A Review on Effective Interventions for Managing Behaviours of Dementia Patients Admitted in Acute Care Setting

This literature study identified effective interventions aimed at improving and managing the behavior of dementia patients admitted in acute care settings. These interventions include activity-based, distraction-based, caregiving, and nonpharmacological interventions.

A Review on Effective Interventions for Managing Behaviours of Dementia Patients
Admitted in Acute Care Setting
University
Unit
Name
Date

2
A Review on Effective Interventions for Managing Behaviours of Dementia Patients
Admitted in Acute Care Setting
Abstract
Behavior-related symptoms play a fundamental role in the overall assessment of aggression
and agitation behaviors among dementia patients. Dementia patients often face various
problems which affect their daily living in nursing homes. These behaviors have shown to
have a significant effect on their livelihood thus affecting their quality of life at the nursing
care facility homes. This literature study identified effective interventions aimed at improving
and managing the behavior of dementia patients. Using search strategies in various databases
such as CINhal, EMBASE, BMJ and Pubmed with effective inclusion and exclusion criteria
found out 5 key interventions on managing aggressive and agitation behaviors among the
dementia patients in various nursing care facilities. These activities include activity based,
distraction based interventions, caregiving activities, and nonpharmacological interventions
activities were found to have a significant effect on managing behavioral aspects of
aggression and agitation among dementia patients. These interventions, however, did not
offer a convincing level of evidence, but its implementation and trails have shown a
significant effect in reduced levels of negative behavior among dementia patients in acute
care settings.
Introduction
Behavioral and psychological symptoms associated with dementia have been shown to
increase various symptoms such as agitation, aggression, depression, and apathy. These
factors are common and multifactor often emanating from dementia patients in a care facility
and lead to the complex state of the severity of dementia and environment in which they are
in (Liu, Lewis & Lewis, 2013, pp.156-158).
Dementia patients have been shown to have difficulties in processing and responding to
stimuli thin their environment. These challenges often result in the deterioration of their
effective cognitive behavior and functional ability. Dementia individuals have the ability to
exhibit behavior which can be described at baseline as anxious or dysfunctional behavior, the
behavior often dependents on the perceived environment and the stage in which they live in
(Husebo et al., (2014).

3
The baseline behavior often entails a general clam state where the function of the individuals
is able to live within the limits of cognitive management. Anxious behaviour often develop
when the older persons when there is excess stimuli in their environment or an present of
dysfunctional behaviours such as being aggressive or verbal (Wharton & Ford, 2014, p.465).
Chen et al., (2015), among 6 groups of stressors which accelerate the underlying transition
from baseline to an anxious and often dysfunctional state. These stressors have been
investigating and include fatigue, environment changes, anger, medication, changes in daily
routine, perception loss and physical changes such as pain or medication intake. The stressors
make an individual to become anxious and be stressed forcing dysfunctional behavior. With
time the disease progresses and the ability of the individual is compromised on their ability to
cope, thus triggering dysfunctional behavioral patterns. With time as the disease progresses
the ability of an individual tends to cope easily and able to adjust to the stressors available
which may diminish progressively.
The baseline behaviors decrease consequential disruptive behavior being. With time the
disease has shown progression. The decrease in behaviors has shown to have an effect on
adaption and understanding of the stimuli. Often interventions which decrease environmental
stimuli and individual stressors are stress which is reduced and promote appropriate behavior,
(Johansson et al., 2013).
In acute care environments, exposures of the environment which are familiar have a
significant role in behavior patterns. These environments do not offer comfort and calm. The
constants disturbance emanating from equipment being moved, visitors and health care staff
moving around and unfamiliar staff can have significant either positive or negative on
behavior, the patients are often exposed to changes in their daily routine on their social and
periods of activity tend to fluctuate immensely between overstimulation and deprived
sensory. Patients with dementia have been shown to have difficulties in adapting to the
environment and often encounter significant level of stress. The stress can be exhibited on
behavior patterns which are disruptive and challenging in the acute care setting. The health
care nursing and health care officials are often not aware of the excessive stimuli being
received by the patient (Hazelholg et al., 2016, p510).
Critical assessment of the environment in which patients lives have been shown to have a
significant in identify various factors which contribute to stress and need urgent modification
for future care. limited understanding of the behavioral outbursts in the population level has

4
been shown to have inappropriate care and frustration for the patient and the health care stuff
in acute settings which contribute to physical restraints an and frustrations (Fauth, Femia &
Zarit, 2016). Most of the time, nurse often receive restrain while enhancing the patients are
kept in a stimulating environment thus increasing the stress level of the patients and thus
being at high risk for injury.
The roles of health care staff have often been put at stake. In many nursing homes and acute
care settings, such as those in the UK, about 5% of the staff located in acute care settings
receive training on dementia care and a third of this had a general feeling that the training
was not at enough at all (Achterberg et al., 2013). Many health care staff lacks the skills to
perform work with confused or unstable patients (Cipriani et al., 2014). In a randomized
controlled trial finding, a specialist for inpatient ward for people with dementia did not
positive any role in helping the patients to cope up with the diseases (Husebo et al., 2014).
Studies have shown that nonpharmacological approaches have been employed managing
interventions and indicate a decrease in behavioral anxious behavior and improve the well
being of the care (Sandvik et al., 2014, pp.1492-1496.). Nonpharmacological intervention has
been used as an alternative in the management of the adverse behavioral observed in the care
homes. The use of antipsychotics as a pharmacological treatment is often employed before
application of nonpharmacological options.
With this overview, acute care settings tend to have an impact on aggressive behaviors
among dementia patients. Various intervention have been employed in managing the stressful
situations, however, none have been established as effective strategic intervention observed
to reduce the aggressive behavior patterns. In a preview of this, this systematic review
endeavors to analyze qualitatively effective interventions which are key in reducing the
aggressive behavior. Thus this stud will come with effective interventions to curb these
behavioral patterns of behavior among the in older persons in acute care settings.
PICO strategy
The research question was framed using PICO strategy. Evidence-based practices use a
process pathway in framing the questions, locating, its assessment and evaluation. This stud
employed the following key terms in framing the question:
Question: What are the effective interventions to manage behaviors of dementia patients

5
admitted to an acute setting?
Population; dementia patients
Intervention : behaviors
Control:-
Outcome : effective interventions
Methodology
The methodology search entailed utilization of CINhal,EMBASE, BMJ and Pubmed
databases. The key search terms used include; ‘interventions’, behaviors’, dementia patients
’and ‘acute care settings’. The study included both qualitative and quantitative studies
conducted between the last 7 years, focused on dementia patients, further, systematic reviews
of randomized control studies and quasi-experimental studies were only considered. The
search key terms were obtained and filtered from the databases using a combination of
Boolean operators. The key parameters included, ‘and’, ‘or’ and ‘and ‘and or’. Further
studies conducted in an acute care setting were used as a basis for starting off. The search
excluded studies beyond the key time frame. Further studies not performed based on the three
types of methodology were not included in the study. The articles of the literature review
were carefully assessed and analyzed, with key themes which informed the literature review
analysis. The study came up with 6 key themes which include; assessment of factors affecting
behavior, activity-based interventions, and distraction based activities, care giver s
intervention, nonpharmacological interventions and none-pharmacological interventions on
the management of distractive behavior. These key themes are the focus of this literature and
reviews as based on effective interventions applied to manage acute care behavioral aspect
among patients diagnosed with dementia.
Literature Review
Research has indicated that an estimate of about 90% of dementia patients are likely to
exhibit behavioral practices at some stage, with the symptoms being advanced at some stage.
Often the symptoms occur in cluster forms and include psychosis, aggression, anxiety,
agitation and wandering, and depression, (Selbaek, Engedal & Bergh, 2013). Psychological
and behavioral aspects of these symptoms have been shown to have a considerable effect on

6
patient distress and increased or accelerated functional and cognitive decreased psychological
health. The associated symptoms on behavior and psychology have effects on the family and
caregivers and health care staff in the acute care settings. Various models have been
postulated to explain the behavioral disturbance surrounding due to dementia symptoms. The
behavioral model offers that behaviors often stem from complicated relationships among the
patients and the environment they live in. Further, used stress threshold model depicts that
dementia reduces the ability of the individual the ability to responding to environmental
stimuli (Pieper et al., 2013). These models depict adamant agitation and behavioral
disturbances among dementia patients. In this view, the systematic review has identified key
themes in assessing how interventions can be applied to manage the level of aggressive
behavior among dementia patients. Factors affecting behavior are thus previewed so as to get
deeper insights into effective behavior management interventions.
Factors affecting behavior
In a view of assessing and understanding aggression behaviors of dementia patients, factors
affecting behavior is crucial. Patient factors have been identified. Nurses or caregivers need
to rule any physical cause to behavior; dementia patients have difficulty in expressing
discomfort. Agitation and aggressive behaviors can be displayed in a variety of factors and in
an array of undiagnosed health conditions such as pain, infection and other conditions. Thus
patient factor is crucial in assessing aggression (Beerens et al., 2013). Further, environmental
factors have an effect on aggression. Caregivers and nurses awareness on the cues of
environmental is necessary to modify patient information received, impact on patient
behavior can fluctuate thus affecting aggression behavior. Activities such as lighting patient’s
rooms have been shown to causing frightening conditions on the patients stimulating
aggressive behaviors (Tuffrey-Wijine et al., 2013). Caregiving factors responsibilities with
dementia in long term care settings is crucial in assessing aggressive behavior. Health care
practitioners need to enhance their involvement of informal caregivers in understanding the
usual behaviors of dementia patients. In this were studies have indicated, that aggressive
behaviors can be determined and established accurately (Feast et al., 2016).
Distraction based interventions
Three reviewed studies assessed utilised distractive based activities for aged dementia
patients with aggressive behavior during bathing. In a study, (Ray & Fitzsimmons, 2014), a

7
case example was the utilization of music during bathing to reduce aggressive behavior
during bathing as indicated 14 persons in aged care settings amigo persons diagnosed with
dementia. Music preference was offered to the elderly before the bathing process and during
the entrance into the bathrooms. The assessment tool used in this process entailed the use of
Cohen -Mansfield Agitation Inventory used as an effective measure on assessment of
behaviors including aggression. The tool has dichotic key assessment score for caregivers to
score behavior during the bathing sessions.
Data collection entailed 9 episodes of 3 baseline assessment, 3 music therapy, and 3 post-
intervention sessions. The statistical analysis conducted jointly he assessments show
statistical significance of reduced frequencies of aggressive behavior between a certain type
of music and therapy sessions and post-therapy sessions differential. The findings reveal, no
differences between baseline and post-intervention sessions.
Similarly, other studies have indicated such (Gomezz-Romeo et al., 2017; Whear et al.,
2014), used a similar approach to bathing episodes. The study inclusion of 18 dementia
subjects with a history of aggression in a random allocation revealed that a higher frequency
of music frequency and no music conditions, twelve out of 15 behaviors was observed less
frequently after treatment. There was observed statistical significance on the reduction of
variables of hitting and an overall number of aggressive behaviors.
Activity-based interventions
Studies search revealed that an investigation and consequent association of activity effects on
managing aggression. In a study by Van der Ploeg et al., (2013), performance of structured
walking program for 11 subjects living with dementia in nursing home, aggression-related
incidence report was assessed over a period of one year and results found out that there was a
reduction of 30% in aggressive acts being noted on walking day’s program implementation.
Further other studies (Roberts et al., 2015; Majić, et al., 2013), used various forms of musical
and animal-based therapies in managing aggression among three subjects with severe
dementia. The activities were offered twice daily for a period of four weeks. Aggression
behavior was monitored and compared in a four-week baseline using SDAS tool. In the
period of the four-week baseline, no significant changes were observed among the group
participants, with results showing inverse outcomes with two subjects showing an increase in
aggression. This study concludes that group-based activities do not produce any significant

8
reduction on the aggression behaviors, but rather individualized behavioral activities are
effective approaches in reducing aggressive behaviors.
None pharmacological interventions
The use of nonpharmacological intervention has been identified and implemented in
monitoring aggression behavior. The interventions have aimed at preventing agitation
incidence, episodes response, and reduction of caregiver stress. The interventions have
focussed on patients or the caregiver, it implementations have done on varied frameworks of
methodology and others targeting specific behavior patterns. In a systematic review article on
the usage of nonpharmacological; interventions among dementia patients living in nursing
homes revealed that therapeutic touch had a significant effect on reducing aggression
behaviors among dementia patients. Physical therapy was established but did not offer
enough evidence to support their effectiveness with psychosocial interventions being the
most evaluated forms of non pharmacology interventions (Cabrera et al., 2015).
Further in a similar systematic review conducted by Marjoleine et al., (2013), indicated that
pain was a contributing factor to aggressive behavior. In studies focusing on pain and
behavior interventions, suggested that such interventions were key in reducing pain and
behavioral symptom which were displayed through aggressive acts among the dementia
patients living in nursing homes.
Caregivers interventions
Implementation of caregiving interventions has been implemented to manage dementia
patients. In various studies implemented, caregiving training has been shown to significantly
reduce aggression behaviors. In a study by (Huang et al., 2013), implementation of 3 sessions
of educational programs among a group of 135 nurses in a large nursing based care facility,
showed that sessions conducted having information on the nature of dementia, aggression
risks factors and strategies for its prevention and de-escalation strategies were offered during
the sessions. Aggression assessment was done using Ryden Aggression Scale among staff
prior to the sessions after the sessions on various instances of aggressive behavior among
dementia patients. The results indicated a significant difference in aggression management
acts and showed a pre and post intervention -182 incidents of pre-intervention and 92 post
interventions. Further aggression was observed to appear during day times after completion
of personal acres.

9
Further in implementation of staff education intervention management among 3 nurses and
10 dementia patients, the interventions entailed bedside consultation bathing plans and
change some the physical environment. The assessment entailed an assessment of verbal and
physical aggression after pre-intervention and post interventions across the two settings.
Statistical; significance was observed on the reduction of both verbal and physical aggression
during the two treatment episodes (Konno, Knag & Makimoto, 2014).
Other interventions
Other interventions which were obtained but did not meet the thematic analysis above
included the use of cognitive behavioral interventions (Whear et al., 2014), studies have
shown that implementation among 72 years old dementia patients in nursing home engaged
in verbal outbursts, recording of aggressive behavior was done, and 1 hour therapy sessions
on an alternative mechanism was done. In A-B design implemented in 2 weeks and week
intervention period, the results indicated a declined dint the number of outbursts made by the
patient. There was an immense decrement on the severity of outbursts, thus signifying
reduced levels of aggressive behavior.
Conclusion
In conclusion, various interventions have been implemented to monitor and manage
aggressive behavior among dementia patients. Effective interventions as showcased in the
literature have identified various interventions which have been noted to be able to improve
agitation and aggressive among dementia patients. The studies have indicated that activity-
based interventions, distraction based interventions, nonpharmacological interventions, and
caregiving intervention were best suited to offer effective approaches to dementia patients
having aggression. Despite the fact that these interventions did offer a plausible level of
evidence, a significant effect was observed in their implementation and showed to have a
significant effect on the aggression and agitation behavior of dementia patients in acute care
facilities.

10
References
Achterberg, W.P., Pieper, M.J., van Dalen-Kok, A.H., De Waal, M.W., Husebo, B.S.,
Lautenbacher, S., Kunz, M., Scherder, E.J. and Corbett, A., 2013. Pain management in
patients with dementia. Clinical interventions in aging, 8, p.1471.
Cabrera, E., Sutcliffe, C., Verbeek, H., Saks, K., Soto-Martin, M., Meyer, G., Leino-Kilpi,
H., Karlsson, S., Zabalegui, A. and RightTimePlaceCare Consortium, 2015. Non-
pharmacological interventions as a best practice strategy in people with dementia living in
nursing homes. A systematic review. European Geriatric Medicine, 6(2), pp.134-150.
Chen, H.M., Huang, M.F., Yeh, Y.C., Huang, W.H. and Chen, C.S., 2015. Effectiveness of
coping strategies intervention on caregiver burden among caregivers of elderly patients with
dementia. Psychogeriatrics, 15(1), pp.20-25.
Fauth, E.B., Femia, E.E. and Zarit, S.H., 2016. Resistiveness to care during assistance with
activities of daily living in non-institutionalized persons with dementia: Associations with
informal caregivers’ stress and well-being. Aging & mental health, 20(9), pp.888-898.
Feast, A., Orrell, M., Charlesworth, G., Melunsky, N., Poland, F. and Moniz-Cook, E., 2016.
Behavioural and psychological symptoms in dementia and the challenges for family carers:
systematic review. The British Journal of Psychiatry, 208(5), pp.429-434.
Gómez-Romero, M., Jiménez-Palomares, M., Rodríguez-Mansilla, J., Flores-Nieto, A.,
Garrido-Ardila, E.M. and González-López-Arza, M.V., 2017. Benefits of music therapy on
behaviour disorders in subjects diagnosed with dementia: A systematic review. Neurología
(English Edition), 32(4), pp.253-263.
Hazelhof, T.J.G.M., Schoonhoven, L., van Gaal, B.G.I., Koopmans, R.T.C.M. and Gerritsen,
D.L., 2016. Nursing staff stress from challenging behaviour of residents with dementia: a
concept analysis. International nursing review, 63(3), pp.507-516.
Huang, H.L., Kuo, L.M., Chen, Y.S., Liang, J., Huang, H.L., Chiu, Y.C., Chen, S.T., Sun, Y.,
Hsu, W.C. and Shyu, Y.I.L., 2013. A home-based training program improves caregivers'
skills and dementia patients' aggressive behaviors: a randomized controlled trial. The
American journal of geriatric psychiatry, 21(11), pp.1060-1070.

11
Husebo, B.S., Ballard, C., Cohen-Mansfield, J., Seifert, R. and Aarsland, D., 2014. The
response of agitated behavior to pain management in persons with dementia. The American
Journal of Geriatric Psychiatry, 22(7), pp.708-717.
Johansson, L., Guo, X., Hällström, T., Norton, M.C., Waern, M., Östling, S., Bengtsson, C.
and Skoog, I., 2013. Common psychosocial stressors in middle-aged women related to
longstanding distress and increased risk of Alzheimer's disease: a 38-year longitudinal
population study. BMJ open, 3(9), p.e003142.
Konno, R., Kang, H.S. and Makimoto, K., 2014. A best‐evidence review of intervention
studies for minimizing resistance‐to‐care behaviours for older adults with dementia in nursing
homes. Journal of advanced nursing, 70(10), pp.2167-2180.
Liu, J., Lewis, G. and Evans, L., 2013. Understanding aggressive behaviour across the
lifespan. Journal of psychiatric and mental health nursing, 20(2), pp.156-168.
Majić, T., Gutzmann, H., Heinz, A., Lang, U.E. and Rapp, M.A., 2013. Animal-assisted
therapy and agitation and depression in nursing home residents with dementia: a matched
case–control trial. The American Journal of Geriatric Psychiatry, 21(11), pp.1052-1059.
Pieper, M.J., van Dalen-Kok, A.H., Francke, A.L., van der Steen, J.T., Scherder, E.J.,
Husebø, B.S. and Achterberg, W.P., 2013. Interventions targeting pain or behaviour in
dementia: a systematic review. Ageing research reviews, 12(4), pp.1042-1055.
Ray, K.D. and Fitzsimmons, S., 2014. Music-assisted bathing: making shower time easier for
people with dementia. Journal of Gerontological nursing, 40(2), pp.9-13.
Roberts, G., Morley, C., Walters, W., Malta, S. and Doyle, C., 2015. Caring for people with
dementia in residential aged care: Successes with a composite person-centered care model
featuring Montessori-based activities. Geriatric Nursing, 36(2), pp.106-110.
Sandvik, R.K., Selbæk, G., Seifert, R., Aarsland, D., Ballard, C., Corbett, A. and Husebo,
B.S., 2014. Impact of a stepwise protocol for treating pain on pain intensity in nursing home
patients with dementia: a cluster randomized trial. European journal of pain, 18(10),
pp.1490-1500.

12
Selbaek, G., Engedal, K. and Bergh, S., 2013. The prevalence and course of neuropsychiatric
symptoms in nursing home patients with dementia: a systematic review. Journal of the
American Medical Directors Association, 14(3), pp.161-169.
Tuffrey-Wijne, I., Giatras, N., Goulding, L., Abraham, E., Fenwick, L., Edwards, C. and
Hollins, S., 2013. Identifying the factors affecting the implementation of strategies to
promote a safer environment for patients with learning disabilities in NHS hospitals: a mixed-
methods study.
van der Ploeg, E.S., Eppingstall, B., Camp, C.J., Runci, S.J., Taffe, J. and O'Connor, D.W.,
2013. A randomized crossover trial to study the effect of personalized, one-to-one interaction
using Montessori-based activities on agitation, affect, and engagement in nursing home
residents with dementia. International psychogeriatrics, 25(4), pp.565-575.
Wharton, T.C. and Ford, B.K., 2014. What is known about dementia care recipient violence
and aggression against caregivers?. Journal of gerontological social work, 57(5), pp.460-477.
Whear, R., Abbott, R., Thompson-Coon, J., Bethel, A., Rogers, M., Hemsley, A., Stahl-
Timmins, W. and Stein, K., 2014. Effectiveness of mealtime interventions on behavior
symptoms of people with dementia living in care homes: a systematic review. Journal of the
American Medical Directors Association, 15(3), pp.185-193.