The best evidence for minimizing resistance-to-care during assisted personal care for older adults with dementia in nursing homes: a systematic review.

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. Many older adults with dementia live in nursing homes and most of them require assistance with personal care due to having dementia-related symptoms. Nursing staff and formal caregivers frequently experience resistance or rejection from such residents 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, bathing, feeding, dressing and toileting.The definition of "resistance-to-care" 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). 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. 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", "resistant behaviour", "resistivenessto care (RTC)", "care-resistant behavior (CRB)", and "resistance to care". 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 study 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. 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 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. 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. For the residents such behaviors can lead to malnutrition, skin breakdown, dehydration, constipation, weight loss 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. This in turn may result in residents being inappropriately physically and/or medically restrained. 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, aggressive behavior toward caregivers, therapeutic effects of music and singing, the use of preferred music intervention at mealtimes, feeding-related nursing care, and a review on interventions to promote oral nutritional intake of older people with dementia and feeding difficulty. A recently published review 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. 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", "disruptive behaviours", "aggression/aggressive behaviours", "combative behaviour", or "agitation/ agitated behaviours". 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.