Journal of Gerontological Nursing

Nursing Care of Cognitively Impaired, Institutionalized Elderly

Sandy C Burgener, PhD, RNC; Debra Barton, BSW, RN

Abstract

Caring for elderly persons with irreversible dementia has been, and will increasingly become, a major healthcare concern. Growing numbers of institutionalized elderly, along with dwindling staff numbers, increase the importance of explicating researchbased nursing management techniques. Characteristics of disease processes, such as Alzheimer's dementia (AD), include a long, steady decline in functional and intellectual ability, often resulting in a lengthy institutional stay.1'2 Additionally, behavioral changes, such as increased combativeness, aggression, personality changes, repetitive behaviors, and decreased ability to interpret environmental stimuli, result in challenging nursing management dilemmas.3,4 A recent review article by Duffy, Hepburn, Christensen, and Brugge- Wiger points to the dearth of research-based nursing management techniques specific to populations of demented elderly.5

High technology and complex medical interventions are often not required or appropriate in the care of AD victims. Nursing care is centered around supporting the existing level of functioning, assisting with instrumental and functional activities of daily living, and maximizing the patient's wellbeing. The basis for care, then, becomes the interactive process through which nursing care is delivered and the patient's well-being is maintained or enhanced. Because persons with AD have decreased ability to interpret and respond appropriately in interactions, nursing staff need increased sensitivity to and awareness of the patient's abilities and responses to interactions. This concern, coupled with the lack of existing research, prompted the study of interactive processes with cognitively impaired institutionalized elderly. The research findings support the significance of the relationship between nursing staff interaction variables and resident behaviors, and can begin to give some direction to effective staff interactive behaviors. The purpose of this article is to increase direction for clinical care through a description of nursing staff behaviors found to be related to cognitively impaired residents' behavior.

REVIEW OF LITERATURE

A general agreement regarding the lack of research-based nursing management techniques specific to dealing with cognitively impaired elderly is found in the literature. A recent literature review revealed few empirical studies involving nursing management issues.5 The literature does contain severa! research reports specific to interactions with elderly populations, although few of these address cognitively impaired elderly.

Two studies were found that examined characteristics of institutionalized elderly that influence nursing care delivery. Jones and Jones found that verbal contact with residents varied as a function of the resident's ethnicity, whether it was congruent with the caregiver's ethnic origin or different.6 Nursing staffs verbalizations were less frequent if the resident's ethnic background was different from that of the staff, although verbalization was sparse, about seven words per person in a 2-hour period. Armstrong-Esther discovered that caregivers spent less time with confused versus lucid residents, with confused residents spending only approximately 16% of their time in purposeful activities.7

The importance of touch in interactions with institutionalized elderly has been studied by several nurse researchers. Langland and Panicucci8 found that when touch was included in a verbal request, elderly women residents responded with increased positive behaviors, including more attentiveness and appropriateness. Copstead's results revealed that use of touch by nursing staff while giving medication was related to the resident's positive appraisal of themselves following the interaction.9 Feelings of self-worth were increased when touch was included in the task-oriented interaction.

Several studies have examined aspects of the environment, including staff interactions, that can decrease disability in institutionalized elderly. Burnside observed the care of 10 cognitively impaired elderly residents to define environmental parameters resulting in calm, functional resident behaviors.10 She concluded that several aspects of the environment were positive, including use of touch, stable staff, consistent routines, positive nonverbal behaviors, and affectional responses by staff.

Dawson, Kline, Wiancko, and Wells also found the nonverbal behaviors of staff…

Caring for elderly persons with irreversible dementia has been, and will increasingly become, a major healthcare concern. Growing numbers of institutionalized elderly, along with dwindling staff numbers, increase the importance of explicating researchbased nursing management techniques. Characteristics of disease processes, such as Alzheimer's dementia (AD), include a long, steady decline in functional and intellectual ability, often resulting in a lengthy institutional stay.1'2 Additionally, behavioral changes, such as increased combativeness, aggression, personality changes, repetitive behaviors, and decreased ability to interpret environmental stimuli, result in challenging nursing management dilemmas.3,4 A recent review article by Duffy, Hepburn, Christensen, and Brugge- Wiger points to the dearth of research-based nursing management techniques specific to populations of demented elderly.5

High technology and complex medical interventions are often not required or appropriate in the care of AD victims. Nursing care is centered around supporting the existing level of functioning, assisting with instrumental and functional activities of daily living, and maximizing the patient's wellbeing. The basis for care, then, becomes the interactive process through which nursing care is delivered and the patient's well-being is maintained or enhanced. Because persons with AD have decreased ability to interpret and respond appropriately in interactions, nursing staff need increased sensitivity to and awareness of the patient's abilities and responses to interactions. This concern, coupled with the lack of existing research, prompted the study of interactive processes with cognitively impaired institutionalized elderly. The research findings support the significance of the relationship between nursing staff interaction variables and resident behaviors, and can begin to give some direction to effective staff interactive behaviors. The purpose of this article is to increase direction for clinical care through a description of nursing staff behaviors found to be related to cognitively impaired residents' behavior.

REVIEW OF LITERATURE

A general agreement regarding the lack of research-based nursing management techniques specific to dealing with cognitively impaired elderly is found in the literature. A recent literature review revealed few empirical studies involving nursing management issues.5 The literature does contain severa! research reports specific to interactions with elderly populations, although few of these address cognitively impaired elderly.

Two studies were found that examined characteristics of institutionalized elderly that influence nursing care delivery. Jones and Jones found that verbal contact with residents varied as a function of the resident's ethnicity, whether it was congruent with the caregiver's ethnic origin or different.6 Nursing staffs verbalizations were less frequent if the resident's ethnic background was different from that of the staff, although verbalization was sparse, about seven words per person in a 2-hour period. Armstrong-Esther discovered that caregivers spent less time with confused versus lucid residents, with confused residents spending only approximately 16% of their time in purposeful activities.7

The importance of touch in interactions with institutionalized elderly has been studied by several nurse researchers. Langland and Panicucci8 found that when touch was included in a verbal request, elderly women residents responded with increased positive behaviors, including more attentiveness and appropriateness. Copstead's results revealed that use of touch by nursing staff while giving medication was related to the resident's positive appraisal of themselves following the interaction.9 Feelings of self-worth were increased when touch was included in the task-oriented interaction.

Several studies have examined aspects of the environment, including staff interactions, that can decrease disability in institutionalized elderly. Burnside observed the care of 10 cognitively impaired elderly residents to define environmental parameters resulting in calm, functional resident behaviors.10 She concluded that several aspects of the environment were positive, including use of touch, stable staff, consistent routines, positive nonverbal behaviors, and affectional responses by staff.

Dawson, Kline, Wiancko, and Wells also found the nonverbal behaviors of staff to be important in decreasing the resident's "excess disability" in their descriptive study.1 ' They felt the use of nonverbal approaches decreased social isolation and helped focus the resident's attention. Environmental stability is also supported as a relevant variable to resident outcomes by Athlin and Norberg.12 A permanent assignment procedure during feeding tasks was used so that staff would become more familiar with individual resident's needs and abilities. This resulted in decreased difficulty during eating tasks and a more positive attitude of staff toward the resident. Nursing management techniques, including consistent staff assignments and approaches, individualized nonverbal behaviors, and use of affection and touch, have received initial support as positive caregiver approaches in interactions with cognitively impaired institutionalized elderly.

Table

FIGUREINTERACTION BEHAVIORMEASURE

FIGURE

INTERACTION BEHAVIORMEASURE

RESEARCH STUDY

The purpose of this report is to summarize nursing interaction approaches found to be related to behaviors of cognitively impaired institutionalized elderly; however, the research design will be briefly described. Using a middle-range theory developed to address variables and relationships relevant to nursing staff-resident interactions, Interacting with Cognitively Impaired Elderly, a participant-observer approach was used to collect information about interaction variables. Interactions were observed and rated for nursing staff and resident behaviors in one long-term care institution.

The Interaction Behavior Measure (IBM), containing 1 2 items describing interaction behaviors on a seven-point semantic rating scale, was used as the major instrument (Figure).13 The 12 items represent six subscales, including personally oriented, verbosity, relevance, interest, relaxed, and flexible behaviors. The instrument has been found to be internally consistent, with alpha estimates ranging from .64 to .92.14 Internal consistency was supported in this study, with an overall alpha of .79, and subscale alphas ranging from .79 for flexibility to .99 for verbosity. Inter-rater reliability estimates have also been reported as consistently high, from r=.89 to r=.95 for individual IBM subscale ratings.14 In this study, inter-rater reliability estimates ranged from r = .56 to r = .80 for individual IBM subscales.

Two additional variables, agitation/ calm and resistance/cooperation, were rated for resident behaviors only. Because two IBM behavior ratings, the relevance and verbosity subscales, were not found to be reliable indicators of behavior in cognitively impaired persons, these two subscales were eliminated for resident ratings and two additional variables, agitation/calm and resistance/cooperation, were added. This modified IBM measure was supported as being internally consistent, with an overall alpha of .82 and subscale alphas ranging from .79 for flexibility to .92 for relaxed resident behaviors. Inter-rater reliability was adequate with ranges of r= .58 to r = .83.

Information was collected about interaction variables not contained in the IBM, including interruptions of the interaction by another person, use of touch and smiling by nursing staff, and time of day. The resident's mental status was measured with the MiniMental State Exam (MMSE), a widelyused measure of cognitive functioning.15 The MMSE includes 11 indicators of mental function, and is a short, easy-to-administer instrument. MMSE scores range from 0 to 30, with scores below 20 being indicative of dementia. The consistency of MMSE ratings over time has been high, with test-retest coefficients of .83 to .98. The MMSE's validity is supported through its ability to differentiate persons with no cognitive impairment from depressed and demented elderly persons. The MMSE has been one of the most frequently used mental status measures in persons with Alzheimer's disease and has been found to be consistently reliable with this population.16,17

All observations and ratings of behaviors occurring between nursing staff and residents were made by one of the two researchers. Nursing assistants and residents were observed in one of two situations: dressing the resident and an interpersonal contact with no specific task purpose. Each assistant/ resident combination was observed only once in each situation, resulting in the 239 interactions (one assistant was reluctant to dress one agitated resident). Anecdotal observations were also made during ratings of interactions.

Resident subjects included 12 residents on the institution's AD unit. Table 1 describes resident variables of age and mental status by level of mental functioning. Although all residents scored within the demented category on a mental status examination, six residents scored in the lower (O to 10) range, and six scored in the higher (1 1 to 20) range, representing two levels of mental functioning. Nursing assistant variables of age, education, and nursing experience by working shift are found in Table 2. Nursing staff were experienced in long-term care, with a mean of 11.13 years.

A total of approximately 150 hours were spent in observation over a 3month period. Written consent was obtained from all staff participants, as well as each resident's guardian. Verbal assent was also obtained from resident subjects. The researchers spent time with both staff and residents prior to actual data collection to minimize the possibility of altered behavior due to an observer's presence. Both researchers observed about 10% of the interactions, approximately 25, to obtain inter-rater reliability data. Both researchers rated the behaviors of nursing staff and residents simultaneously while observing the interaction. Data collection proceeded smoothly, with excellent staff cooperation. Implications for nursing care of cognitively impaired elderly will be described as they evolved from data analysis and anecdotal observations made by the two researchers throughout data collection.

IMPLICATIONS FOR NURSING CARE

Findings revealed that several nursing assistant behaviors were important in relation to the residents' behaviors when assisting the resident with a task (dressing), with significant correlation coefficients ranging from r=.24 to r =.69. An overview of the nursing assistants' interactive behaviors related to residents' behaviors is found in Table 3. The assistants' relaxed behaviors were highly related to the residents' flexible, = .69; relaxed, r= .60; calm, r=.52; and cooperative, r=.59, behaviors. The assistants' ability to be flexible in the interaction was also highly related to resident behaviors, with correlations ranging from r=.41 to r =.44.

Approaching the resident in a personal versus authoritarian or taskoriented manner was supported, especially when the assistant was attempting to have the resident dress, with r = .29 for assistant personal and resident calm behaviors to r=.41 for assistant personal and resident relaxed behaviors. Residents were found to be more flexible, relaxed, calm, and cooperative in the interaction when the assistant was more personal toward them. In interpersonal interactions, a personal assistant approach was important only to flexibility in resident behaviors.

The amount of verbal content by the assistant was more important to residents' behaviors in attempting to have the resident dress. The assistant's verbal output was especially related to the resident's interpersonal, r=.24, and interested, r =.24, behaviors. When not attempting to have the resident complete a task, the assistant's wordiness or verbal content was not apparently important to any resident behavior. Overall, the amount of verbal content in the assistant's communication was more important than the relevancy or applicability of the content. It is possible that cognitively impaired persons may respond well to verbal stimulation, regardless of how applicable the content is to the specific situation. This may indicate that it may not be so important what the assistant says as long as thé nurse verbalizes at least at moderate levels with the resident in a personal rather than authoritarian way. Hie findings may also indicate the difficult nature of defining what is relevant for a cognitively impaired person. It may be impossible for an objective observer to tell what would be relevant to a person who is not able to perceive and interpret their environment realistically.

Table

TABLE 1DESCRIPTIVE DATA FOR RESIDENT VARIABLES FOR AGE AND MENTAL STATUS

TABLE 1

DESCRIPTIVE DATA FOR RESIDENT VARIABLES FOR AGE AND MENTAL STATUS

Although not as striking, the assistant's interest in the resident showed some relationship to resident behaviors, with correlations ranging from r=.24 to r = .36. Increased assistant interest was related to the resident's ability to be relaxed, calm, and cooperative, especially while attempting to complete a task. Nursing assistant interest was not as important in an interpersonal situation, where no clear relationship to resident behaviors exists.

Results support the importance of the type of interaction to both nursing staff and resident behaviors. Many nursing assistant behaviors were found to be related to resident behaviors when the resident was being asked to complete a task, but only the assistant's adaptability was found to be related to more than one resident behavior in interpersonal interactions (Table 3). Increased relatedness between nursing assistant and resident behaviors in a task situation is easily understood, because the assistant is attempting to accomplish a specific objective, requiring increased congruence and interaction with the resident. In strictly interpersonal interactions, the assistant's and the resident's behaviors would not be as interdependent because no specific task, such as dressing, requires completion.

Table

TABLE 2DESCRIPTIVE DATA FOR NURSING ASSISTANT VARIABLES OF AGE, EDUCATION, AND LENGTH OF SERVICE BY WORKING SHIFT

TABLE 2

DESCRIPTIVE DATA FOR NURSING ASSISTANT VARIABLES OF AGE, EDUCATION, AND LENGTH OF SERVICE BY WORKING SHIFT

As cause and effect relationships cannot be posited by this analysis, it is difficult to determine if the increase in range of resident behaviors when asked to complete a task resulted in different assistant behaviors, or if assistant behaviors, somehow inherent in a task interaction, affected the variability of residents' responses. Difference in both assistant and resident "behavior occurred as the purpose of the interaction varied. Using the Progressively Lowered Stress Threshold (PLST) model proposed by Hall and Buckwalter, the increased range of resident behaviors and tendency toward a more dysfunctional behavior in a task situation may be explained by situational demands beyond the resident's ability.18 Residents may become more easily frustrated when they know a demand is being made, but are not able to respond in the desired way. Interpersonal interactions, however, require very little of the resident and should not increase the resident's stress. Some support for the PLST model as a stress and coping model for cognitively impaired elderly may be generated from the results defining resident behavior as a function of the situation.

Interruptions in the interaction were found to alter both the nursing assistants' and residents' behaviors, with F( 12,230) = 2.389, P = .006, using MANOVA analysis. When interruptions occurred, changes in resident behaviors of decreased adaptability and increased tension and agitation were evident, whereas nursing assistant behaviors of decreased flexibility, relevance, and personal content were apparent. Again, it is not possible to understand from this analysis if changes in resident behaviors in the presence of interruptions occurred as a result of changes in the assistants' behaviors or if changes in resident behaviors resulted in altered assistant behavior.

Although no cause-effect relationship can be denned, nursing staff need to be aware of possible altered resident behavior when interruptions occur, as the behavioral changes found were typical of dysfunctional resident behaviors, such as becoming less flexible, more tense, and more agitated. Nursing staff should consider the possible benefits of interrupting interactions with cognitively impaired residents against possible negative outcomes. It may be more productive to delay contact with another staff member until the interaction is complete rather than risk a negative outcome.

Although nursing assistant behaviors of being relaxed and interested were different in morning and evening interactions, F(6,224) = 2.51, P = .004, specific resident behaviors were not found to vary significantly according to time of day. The concept of "sundowning," an increase in agitation in cognitively impaired elderly at nightfall, has been discussed in the literature as being an explanation of increased agitation in the evening. As residents in this study were asked to perform tasks in both morning and evening (ie, eating, dressing, and bathing), the resulting behaviors and lack of differences from morning to evening may be a function of task versus time.

The assistant's behavior of smiling in the interaction was related to resident behavior, F(6,221) = 2.80, P = .01, as suggested by the Dawson et al study.11 Presence of nursing assistant smiling was related to more adaptable, relaxed, calm, and cooperative resident behaviors. Use of touch by nursing assistants was found to be related only to the resident's personal content, F(6,220) = 3.608, P=. 002. Because previous research has found touch to be important to other resident responses, such as appropriate attending and positive self-appraisal, findings were not as dramatic as expected for use of touch in this study.8-9 The finding of limited relatedness between nursing assistant touch and resident behaviors indicates that nonverbal behaviors of nursing staff need further study prior to employing them as standard nursing care approaches.

ANECDOTAL OBSERVATIONS

Observations not subject to quantitative analysis will be presented as they relate first to task and then interpersonal interactions (Table 4). In task interactions, nursing staff would often perform tasks for lower-functioning residents rather than eliciting their participation or attempting to help them perform care themselves. Whereas "doing for" was increased for residents described as low-functioning, residents with higher mental function but low function in activities of daily living would sometimes comment on the staffs lack of attention to them personally. Comments such as, "Don't you talk to me when we're in here?" or "Don't rush me, I will do it when I'm ready," were not unusual. This type of interaction did not seem to vary according to the demands on the nursing assistant, but rather seemed to be more a function of individual interactive style consistent within task functions.

Some nursing assistants' interactive behaviors were observed to be directed to prevention of difficult resident responses. One staff behavior included engaging the attention of difficult residents by forcing and maintaining eye contact. This could sometimes make the difference between cooperation with a task and an agitated reaction. Also, use of praise and a positive, caring tone of voice could prevent a negative mood swing within a task. Some residents were emotionally labile and could vacillate from calm to agitated in a single sentence. In fact, if any behavior seemed to be able to "turn a resident around" and elicit a less agitated response, it was a show of positive regard. Staff would say such things as, "You know I really care about you," often combined with touch, and the resident would seem to forget what they were about to get upset about. Eye contact and warm, positive regard, although not systematically measured, were noted to be important behaviors at times.

In both task and general situations, environmental manipulation was also used frequently for allaying difficult responses of residents who had a "pattern" of difficult behaviors. In one room, the water had to be turned almost off so that no more than a trickling stream would emerge with the faucet fully open. This prevented the staff from constantly arguing with residents whose repetitive behaviors included running water and flooding bathrooms. Clothes were kept in a hall rather than room closet for other residents who insisted on putting on layers of clothing regardless of environmental temperature. Environmental manipulation was successful in avoiding difficult encounters.

Table

TABLE 3SIGNIFICANTPEARSON rCORRELATION COEFFICIENTS FOR NURSING ASSISTANT IBM DIMENSION SCOREAND RESIDENT MODIFIED IBM DIMENSION SCORE BY INTERACTION TYPE

TABLE 3

SIGNIFICANTPEARSON rCORRELATION COEFFICIENTS FOR NURSING ASSISTANT IBM DIMENSION SCOREAND RESIDENT MODIFIED IBM DIMENSION SCORE BY INTERACTION TYPE

For interpersonal interactions, assistants often used distraction and redirection to avoid an uncooperative, tense, or agitated incident with a resident. Changing the interaction approach or focus would cause residents to forget why they were disturbed, keeping the interaction calm. Lower-functioning residents were not approached as often by staff for interpersonal communication as were higher-functioning residents. Residents who exhibited difficult behaviors or were verbose received the largest amount of the staffs attention. Higher-functioning residents were often observed using humor appropriately, possibly making interactions with them more positive for staff.

In interpersonal interactions, nursing staff were found to concentrate more on the content of the interpersonal interaction (what the resident was saying) versus the behavior or resident's underlying emotions. This would keep the interaction at a superficial level and prevent staff involvement For some residents this did not seem to be an issue, especially those who had consistent wandering or repetitive behaviors. For them, moving about the unit consumed most of their time. They tended to avoid group activities and would only engage in interpersonal interactions for brief intervals. FOT others, more in-depth interactions may have been helpful, especially those who were able to relate to their environment and what was happening around them.

For all types of interactions, the researchers observed that if a resident became upset with one staff member, it was often best for another to intervene. If residents were already upset or paranoid with the assistant involved in the interaction, their behavior would tend to worsen if that assistant continued in the interaction or attempted to comfort the residents. When another staff member intervened, however, the resident usually quickly forgot the problem and would be more positive with the second person. This was true also for conflicts between residents. When an assistant intervened between residents, the residents almost immediately forgot the entire episode. This observation suggests that the presence of a second caregiver may be important, especially in AD persons prone to paranoia or swift changes in affect.

CONCLUSIONS

Findings regarding interactions between nursing staff, especially nursing assistants, and institutionalized cognitively impaired elderly give some direction for designing specific nursing approaches helpful in the management of difficult resident behaviors. Although it is recognized that this is a beginning effort to describe a complex process, findings have quantitatively given support to nonsystematic observations previously made by clinicians, helping to define important variables in nursing staff/resident interactions. A number of variables have been observed simultaneously, acknowledging the multitude of variables relevant to the interactive process.

Additional interaction studies are needed to refine, expand on, and further support the relevance of the findings described here. Nursing staff in longterm care institutions face increasing numbers and lengths of stay of cognitively impaired elderly. Effective nursing measures, potentially decreasing staff stress as well as increasing the resident's sense of well-being, need to be supported by a body of research directed to outcome measures. This study provides a beginning step in this process from which additional, clinicallyrelevant knowledge can be generated.

Table

TABLE 4SUMMARY OF ANECDOTAL OBSERVATIONS BY TYPEOFINTERACTION

TABLE 4

SUMMARY OF ANECDOTAL OBSERVATIONS BY TYPEOFINTERACTION

REFERENCES

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  • 3. Swearer JM, Drachmen DA, O'Donnell BR, Mitchell AL. Troublesome and disruptive behaviors in dementia: Relationships to diagnosis and disease severity. J Am Geriatr Soc. 1988; 36:784-790.
  • 4. Ten L, Larson EB, Reifler BV. Behavioral disturbance in dementia of the Alzheimer's type. JAm Geriatr Soc. 1988; 36:1-6.
  • 5. Duffy LM, Hepburn K, Christenson R, Brugge- Wiger P. A research agenda in care for patients with Alzheimer's disease. Image. 1989; 21:254-257.
  • 6. Jones DC, Jones A. Communication patterns between nursing staff and the ethnic elderly in a long-term care facility. J Mv NUTS. 1986:11:265-272.
  • 7. Armstrong-Esther C A. The influence of elderly patients' mental impairment on nursepatient interaction. J Adv Nurs. 1986; 11:379-387.
  • 8. Langland RM, Panicucci CL. Effects of touch on communication with elderly confused clients. Journal of Gemniological Nursing. 1982; 8:152-155.
  • 9. Copstead LC. Effects of touch on selfappraisal and interaction appraisal for permanently institutionalized older adults. Journal ofGerontological Nursing. 1 980; 6:747-752.
  • 10. Bumside IM. Alzheimer's disease: An overview. Journal of Gerontologtcal Nursing. 1979; 5(4): 14-20.
  • 11. Dawson P, Kline K, Wiancko DC, Wells D. Preventing excess disability in patients with Alzheimer's disease. Geriatr Nurs. 1986; 7:298-301.
  • 12. Athlin E, Norberg A. Caregivers' attitudes to and interpretations of the behavior of severely demented patients during feeding in a patient assignment care system. Int J Nurs Stud. 1987; 24:145-153.
  • 13. McCroskey JC, Wright DW. The development of an instrument for measuring interaction behavior for groups. Speech Monographs. 1971; 38:335-340.
  • 14. Burgoon JK, Aho L. Violations of conversational distance. Communications Monographs. 1982; 49:71-88.
  • 15. Folstein MF, Folstein S, McHugh PR. MiniMental State: A practical method for grading the cognitive state of patients for the clinician. JPsychiair Res. 1975; 12:189-198.
  • 16. Folstein MW, Whitehouse PJ. Cognitive impairment of Alzheimer's disease. Neurobehavioral Toxicology and Tetratology. 1983; 5:631-634.
  • 17. Ten L, Borson S, Kiyak HA, Yamagishi M. Behavioral disturbance, cognitive dysfunction, and functional skill. J Am GeriairSoc. 1989; 37:109-116.
  • 18. Hall GR, Buckwalter KC. Progressive lowered stress threshold: A conceptual model for care of adults with Alzheimer's disease. Arch Psych Nurs. 1987; 1:399-406.

FIGURE

INTERACTION BEHAVIORMEASURE

TABLE 1

DESCRIPTIVE DATA FOR RESIDENT VARIABLES FOR AGE AND MENTAL STATUS

TABLE 2

DESCRIPTIVE DATA FOR NURSING ASSISTANT VARIABLES OF AGE, EDUCATION, AND LENGTH OF SERVICE BY WORKING SHIFT

TABLE 3

SIGNIFICANTPEARSON rCORRELATION COEFFICIENTS FOR NURSING ASSISTANT IBM DIMENSION SCOREAND RESIDENT MODIFIED IBM DIMENSION SCORE BY INTERACTION TYPE

TABLE 4

SUMMARY OF ANECDOTAL OBSERVATIONS BY TYPEOFINTERACTION

10.3928/0098-9134-19910401-08

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