Dementia has been shown to account for more admissions and hospital days than any other psychiatric problem in the elderly.1 Although many forms of dementia are treatable and reversible,2,3 the degree of dysfunction in such disorders (eg, depression) is frequently similar to that observed in nontreatable dementing illnesses (eg, dementia of the Alzheimer's type).2,4 This situation has led to unacceptable rates of misdiagnosis. Thus, all health professionals working with the elderly should be thoroughly familiar with the symptoms and course of progressive dementias, as well as many reversible disorders that are sometimes indistinguishable.
Because nursing professionals are likely to have the most contact with institutionalized elderly patients, it is especially important that they be aware of the frequent misdiagnosis of dementia and the reversible disorders, particularly depression, that most often mimic progressive dementia. In addition, they should be informed about the different types of dementing disorders and their respective courses. Although there have been a few attempts to assess specific knowledge of dementia of the Alzheimer's type,5 we could not find any previous attempt to assess general knowledge of dementia. Also, these previous attempts focused on family caregivers rather than nurses.
In addition to this dearth of information, there has been little investigation of the effects of the label of dementia on subsequent nursing care. These effects are particularly important because it has been suggested that health professionals have demonstrated a bias resulting in greater attribution of symptoms to the dementia and fewer judgments of depression simply as a function of increasing age.6 Also, there is a substantial amount of literature indicating that the prevailing attitudes toward old age remain negative and may be even stronger among health providers who work most closely with older patients,712 although a recent study has found more neutral results. However, there are no studies to date investigating the effects of labeling a patient as "demented" on nurses' attitudes and expectations regarding rehabilitation and care requirements.
In this study, we surveyed a group of Veterans Administration (VA) nurses to address two questions: How knowledgeable are nurses (including registered nurses, licensed vocational nurses, and nursing assistants) regarding dementing illnesses and conditions that mimic dementia? Does the label of dementia have any effect on nurses' expectations regarding the treatment and care of elderly patients?
The subjects for the study were 81 registered nurses (RNs), licensed vocational nurses (LVNs), and nursing assistants on staff at a large VA medical center. Subjects were recruited from three patient care areas: the nursing home care unit, where the mean age of the patients was 73 and 79% were over 65 years; intermediate care, where the mean age of the patients was 67 and 64% were over 65 years; and general acute care wards, where the patient population was similar in age to that of the nursing home and intermediate care units. Both long-term and shortterm care units were included because of evidence suggesting that nurses with more extended contact with the elderly may have more negative attitudes toward this population.10,13
Knowledge of Dementia
Knowledge of dementia was assessed by a 10-item true-false questionnaire (Figure 1). To ensure that these questions were not unreasonably difficult, we sent them to a group of 32 adult and geriatric nurse practitioners who had graduated within the past year. All 32 (100%) nurse practitioners answered 8 of 10 questions correctly, whereas 84.4% (n = 27) gave correct answers to all 10 questions. Because of the high level of accuracy, all 10 questions were included in the study. A knowledge score for each subject was obtained by calculating the number of correctly questions answered.
Attitudes and Expectations
Attitudes and expectations regarding treatment potential and care requirements were assessed by a case description of a typical nursing home patient followed by a 25-item questionnaire. This case description was a slightly modified account of an elderly patient who was originally thought to have a progressive dementia but was later found to have been suffering from pseudodementia secondary to depression. The case description had two forms, the only difference being that the first form included the label of dementia in two places (Figure 2). Both forms were followed by the 25item seven-point Likert scale (1= strongly agree; 7 = strongly disagree) designed to assess nurses' expectations regarding the likelihood that this patient would benefit from rehabilitation and the amount of nursing care he would require. Questions included, "this patient will be unlikely to return to independent living," and "very little nursing time will be involved in caring for this patient."
As with the knowledge questionnaire, these questions were sent to 32 adult and geriatric nurse practitioners prior to the start of the study. Internal consistency of the items as measured by Cronbach's alpha reliability coefficient was .86. Because the questions tapped heterogeneous areas, these nurse practitioners indicated whether each question pertained to potential for improvement and rehabilitation, expectation for nursing care or time, or neither.
Eighty-one questionnaires were completed of 248 that were given to head nurses to distribute, a response rate of 33%. The sample was predominately female (n = 76; 96%), and 41% (n = 33) had been employed at the medical center 3 years or less. The mean age of the respondents was 43.2 years. RNs accounted for 55% (n=44) of the respondents, whereas nursing assistants accounted for 32.5% (n = 26) and LVNs accounted for the remaining 12.5% (n= 10). Most (72%, ? = 57) of the respondents came from the day shift and the nursing home care unit (52%, n = 42).
Overall, the respondents demonstrated a high level of knowledge with 80.1% (n=60) giving the correct answer to at least 8 of 10 questions, and 35% (n = 26) correctly answering all 10 questions. Despite the high level of overall knowledge, three questions were missed by at least 25% of the respondents, including "many forms of intellectual impairment in the elderly are treatable and reversible" (missed by 27%, ? = 21); "there is no effective treatment for any of the dementias" (missed by 26%, ? = 20); and "all dementias have a steady, progressive downhill course" (missed by 25%, n= 19).
There was no relationship between number of correct answers and age. Likewise, there were also no differences in the number of correct answers according to position (ie, RNs, LVNs, and nursing assistants). Similarly, there were no differences in the number of correct answers according to shift or length of time employed. Finally, there were no differences in knowledge between nurses who reported that at least 75% of their patients were over the age of 65 and those who reported caring for fewer patients over 65 years old.
Attitudes and Expectations
Forty-four subjects received the first form of the case description, which included the label of dementia, whereas 37 subjects received the second form. Regardless of whether the patient was labeled demented, nurses endorsed generally positive expectations regarding the elderly patient presented in the case description. The label of dementia had no effect on the attitude and expectation statements endorsed by this sample of nurses. Because the three groups of nurses did not differ in terms of position, shift, or length of time employed, they were initially considered together. Only one question, "this patient functions best when left alone," produced a significant difference (F(1, 78) = 4.5, P<.05). However, this was in the opposite direction than was expected as nurses endorsed more positive ratings for the patient labeled demented (the first case description). There were also no significant differences between the two forms in expectations regarding either rehabilitation potential or nursing time and care requirements.
Because the three groups of nurses differed in their reports of what percentage of their patients were over the age of 65, (?2 (2, n = 80) = 25.4, P<.001), each group of nurses was also considered separately. The label of dementia had no effect on any of the individual attitude and expectation statements of subjects from the nursing home care unit, the intermediate care unit, or the acute care wards. There were also no significant differences in expectations regarding rehabilitation potential or nursing time requirements for any of the three groups. Thus, the label of dementia had no effect on the attitude and expectation statements endorsed by this sample of nurses.
CASE DESCRIPTION (FORM 1)
There was no relationship between age and expectation regarding either rehabilitation potential or nursing time and care requirements. However, knowledge of dementia was significantly correlated with expectations regarding both rehabilitation potential (r=.31, p = 81, p><.003) and nursing time and care requirements (r=.26, n = 81,P<.01).
DISCUSSION AND IMPLICATIONS
Contrary to our expectations, nurses in all positions showed a high level of knowledge regarding dementia, and there was no relationship between knowledge of dementia and any of the demographic variables. Similarly, labeling a patient as demented had no effect on the attitude and expectation statements endorsed by this sample of nurses as they generally endorsed positive statements regardless of the label. These findings are encouraging given that nurses are likely to have the most contact with institutionalized elderly and are, therefore, in the best position for questioning a diagnosis of progressive dementia that may be inappropriate.
Although there was a high level of overall knowledge of dementia, the three knowledge questions that were missed most frequently by at least 25% of the sample pertained to the reversibility and course of the dementias. One could reasonably expect different behavior from those who believe that no forms of intellectual impairment in the elderly are reversible and that all dementias have a steady, progressive downhill course. This is somewhat supported by the significant (albeit weak) positive correlations between knowledge scores and expectations regarding both rehabilitation potential and nursing time and care requirements. Thus, it may be beneficial to focus more nursing education efforts to address specifically the reversibility and course of various dementias.
Despite these positive findings, we must exercise caution in generalizing from these results. Although nurses endorsed positive expectation statements, it is unclear how this relates to actual behavior. It has been our clinical experience that nurses in long-term care rarely question the diagnosis or label of dementia and that this label is frequently invoked to explain why a patient is unable to participate in selfcare or is not making any progress. It is also possible that simply including the label of dementia in two places on the case description was not enough to highlight the label; therefore, a number of respondents may simply have overlooked it.
The major limitation of the present study, however, is the low response rate as only one third of the nurses actually completed and returned the questionnaires. It might be reasonable to assume that those who actually participated in the study selectively had more knowledge of dementia and more positive expectations than those who did not. Rather than a specific selection factor, it is also possible that a number of questionnaires were simply not distributed by the head nurses to the off-duty nursing personnel. The latter possibility is supported somewhat by comparing the nursing position breakdown of our sample with position breakdowns of the medical center as a whole. For example, RNs composed 55% of our sample, whereas LVNs and nursing assistants composed 12.5% and 32.5% respectively; for nursing service as a whole, RNs compose 54%, LVNs compose 11%, and nursing assistants compose 36%. Unfortunately, data were unavailable for additional comparisons of age and length of employment within nursing service.
Our response rate would likely have improved if we had been able to make individual presentations to all of the evening and night shift nurses rather than having to rely on the head nurses for distribution. For example, in the nursing home, where we were more familiar with and had more access to staff, our response rate was 53%, compared with 22% from intermediate care and 13% from acute care. When considered separately, the label of dementia, even in the nursing home care unit with its higher response rate, had no effect.
Although the lower than expected response rate limits the conclusions of this study, it appears that nurses in all positions may have more knowledge regarding dementia and more positive expectations and attitudes toward demented elderly than has previously been assumed. Despite this, it may be beneficial for geriatric nursing education to focus on the reversibility and course of the dementias given the high frequency of occurrence in the elderly. In addition, future research should address whether labeling a patient as demented affects actual behavior and nursing care of elderly patients.
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