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RESEARCH ARTICLE |
a Department of Nursing, Faculty of Health Sciences, Hiroshima International University, Hiroshima Ken, Japan.
Andrea S. Schreiner, Department of Nursing, Hiroshima International University, Kurose-cho, Kamo-Gun, Hiroshima Ken, 724-0695, Japan E-mail: a-streit{at}hs.hirokoku-u.ac.jp.
Decision Editor: Toni C. Antonucci, PhD
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Abstract |
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). Despite major differences between Japanese and American cultures, findings were highly consistent with those of previous U.S. studies. Physically aggressive behavior, although evidenced by only 10–20% of the sample, comprised the strongest factor. A separate factor for verbal agitation also emerged. The behaviors declined during the evening and night shifts. In both the Japanese and U.S. samples, wandering, general restlessness, verbal agitation such as repetitious questioning, cursing, and complaining occurred most frequently. Another 4-point scale was used to code the degree to which agitated behavior occurred during eating, dressing, bathing, and toileting for each resident. The majority of aggressive behavior occurred in relation to personal caregiving, especially in regard to bathing. Despite major cultural differences, Japanese findings paralleled previous U.S. results.
JAPAN continues to have the world's longest average life expectancy with the most recent estimates for men and women being 76.4 and 82.8 years, respectively; the current median age of the population aged 65 and over being 79.5 (men) and 85.7 (women) years (Japanese Ministry of Health and Welfare Management and Coordination Agency Statistics Bureau 1999). Currently, persons 65 years of age and older comprise 16% of the total population. The number of one-person households among elderly Japanese has also increased by a factor of almost 35% in the years between 1990 and 1995 and now represents 12% (Japanese Ministry of Health and Welfare Management and Coordination Agency Statistics Bureau 1999) of the total households of elderly Japanese. Living alone has been found to be a significant predictor of earlier use of nursing home services among persons with Alzheimer's disease (Miller et al. 1998).
To meet the growing health care needs of this aging population and changing social structure, the Japanese government began planning a comprehensive package of social benefits and health care reforms, based largely on the U.S. experience and referred to as the Gold Plan, over 10 years ago. One of the benefits of this plan, long-term care insurance (Kaigo Hoken) for the elderly Japanese population, will come into effect in April of 2000. Thus, the number of nursing homes, which has been comparatively low in Japan, roughly 22.6 beds per thousand Japanese age 65 and over (Japanese Health and Welfare Statistics Association 1998) versus the U.S. ratio of 52.6 beds per 1,000 (Strahan 1997), is expected to burgeon in the next few years.
The demographics of the Japanese population, their increased longevity, as well as the increase in cerebral vascular disease, now second only to cancer as the leading cause of death in the elderly population (Japanese Health and Welfare Statistics Association 1995), suggest that the incidence and prevalence of dementia is going to increase in Japan and probably become the highest in the world.
There is a growing need for information on the behaviors and care-giving needs of this elderly dementia population. Despite this information need, very little, if any, empirical research has been carried out in Japanese nursing homes on the actual behavior of elderly dementia patients. However, several recent studies have examined dementia prevalence rates among both community-dwelling and institutionalized elderly Japanese (Seno et al. 1999; Yamada et al. 1999) and have found the rates to be higher than previously reported and closer to U.S. estimates.
The present study used a structured data collection tool to gather information on 29 behaviors of dementia patients that have been identified as both troublesome in terms of indicating unmet needs, disturbing other residents, and/or being potentially harmful to the self or to others, as well as frequent (Aarsland, Cummings, Yenner, and Miller 1996; Beck, Rossby, and Baldwin 1991; Cohen-Mansfield, Marx, and Rosenthal 1989; Cohen-Mansfield, Marx, and Werner 1992; Deutsch and Rovner 1991). To our knowledge, this is the first study that collects information on the actual behavior of dementia patients in Japanese nursing homes.
Given the extensive research documenting major differences between Japanese and Western cultures in terms of codes of conduct and norms for everyday life (Diamond 1998), we were curious to know if these differences would appear in our findings. Would the behavior of persons with dementia in an Asian culture that is described as valuing harmony and passive acceptance be different from that of persons in a Western culture that presumably places greater value on individualism and assertiveness?
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Methods |
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Data were collected only on all residents who had been in the facility for 3 months or longer. Only dementia residents who were completely bedbound because of their poor physical condition were excluded from the study. Research methods rigorously protected the confidentiality of facilities, respondents, and residents.
Measures
Data on behavior was collected using the Cohen-Mansfield Agitation Inventory (CMAI; Cohen-Mansfield 1991). This instrument asks caregiving staff to rate the frequency of 29 typical agitated behaviors among dementia patients (see Table 1 ). Staff were trained in the definitions and classifications of each behavior and asked to rate the frequency at which it had occurred during the past 2 weeks on a scale ranging from (1) never occurs to (7) occurs several times an hour. The data were collected in interview fashion with a member of the research team coding the responses of the caregiver. To control for facility-level rater bias, the sample subjects were divided among three different caregivers at each site. These three caregivers then rated their sample across all shifts. The scheduling system in Japan is structured so that all caregiving employees must rotate between shifts, thus each caregiver is equally familiar with residents' behavior during all three shifts. Because nursing assistants spend the most actual time caring for the patients, we made an effort to have at least one nursing assistant at each site participate in the data collection.
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To test for the reliability of the instrument, a subsample of 29 dementia residents was rated by two different caregivers. Interrater agreement (using 0- or 1-point discrepancy) was .91 for this subsample.
After coding each resident with the CMAI, staff were asked to rate each resident in terms of their behavior during personal care using the following scale: (1) resident comprehends purpose of the task and completes it by his- or herself or offers no resistance to assistance, (2) resident needs some verbal guidance to perform the task but will usually do so without major problem, (3) resident usually argues and will not perform the task without the caregiver's verbal persuasion and/or physical guidance, and (4) resident is so strongly opposed to performing the task and resists to such an extent that force must be used at times and/or the task must be postponed. Staff were instructed to rate residents only in terms of their cognitive and emotional status regarding task performance and to disregard their functional activities of daily living (ADL) level. Examples of representative behaviors were given for each of the 4 scale anchors.
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Results |
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Agitated Behaviors
In Table 1 we compare means across shifts with U.S. results (Cohen-Mansfield et al. 1989). Sample sizes were 392 (Japan) and 408 (United States). U.S. and Japanese means were compared using the paired t test and no significant difference was found ( p 
< .01). The majority of the behavior means did not differ by a factor of greater than 0.3. Only the means for inappropriate (dis)robing, exit seeking, negativism, inappropriate handling, and repetitious mannerisms differed by more than 0.3 between U.S. and Japanese samples. The Japanese sample showed higher means for exit seeking, inappropriate (dis)robing, and inappropriate handling, whereas the U.S. sample showed higher negativism and repetitious mannerisms.
The behaviors showed the same trend to decrease during the night. In both samples, wandering, general restlessness, and repetitious questions were the most frequent behaviors. Cursing ranked higher in the Japanese sample than did negativism and complaining, but all three were among the most frequent behaviors in both samples.
The means for the behaviors that were found to comprise a factor referred to as physically aggressive behavior (Cohen-Mansfield et al. 1989), such as hitting, grabbing, pushing, and biting were very similar in both Japanese and U.S. samples.
Actual Frequency of Agitated Behaviors
To get a better idea of the actual frequency of the behaviors in our sample we looked at the distribution of the behaviors with the highest means. These were wandering, general restlessness, repeating questioning, exit-seeking, cursing, complaining, inappropriate (dis)robing, and inappropriate handling, in that order.
The modal frequency for each behavior was 1, indicating that it never occurs. However, if a physically nonaggressive behavior is present, it tends to occur next most often at a frequency of several times a day or several times an hour. For example, as can be seen in Table 2 , 63% of residents do not wander. However, among those that do, almost 10% wander several times an hour and 14% wander several times a day. Thus, 24% of all residents are on the move around their nursing home unit all day long. The pattern with the verbally agitated behaviors was flatter, with fairly equal groups of residents questioning, or seeking attention, either several times a week or several times a day. The same was true for complaining and negativism, except that they most often tended to occur just once or twice a week.
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Eighty-two percent of the residents were found to manifest one or more behaviors at least once a week, which is lower than the rate of 93% reported by Cohen-Mansfield and colleagues 1989 but comparable to other reported estimates (Rovner, Kafonek, and Filipp 1986). The mean number of different behaviors exhibited per resident per day shift, at any frequency of occurrence (i.e. from 2 to 7 on the scale) was found to be 4.63. This is higher than the U.S. rate of 3.8 (Cohen-Mansfield et al. 1989). This suggests that although fewer patients evidence agitated behaviors, those that do have more of them and do them more frequently.
Correlation Matrix
The correlation matrix (see Table 3 ) shows the relationships between the agitated behaviors (behaviors that occurred in less than 5% of the sample were dropped). The behaviors are strongly intercorrelated; only 66 (27%) of the 241 correlations lacked significance. The lack of significance was found mainly between verbally agitated and physically aggressive behaviors. In addition, hiding and hoarding did not correlate with the aggressive behaviors for the most part.
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We included age in the correlation matrix and found it did not correlate significantly with any of the behaviors using a significance level of .001 (Bonferroni correction). It did correlate negatively with wandering and exit-seeking at the .05 level of significance.
Personal Care
Next, we looked at the degree to which agitated behavior occurred during the four personal caregiving tasks of eating, dressing, bathing, and toileting (see Table 4 ).
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The pattern for dressing, bathing, and toileting was somewhat different with almost twice as many men in level 4 as women. This means that men are more likely to resist the performance of these tasks to such an extent that they must be postponed or force must be used. The most difficult task in this regard was bathing, followed by dressing, then toileting. Eighty-eight percent of men and 87% of women required some kind of guidance and/or assistance to perform the task of bathing. However, 19% of men, compared to 11% of women, opposed this task to such an extent that it usually had to be postponed or force had to be used to accomplish it. Again, this personal care scale measured psychosocial behavior not physical ability.
As can be seen in the Table 3 , cursing correlated strongly with bathing and toileting (negatively). This indicates that residents rated as more difficult in regard to toileting or bathing were also rated as having a higher frequency of cursing, as well as hitting, kicking, grabbing, throwing, screaming, and scratching. In fact, staff reported that most of the physically and verbally aggressive behavior took place during personal care, particularly during bathing time. The frequency distribution for the physically aggressive behaviors seems to corroborate this fact, as they occurred most frequently once or twice a week and baths are given once or twice a week.
In general, the personal care tasks were highly intercorrelated (see Table 3 ). Toileting and bathing were highly correlated (.773) indicating that persons who tended to be aggressive with staff in one of these functions were aggressive in both.
Factor Analysis
Next we looked at the factor structure of the daytime data (see Table 5 ). In keeping with the factor analysis of U.S. data (Cohen-Mansfield et al. 1989), we dropped behaviors that occurred in less than 5% of our sample (these were falling intentionally, hurting self, verbal sexual advances, physical sexual advances, repetitious mannerisms, and tearing things). We also adopted their four-factor solution and generalized least squares method with a varimax rotation.
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Table 5 compares our findings with Cohen-Mansfield and colleagues 1989 results (see also DeJonge and Kat 1996, for a factor analysis of the CMAI in the Dutch culture). In general, the same pattern emerged with discreet factors for the physically aggressive behaviors and the verbally agitated behaviors. Interestingly, hiding and hoarding did not relate to any other behaviors in both U.S. and Japanese samples. The physically agitated behaviors of wandering, exit-seeking, general restlessness, and inappropriate handling and (dis)robing were found to load on 2 factors in our sample, suggesting subgroups of residents with these behaviors.
In our sample, verbal agitation is best conceptualized as two distinct domains, verbally agitated versus verbally aggressive, in keeping with U.S. findings. The correlation matrix and factor matrix reveal that cursing, screaming, and making strange noises correlated most strongly with the physically aggressive behaviors rather than with the other verbal behaviors of questioning, wanting attention, or complaining.
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Discussion |
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). One of the main differences was that in our sample, although a smaller percentage of residents were found to manifest agitated behaviors, on average, they exhibited a slightly greater number of these agitated behaviors. This could be due to factors that were not controlled for in this study, such as differences in medication use between facilities and/or differences in the diagnostic accuracy of residents included in the dementia sample.
The fact that the physically agitated behaviors, such as wandering and inappropriate handling, loaded on two factors supports the research (Logsdon et al. 1998) that has identified different subpopulations of wanderers, some with aggressive behavior (factor 1 loading group) and others without (factor 2 loading group).
Beck and colleagues 1998 and Cohen-Mansfield and colleagues 1992 examined the individual characteristics that were related to disruptive behavior and found that age had a negative relationship, possibly because of the decreased physical functioning of this population. We also found that age was negatively correlated with general restlessness and wandering. When we looked more closely at age groups we found that wandering peaked with residents (both men and women) up to 74 years of age and then started to decline. Beck and colleagues 1998 also found that men tended to have slightly higher total disruptive behavior scores, and our sample supports this finding as well.
The difference in exit-seeking behavior (higher in our sample) may be due to a difference in ward or nursing home design. The Japanese facilities had little to distract or entertain those residents who wandered, so they constantly tried to exit via the locked unit doors. The U.S. facilities might have had more stimulation in the halls to occupy the wanderers or some kind of visual barrier to the doorways.
The factor structure revealed that persons who exhibited one physically aggressive behavior tend to exhibit several others as well. That is, if a resident kicks, they are also likely to hit, grab, push, and scratch. The same was true of the personal care tasks. If a resident was combative during toileting, he or she was also likely to be combative during bathing and, to a lesser extent, during dressing.
Again, it was clear from staff reports that most physically aggressive behavior occurred in relation to personal care. Other research has shown that dependency in personal care is related to aggressive behavior (Deutsch and Rovner 1991; Middleton, Stewart, and Richardson 1999), which probably relates to overall decline in cognitive functioning (Beck et al. 1998). We found that staff truly enjoyed providing anecdotal information during the survey interview, and although we kept the interview focused, we did not discourage them entirely from doing this. One of the benefits of this research is that staff have an opportunity to talk about their caregiving concerns.
It is important to note that the staff in this study have never received any special training in how to deal with dementia in this population. Thus, although level 1 (using force or postponing task) on the personal care scale is a completely undesirable outcome, it is a fact of current nursing home work and not unusual (Deutsch and Rovner 1991; Ryden 1988). Unfortunately, a common human response to aggression is return aggression.
Staff also anecdotally reported that screaming and making strange noises were associated with pain, which concurs with other recent studies (Cohen-Mansfield and Werner 1998a). Staff specifically reported these behaviors among residents in whom cancer had been deemed inoperable. Researchers (Horgas and Tsai 1998) have found that nursing home residents with dementia receive significantly less pain medication than other residents ceteris parebis, and this warrants further investigation.
The findings revealed that 73% of women and men were able to feed themselves independently with only 3–4% offering resistance to this task as defined by the scale shown in Table 4 . This is a task with the most obvious meaning and desirability. In addition, because it requires only upper body mobility, it is a task that residents can continue to do independently for longer than other tasks. Thus, it might be beneficial to try to integrate these characteristics of desirability, meaningfulness, and independence into the other personal care tasks in some way to make them more attractive to the dementia residents.
Deutsch and Rovner 1991 note that dementia behaviors, like all human behaviors, are motivated and are thus comprehensible and manageable to some degree. Current research is looking deeper into the relationship between the antecedents and consequences of these agitated behaviors (Cohen-Mansfield et al. 1992; Cohen-Mansfield and Werner 1998a) and has linked agitation to unmet needs stemming from poor health, depression, or pain. The fact that inappropriate disrobing correlated strongly with wandering in our sample may indicate that these residents have an unmet physical need, or they may be either in pain or tired and looking for rest.
Interventions to improve caregiving in this population by means of behavioral and/or environmental modification strategies have emerged in the recent research literature (Burgio and Scilly 1994; Cohen-Mansfield and Werner 1998b; Smyer, Brannon, and Cohn 1991) and deserve cross-cultural validation.
Finally, because Japanese culture is widely described as one of the most unique in the world in terms of the high amount of rituals and rules prescribing norms for social behavior, we expected our findings to be unique in some way. For example, because bathing is such a culturally important and universally appreciated custom in Japan (people of all ages bathe almost every night), we were told by researchers outside this field to expect Japanese dementia patients would not be as averse to bathing. However, as the results show, the greatest degree of aggressive behavior occurred during personal care and particularly during bathing, despite the fact that bathing in nursing homes is carried out in the traditional manner.
Thus, the effects of culture do not appear to mediate the effects of dementia on the behavior of elderly persons, at least in this sample. Although there is not a great deal of research on cultural differences in neuropsychiatric disorders such as dementia, our findings are in keeping with those of Cohen, Hyland, and Magai 1998 regarding the predominance of clinical similarity in culturally distinct populations. This bodes well for cross-cultural intervention research and suggests that successful techniques should be able to cross cultures and work among different populations.
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Acknowledgments |
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Received for publication May 24, 1999. Accepted for publication November 22, 1999.
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