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Purpose: To examine the efficacy of a comprehensive behavior management skills training program for improving certified nursing assistants' (CNA) skill performance in the nursing home, to assess the effectiveness of a staff motivational system for maintaining newly acquired behavior management skills for a 6-month period, and to evaluate any resulting effects on resident agitation. Design and Methods: This study used a randomized clinical trial of 88 residents with behavior disturbances and 106 CNAs who cared for them in two urban nursing homes. After CNAs received 4 weeks of behavior management training, supervisory nursing staff implemented formal staff management (FSM), designed to maintain training effects over time. The supervisory staff used conventional staff management (CSM, usual supervisory routine) on control units. We completed behavioral observations and paper-and-pen assessments at baseline and repeated them during a 4-week post-intervention phase and at 3- and 6-month follow-ups. Results: During the immediate post-training phase, both the FSM and CSM groups improved five out of seven communication skills and the ability to delay physical assistance during care routines. Although CNAs showed a reduction in the use of ineffective behavior management strategies, they did not increase their use of effective behavioral strategies. Follow-up assessments suggested that the FSM system was more effective than CSM for maintaining and even improving communication skills over time. Resident agitation was reduced during care interactions and maintained at follow-up. Implications: The behavior management skills training program improved CNAs' ability to interact with behaviorally disturbed nursing home residents and produced sustained reductions in agitation. The FSM system was more effective for maintaining communication skills 6 months after training. Key Words: Behavior management, Nursing homes, Staff training and motivation, Agitation

This article describes a nursing staff training program in basic behavior management skills and a formal staff management system to encourage the application of these basic skills on the nursing unit. Behavioral skills training consists of a 5-hour in-service followed by three weeks of on-the-job training to ensure accurate application of behavior management skills. Following training, a staff management system is used to facilitate long-term use of the skills. Components of the staff management system include supervisory monitoring of the nursing assistants (NAs) by licensed practical nurses (LPNs), NA self-monitoring, verbal and written performance feedback, and incentives. Key Words: Behavior management, Staff training, Staff motivation, Quality of care

Disruptive vocalization (DV) is a common problem in the management of cognitively and physically impaired older people. This article reports the results of a consensus meeting convened to provide guidelines for clinicians and recommendations for researchers in this difficult and little-studied behavioral problem. DV arises largely in people with cognitive impairment and generally reflects an underlying need or discomfort. A variety of factors can precipitate and aggravate DV; the key to management is appropriate identification of all possible factors and development of an individualized treatment plan. Key Words: Disruptive vocalization, Screaming, Behavioral problems, Dementia, Nursing homes

A comprehensive measurement for problem behaviors in dementing illness remains to be formed, although recent developments offer the possibility of improvement. Five factors that often complicate measuring problem behaviors in dementia include: shifting domains, research construct slippage, unanalyzed bias in rater and scoring, and the lack of benchmarking studies. Precise definition of these issues could be used to create a methodology for improving the measurement of problem behaviors.

Seven caregivers of a home-dwelling spouse with Alzheimer's disease were trained during 12 weekly home visits to implement behavior management programs including written cuing procedures in response to repetitive verbalizations. Data from 7 trained caregivers and 7 matched control caregivers who only tracked repetitive behavior were compared. Results revealed that trained caregivers were successful at decreasing patient repetitions using written cues. Patients of control subjects showed no systematic changes in behavioral disturbances clue to behavior tracking. In addition, intervention effects lasted for 16 weeks or longer and several caregivers reported applying the cuing intervention to other, nontargeted behaviors. Trained caregivers' perceptions of their efficacy in managing difficult patient behavior improved significantly at the 3-month follow-up assessment when program staff were no longer visiting them weekly. Key Words: Dementia, Behavior management, Disruptive behavior, Caregiver, Intervention

This study presents preliminary data on the efficacy of two environmental 'white noise' audiotapes for the treatment of verbal agitation in severely demented nursing home residents. The researchers employed a computer-assisted real-time observational system to assess both the frequency of verbal agitation and the actual use of the intervention on the nursing units (treatment fidelity). Intervention by nurse aides (NAs) on the unit was preceded by a researcher-controlled functional analysis phase that provided information regarding which of the two audiotapes would be most effective for individual residents. Results indicate a 23% reduction in verbal agitation with this individualized treatment strategy on the nursing units. These results were obtained even though treatment fidelity data showed that the audiotapes were used during only 51% of the observations. The authors discuss the need for formal staff management procedures for increasing staff compliance with treatment regimens.

Primary and secondary caregivers of patients with Alzheimer's disease substantially disagree in their perceptions about various caregiving domains. While the disagreement is less about patient problem behavior and primary caregiver strain, it is more about primary caregiver coping efficacy. Primary caregivers assisted by secondary caregivers with pessimistic views have less psychosocial distress than those with optimistic helpers. Female-female caregiving dyads exhibit strongest relationships of this kind.

Current reviews of the caregiver intervention literature have focused primarily on the outcomes of interventions for caregivers and general methodological limitations of individual studies (i.e., sampling and recruitment issues, adequacy of outcome measures, and generalization issues). Little attention has been paid to the specific factors affecting the therapeutic process, including the intensity and integrity of the interventions used. The purpose of this review is to examine closely the content and process of Alzheimer's disease (AD) caregiver interventions. We describe the types of interventions currently in use, factors affecting intervention outcomes, and we conclude with specific recommendations for the application of intervention technology and for the documentation of intervention research.

The current study translated the Resources for Enhancing Alzheimer's Caregiver Health: Offering Useful Treatments (REACH OUT), a skills-building stress and burden intervention, for the primary care setting and pilot the resulting intervention. The 16-week intervention consisted of a combination of clinic-based group and one-on-one sessions offered within a medical home, geriatrics clinic. A quasi-experimental pre- and post-test study design without a control group tested the resulting intervention. Semi-structured qualitative exit interviews evaluated program satisfaction. Twenty-five caregivers participated in one of four intervention groups; 21 caregivers completed the intervention (attended at least five of six group sessions). Caregiver burden on standardized assessments was significantly reduced between pre- and post-intervention, specifically for physical/emotional strain and caregiving uncertainty. Significant reductions were found in the frequency of reported disruptive behaviors; increased caregiver confidence in handling behavior problem frequency, depressive symptoms, disruptive behaviors, and memory-related problems; and decreased bother with respect to behavioral problem frequency and care recipient depression. Program satisfaction was high. This work suggests that the REACH OUT program can be successfully modified for use within a primary-care medical home setting. [ABSTRACT FROM AUTHOR]

A computer-aided real-time data collection system used for monitoring and recording the disruptive vocalization (DV) of 11 residents in a nursing home showed that the average duration and frequency of DV occurrence were 6 seconds and 22 per hour, respectively. The occurrence of DV increased along the day and reached a maximum in the evening, indicating its correlation with the sundowning hypothesis. High DV frequency correlated with high ADL damage and high DV duration and frequency correlated with high cognitive damage.

A study was conducted to examine the effects of written and verbal supervisory feedback on staff compliance. The study applied both feedback types to a nursing home. It was expected that the procedures will increase prompted voiding frequency and generate constant continence improvements. Results show that although verbal feedback already exhibited a positive impact on worker compliance, a written feedback further enhanced the level of prompted voiding.

Nursing home staff play a key role in the quality of care that residents receive. It seems that most of the literature has neglected to include the results of actual observations in measuring the various behaviors of staff. To compensate for the lack of inclusion of this method of data collection in prior research, a study was devised to provide descriptive data on the behaviors of nursing home staff. Observations were conducted in a facility that housed intermediate and skilled nursing patients, as well as chronic care recipients. Behaviors were recorded five days per week over a 37-month period, and included observation of 7 registered nurses (RNs), 12 licensed practical nurses (LPNs), and 77 nursing assistants (NAs). Behaviors were coded as patient care activities, nonwork activities, walking, phone use, staff-staff verbal interaction, staff-patient verbal interaction, off unit, positive verbal interaction, negative verbal interaction, neutral verbal interaction, and unidentified patient-staff interaction. It was found that the most frequent behavior was patient care, which occurred 56.9 percent of the time. This was followed by walking (28.5 percent), staff-staff interaction (19.5 percent) and patient-staff interaction (10.7 percent). LPNs had the highest percentage of patient care behaviors and NAs had the most nonwork behaviors. In general, it was concluded that the nursing staff spent most of their time addressing patient needs and relatively little time on nonproductive activities. (Consumer Summary produced by Reliance Medical Information, Inc.)

The article discusses areas of behavioral gerontology that would profit from additional research, such as self-management, community caregiver training, and geriatric behavioral pharmacology. Considerations for adapting behavioral procedures for the elderly are discussed, and suggestions for expanding the role of behavior analysis in geriatric care are offered. (Author/JW)

Four experimental Ss (9 to 14 years) were taught through self-instruction to focus attention and cope with math and printing tasks, then were systematically and sequentially exposed to photo slides of distracting situations, to audio distractors, and to in vivo distractors. Results suggested that the training package produced changes in self instructional behavior. (Author/CL)

The study evaluated a participative management approach for increasing the frequency of interactions between institutional staff and 15 severely/profoundly retarded residents. Results indicated that during the participative management program there was an increase in staff interactions that were contingent on appropriate resident behavior. (Author/SW)