Behavioral Caregiving for Adults with Traumatic Brain Injury Living in Nursing Homes: Developing a Practice Model
McLean, Alison M., Koppang, Jill, Journal of Theory Construction and Testing
Caring for individuals with traumatic brain injury (TBI), many of whom display difficult behaviors, presents a significant challenge to nursing home caregivers. Many of the behavioral caregiving strategies developed for other nursing home residents, such as those with dementia, are not effective for individuals with TBI. Many types of behavioral interventions are effective for adults with TBI in other settings, such as specialized rehabilitation or community support programs, but these interventions may not be feasible within the context of a nursing home. Guided by the approach of a realist review, the authors sought to identify which TBI behavioral interventions may be most successful within the context of a nursing home. The authors analyzed emergent themes, leading to the creation of a Model of Behavioral Caregiving for Traumatic Brain Injury. This model illustrates the essential factors to be considered when developing an effective behavior plan for an individual with TBI living in a nursing home. Suggestions for research to test this model are provided.
Key Words: Brain injury, nursing home, behavior, caregiver
Traumatic brain injury (TBI) is a leading cause of lifelong disability (Colantonio et al., 2004; Greenwald, Burnett, & Miller, 2003). Each year in developed countries, 1-2 people out of 1,000 require hospitalization as a result of TBI (Rutland-Brown, Langlois, Thomas, & Xi, 2006), and in the US, an estimated 20-30% are discharged to nursing homes (Finkelstein, Corso, &C Miller 2006). The care needs of adults with TBI differ from the needs offrali, elderly nursing home residents, posing a challenge to caregivers (Woodhead & Edelstein, 2008). One of the most frequently reported difficulties is problem behavior, including verbal or physical aggression, wandering, self-injury, sexually inappropriate behaviors, and resistance or non-compliance to care (Belanger et al., 2008; Cameron, Pirozzo, & Tooth, 200; Gabella, Mangione, Hedegaard, & Kelly, 2007; Yody et al., 2000). These behaviors may relate to fatigue, impaired language skills, disinhibition, impulsivity, poor anger control, and cognitive deficits affecting attention, memory, information processing, reasoning, initiation, or self-awareness (Ashman, Gordon, Cantor, & Hibbard, 2006; Knight, Rutterford, Alderman, & Swan, 2002; Lippert-Griiner, Kuchta, Hellmich, & Klug, 2006). Because nursing home environments lack age-appropriate and personally meaningful activities (Kelly & Winkler, 2007), adults with TBI may experience loneliness, boredom, frustration, and social and family isolation, which exacerbate problem behaviors.
Behavioral caregiving refers to use of specific strategies or interventions, including medication, aimed at reducing or eliminating challenging behaviors and improving the safety and well-being of individuals and their caregivers. Many behavioral interventions are effective for individuals with dementia, a large population in nursing homes (Gabella et al., 2007). However, these interventions may not be successful for individuals with TBI, despite symptoms such as memory impairment and agitation appearing similar between individuals with TBI and individuals with dementia. For example, reminiscence therapy (Woods, Spector, Jones, Orrell, & Davies, 2007) and validation therapy (Jervis, 2002; Tondi, Ribani, Bottazzi, Viscomi, & Vulcano, 2007) are based on the understanding that the well-being of people with dementia, who have little capacity to learn, can be enhanced by focusing on their past memories and not confronting their disorientation to the present. Instead, adults with TBI benefit from activities that orient them to the present, and promote new learning through repetition and practice. Outside of the nursing home setting, many behavioral interventions have been found to be effective for individuals with TBI (Ylvisaker, Feeney, & Capo, 2007). Some are more successful than others, and many require specialized supports or programs (Giles & Manchester, 2006; Yody et al. …