Living with dementia magazine October 2010

A cross cultural nursing homes study aimed at identifying causes of agitation in people with dementia suggests that structural and cultural changes can improve quality of life.

By Caroline Bradley

Behavioural and psychological symptoms such as agitation and aggression are commonly experienced in people with dementia. The term agitation is used to cover a broad range of behaviour, such as general restlessness, hiding things, asking frequent questions, walking about, as well as more aggressive behaviour such as kicking and pushing.

Agitation affects up to 96 per cent of people with dementia who live in nursing homes. It frequently leads to the inappropriate use of medication such as powerful tranquillisers which can have harmful side effects and also cause distress to patients with dementia and professional and family caregivers.

Working out how best to manage or reduce agitation in people with dementia is a complex task. Agitation may be a result of changes in the brain caused by dementia, everyday physical illnesses such as bladder or chest infections, pain, boredom, or the type of personality someone had before the dementia. Environmental factors and the way people are treated can be additional causes of distress.

Approaches to care

There has been little systematic research into the impact organisational approaches to care in homes have on levels of agitation. Researchers in Austria, Norway and England recently compared statistics between a selection of homes in each of their countries. The aim of the study was to compare severity of agitation and drug use in nursing homes with different organisations and structures.

The researchers found important differences between the countries in the use of tranquillising or antipsychotic medication, and that having more staff per resident was linked to lower levels of agitation.

Findings

The study showed that levels of agitation were higher in the sample of nursing home residents in Austria (52 per cent) than in Norway (42 per cent) or the UK (43 per cent). However, there was a substantially higher level of the use of antipsychotic or tranquillising medication in the UK (48 per cent) and Austria (53 per cent) when compared to Norway (19 per cent).

Norway was the only country to have low agitation levels and a comparatively low use of antipsychotics. The other difference was the higher staff to resident ratios in Norway.

The Norwegian researchers believe their figures are linked to the way the homes are structured. Their nursing care is delivered in small, specialised units where most residents have single rooms and private bathrooms. The number of residents per unit ranged from seven to 14. With smaller numbers of people, there is less background noise and disruption, both of which are thought to trigger agitation.

In the last 20 years, there has been an increase in staff to resident ratios in Norway as well as an emphasis on improving the skills needed to deliver person-centred care.

Dutch research

Holland is another potential source of interesting ideas about the provision of care. As with Norway, nursing homes are organised into small living groups of between six and 12 residents. Specially trained nursing home doctors are employed by the homes to care for every resident. They provide a much higher degree of medical expertise and input in end of life care than is typically the case in homes in the UK.

Dr Sytse Zuidema is a Dutch elderly care doctor researching the levels and causes of agitation amongst Dutch nursing home residents with dementia. His most recent research identified a clear link between a patient's environment and symptoms of agitation. However, the research could not identify any specific factors to account for this (such as size of unit or accessing safe areas to walk).

Dr Zuidema is keen to explore this subject further and particularly to understand the interactions between staff and residents. He suspects that team culture, and the extent to which people work together towards a common goal, is the underlying factor.

The Society's Director of Research, Professor Clive Ballard, co-wrote the cross-cultural research paper. He said,

'Our findings highlight the urgent need to improve the quality and consistency of care for people with dementia in nursing and care homes in the UK. Introducing specialist dementia training, as emphasised in the National Dementia Strategy, is one key factor in achieving this.

'However, rather than re-invent the wheel, it is important to look at care models in other countries to find out what works. Norway and Holland provide two successful models we can learn from, and which can contribute to the development of better care in the UK.'