Effects of Behavioral Interventions on Disruptive Behavior and Affect in Demented Nursing Home Residents Essay

demeanoral throwlings qualification ameliorate them and beat a confirming effect on residents mood ( displace). Objectives This subject tested dickens preventivesan activities of occasional living and a psycho t fetch uper practise interjectionand a combination of the dickens to patch up their efficacy in reduce disruptive behaviors and improving uphold in brood bag residents with lunacy. Methods The discover had triad interference mathematical groups (activities of chance(a) living, psychosocial activity, and a combination) and two lock groups (placebo and no intervention).Nursing assistants hired specifically for this study enacted the interventions under the direction of a sea captains fain gerontological clinical nurse specialist. Nursing assistants employed at the treat roots preserve the occurrence of disruptive behaviors. Raters analyzed ikontapes filmed during the study to determine the interventions influence on fix. Results Findings indicated authoritatively much irresponsible push b arly non reduced disruptive behaviors in treatment groups comp atomic number 18d to support groups.Conclusions The treatments did not specifically take the factors that may agree been triggering disruptive behaviors. intercessions much more precisely intentional than those employed in this study require cultivation to quell disruptive behaviors. Nontargeted interventions might increase cocksure strike. Treatments that produce correct a brief improvement in affect indicate meliorate quality of mental health as mandated by federal law. detect Words affect Alzheimers disease behavior therapy dementia nursing homes Nursing search July/August 2002 Vol 51, No 4 proximately 1. 3 one thousand million older Americans live in nursing homes to solar day (Magaziner et al. , 2000). By 2030, with the develop of the population, the estimated demand for long-term precaution is expected to more than double (Feder, Komisar, & deoxyadenosine monophosphate Niefeld, 2000). Thus, nursing home expenditures could grow from $69 million in 2000 to $330 billion in 2030 (Shactman & axerophthol Altman, 2000). About half of new nursing home residents founder dementia (Magaziner et al. , 2000). The disease has an impact on quadruple major(ip) categories of functioning in persons with dementia.These are disruptive behavior (DB), affect, functional status, and intuition (Cohen-Mansfield, 2000). This article will focus on the showtime two categories. dissipated behavior has received much more attention than affect has (Lawton, 1997), possibly for trine reasons. First, more than half (53. 7%) of nursing home residents discover DB with aggression (34. 3%) occurring the most often (Jackson, Spector, & Rabins, 1997). Second, DB threatens the wellbeing of the resident and antitheticals in the environment. Consequences implicate (a) stress experienced by other resiCornelia K.Beck, PhD, RN, is Professor, Coll eges of Medicine and Nursing, University of atomic number 18 for Medical Sciences. Theresa S. Vogelpohl, MNSc, RN, is President, ElderCare Decisions. Joyce H. Rasin, PhD, RN, is Associate Professor, School of Nursing, University of northerly Carolina. Johannah Topps Uriri, PhD(c), RN, is Clinical coadjutor Professor, College of Nursing, University of Arkansas for Medical Sciences. Patricia OSullivan, EdD, is Associate Professor, placement of Educational Development, University of Arkansas for Medical Sciences.Robert Walls, PhD, is Professor Emeritus, University of Arkansas for Medical Sciences. Regina Phillips, PhD(c), RN, is Assistant Professor, Nursing Villa Julie College. Beverly Baldwin, PhD, RN, deceased, was Sonya Ziporkin Gershowitz Professor of Gerontological Nursing, University of Maryland. A Note to Readers This article employs a number of acronyms. Refer to Table 1 to facilitate reading. 219 220 effects of Behavioral Interventions Nursing look into July/August 2002 Vol 51, No 4 defer 1.Acronyms frontier Activities of routine living Analysis of variance homely affect evaluation master Arkansas Combined Disruptive behavior(s) Disruptive behavior plateful Licensed practical nurse(s) Maryland Mini mental status scrutiny Negative visual analogue racing shell Nursing home nursing assistant(s) Observable displays of affect scale Positive visual analogue scale Project nursing assistant(s) Psychosocial activity Research assistant(s) Acronym ADL ANOVA AARS AR CB DB DBS LPN MD MMSE NVAS NHNA ODAS PVAS PNA pro raise specific antigen RA belittles in targeted behaviors (Gerdner, 2000 Matteson, Linton, Cleary, Barnes, & Lichtenstein, 1997).However, others describe nonsignificant reductions (Teri et al. , 2000), no transmit (Churchill, Safaoui, McCabe, & Baun, 1999), or change magnitude behavioral symptoms (Mather, Nemecek, & Oliver, 1997). These studies employ nursing home staffs to collect information, had savor sizes at a lower pl ace 100, and mensural an array of DB with diverse assessments. Only in the conk decade view as look forers investigated affect. Compared to studies to reduce DB, far fewer studies have broadsheetd interventions using affect as an outcome measure.Studies make-uped official outcomes on affect from such interventions as simulated forepart therapy (Camberg et al. , 1999), Montessori-based activities (Orsulic-Jeras, Judge, & Camp, 2000), pass on practice nursing (Ryden et al. , 2000), music (Ragneskog, Brane, Karlsson, & Kihlgren, 1996), rocking chair therapy (Watson, Wells, & Cox, 1998), and positron emission tomography therapy (Churchill et al. , 1999). The studies on affect used global measures that relied on observer interpretation, which could have com heraldd objectivity. Theoretical BasesA number of conceptual frameworks have extendd intervention query on persons with cognitive impairment (Garand et al. , 2000). The theoretical basis for this study was that item-by-itemistics have raw material psychosocial require, which, when met, reduce DB (Algase et al. , 1996) (Table 2). The interventions, one focusing on activities of daily living (ADL) and the other focusing on psychosocial activity (prostate specific antigen), and a combination (CB) of the two, were developed to meet most of the basic psychosocial needs that Boettcher (1983) identified.These include territoriality, privacy and unembellisheddom from unwanted physical intrusion chat, opportunity to chat openly with others self-esteem, respect from others and freedom from insult or shaming safety and security, guard from harm autonomy, witness over ones life own(prenominal) identity, access to personal items and strikeing material, and cognitive understanding, awareness of surroundings and mental clarity. The subdivision on study groups specifies which interventions were frameed to meet which needs. Positive affect ordinarily accompanies interventions that meet basic psychosocial needs (Lawton, Van Haitsma, & Klapper, 1996).Several researchers and clinicians have suggested that displays of affect may offer a window for revealing sick residents needs, preferences, aversions (Lawton, 1994), and responses to daily events (Hurley, Volicer, Mahoney, & Volicer, 1993). The study reported here dents and staff (b) increased falls and injury (c) economic costs, such as property ravish and staff burn-out, absenteeism, and turnover (d) emotional deprivation such as social isolation of the resident and (e) use of physical or pharmacologic restraints (Beck, Heithoff, et al. 1997). Third, forward the Nursing Home Re year Act (Omnibus Budget Reconciliation Act, 1987), nursing homes routinely applied physical and chemical restraints to control DB with simply moderate results (Garand, Buckwalter, & Hall, 2000). However, the Act mandated that residents have the right to be free from restraints imposed for discipline or convenience and not required to treat the residents medical symptoms. Thus, researchers have tested a wide operate of behavioral interventions to reduce DB and replace restraints.The Act (1987) as well stipulated that all residents are entitled to an environment that improves or maintains the quality of mental health. Interventions that promote haughty mood or affect fulfill this entitlement. Therefore, this article will report the effects of an intervention to increase functional status in activities of daily living (Beck, Heacock, et al. , 1997), a psychosocial intervention, and a combination of some(prenominal)(prenominal) on reducing DB and improving affect of nursing home residents with dementia. TABLE 2. staple Psychosocial Needs Relevant Literature Literature suggests that behavioral interventions offer promise in managing DB.A wide head for the hills of modalities and approaches have been tested (a) sensational stimulation (e. g. , music) (b) physical environment changes (e. g. , walled garden) (c) psychosocial measures (e. g. , pet therapy) and (d) multimodal strategies. M all studies found significant Territoriality Communication Self-esteem Safety and security Autonomy Personal identity Cognitive understanding Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 221 adopted the inference by Lawton et al. (1996) that frequent displays of prescribed affect when basic psychosocial needs are met might indicate alter emotional wellbeing. is leg continually and without apparent reason needs redirection. This intervention lasted 4560 minutes a day during various ADL. PSA Intervention. A PNA also conducted the PSA intervention, which involved 25 standardized modules designed to meet the psychosocial needs for communication, selfesteem, safety and security, personal identity, and cognitive understanding by engagement in meaningful activity while respecting the souls unique cognitive and physical abilities (Baldwin, Magsamen, Griggs, & Kent, 1992 ).The intervention was chosen because it (a) provided a systematic plan for the PNA to address some of the participants basic psychosocial needs and (b) stand for clinical interventions that many long-term attending facilities routinely used, simply had not been formalized into a research protocol or systematically tested. apiece module contained finr psychosocial areas of content ( channelion of feelings, expression of thoughts, warehousing/recall, recreation, and education) and stimulated five sensory modalities ( oral, visual, auditory, tactile, and gustatory/olfactory).For instance, Activity Module I involved life review, communicating ideas visually (identifying and making drawings), clapping to different rhythms, massaging ones face, and eating a snack. signly, many participants tolerated less than 15 minutes of the activity but eventually habituated and participated 30 minutes. CB Intervention. This treatment consisted of both the ADL and PSA interventions and lasted 90 minutes daily. Placebo Control. This involved a one-to-one fundamental interaction between the participant and PNA.It controlled for the effect of the personal attention that the PNA provided to the three treatment groups. The PNA asked the participant to choose the activity, such as holding a conference or manicuring nails. It lasted 30 minutes a day. No Intervention Control. This occasion consisted of routine care from a NHNA with no scheduled contact between participants and the PNA. Instruments Disruptive Behavior outmatch. The 45-item disruptive behavior scale (DBS), designed to take a crap places based on the occurrence and severity of behaviors, assessed the effect of the interventions on DB (Beck, Heithoff et al. 1997). Gerontological experts (n 29) launch content validity, and interrater dependableness tests yielded an interclass correlation coefficient of . 80 (p . 001). Geropsychiatricnursing experts weighted the behaviors using a Q-sort to improve the scales e fficacy to predict perceived patient disruptiveness. Factor epitome identified four factors (Beck et al. , 1998). twain corresponded to twophysically aggressive and physically nonaggressiveof the three categories from the factor analysis of the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield, Marx, & Rosenthal, 1989).The third phratry of the Inventory was verbally foment in contrast, the factor analysis of the DBS produced a third and fourth category frankly agitated and vocally aggressive. To accomplish a score for the DBS, a skilled individual perpetrated a DBS form for every hour of a shift by check- Methods The primary coil aim was to conduct a randomized trial of the ADL and PSA interventions respectively and in combination (CB) for their effect on DB and affect on a gargantuan sample of nursing home residents. The experimental design consisted of three treatment groups (ADL, PSA, and Combined) and two control groups (placebo and no intervention).Individual res idents were depute to one of the five groups at severally of seven sites in Arkansas and Maryland, which controlled for site differences. To demonstrate the practicability of the interventions and assure adherence to the treatment protocols, certifiable nursing assistants were hired and happy as project nursing assistants (PNA). They enforced the interventions MondayFriday for 12 hebdomads. Afterward, one-calendar month and two-month implement periods occurred. Nursing assistants employed by the nursing homes (NHNA) recorded DB. To measure affect, raters were hired for the study to analyze records filmed during intervention.Research Subjects The sample initially consisted of 179 participants. The study design allowed for the detection of an improvement in DB lashings on the Disruptive Behavior Scale (DBS) (Beck, Heithoff et al. , 1997) across condemnation of at least 1. 6 units with a superpower of 80%. This power calculation assumed that the repeated measures would be cor related with one other at 0. 60. Inclusion criteria were age 65 a dementia diagnosis a Mini Mental lieu Exam (MMSE) (Folstein, Folstein, & McHugh, 1975) score of 20 and a report of DB in the former two weeks.To form a more homogeneous group for generalizing findings, exclusion criteria were a physical disability that severely limited ADL a psychiatric diagnosis and a progressive or recurring medical, metabolic, or neurological stipulation that might interfere with cognition or behavior. Study conventions ADL Intervention. A PNA used the ADL intervention during bathing, grooming, dressing, and the noon meal based on successful protocols that better functional status in dressing (Beck, Heacock et al. , 1997).It attempted to meet residents psychosocial needs for territoriality, communication, autonomy, and self-esteem to promote their sense of safety and security. The intervention also try to respect participants cognitive and physical abilities by prescribing three types of strategies specific to the individual participant. First, strategies to complete an ADL address specific cognitive deficits. For example, the person with ideomotor apraxia needs feel or physical guidance to start movements. Second, standard strategies are behaviors and communication techniques that work for almost everyone with dementia.For example, the caregiver gives a series of one-step commands to guide the resident to put on her shoe. Third, problem-oriented strategies address particular disabilities such as fine motor impairment, physical limitations, or perseveration. For example, a subject who rubs his hand back and forth on 222 Effects of Behavioral Interventions ing the behaviors that occurred. The score for a behavior was the frequency (08) times the weight. The item scores were summed to obtain apiece of the four subscale scores. Mini Mental Status Exam. The Mini Mental Status Exam (MMSE) (Folstein et al. 1975) provided a global evaluation of participants cognitive st atuses for screening subjects for the study. Test-retest reliability of the MMSE is . 82 or better (Folstein et al. ). Cognition is assessed in seven areas, and scores lower than 24 out of 30 indicate dementia. Nursing Research July/August 2002 Vol 51, No 4 Observable Displays of prompt Scale. The Observable Displays of Affect Scale (ODAS) (Vogelpohl & Beck, 1997), designed to rate videotaped data, contains 41 behaviors categorized into sextet subscales of peremptory and minus facial displays, vocalizations, and body movement/posture.Raters indicate presence/absence of each(prenominal) behavior during five 2-minute intervals from a 10minute videotape. Scores range from 05 for each item. The range of scores for each scale is facial positive (020), Aggression during bathing facial negative (020), vocal positive (045), vocal negative (050), body could stem from physical positive (030), and body negative discomfort or bumpy (040). Interrater reliabilities (Kappa handling coeffic ients) for the ODAS range from . 681. 00, and intrarater reliability is . 971. 00.Ten gerontological nursing experts established content validity (Vogelpohl & Beck). Apparent Affect Rating Scale. The Apparent Affect Rating Scale (AARS) (Lawton et al. , 1996) is designed for direct observation of persons with dementia and contains sixsome affective states pleasure, anger, anxiety/fear, tragicalness, interest, and contentment. (In later work, Lawton, Van Haitsma, Perkinson, & Ruckdeschel 1999 deleted contentment). each(prenominal) item has a noninclusive list of behaviors that might signal the presence of the affect from which observers infer the affect.The observer assigns a score of 1 to 5 to measure the duration of the behavior. Visual Analogue Scales. The Positive Visual Analogue Scale (PVAS) and Negative Visual Analogue Scale (NVAS) (Lee & Kieckhefer, 1989 Wewers & Lowe, 1990) are two 10centimeter lines on separate pages for rating positive and negative affect. The PVAS has end anchors of no positive affect and a great assign of positive affect. The NVAS has end anchors of no negative affect and a great deal of negative affect. Scores range from 0 to 100.Procedure The study consisted of six phases (a) preliminary activities, (b) a three-week normalization/desensitization period, (c) a 12-week intervention period, (d) a onemonth revue period, (e) a two-month follow-up period, and f) a videotape analysis. Preliminary Activities. The institutional review boards at the University of Arkansas for Medical Sciences and the Univer- sity of Maryland approved the research. Each nursing home identified residents with dementia and sent letters ratting persons responsible for the residents that researchers would be contacting them.Responsible persons could return a signed form if they did not want to participate. Willing responsible persons received a bid call explaining the study followed by a mailed written rendering along with two concur forms. Those willing kept one consent form for their records and signed and mailed back the other. Screening involved a review of the residents charts, recording their diagnoses, and interviews with the staff to find evidence of DB during the previous two weeks. Each resident took the MMSE to meet inclusion criteria.Within each home, female residents who passed these screens were randomized to one of the five groups by a drawing, but males were assigned to the five groups to ensure even distribution of their small number. Simultaneously, research staff members were hired and trained. Normalization/Desensitization. For the next three weeks, each PNA attended a NHNA to learn the routines of the facility but did not help care for potential study participants. A videotape technician situated a tv camera that was not running in the dining and shower rooms to modify residents and staff to its presence.In addition, nursing home staffs participated in two-hour training sessions on the DBS. Throu ghout the study, a gerontological clinical nurse specialist trained any new NHNA and retrained if behaviors reported on the DBS differed from those she notice during randomized checks. Intervention. During the 12-week intervention period, the first three weeks were considered baseline and the last two weeks postintervention. The PNA administered the treatment/s or placebo five days a week. Every day, they asked participants to give their assent and espected any dissents. During weeks 1112 (postintervention), the PNA prepared the participants for their departure by relation them that they were leaving soon. To facilitate data collection, a separate form of the DBS for each of the three eight-hour daily shifts was developed. Eight one-hour blocks accompanied each item of the scale. The NHNA placed a check mark in the block that corresponded to the hour when the NHNA observed the behavior. The NHNA completed the DBS on all participants during or at the end of a shift.In addition, a technician videotaped participants in the treatment and placebo groups every other week during an interaction with the PNA and no intervention group monthly during an ADL. The technician monitored positioning and motion of the camera from outside the room or behind a pall to respect the participants privacy. One-Month and deuce-Month Follow-up. One month and two months after the research team up left the nursing home, Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 223 esearch assistants (RA) retrained nursing home staffs on the DBS. The NHNA then compile DB data on their shifts MondayFriday for one week. tervention, week 16 as one-month follow-up, and week 20 as two-month follow-up. Participants with fewer than six observations at any time period were omitted. For each period, a rack up DBS score represented an averVideotape Analysis. The videotapes ranged in length from age of the participants data for the three shifts of each day less than five minutes to 40 minutes, depending on the across the five days of the observation week.Therefore, activity and the participants willingness to cooperate with total DBS scores were obtained for baseline (M of weeks the treatment (baseline and control participants tapes 13), intervention (M of weeks 410), postintervention (M tended to be shorter). To standardize the opportunity for of weeks 1112), first follow-up (M of week 16), and secbehaviors to occur, an editor took 10-minute segments ond follow-up (M of week 20). The same influence from the middle of baseline and final treatment eek tapes yielded subscale scores for physically aggressive, physically and randomized them onto videotapes for rating. Because nonaggressive, vocally aggressive, and vocally agitated videotaping occurred to ensure appropriate implementabehaviors for each of the five time periods. tion of interventions, the treatment groups had more A repeated measures analysis of variance (ANOVA) usable videotapes t han the control groups did. consisted of two between-subjects and one within-subjects A masters prepared gerontological factors.The between-subjects factors nurse specialist intensively trained six were intervention group and state (AR raters on the Observer tercet Software or MD) to account for regional differSystem (Noldus Information Technolences in get ahead DB, and the withinogy, 1993) for direct data entry and subjects factor represented DBS scores the affect rating scales. The raters for the five different time periods. Each reached . 80 accordance with the speanalysis allowed for testing by intervencialist on practice tapes before they tion group, time period, and state. The shout out may started rating the study videotapes. nalysis of the interaction effect of She monitored reliability for each tape intervention group by time period express pain or monthly, retrained as needed, and rantested the guess that the intervenself-stimulation domized the sequence of rating the tions would decrease DB across time in scales. The raters entered the ODAS treatment conditions as compared to and AARS data directly into a comcontrol conditions. The analysis was puter using the Observer. The system repeated five times, once for each suballowed raters to watch videos repeatscale of the DBS and once for the total edly in true time and slow action to score.Level of significance was set at document behaviors objectively and 0. 05. The researchers believed that the precisely. The raters indicated their small group sizes justified the liberal apprehension of the participants positive and negative level of significance. For the videotape analysis, analyses of affect by placing a vertical mark at some point between covariance occurred for the 14 variables observed from the the two end anchors of the PVAS and NVAS. They videotapes during intervention. The baseline score served marked impersonal affect as negative. s a covariate for the final score. While a multivariat e analysis would have been desirable, it would have had Intervention Integrity The PNA and video camera techniinsufficient power with this number of variables and subcian underwent two weeks of intensive training on general jects. The 14 univariate analyses do inflate the Type I erroneousness aging topics, stress management, information on dementia, rate. and confidentiality/privacy issues. Training also involved instruction on the study interventions, DBS, and research Results protocols.Of the 179 initial participants, 36 did not finish the greatA gerontological clinical nurse specialist viewed treatest abrasion occurred in the no intervention control group. ment and placebo videotapes biweekly in a private office to Attrition resulted from death (39%), withdrawal of fammonitor PNA compliance with research protocols, provide ilys consent or at nursing home staffs request (26%), discorrective feedback to PNA, and help PNA recognize and charge (18%), and change in health status/medi cations meet participants needs as they changed during treatment. hat did not meet inclusion criteria (17%). This left 143 The possibility for contamination appeared to be low participants 29 in the ADL, 30 in PSA, 30 in CB, 30 in the because NHNA were unlikely to change their care practices placebo, and 24 in the no intervention, but 16 with incomand had little opportunity to observe PNA. Further, NHNA plete data were dropped. Table 3 gives the demographic were blinded to the hypothesis of the study, the nature of the statistics for the 127 participants with complete data.No interventions, and the participants group assignments, statistically significant demographic differences emerged although they probably could identify the no intervention among the five groups. In short, this sample primarily conparticipants. sisted of elderly, color females with severe cognitive impairment. Analysis Reviewers checked for completeness of all data. For the videotape analysis, the final number w as 84 The researchers designated intervention weeks 13 as baseparticipants with 168 videotape segments. Most were line, weeks 410 as intervention, weeks 1112 as postin- 224 Effects of Behavioral InterventionsNursing Research July/August 2002 Vol 51, No 4 TABLE 3. Description of the Sample by Intervention Group No Intervention 19 89. 5 78. 9 84. 2 86. 47 (6. 37) 11. 47 (6. 43) ADL Number in group Percent female Percent exsanguinous Percent widowed immoral age (SD) M MMSE (SD) 28 78. 6 82. 1 64. 3 82. 29 (8. 40) 11. 44 (7. 69) PSA 29 82. 1 85. 7 66. 7 82. 18 (7. 64) 10. 65 (6. 76) CB 22 81. 8 77. 3 77. 3 82. 82 (9. 81) 7. 91 (5. 41) Placebo 29 75. 9 86. 2 75. 9 86. 45 (6. 92) 11. 11 (6. 39) Total 127 81. 0 82. 5 72. 8 83. 64 (7. 97) 10. 55 (6. 64) Note. ADL = activities of daily living PSA = psychosocial activity CB = combination. emale (79%) and widowed (69%) with a mean age of 83 (SD 7. 44). Participants had a mean score of 10 (SD 6. 34) on the MMSE, indicating moderate to severe cognitive impairment. Table 4 displays the instrument and standard deviations for the DBS general and the four subscales across the five time periods for the five groups. No significant differences emerged for the intervention-by-time interaction for any of the dependent variables. Thus, the results failed to support the hypothesis that the interventions would decrease DB across time in treatment groups as compared to control groups (statistical analysis tables on Website at http//sonweb. nc. edu/nursing-research-editor). However, the main effect of state was significant in three analyses. Arkansas recorded significantly more behaviors than Maryland did for the dependent variables of physically nonaggressive (p . 001), vocally agitated (p . 001), and overall DBS (p . 002). Further, the main effect of time was significant for overall DBS (p . 002) and the four subscales of physically aggressive (p . 001), physically nonaggressive (p . 027), vocally aggressive (p . 021), and vocally agitated behaviors (p . 008).The significance resulted from increased DB after the PNA had left the home (generally from intervention or postintervention to first follow-up). For the videotape analysis, the hypothesis stated that treatment groups, compared with control groups, would display more indicators of positive affect and fewer indicators of negative affect following behavioral interventions. In general, neither the positive nor the negative affect scores were particularly high, indicating that this sample had relatively flat affect. Results from the analysis of covariance tests back up increased positive affect but not decreased negative affect.Compared to the control groups, the treatment groups had significantly more positive facial expressions (p . 001) and positive body posture/movements (p . 001), but not more positive verbal displays on the ODAS. The treatment groups displayed significantly more contentment (p . 037) and interest (p . 028) than the control groups did on the AARS. For the negative affects on the AARS, the treatment groups had a shorter duration of sad behaviors (p . 007) than the control groups did. Comparison of VAS scales likewise showed that the treatment groups displayed more positive affect (p . 012). Discussion In contrast to other studies (e. . , Hoeffer et al. , 1997 Kim & Buschmann. , 1999 Whall et al. , 1997), this study found no treatment effect on DB. The interventions were a tax write-off of approaches believed to globally address triggers of DB and meet psychosocial needs (Boettcher, 1983). They did not address the specific factors that might have been triggering the particular behavior (Algase et al. , 1996). Such triggers include under/over stimulation, unfamiliar or impersonal caregivers, and particular individual unmet psychosocial needs. For example, aggression during bathing could stem from physical discomfort or rough handling (Whall et al. 1997). Interventions much more individually designed require dev elopment. change magnitude DB across all groups was reflected in the DBS scores at 1-month follow-up. Two factors may explain this increase. First, the PNA had warned participants that they would be leaving. Second, the ADL and CB participants no longer received care from the familiar PNA, and PSA, CB, and placebo participants no longer had a daily activity or visit. The increased stress and time constraints for NHNA as they resumed caregiving of the ADL and CB participants may explain the heightened DB in the control groups.Such changes may trigger increased behavioral symptoms in persons with dementia (Hall, Gerdner, Zwygart-Stauffacher, & Buckwalter, 1995). Two measurement issues may have affected outcomes. First, observers view behaviors differently (Whall et al. , 1997) and come to expect particular behaviors from genuine residents (Hillman, Skoloda, Zander, & Stricker, 1999). If the NHNA were accustomed to a participants DB pattern, such as persistent screaming, they m ay have overlooked decreases in that behavior. Initial training and retraining of raters occurred as needed however, some Nursing Research July/August 2002 Vol 51, No 4Effects of Behavioral Interventions 225 TABLE 4. burden Scores for Disruptive Behavior by Intervention Group and magazine Period No Intervention (n = 19) entail (SD) 408. 71 (427. 24) 303. 69 (408. 44) 281. 97 (410. 85) 418. 31 (630. 58) 292. 85 (405. 15) 114. 66 (202. 89) 90. 85 (182. 70) 77. 98 (173. 15) 130. 92 (257. 12) 128. 20 (195. 67) 191. 97 (157. 75) 117. 11 (112. 30) 118. 23 (137. 08) 154. 46 (225. 05) 100. 45 (153. 30) 55. 16 (74. 70) 42. 89 (54. 54) 33. 26 (47. 06) 64. 72 (77. 89) 28. 09 (37. 02) (continues) DB Category Time Period DBS total service line ADL (n = 28) intend (SD) 172. 51 (191. 47) 182. 45 (181. 3) 164. 56 (154. 95) 207. 22 (205. 58) 190. 70 (291. 06) 20. 67 (30. 52) 32. 59 (51. 29) 15. 02 (26. 10) 44. 18 (100. 62) 21. 45 (36. 47) 95. 50 (105. 28) 87. 58 (87. 58) 85. 04 (89. 60) 88. 81 (8 5. 69) 148. 75 (187. 28) 22. 85 (32. 10) 28. 37 (32. 50) 21. 15 (26. 54) 30. 72 (48. 95) 18. 28 (24. 55) PSA (n = 29) Mean (SD) 348. 02 (467. 50) 306. 81 (393. 03) 303. 24 (367. 54) 373. 17 (533. 05) 300. 20 (366. 42) 85. 87 (199. 01) 83. 94 (167. 53) 82. 82 (166. 93) 113. 49 (235. 71) 81. 30 (151. 85) 162. 41 (206. 65) 130. 82 (142. 72) 133. 92 (145. 97) 141. 47 (188. 99) 164. 92 (223. 63) 49. 64 (93. 15) 43. 80 (64. 6) 37. 90 (53. 43) 54. 47 (90. 33) 40. 26 (45. 26) CB (n = 22) Mean (SD) 287. 66 (373. 73) 300. 84 (379. 33) 286. 21 (365. 78) 374. 10 (510. 10) 312. 83 (433. 18) 68. 84 (126. 18) 67. 14 (137. 79) 61. 04 (127. 78) 92. 68 (205. 52) 60. 40 (131. 54) 136. 67 (189. 03) 124. 64 (164. 49) 125. 99 (157. 78) 159. 97 (202. 75) 146. 53 (201. 83) 34. 49 (55. 91) 40. 73 (52. 60) 31. 18 (33. 85) 36. 95 (42. 70) 32. 82 (51. 32) Placebo (n = 29) Mean (SD) 325. 96 (337. 14) 337. 60 (328. 94) 336. 80 (366. 55) 389. 92 (434. 43) 319. 15 (384. 59) 49. 26 (90. 24) 62. 10 (112. 71) 59. 67 (106. 37) 76. 79 (165. 45) 48. 25 (101. 4) 167. 01 (177. 80) 164. 62 (161. 48) 175. 36 (189. 80) 201. 68 (212. 06) 87. 67 (127. 38) 47. 20 (79. 70) 39. 55 (57. 74) 32. 69 (55. 77) 29. 30 (47. 60) 30. 18 (52. 85) Intervention Postintervention 1 month follow-up 2 month follow-up Physically aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up Physically nonaggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up Vocally aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up 226 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4TABLE 4. Weighted Scores for Disruptive Behavior by Intervention Group and Time Period (Continued) NoIntervention (n = 19) Mean (SD) 47. 65 (97. 22) 68. 32 (103. 13) 68. 01 (116. 62) 84. 50 (112. 48) 73. 07 (117. 12) DB Category Time Period Vocally agitated Baseline ADL (n = 28) Mean (SD) 33. 49 (84. 39) 33. 91 (62. 52) 43. 17 (72. 10) 43. 48 (64. 39) 50. 53 (117. 95) PSA (n = 29) Mean (SD) 46. 92 (98. 70) 52. 84 (96. 03) 52. 50 (90. 78) 68. 22 (98. 89) 48. 89 (92. 33) CB (n = 22) Mean (SD) 62. 49 (98. 97) 70. 43 (110. 85) 69. 08 (107. 29) 82. 14 (118. 97) 75. 80 (129. 67) Placebo (n = 29) Mean (SD) 50. 0 (92. 05) 48. 25 (81. 63) 48. 59 (72. 20) 63. 74 (95. 30) 54. 11 (80. 61) Intervention Postintervention 1 month follow-up 2 month follow-up Note. Scores were created by assigning each behavior with a severity weight prior to summing and then averaging across day and then week(s). DBS = disruptive behaviors ADL = activities of daily living intervention PSA = psychocial activity intervention CB = combination of the two interventions. NHNA appeared to continue to consider participants behaviors, such as repetitive questioning, to be personality characteristics or attention-seeking efforts rather than DB.Thus, they may have under-reported behaviors. Further, staff may prefer withdrawn behaviors, such as discriminate self and muteness (Camberg et al. , 1999), and view them as nonproblematic. Second, categorizing a behavior as disruptive without understanding its meaning to the person with dementia may be conceptually flawed. For example, screaming may express pain or self-stimulation. Two design features may explain differences between the findings of this study and others. First, this study had both placebo and no intervention control conditions.Just a few other studies randomized subjects to treatment or control groups or included two control groups (e. g. , Camberg et al. , 1999). In most studies, control conditions preceded or followed treatment conditions (e. g. , Clark, Lipe, & Bilbrey, 1998). In both designs, subjects served as their own controls, which limits examination of simultaneous intra- and extra-personal events that might affect DB frequency. Second, many control groups came from separate units or different nursing homes (e. g. , Matteson et al. , 1997), which makes it difficult t o control for differences in environment, staff relationships, and personalities.This study occurred at seven sites in two different geographical areas, but at each site, the randomization of female participants distributed the groups across all nursing units to control for environmental and staff characteristics. Acknowledged limitations include the following. First, in spite of the large overall sample, the group sizes were small (range 1930) with the greatest loss in the no inter- vention group. Larger groups might have provided more definitive findings on the relationship between behavioral interventions and DB frequency as Rovner et al. (1996) did (treatment group 42 control group 39).Second, NHNA served as data collectors because using self-employed person observers would have been cost-prohibitive. These results suggest that future intervention research should consider the individual characteristics of the person with dementia (Maslow, 1996) and the triggers of the behavior (Algase et al. , 1996). Studies that have individualized interventions have present decreased DB (Gerdner, 2000 Hoeffer et al. , 1997). Researchers need to continue to refine methods for identifying what works for whom (Forbes, 1998) to downplay the prevalent trial-anderror approach to DB management.