Current Topics in Care

Change and Predictors of Change in Social Skills of Nursing Home Residents With Dementia

American Journal of Alzheimer’s Disease & Other Dementias® 2014, Vol. 29(1) 23-31 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1533317513505129 aja.sagepub.com

Neena L. Chappell, PhD, FRSC1, Helena Kadlec, PhD2, and Colin Reid, PhD3

Abstract Background: Social skills are of primary importance for those with dementia and their care providers, yet we know little about the extent to which basic social skills can be maintained over time and the predictors of change. Methods: A total of 18 nursing homes with 149 newly admitted residents with moderate to severe dementia, 195 direct care staff, and 135 family members, in British Columbia, Canada, contributed data on change in social skills from admission to 6 months and 1 year later. Results: Three-quarters of residents maintained or improved their basic social skills during both the time periods. Decline was explained primarily by cognitive status at the time of admission, notably present orientation. However, staff-to-resident communication becomes more important over time. Conclusions: Social skills appear to present an opportunity to maintain interaction with these residents. The findings also suggest that a focus on the present orientation before and following admission and on staff-toresident communication may be beneficial. Keywords social skills, cognitive function, dementia care, nursing homes, Alzheimer’s disease

The fact that dementia is a progressive syndrome, which can be due to multiple pathologies with no known cure and is devastating for the afflicted individual needs no repetition here. One area affected by cognitive impairment is a person’s social skills and subsequently their ability to interact socially. A minimal level of social skill is necessary for meaningful interaction. Yet, as Lawton1,2 noted, interaction is a basic need of those with dementia, even though their context becomes more restricted as dementia progresses.3,4 A lack of interaction can also lead to loneliness,5-7 and we know that those with fewer social skills in nursing homes are less likely engaged with nurses, more likely socially isolated,8 and more likely prescribed antipsychotic drugs.9 Although we know that a decrease in the ability to communicate accompanies disease progression,10,11 we do not know the extent to which social skills decline or whether these skills can be maintained or even improved over time. And, as O’Connor and colleagues12 noted, there is growing evidence that some of the undesirable impacts of dementia might be slowed through the promotion and delivery of key dimensions of care (such as staff-to-resident communication, resident autonomy, involvement of family, etc). This article reports the findings on change in basic social skills at 6 and 12 months after admission and the predictors of change including measures of the dimensions of care among a sample of nursing home residents with moderate to severe dementia.

Review of the Literature Social interaction is increasingly recognized as an important component of quality indicators within nursing homes.13 McLean14 and Robinson and colleagues15 argued that such interaction must be prized over instrumental tasks and that without opportunities for meaningful social interaction, nursing homes are not person-supporting communities. Especially among residents who are cognitively impaired, social skills are important in terms of how others react to them, a consequence complicated by physical limitations, including those conditions that affect the ability to communicate.8 Other well-known problems in the nursing home context include understaffing, which can leave little time for staff–resident social interaction, unsatisfactory resident–resident interaction due to dementia-

1 Department of Sociology, Centre on Aging, University of Victoria, British Columbia, Canada 2 Hollander Analytical Services, Ltd., Victoria, British Columbia, Canada 3 Faculty of Health and Social Development, UBC Okanagan, Kelowna, British Columbia, Canada

Corresponding Author: Neena L. Chappell, PhD, FRSC, Department of Sociology, Centre on Aging, University of Victoria, PO Box 1700 STN CSC, Victoria, British Columbia, Canada V8 W 2Y2. Email: [email protected]

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American Journal of Alzheimer’s Disease & Other Dementias® 29(1)

24 related communication difficulties, and isolation from the outside world. The literature6-8 is replete with terms that fall under the umbrella of social interaction including but not limited to social support, expressive language skills, social skills, relations, and relational interaction. Interaction can be measured in terms of face-to-face contact, all contact (including letter writing, telephoning, Skyping, and texting), quality of the interaction, and relationship-specific interaction (with spouses, daughters, etc). Most of this focuses on the extent and/or quality of interaction. Concern in this article is directed toward the individual’s basic social skills or, said another way, the person’s competence to engage in social interaction. For example, does she or he respond appropriately when spoken to, acknowledge another’s comment, look at the person speaking to him or her? The extent to which care can improve or slow the deterioration in social skills among those with dementia is unknown. Much of the research focuses on other aspects of interaction. One study in the United Kingdom16 found that a diagnosis of dementia is unrelated to social withdrawal while impairment in activities of daily living (ADL) is related. Similarly, the degree to which individual characteristics are related to change or lack of deterioration in social skills is also unknown. Chappell and Reid17 reported that female residents with dementia are less likely than male residents to exhibit decline in expressive language skills over time. Although older age and lower education have been identified as potential risk factors for dementia,18,19 their relevance for the social skills of those with dementia has not been investigated. It is intuitively plausible that social support, such as number of friends/family visits per week, and their relationship to the resident (spouse, daughter, etc), is important for maintaining basic social skills. Determining which aspects of the nursing home environment might also affect social skills is challenging. Basic social skills are seldom studied as a care outcome despite their obvious importance for person-centered care.2,20 In the United States21-23 and Canada,17 all studies with rigorous scientific designs report little if any empirical relationship between the dimensions of care and a variety of other (ie, not social skills) outcomes (such as expressive language skills, functioning, agitation, etc).24 Most research linking dimensions of care with resident outcomes is restricted to the study of a single dimension of care with an emphasis on staffing issues being critical to the provision of optimal care for those with dementia.25 Studies26,27 have linked staff education to a reduction in physical aggression toward nursing staff and quality of care that is measured, for example, by completing the basic physical tasks of caring. Early research28 also linked professional staff-to-resident ratios to the quality of resident life. Castle and Fogel29 reported that a higher ratio of nurse aides but a lower ratio of licensed practical nurses (LPNs) to residents was associated with improvement in social engagement. Reid and Chappell30 however did study social skills and found that the ratio of nursing staff to residents is unrelated to change in social skills. They also reported a significant overall decline in social skills during the first year of residency.

Other aspects of the nursing home environment (such as forprofit status and percentage of residents with dementia) have not been studied in relation to social skills. Size of facility (number of beds) has been shown to affect resident outcomes in areas other than social skills. Day and Calkins,31 for example, found that smaller units (6-12 vs 20-60 residents) led to decreased overstimulation for persons with dementia. Other research32,33 found that smaller units are associated with benefits such as reduced anxiety, depression, and psychotropic drug use as well as increased mobility. In summary, basic social skills are important for residents with dementia in nursing homes if they are to optimally engage/interact with staff and others, yet surprisingly little research attention has been devoted to this area. Indeed, basic information concerning whether and the degree to which change in basic social skills takes place over time remains undocumented. Despite the lack of empirical evidence, there are many factors that could potentially be important for the maintenance or enhancement of residents’ social skills including individual factors such as gender, age, and social support and institutional factors such as dimensions of care, staffing, size of facility, and profit/not-for-profit status. The cognitive impairment itself may also be relevant for both level of and change in level of basic social skills.

Purpose of the Present Study This study examines change, and predictors of change, in social skills among residents with moderate to severe dementia in nursing homes in British Columbia, Canada. Change is measured from admission to 6 and 12 months later.

Methods Study Design A 2-level (facility and individual) prospective design was implemented in an observational cohort study.34 Power analyses indicated that 14 facilities with 8 residents at each would be sufficient to detect a moderate relationship between variables, with statistical power of .80 at the .05 level of significance and taking into account a 10% attrition rate. Such a multimethod approach was necessary given the complexity of the questions being asked.35 Ethics approval was received from the university and regional health authorities.

The Institutional Level In total, 18 nursing homes were recruited, chosen to reflect diversity in terms of size, type of ownership, and percentage of residents with dementia. Facility-level data were collected using interviews with facility staff and family members and averaging scores for each facility. As shown in Table 1 panel A, just over a fifth (22.2%) of the facilities were public, 44.4% private, nonprofit, and 33.3% private, for profit. Over three-quarter (77.8%) had specialized dementia care units; 61.1% permanently assigned their staff to residents, and most

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Chappell et al

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Table 1. Selected Sample Characteristics.

Table 1. (continued) N

(A) Facilities (N ¼ 18) Ownership Public Private, nonprofit Private, for profit Have specialized dementia unit Staff permanently assigned to units Staff permanently assigned to residents Staff required to have dementia training prior to employment Staff unionized # of beds # of units % residents with dementia (B) Family members (N ¼ 135) Female Relationship Daughters Sons Wives Husbands Other (eg, nieces) (C) Direct care staff (N ¼ 195)a Type of staff Resident care aide Health care workers/aides Personal care attendants Nurse’s aides/RAs/LPNs Female English first language Years at facility >7 1-7

Change and predictors of change in social skills of nursing home residents with dementia.

Social skills are of primary importance for those with dementia and their care providers, yet we know little about the extent to which basic social sk...
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