The best evidence for minimizing resistance‐to‐care during assisted personal care for older adults with dementia in nursing homes: a systematic review
The best evidence for minimizing resistance‐to‐care during assisted personal care for older adults with dementia in nursing homes: a systematic review
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在疗养院对患有痴呆症的老年人进行辅助个人护理期间最大限度地减少护理阻力的最佳证据：系统评价
DOI：
10.11124/jbisrir-2012-431
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发表时间：
2012
期刊：
影响因子：
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通讯作者：
K. Makimoto
中科院分区：
文献类型：
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作者：
R. Konno;H. Kang;K. Makimoto
目的探讨干预措施对老年痴呆患者辅助个人护理过程中抗护行为的影响。•哪些干预措施可以有效降低老年痴呆症患者在辅助个人护理活动（即用餐时间协助、如厕、口腔护理、晨间护理和淋浴/沐浴）期间抵抗护理行为的频率和强度？•哪些干预措施可以有效降低老年痴呆症患者总体日常个人护理活动中抗护理行为的频率和强度？在许多国家，老年痴呆症患者的比例正在稳步上升许多患有痴呆症的老年人住在养老院，其中大多数人由于患有痴呆症相关症状而需要个人护理协助。护理人员和正式护理人员在提供护理时经常受到这些居民的抵制或排斥。这种行为可能是一个很大的障碍，特别是当照顾者试图在日常个人护理中提供帮助时，包括口腔护理、洗澡、喂食、穿衣和如厕“抵抗-护理”的定义15,16是指身体和/或心理上的抵抗行为，例如“远离工作人员，收紧四肢，使身体僵硬，在护理期间故意停止或拒绝负重，挥舞手臂和腿，用言语和/或声音口头反对护理”（第7页）。17在文献中可以找到一些其他的定义，这些定义涉及痴呆症养老院居民所表现出的抗拒护理行为。术语的含义似乎没有明显的区别，它们在护理研究中经常互换使用。例如，Mahoney等人将“抗拒照顾”一词定义为“痴呆症患者抗拒或反对照顾者努力的一系列行为”（第28页）。其他常用术语包括“拒绝护理”，7“抵抗行为”，10“抵抗护理（RTC）”，18,11,13“抵抗护理行为（CRB）”，19和“抵抗护理”。在本综述中，将使用术语“抵抗-抵抗-护理”来保持含义的一致性。抗护理行为是老年护理领域中常见的现象。一项美国研究报告称，23,837名患有痴呆症的养老院居民中有9%表现出对护理行为的抗拒，另一项美国研究也报告了类似的百分比，即3,230名居民中的9.7%。21从护理者的角度来看，面对这些护理抵抗行为的经验已经有了很好的记录。在瑞典进行的一项研究显示，瑞典斯德哥尔摩86名养老院工作人员中有79%的人报告被居民拒绝，挪威11家养老院的494名护士中有96.9%的人报告他们在个人护理期间经历过居民的抵抗行为。对护理的抗拒行为会给护理者和痴呆症患者带来严重的问题。照顾者会因为住院病人的这种行为而经历巨大的身体和精神上的痛苦。抗拒照顾行为会对照顾者造成身体和心理上的伤害对于居民来说，这样的行为会导致营养不良、皮肤破裂、脱水、便秘、体重减轻和其他健康问题。此外，无法控制对照顾的抗拒行为可能会导致言语和非言语的虐待行为以及对照顾者的身体和心理伤害这反过来又可能导致居民在身体和/或医学上受到不适当的限制。因此，有效的预防和管理这些行为对于护理人员和老年痴呆症患者来说都是至关重要的。一些系统的文献综述已经发表了关于痴呆相关行为的性质和管理。这些综述涉及的主题包括住宅老年护理机构的卫生保健，23对照顾者的攻击行为，8音乐和唱歌的治疗效果，24在用餐时间使用首选音乐干预，26与喂养相关的护理，27以及对促进痴呆和喂养困难老年人口服营养摄入的干预措施的回顾最近发表的一篇综述报道了引发抗护理行为的相关因素。通过检查以前发表的系统综述，很明显，他们的重点往往是广泛的，而不仅仅是关注日常个人护理背景下的抗护理行为。或者，他们针对特定的护理情况，如口腔护理或用餐时间，提出了是否应该针对每种护理活动采取不同的干预措施，或者任何干预措施是否可以在一般的日常个人护理中有效的问题。因此，本综述旨在研究哪些干预措施对管理或减少老年痴呆症患者的抗护理行为有效。审查将侧重于日常个人护理和整体日常个人护理中每个护理活动的有效干预措施。因此，回顾的结果将提供实用的建议，有效护理的每一个日常护理活动和整体的日常护理活动，以管理老年痴呆症患者的护理抵抗行为。实际上，抗拒护理行为通常很难与其他与痴呆症相关的行为区分开来。例如，在一项研究中，“不服从”一词指的是“对护理的抗拒”，这是在居民的个人空间受到侵犯时发生身体攻击行为之前发生的。这清楚地概括了养老院居民所表现出的抗拒性行为。其他可能与“抗拒-关心”行为的含义重叠的术语包括“不合作行为”、“破坏性行为”、“攻击/攻击行为”、“战斗行为”、“激动/激动行为”。同样，这些术语在很大程度上是可以互换使用的，在护理文献中似乎没有明显的区别。因此，只要符合纳入标准，本综述将纳入任何使用上述定义的论文。对JBI系统综述图书馆、PubMed、CINAHL和Cochrane图书馆的初步搜索显示，没有关于本主题的系统综述。
Objective To determine the effectiveness of interventions in minimizing resistance‐to‐care behaviors during assisted personal care for nursing home residents with dementia. Review Questions • What interventions are effective for reducing the frequency and intensity of resistance‐to‐care behaviors during assisted personal care activities (i.e. mealtime assistance, toileting, mouth care, morning care and shower/bathing) for nursing home residents with dementia? • What interventions are effective for reducing the frequency and intensity of resistance‐to‐care behaviors for overall daily personal care activities for nursing home residents with dementia? Background In many countries the proportion of older adults with dementia is steadily increasing.1,2,3 Many older adults with dementia live in nursing homes4 and most of them require assistance with personal care 5 due to having dementia‐related symptoms. Nursing staff and formal caregivers frequently experience resistance or rejection from such residents 6,7,8 when they are providing care. Such behavior can be a large obstacle, particularly when caregivers attempt to provide assistance in daily personal care including oral care, 9,10 bathing, 11 feeding, 12 dressing and toileting.13 The definition of “resistance‐to‐care” 15,16 means physically and/or psychologically resistive behavior, for example “pulling away from staff, tightening limbs, stiffening the body, deliberately ceasing or refusing to weight bear during care, waving arms and legs and verbally objecting to care using words and/or sounds” (p.7).17 Several other definitions can be found in the literature concerning the resistance‐to‐care behaviors exhibited by nursing home residents with dementia. No distinct difference seems to exist for what terms mean and they are often used interchangeably in the studies on nursing. For instance, Mahoney et al.13 have defined the term “resistive to care” to mean “the repertoire of behaviors with which persons with dementia withstand or oppose the efforts of a caregiver” (p.28). Other commonly used terms include “rejection of care”, 7 “resistant behaviour”,10 “resistiveness to care (RTC)",18,11,13 “care‐resistant behavior (CRB)”,19 and “resistance to care”. 17 In this review the term “resistance‐to‐care” will be used to retain consistency of meaning. Resistance‐to‐care behaviors are commonly reported phenomena in the aged care field. One US study20 reported 9% of 23,837 nursing home residents experiencing dementia demonstrated resistance‐to‐care behaviors and another US study also reported a similar percentage, i.e. 9.7% of 3,230 residents. 21 From the caregivers’ perspective experiences of confronting these care resistant behaviors have been well documented. A study conducted in Sweden showed 79% of 86 nursing home staff in Stockholm, Sweden 9 reported being rejected by the residents and 96.9% of 494 nurses in 11 Norwegian nursing homes reported that they experienced resistant behavior from the residents during personal care. 10 Resistance‐to‐care behaviors can cause serious problems for both caregivers and dementia‐stricken residents. Caregivers experience enormous physical and emotional distress from such behaviors carried out by their residents. Resistance‐to‐care behaviors can cause physical and psychological injury to caregivers.17 For the residents such behaviors can lead to malnutrition, skin breakdown, dehydration, constipation, weight loss 15 and other health problems. Furthermore, inability to manage resistance‐to‐care behaviors may cause verbal and non‐verbal abusive behaviors and physical and psychological harms to caregivers.22 This in turn may result in residents being inappropriately physically and/or medically restrained. 16 Therefore, effective prevention and management of such behaviors is crucial for both care providers and nursing home residents with dementia. Several systematic literature reviews have been published on the nature and management of dementia‐related behaviors. Those reviews addressed topics including hygiene care in residential aged care facilities,23 aggressive behavior toward caregivers,8 therapeutic effects of music and singing, 24 the use of preferred music intervention 25 at mealtimes,26 feeding‐related nursing care, 27 and a review on interventions to promote oral nutritional intake of older people with dementia and feeding difficulty.27 A recently published review 7 has reported on the relevant factors that trigger resistance‐to‐care behaviors. By examining previously published systematic reviews, it was evident that their focus tended to be broad and not solely concerned with resistance‐to‐care behaviors in the context of daily personal care. Alternatively, they addressed a specific care situation such as oral care or mealtime, raising questions whether interventions should differ for each care activity or if any interventions can be effective in daily personal care in general. Thus, the present review will aim to examine what interventions are effective for managing or reducing resistance‐to‐care behaviors of nursing home residents who have dementia. The review will focus on effective interventions for each care activity in daily personal care and overall daily personal care. Thus the review's results will provide practical recommendations concerning the effective nursing care for each daily care activity and overall daily care activities for managing resistance‐to‐care behaviors of older adults with dementia in nursing homes. Resistance‐to‐care behaviors are, in reality, often very difficult to differentiate from other dementia‐related behaviors. For instance the term “noncompliance” was used in one study referring to “resistiveness to care”, which preceded physically aggressive behavior occurring in response to the invasion of the resident's personal space. 28 This clearly encapsulates the resistive nature of the behavior demonstrated by nursing home residents. Other terms possibly overlapping with the meaning of “resistance‐to‐care” behaviors include “uncooperative behaviours”,29 “disruptive behaviours”,30 “aggression/aggressive behaviours”,8 “combative behaviour”,6 or “agitation/ agitated behaviours”. 31 Again, these terms are largely used interchangeably and no clear cut difference appears to exist in the nursing literature. For this reason the review will include any papers that have used any of those definitions as long as the studies meet the inclusion criteria. A preliminary search of the JBI Library of systematic reviews, PubMed, CINAHL and the Cochrane library have shown there is no systematic review on the present topic.