Browsing by Subject "Cognitive Impairment"

Behavioral symptoms of dementia cause considerable distress for persons with dementia and their caregivers and are related to adverse outcomes that have significant social and economic impact. Thus, behavioral symptoms represent one of the most challenging aspects of dementia care. Over the past three decades, research on behavioral symptoms of dementia has laid the foundation for development of non-pharmacological interventions by identifying underlying mechanisms of symptom development. However, the research has largely overlooked how the needs of military veterans may influence development and treatment of behavioral symptoms of dementia, including those needs associated with co-occurring dementia and posttraumatic stress disorder (PTSD). This dissertation aimed to develop knowledge related to behavioral symptoms of dementia among older veterans with and without PTSD by synthesizing current understanding of neurocognitive and psychiatric comorbidities of PTSD among veterans as well as explicating relationships among background factors, proximal factors, and behavioral symptoms of dementia among veterans living in residential care using the need-driven, dementia-compromised behavior (NDB) model.

This dissertation includes a systematic review in Chapter 2 that synthesized the patterns of neurocognitive and psychiatric comorbidities of PTSD in older veterans and revealed a substantial gap in the literature with regards to understanding manifestations and treatment of behavioral symptoms of dementia among older veterans with co-occurring dementia and PTSD. The primary study of this dissertation that encompasses Chapters 3 and 4 utilized an exploratory sequential mixed methods design using secondary data derived from the evaluation dataset of the STAR-VA training program. In Chapter 3, a qualitative study, as the first phase of the mixed methods study, analyzed text data that captured the interdisciplinary care team’s observation of behavioral symptoms of dementia and their circumstances for the subsample of 33 veterans from the STAR-VA dataset. This qualitative study described how behavioral symptoms of dementia are manifested among veterans with and without PTSD in the context of personal, interpersonal/social, and environmental factors that trigger the symptoms. Findings demonstrated that behavioral symptoms of dementia are heterogeneous, with distinct clusters of triggers that are multi-level, thereby warranting an interdisciplinary, multi-level approach to developing person-centered interventions. In addition, findings from this qualitative study informed the development of the second phase of the sequential mixed methods study in Chapter 4 that aimed to test hypothesized pathways between background factors, interpersonal triggers (proximal factors), and behavioral symptoms of rejection of care and aggression and to explore the moderating effect of PTSD on the hypothesized pathways. The mixed methods approach integrated quantitative data measured by standardized scales and text data for 315 veterans derived from the STAR-VA dataset. After converting text data into categorical variables, structural equation modeling (SEM) was performed to compare the patterns of relationships among background factors, interpersonal triggers, and behavioral symptoms of rejection of care and aggression between veterans with and without PTSD. The direct effect of interpersonal triggers and the indirect effect of background factors through interpersonal triggers on rejection of care and aggression emphasizes the importance of developing and implementing psychosocial interventions that improve interpersonal relationships. The multi-group SEM revealed that the full model was not moderated by PTSD. However, the differential direct and indirect effect of background factors and interpersonal triggers as a proximal factor on the behavioral outcomes between veterans with and without PTSD suggest potential different mechanisms of behavioral outcomes between veterans depending upon whether or not PTSD is present. Evidence for the PTSD-moderated mediating effect of interpersonal triggers on the relationship between depression and rejection of care was demonstrated, suggesting the need to develop targeted interventions for veterans with dementia and PTSD who have greater depressive symptoms.

The new knowledge generated from this dissertation helps to clarify complex patterns of associations among background factors such as PTSD and proximal factors and behavioral symptoms of dementia consistent with the NDB model, strengthening the foundation for development of novel approaches to designing and implementing person-centered care for veterans with co-occurring dementia and PTSD.

Problem: Dementia has become a global public health priority. A total of 47 million people worldwide lives with dementia, and nearly 60% of whom live in low-and middle-income countries (LMIC). The fastest growth of population living with dementia takes place in China. In addition, the number will be greater if we take persons with mild cognitive impairment (MCI) into account. The estimated prevalence of MCI and dementia among older adults in China is between 13% and 20%. My population of study are persons with cognitive impairment (PWCI) and their informal care partners, including those living with MCI or mild dementia. It is estimated that over 80% of the population with cognitive impairment in China are living in the community and receiving care from their informal caregivers.

There is a severe lack of residential dementia care service and dementia management support at community level in China. The lack of supportive resources and quality services in China posed severe challenges to PWCI and their informal care partners. The complexity of PWCI and their care partners’ changing experience of living with cognitive impairment is interpreted in the dynamic nature of their spousal relationship and relationship with others, patterns of communication, daily activities and care during the extended period of cognitive decline. The purpose of my dissertation is to describe the cultural relevance of person-centered dementia care in home and community-based setting and provide empirical evidence for understanding the changing experience of living with cognitive impairment through the dyadic experiences of PWCI and their spousal care partners.

Methods: We used semi-structured open-ended interviews (Ashton, 2014) to explore the experiences and perceptions of PWCI and their care partner’s, regarding living with cognitive impairment, working with each other, communicating with each other and taking care of each other. We then applied the person-centered dementia care framework, and Nolan’s senses framework to the analysis of the interviews to understand their experiences and perceptions. We conducted a longitudinal qualitative study of a subset of 6 dyads of PWCI and their care partners over three years with three data collection time points (2015 to 2017). We employed the approach of prospective QLS in this study to capture the complexities of relationships, experiences, and the impact on health policy.

Findings: Person-centered care processes are a means of establishing and nurturing the healthy relationships between PWCI and their care partners. Our findings suggest that PWCI and their spouses experience the six senses through the person-centeredness in their daily interactions with each other. It also indicated successes and challenges to being person-centered early in the disease and identified their unmet needs as well as barriers and facilitators to improve their well-being. PWCI and their care partners used strategies to adapt to the changes and cope with challenges. The dyads experienced a lack of sense of continuity of their relationships, communication patterns, and daily life and activities. PWCI and their care partners have a lack of access to clinical expertise and quality care services in the home and community-based settings and formal LTC settings. It is acknowledged that PWCI deserves opportunities to be engaged in meaningful social relationships with others. It is crucial to help PWCI and their care partners choose a more positive attitude and nurturing the belief that there is a significant meaning in the journey of living with cognitive impairment. A lack of knowledge of the disease, treatment, and caregiving can potentially negatively affect PWCI and their care partners’ coping and overall well-being throughout the process of living with cognitive impairment. Our findings also provided many examples of when care partners respected PWCI’s choices, regarding caregiving as assisting and guiding PWCI to help themselves instead of telling them what to do, resulting in a profound positive impact on the well-being of PWCI and their care partners and most importantly, on their spousal relationships.