Objective: Uncomfortable behavioral symptoms during bathing are common for persons who suffer from dementia. These behaviors are linked theoretically to a stress response; thus, reducing stress associated with bathing should alleviate resistiveness to care (rtc) and discomfort. The challenge is to identify theoretically-based, empirically sound interventions that are clinically significant for individuals. The purpose of this presentation is to evaluate the evidence for choosing interventions to reduce uncomfortable behaviors when bathing individuals with AD by juxtaposing two approaches to within-person analyses. Data are from a pilot study examining the efficacy of relaxation before bathing and reminiscence during bathing in reducing stress and resistiveness to care in residents with advanced dementia. We hypothesized that care recipients receiving relaxation before bathing and reminiscence during bathing would experience (a) a less intense physiological stress response, (b) less rtc, and (c) less discomfort than occurred during the control condition.
Design: Interrupted time series with multiple switching replications.
Sample: Thirteen veterans identified by nursing staff as resistive to care during bathing participated during 208 baths (16/veteran). All were residents of a DSCU and had severe dementia.
Outcome Variables: resistiveness to care, change in heart rate, salivary cortisol
Interventions: (1) Relaxation before bathing, (2) Reminiscence during bathing (3) Relaxation + reminiscence, (4) "Plain talk" control
Methods: expert nurses gave all baths using a standardized protocol. Two nurses administered each of the 4 protocols twice in random order. Five-minute segments were videotaped and rtc behaviors rated by blinded observers
Findings: This was a pilot study with 13 participants, and our intent was to evaluate the effect size of the interventions to determine sample size for a future randomized controlled clinical trial. The finding that the experimental interventions had an effect beyond the good care of the Control condition was very encouraging. We did not expect to achieve statistical significance with repeated measures analysis of variance, and so were not surprised when we didn't. What warranted further analysis, however, was the strong conviction of the nurse interventionists of clinically significant differences among participants' responses to the different interventions.
Our first step was to examine the results visually for individual participants using single-subject methods. Several different patterns of response to the interventions were revealed. Next, we used the Sign Test to identify participants who responded to interventions using relaxation and those using reminiscence. We used median rtc scores, dividing the sample into "high-" and "low-resistiveness" groups. We categorized interventions as "relaxation" and "reminiscence" protocols to create 2 dichotomous groups. The Sign Test showed significant differences in treatment response for 6 out of the 13 participants.
For the 6 "responders" we used the Friedman test for differences across treatment groups (Chi-square=9.80 (3), p=.02). Comparison between treatment groups with the Wilcoxon Matched-Pairs Signed-Ranks Test indicated significant differences for the combination of relaxation and reminiscence and for reminiscence alone, compared to the Control.
The 7 "non-responders" fell into two groups. Group 1 (N=3), responded randomly to the interventions. They had the highest scores on the BANS-S, a measure of dementia severity. The remaining 4 people had low rtc scores overall, and so the "floor effect" precluded further decrease in rtc. Since staff identified all participants as highly resistive to bathing, this group may have responded to the standardized bathing procedure alone, suggesting the possibility that different intensities of interventions may achieve improved outcomes.
Conclusions: There is a pressing need for empirically supported interventions to make bathing more comfortable. This requires knowledge at the level of the population and at the level of the individual. Within-persons repeated measures design accounts for anticipated intra-individual variability in behavior characteristic of this population and allows individuals to serve as their own controls. However, the analysis of variance statistical procedure combines scores from all individuals, thus masking rather than reflecting these individual differences. Individual patterns of response can be identified and used to match empirically supported interventions with individuals. Furthermore, our findings suggest that different intensities of intervention are effective for different individuals.
Implications: Clinical significance means making a difference for individuals. We recommend a "tool-box" of empirically supported interventions (population level support), combined with criteria for choosing and sequencing these interventions for individuals (individual level support).Single-subject design is recommended for future studies as a methodology that is able to capture individualized responses while accommodating incremental intervention intensity.
Back to Improving Care For Persons With Alzheimer's Disease: Preventing Injury In The Home, Mamagement Of Resistiveness To Care, And Pain Assessment - Methods, Outcomes, Qritique And Application To Practice
Back to The Advancing Nursing Practice Excellence: State of the Science