatment groups as compared to carry groups (statistical analysis tables on Website at http//sonweb. nc. edu/nursing-research-editor). However, the main effect of state was significant in three analyses. Arkansas recorded significantly more behaviors than Maryland did for the de pendent variables of physically peaceable (p . 001), vocally agitated (p . 001), and general DBS (p . 002). Further, the main effect of time was significant for overall DBS (p . 002) and the four subscales of physically aggressive (p . 001), physically nonaggressive (p . 027), vocally aggressive (p . 021), and vocally agitated behaviors (p . 008).The significance resulted from increased DB after the PNA had left the home (generally from intervention or postintervention to first follow-up). For the videotape analysis, the hypothesis stated that treatment groups, compared with control groups, would display more indicators of positive affect and fewer indicators of negative affect following behavioral interventions. In general, neither the positive nor the negative affect scores were particularly high, indicating that this sample had relatively flat affect. Results from the analysis of covariance tests support increased positive affect but not decreased negative affect.Compared to th e control groups, the treatment groups had significantly more positive facial expressions (p . 001) and positive body posture/movements (p . 001), but not more positive verbal displays on the ODAS. The treatment groups displayed significantly more contentment (p . 037) and interest (p . 028) than the control groups did on the AARS. For the negative affects on the AARS, the treatment groups had a shorter duration of sad behaviors (p . 007) than the control groups did. Comparison of VAS scales likewise showed that the treatment groups displayed more positive affect (p . 012). parole In contrast to other studies (e. . , Hoeffer et al. , 1997 Kim & Buschmann. , 1999 Whall et al. , 1997), this study found no treatment effect on DB. The interventions were a synthesis of approaches believed to globally address triggers of DB and meet psychosocial needs (Boettcher, 1983). They did not address the specific factors that might have been triggering the particular behavior (Algase et al. , 1996 ). much(prenominal) triggers include under/over stimulation, unacquainted(predicate) or impersonal caregivers, and particular individual unmet psychosocial needs. For example, aggression during bathing could stem from physical discomfort or rough handling (Whall et al. 1997). Interventions much more individually designed require development. Increasing DB across all groups was reflected in the DBS scores at 1-month follow-up. Two factors may explain this increase. First, the PNA had warned participants that they would be leaving. Second, the ADL and CB participants no longer received care from the familiar PNA, and PSA, CB, and placebo participants no longer had a daily activity or visit. The increased stress and time constraints for NHNA as they resumed caregiving of the ADL and CB participants may explain the heightened DB in the control groups.Such changes may trigger increased behavioral symptoms in persons with dementia (Hall, Gerdner, Zwygart-Stauffacher, & Buckwalter, 1995) . Two measurement issues may have bear on outcomes. First, observers view behaviors differently (Whall et al. , 1997) and come to brook particular behaviors from certain residents (Hillman, Skoloda, Zander, & Stricker, 1999). If the NHNA were accustomed to a participants DB pattern, such as persistent screaming, they may have overlooked decreases in that behavior. Initial training and retraining of raters occurred as needed however, some Nursing Research July/August 2002 Vol 51, No 4Effects of Behavioral Interventions 225 TABLE 4. Weighted Scores for Disruptive Behavior by Intervention Group and age Period No Intervention (n = 19) mean(a) (SD) 408. 71 (427. 24) 303. 69 (408. 44) 281. 97 (410. 85) 418. 31 (630. 58) 292. 85 (405. 15) 114. 66 (202. 89) 90. 85 (182. 70) 77. 98 (173. 15) 130. 92 (257. 12) 128. 20 (195. 67) 191. 97 (157. 75) 117. 11 (112. 30) 118. 23 (137. 08) 154. 46 (225. 05) 100. 45 (153. 30) 55. 16 (74. 70) 42. 89 (54. 54) 33. 26 (47. 06) 64. 72 (77. 89) 28. 09 (3 7. 02) (continues) DB Category Time Period DBS total Baseline ADL (n = 28) basal (SD) 172. 51 (191. 47) 182. 45 (181. 3) 164. 56 (154. 95) 207. 22 (205. 58) 190. 70 (291. 06) 20. 67 (30. 52) 32. 59 (51. 29) 15. 02 (26. 10) 44. 18 (100. 62) 21. 45 (36. 47) 95. 50 (105. 28) 87. 58 (87. 58) 85. 04 (89. 60) 88. 81 (85. 69) 148. 75 (187. 28) 22. 85 (32. 10) 28. 37 (32. 50) 21. 15 (26. 54) 30. 72 (48. 95) 18. 28 (24. 55) PSA (n = 29) stringent (SD) 348. 02 (467. 50) 306. 81 (393. 03) 303. 24 (367. 54) 373. 17 (533. 05) 300. 20 (366. 42) 85. 87 (199. 01) 83. 94 (167. 53) 82. 82 (166. 93) 113. 49 (235. 71) 81. 30 (151. 85) 162. 41 (206. 65) 130. 82 (142. 72) 133. 92 (145. 97) 141. 47 (188. 99) 164. 92 (223. 63) 49. 64 (93. 15) 43. 80 (64. 6) 37. 90 (53. 43) 54. 47 (90. 33) 40. 26 (45. 26) CB (n = 22) Mean (SD) 287. 66 (373. 73) 300. 84 (379. 33) 286. 21 (365. 78) 374. 10 (510. 10) 312. 83 (433. 18) 68. 84 (126. 18) 67. 14 (137. 79) 61. 04 (127. 78) 92. 68 (205. 52) 60. 40 (131. 54) 136. 6 7 (189. 03) 124. 64 (164. 49) 125. 99 (157. 78) 159. 97 (202. 75) 146. 53 (201. 83) 34. 49 (55. 91) 40. 73 (52. 60) 31. 18 (33. 85) 36. 95 (42. 70) 32. 82 (51. 32) Placebo (n = 29) Mean (SD) 325. 96 (337. 14) 337. 60 (328. 94) 336. 80 (366. 55) 389. 92 (434. 43) 319. 15 (384. 59) 49. 26 (90. 24) 62. 10 (112. 71) 59. 67 (106. 37) 76. 79 (165. 45) 48. 25 (101. 4) 167. 01 (177. 80) 164. 62 (161. 48) 175. 36 (189. 80) 201. 68 (212. 06) 87. 67 (127. 38) 47. 20 (79. 70) 39. 55 (57. 74) 32. 69 (55. 77) 29. 30 (47. 60) 30. 18 (52. 85) Intervention Postintervention 1 month follow-up 2 month follow-up Physically aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up Physically nonaggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up vocally aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up 226 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4TABLE 4. Weighted Sco res for Disruptive Behavior by Intervention Group and Time Period (Continued) NoIntervention (n = 19) Mean (SD) 47. 65 (97. 22) 68. 32 (103. 13) 68. 01 (116. 62) 84. 50 (112. 48) 73. 07 (117. 12) DB Category Time Period Vocally agitated Baseline ADL (n = 28) Mean (SD) 33. 49 (84. 39) 33. 91 (62. 52) 43. 17 (72. 10) 43. 48 (64. 39) 50. 53 (117. 95) PSA (n = 29) Mean (SD) 46. 92 (98. 70) 52. 84 (96. 03) 52. 50 (90. 78) 68. 22 (98. 89) 48. 89 (92. 33) CB (n = 22) Mean (SD) 62. 49 (98. 97) 70. 43 (110. 85) 69. 08 (107. 29) 82. 14 (118. 97) 75. 80 (129. 67) Placebo (n = 29) Mean (SD) 50. 0 (92. 05) 48. 25 (81. 63) 48. 59 (72. 20) 63. 74 (95. 30) 54. 11 (80. 61) Intervention Postintervention 1 month follow-up 2 month follow-up Note. Scores were created by charge each behavior with a severity weight prior to summing and then averaging across day and then week(s). DBS = disruptive behaviors ADL = activities of daily living intervention PSA = psychocial activity intervention CB = combinatio n of the two interventions. NHNA appeared to continue to consider participants behaviors, such as repetitive questioning, to be personality characteristics or attention-seeking efforts quite a than DB.Thus, they may have under-reported behaviors. Further, staff may prefer withdrawn behaviors, such as isolating self and muteness (Camberg et al. , 1999), and view them as nonproblematic. Second, categorizing a behavior as disruptive without understanding its meaning to the person with dementia may be conceptually flawed. For example, screaming may express pain or self-stimulation. Two design features may explain differences between the findings of this study and others. First, this study had both placebo and no intervention control conditions.Just a few other studies randomized subjects to treatment or control groups or included two control groups (e. g. , Camberg et al. , 1999). In most studies, control conditions preceded or followed treatment conditions (e. g. , Clark, Lipe, & Bil brey, 1998). In both designs, subjects served as their own controls, which limits examination of simultaneous intra- and extra-personal events that might affect DB frequency. Second, many control groups came from separate units or different nursing homes (e. g. , Matteson et al. , 1997), which makes it difficult to control for differences in environment, staff relationships, and personalities.This study occurred at seven sites in two different geographical areas, but at each site, the randomization of female participants distributed the groups across all nursing units to control for environmental and staff characteristics. Acknowledged limitations include the following. First, in spite of the large overall sample, the group sizes were small (range 1930) with the sterling(prenominal) loss in the no inter- vention group. big groups might have provided more definitive findings on the relationship between behavioral interventions and DB frequency as Rovner et al. (1996) did (treatment group 42 control group 39).Second, NHNA served as data collectors because using independent observers would have been cost-prohibitive. These results suggest that future intervention research should consider the individual characteristics of the person with dementia (Maslow, 1996) and the triggers of the behavior (Algase et al. , 1996). Studies that have individualized interventions have demonstrated decreased DB (Gerdner, 2000 Hoeffer et al. , 1997). Researchers need to continue to refine methods for identifying what works for whom (Forbes, 1998) to sully the prevalent trial-anderror approach to DB management.