Which unmet needs contribute to behavior problems in persons with advanced dementia?

Highlights

• On average, three unmet needs were identified per nursing home resident.

• The most common were needs for stimulation and for meaningful and social activities.

• The paper presents a methodology for the determination of unmet needs.

Abstract

The Unmet Needs Model states that problem behaviors of people with dementia result from unmet needs stemming from a decreased ability to communicate those needs and to provide for oneself. The purpose of this study is to describe the unmet needs of persons with dementia exhibiting behavior problems. Eighty-nine residents with dementia from six Maryland nursing homes were assessed by research assistants and nursing assistants for their unmet needs using multiple assessment tools. Three unmet needs per resident were identified on average, with informants rating boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activity as the most prevalent needs. Discomfort was associated with higher levels of verbally agitated behaviors (e.g., complaining). Based on results and independent ratings of pain, the authors estimate notable under-detection of discomfort and pain by both types of informants. The study demonstrates methodologies for uncovering unmet needs among persons with dementia and highlights the importance of developing programs that address those unmet needs, especially social and activity needs of nursing home residents. The detection of pain, and possibly that of discomfort, may require a different methodology.

Introduction

Persons with dementia often exhibit inappropriate behaviors, which increases their suffering as well as the burden of caregivers (Cohen-Mansfield, 2001). These behaviors are addressed by both pharmacological and nonpharmacological treatments. There are several theoretical models regarding the etiology of inappropriate behaviors in persons with dementia (Cohen-Mansfield, 2000b), and this paper will focus primarily on the Unmet Needs Model and its implications for the treatment and prevention of these behaviors.

The Unmet Needs Model (Cohen-Mansfield and Werner, 1995, Cohen-Mansfield, 2000b) postulates that the dementia process results in a decreased ability to meet one׳s needs because of an increasing difficulty in communicating these needs, and a decreased ability to provide for oneself (Hancock et al., 2006). The needs may pertain to pain/health/physical discomfort, mental discomfort, the need for social contacts, uncomfortable environmental conditions, or an inadequate level of stimulation. According to the Unmet Needs Model, problem behaviors result from an imbalance in the interaction between lifelong habits and personality, current physical and mental states, and less than optimal environmental conditions (Fig. 1). Most of the unmet needs arise because of dementia-related impairments in both communication and the ability to utilize the environment appropriately to accommodate needs. The environment and caregivers, in turn, either do not provide for the needs or do so in a way that does not accommodate one׳s preferences, habits, and disabilities. Consequently, agitated behaviors, such as pacing, may act to alleviate boredom or repetitious vocalizations may be used to communicate the need. Prior studies have found relationships between certain behaviors and participants׳ conditions and environments which support the notion of unmet needs. Specifically, verbal/vocal behaviors were more likely to be displayed by persons who were rated as having pain, discomfort, or being alone, whereas physically nonaggressive behaviors were more likely under normal environmental conditions when people with dementia were not engaged with any activity (Cohen-Mansfield et al., 1990, Cohen-Mansfield and Werner, 1995, Sloane et al., 1997, Cohen-Mansfield, 2000a).

Understanding unmet needs is central in formulating treatment plans for nursing home (NH) residents with dementia. Indeed, they form the basis for nonpharmacologic interventions for dementia (Bédard et al., 2011, Kolanowski et al., 2011, Cohen-Mansfield et al., 2012). Thus we examined unmet needs as perceived by nursing assistants (NAs) caring for the residents as well as by research assistants (RAs) involved in implementing a nonpharmacological treatment program. As described in Cohen-Mansfield et al. (2012), the nonpharmacolocical interventions were tailored to participants׳ needs. In response to need to alleviate loneliness, participants were presented with interventions, such as simulated social stimuli, a respite video, a lifelike baby doll, or one on one interaction. Those who had a need of relieving boredom were provided with stimuli that matched their past preferences, such as reading materials or music. Those who had needs related to discomfort were helped directly with the specific source of discomfort, and an intervention could involve provision of care requested, such as responding to requests to be taken to one׳s room. The specific research questions are:

• What are the perceptions of unmet needs that contribute to behavior problems? What is the level of confidence in the determination of unmet needs?

• How does RAs׳ determination of unmet needs compare to that of NAs caring for the person?

• How do the unmet needs relate to residents background information? The following hypotheses were examined:

  • The designation by the research assistant of pain relief as an unmet need will correlate positively with ratings of pain (assessed via the PAINE), and to negative affect (Cohen-Mansfield and Marx., 1993).

  • Unmet needs due to anxiety will be positively related to observed negative affect at baseline.

• How do the unmet needs relate to the type of agitation manifested? Specific hypotheses are:

  • Social needs, pain, and discomfort will be related to verbally agitated behaviors (Cohen-Mansfield et al., 1990, Cohen-Mansfield and Werner, 1995, Sloane et al., 1997, Cohen-Mansfield, 2000a).

  • Boredom and need for stimulation will be related to physically nonaggressive agitated behaviors (Cohen-Mansfield, 2000a).