Introduction
Approximately 90% of people with dementia (PWD) in residential aged care facilities (RACFs) will experience behavioral and psychological symptoms of dementia (BPSD) (Lyketsos et al., Reference Lyketsos, Steinberg, Tschanz, Norton, Steffens and Breitner2000; Brodaty et al., Reference Brodaty2001). BPSD are significant as they are frequently the precipitant to placement (Finkel et al., Reference Finkel, Costa, Silva, Cohen, Miller and Sartorius1996; Balestreri et al., Reference Balestreri, Grossberg and Grossberg2000), are associated with increased morbidity of PWD (Herrmann et al., Reference Herrmann2006) and caregiver depression and burden (Okura and Langa, Reference Okura and Langa2011). Worsening BPSD is frequently the reason for referral to aged psychiatry services (Torta et al., Reference Torta, Badino and Scalabrino2004).
A recent systematic review of measures of BPSD (Gitlin et al., Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014) reported that BPSD remain largely unidentified and are thus treated inadequately. It is essential to assess BPSD in detail so that appropriate interventions can be implemented. This group (Gitlin et al., Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014) reviewed 45 validated and reliable measures of BPSD. Fourteen of them (31.1%) were administered by a trained interviewer, and four of them (8.9%) required trained observers to be complete them. The time it took for the measures to be administered varied between 3 to 5 minutes (The Nursing Home Behaviour Problems Scale) to 12 hours (Computer-assisted behavioral Observation). Most of them, including the “Behavioural pathology in AD” (BEHAVE-AD) and “Neuropsychiatric Inventory” (NPI) took between 20 to 30 minutes to administer. The choice of measures depended on the setting, the purpose of the measurement, and the amount of time and resources available (Gitlin et al., Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014).
There is scarce published literature describing the current methods of assessing BPSD in RACFs. We sought to investigate the current BPSD assessment tools being used in RACFs and explore different stakeholders’ views on current practices in metropolitan Victoria, Australia.
Methods
This was a cross-sectional convenience study conducted in Melbourne, Australia, between October to December 2014. The key stakeholders who were identified as important in obtaining information about current practice in BPSD assessment in RACFs were (1) aged psychiatry teams, including OAPs and nurses, who received referrals about BPSD; (2) clinicians (nurses, allied health) who designed and implemented non-pharmacological interventions for management of BPSD (designated as “behavior management teams”); and (3) Staff (nurses, personal care attendants) working with PWD in RACFs.
In Victoria, aged psychiatry and behavior management teams work within catchment areas and people aged over 65 who have psychiatric conditions, including dementia are referred to them (Loi and Hassett, 2011). These teams have experience working in RACFs. Two catchment areas were chosen (inner and north west, and inner urban east and Northcote) (State Government of Victoria, 2008), with clinicians from each of the three stakeholder groups identified for inclusion into the study.
A questionnaire was developed by the first author based on the review by Gitlin et al. (Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014). There were eight questions which had multiple choice answers and option of open-ended responses. These inquired about current methods and limitations of assessing BPSD used in RACFs; the number of symptoms which should be assessed; and the frequency of assessment.
The first author met with each of the stakeholder groups to discuss the study. The questionnaires were left with the clinicians who completed them after the meeting. There were no reminders or follow-up questionnaires. Ethical approval was granted by the local hospital human ethics committee. Statistical analysis was performed using the Statistical Package for Social Sciences and responses were analyzed using percentages.
Results
There were 30 clinicians who were present. Twenty-one completed the questionnaires (70% response rate). Table 1 shows details of the respondents. Questionnaires took approximately 10 minutes to complete.
Origin and number of respondents
Number of behaviors to be assessed
The OAPs and behavior management teams reported that assessing one to three BPSD were useful, as more than three increased the burden of charting, and thus the quality of the assessment. RACF staff from both facilities reported that they were very busy with their other care tasks that recording BPSD was perceived as an “extra” task and not seen as an essential part of their daily schedule.
Types of BPSD assessments
There were no “official” BPSD measures (such as the NPI) currently being used, as reported by those who completed the questionnaires. Instead, the staff from the two RACFs reported that they had their own behavior chart, which was in an “Antecedent, Behaviour and Consequence” format. They reported that they would try complete these but there was no specific instructions with regard to when, the frequency, or for which specific BPSD to monitor.
The behavior management teams stated they usually provided their own charts which had specific written instructions in how to complete it (such as the timing and frequency). The two aged psychiatry teams stated that some RACFs used computers solely for their documentation, including BPSD assessment. However, because only regular RACF staff had access to login and passwords, “agency” and infrequent staff could not login themselves. This meant that BPSD may not be assessed if non-regular staff were working.
What should be monitored?
All respondents except for the RACF staff reported that the frequency and severity of the BPSD should be monitored, but these were often subject to the perceptions of the RACF staff who were responsible for monitoring. Often the severity of the behavior pertained to perception of the severity according to the RACF staff, rather than the severity of the behavior according to the PWD.
Limitations of current methods
Aged psychiatry teams and OAPs reported that when visiting RACFs, the staff who had completed the BPSD assessment were often unavailable, so it was difficult to obtain more details about the behavior. Different staff had different perspectives on BPSD and this inconsistency meant that assessing and then managing these were difficult. Behavior management team respondents commented that on weekends there was frequently a lack of BPSD assessment so it was unclear whether the behavior was not present, or whether it just was not being assessed.
Aged psychiatry team respondents reported that when a behavior did not occur might also be important, but this was not necessarily captured. Being able to add specific contextual information relevant to a BPSD was also important. For example, a resident might become agitated every Saturday afternoon. While this might indicate “sundowning,” if it was noted that this occurred in the context of the resident's spouse leaving the RACF, then this information may be more relevant to this resident's behavior, and an alternative management plan might be implemented.
The behavior management teams commented that RACF staff had different training and educational backgrounds, and there was lack of regular staff. Because of this, providing educational in-services demonstrating the reasons why and how to complete their behavior charts was inefficient. When they did leave their own charts with the RACF, often these would get lost, or be completed incorrectly. They also reported that different behaviors had different definitions to RACF staff. For example, behaviors such as “agitation,” “restlessness,” and “anxiety” could all be perceived as the same behavior. This led to difficulty in proper assessment of the BPSD, and problems in designing a management plan. When a management plan was implemented, assessment of the behavior by RACF staff frequently ceased, so there was no objective method of assessing whether the plan was successful in targeting and reducing the BPSD. RACF staff respondents reiterated that the lack of time led to them not necessarily prioritizing behavior monitoring.
Discussion
This study is one of the first to investigate current methods of assessing BPSD. Results suggested that there was a mismatch in the importance of the BPSD assessment between the RACF staff who were concerned about the behavior and had made a referral, and clinicians (aged psychiatry teams and behavior management teams) who required specific information about the BPSD in order to make a thorough assessment and management plan.
Difficulties relevant to RACF staff included lack of time and specific information about the timing and frequency of when to assess BPSD, differences in perceptions of the definition of behaviors, and access to the assessment charts. There are many BPSD measures which have set parameters for rating the frequency and severity of behaviors, which include definitions of the behaviors, such as the NPI and the BEHAVE-AD. However, these can take between 10 to 30 minutes to complete (Gitlin et al., Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014). Some RACFs have rapid turnover of staff so training individual staff is difficult and impractical.
It is acknowledged that this was a convenience study with a small sample of clinicians, which excluded the community and informal caregivers. In addition, the questionnaire used was not validated. However, the findings from this study are important, suggesting that in some RACFs in a metropolitan city, proper and detailed assessment of BPSD is a challenge, despite it being a critical aspect of managing dementia (Gitlin et al., Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014).
For clinicians who are asked to manage BPSD (aged psychiatry and behavior management teams) having objective measures such as severity of the behavior and its frequency, may be useful in determining the level of intervention required. Having additional information that puts the behavior in context also assists with the management plan (Gitlin et al., Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014) and is consistent with person-centered care (Kitwood, Reference Kitwood1997).
There are many BPSD assessments available so further research might investigate alternatives for RACFs to integrate these into routine care. Ensuring that these are clinically relevant, quick, and easy to complete, yet provide useful and relevant contextual information is essential. Modern technology such as the internet might assist with real-time monitoring (Gitlin et al., Reference Gitlin, Marx, Stanley, Hansen and Van Haitsma2014).
Conflict of interest
None.
Description of authors’ roles
SL designed the study, carried it out, analyzed the data, and wrote the paper, with NL's supervision and feedback.
Acknowledgments
The authors would like to acknowledge the people who completed the questionnaires.
