Agitation and use of restraint in nursing home residents with dementia. Prevalence, correlates and the effects of care staff training

Background:
Dementia is one of the most prevalent syndromes in the elderly population, and over
half of people with dementia live in long-term care homes. 80% of residents in
nursing homes have dementia, the majority with severe functional impairments and
complex needs. Agitation and other behavioural changes are common, with severe
consequences for their functioning and quality of life, including use of restraint and
use of psychotropic drugs. To preserve the personal control, dignity and quality of life
of these vulnerable individuals, as long as possible, is an important goal of our
society. Few studies have explored the relationship between agitation and factors such
as stress in care staff and working conditions, and there is little evidence whether
education and guidance in care staff can improve agitation and reduce use of restraint
and psychotropic drugs.
Objective:
The objective of this thesis was to study the relationship between agitation and use of
restraint, carer burden, organizational and psychosocial factors and whether agitation
and use of restraint could be reduced by means of a novel care staff training.
Methods:
Descriptive, cross-sectional surveys were conducted to analyse the prevalence of
agitation in nursing home residents, and to study correlates of health and well-being
in care staff. Residents and care staff from four nursing homes in Rogaland County
were included. In addition, data from nursing homes in England and Austria were
used. Two cluster-randomized controlled trials were conducted to study the effect of a
novel care staff training program; Relation Related Care (RRC). Data on agitation and
use of restraint and antipsychotics were collected immediately before and after the 6-
month intervention period by a research nurse, blinded for study hypothesis. In the second study, an additional follow-up assessment was conducted 6 months after
completion of the intervention.
Standardized measures were used: Clinical Dementia rating Scale (CDR), Functional
Assessment rating Scale (FAST) and the Global Deterioration Scale (GDS) were used
to rate severity of dementia. Two rating scales were used to score agitation; Brief
Agitation Rating Scale (BARS) and Cohen-Mansfield Agitation Inventory (CMAI).
Frequency of use of restraint was determined by a standardized interview, where all
use of restraint during the last seven days was recorded.
Three scales measured health and well being in care staff: Perceived Stress Scale
(PSS), Psychological Distress (HSCL-10) and Subjective health complaints (SHC).
Organizational and Psychosocial factors were measured by General Nordic
Questionnaire for Psychosocial and Social Factors at Work (QPSNordic).
Results: 
We found that 75.4% of the residents with dementia exhibited at least one agitated
behaviour at least weekly and 65.3% several times a week. The six most common
agitated behaviours were repetitious sentences or questions, complaining, cursing,
pacing, negativism and general restlessness. However, agitation in the Norwegian
nursing homes was less common than in nursing homes in UK and Austria. The level
of agitation differed between countries, with higher CMAI scores in the Austrian
nursing home compared to UK and Norwegian nursing homes. Similarly, the use of
psychotropic drugs differed significantly between the homes, with a higher proportion
on antipsychotic drugs in UK and Austrian compared to Norwegian nursing homes.
Organizational and psychosocial factors, in particular those related to the
organizational structure of the nursing home were associated with all three measures
of health and well-being in care staff. Leadership, mastery and control of work were
the three organizational and psychosocial factors which significantly explained the
variance in care staff health and well being. In contrast, agitation in residents was not significantly associated with any of the measures of health and well being in care
staff.
In the first intervention study, the proportion of restraint declined with 54% in the
treatment group and increased with 18% in the control group. This difference was
significant. In contrast, agitation did not differ between the groups. In the second
study, the intervention led to both reduced severity of agitation and reduction in
restraint, which was evident by a much smaller increase in the intervention group
compared to the control group. The improvement of agitation continued 6 months
after the completion of the intervention, indicating that sustained improvement of
agitation can be achieved by means of staff training. The effect on restraint use
however, seemed to be short-lived, suggesting that continuous supervision is needed
to achieve sustained reduction of the use of restraint.
Conclusion:
Agitation is common in residents with dementia in Norwegian nursing homes. There
is a need to explore factors contributing to agitation, in order to understand and
manage it effectively and to avoid misdiagnose of symptoms, reduce inappropriate
use of drugs and restraint, and thereby improving the conditions and quality of life for
residents with dementia in nursing homes. Our findings from the intervention studies
suggests that by lowering the care staff – resident ratio and by providing additional
education, guidance and support, improved care of residents can be achieved