Caregiver Person-Centeredness and Behavioral Symptoms in Nursing Home Residents With Dementia: A Timed-Event Sequential Analysis

Dementia-related behavioral symptoms, such as motor agitation and care resistance, are experienced by virtually all people with dementia at some point in their disease trajectory and are recognized as a source of considerable distress for people with dementia and their caregivers (Gitlin, Kales, & Lyketsos, 2012). In addition to being very common in nursing home (NH) residents, behavioral symptoms are challenging to manage and contribute to high levels of caregiver burden; worsening high turnover rates among NH staff (Norton, Allen, Snow, Hardin, & Burgio, 2010). Improving the management of behavioral symptoms among NH residents with dementia has been identified as a priority by clinicians, researchers, and end-users of NH services (Morley et al., 2014). Nonpharmacologic treatments are considered first-line therapy for behavioral symptom management (Gitlin et al., 2012). Delivery of person-centered care, which involves individualized, resident-directed care focused on person rather than task, has been identified as one such approach (Edvardsson, Winblad, & Sandman, 2008) and has been shown to improve behavioral outcomes in some instances (Chenoweth et al., 2009; Fossey et al., 2006; Sloane et al., 2004). However, the exact mechanisms by which person-centered care approaches ultimately modify or influence the presentation of behavioral symptoms is not well understood. Previous research has demonstrated that specific behavioral symptoms are sequentially related to some types of caregiver behaviors including infantilizing speech and negative statements (Roth, Stevens, Burgio, & Burgio, 2002; Williams, Herman, Gajewski, & Wilson, 2009). These types of interactions are often characterized as “task-centered,” wherein caregiving is dominated by routines and completion of tasks. And caregiver actions may undermine a resident’s preferences, goals, or status. However, no study has examined sequential associations between person-centered and task-centered caregiver interactions and various behavioral symptoms. Furthermore, variations in the temporal features of sequential associations between caregiver person-centeredness and behavioral symptoms have not been examined. Knowledge of these relationships can inform a broader evidence base for the practice of person-centered care approaches, as caregiver person-centeredness may have both an immediate, as well as cumulative effect on the presentation of behavioral symptoms. Furthermore, identifying the timeframe within which more immediate effects of person-centered interaction are realized is of particular relevance to people with dementia, whose daily experiences are often lived moment-to-moment. This study used video observations of caregiver–resident mealtime interactions to identify sequential associations between caregiver person-centered actions, caregiver task-centered actions, and resident behavioral symptoms and the temporal variation within these associations in NHs engaged in person-centered dementia caregiving. A second aim was to explore possible antecedent–consequence relationships between specific task-centered actions and behavioral symptoms. The overall hypothesis was that caregiver task-centered actions would be associated with higher likelihood of behavioral symptoms than person-centered actions.