This is a secondary analysis of the nursing home Minimum Data Set (MDS) from the state of Florida during calendar year 2009. The first comprehensive assessment for each NH resident was used in this study. The archived data files of the most recent version of MDS (MDS 3.0) were not yet available to researchers, but are due for release in early 2013 [
19]. The MDS data are mandatory in all NHs certified to participate in Medicare and Medicaid. Approval for the study was obtained from the University of Florida Health Science Center Institutional Review Board.
The MDS assessment data, standardized data on residents’ status based on routine and continuous observations by nursing staff, provides comprehensive information on all the NH residents. The MDS assessment is completed on admission to the facility, on a quarterly basis thereafter, and upon significant changes in status [
20]. The complete federal database consists of over 1.5 million older adults who live in NHs throughout the United States. Although it is used primarily for clinical purposes, the MDS has also been used for research on cognition and behavioral symptoms in this population [
21‐
23]. Several MDS subscales have been created and evaluated, and have demonstrated acceptable reliability and validity: MDS-Pain severity scale [
24], MDS-Depression Rating Scale [
25], MDS-Aggression Behavior Scale [
26], MDS-Challenging Behavior Profile [
27], MDS-Discomfort Behavior Scale [
28], MDS-Cognitive Performance Scale [
28,
29], MDS-index of social engagement [
30,
31], MDS-Activities of Daily Living scale [
32,
33], Resident Assessment Instrument-Mental Health [
34], and MDS-Change in Health, End-stage disease and Signs and Symptoms [
35]. Details of the reliability and validity coefficients for each of the major study variables are described in the measurement section.
Data used in this study
The data used in this study were collected on residents with dementia in Medicare- or Medicaid-certified NHs who have a MDS comprehensive assessment on file. The data were acquired from the Centers for Medicare & Medicaid Services. Selection criteria were applied to ascertain data from NH residents older than 65 years old with Alzheimer’ disease or other dementia, based on documented medical diagnosis. Data from comatose residents were excluded, because these residents cannot display the disruptive behaviors investigated in this study. This selection process yielded 56,577 unique cases for the analyses.
The sample is mostly female (67.7%), and a mean age of 84 (years range = 65–109). The prevalence of disruptive behaviors is as follows: wandering behaviors (9.0%), aggressive behaviors (24.4%), and agitated behaviors (24.1%) (Table
1).
Table 1
Sample characteristics
Age, mean ± SD | 56577 | 84.37 ± 7.43 |
Gender, n (%) | 56566 | |
Male | | 18,265 (32.3) |
Female | | 38,301 (67.7) |
MDS-CPS, mean ± SD | 56543 | 3.17 ± 1.52 |
MDS-ADL, mean ± SD | 56577 | 18.66 ± 6.41 |
Pain severity, mean ± SD | 56568 | 0.48 ± 0.70 |
Wandering behaviors, n (%) | 56573 | |
No wandering (MDS-wandering = 0) | | 51,463 (91.0) |
1-3 days in 7 days (MDS-wandering = 1) | | 2,637 (4.7) |
4-6 days in 7 days (MDS-wandering = 2) | | 994 (1.8) |
Wandering daily (MDS-wandering = 3) | | 1,479 (2.6) |
Aggressive behaviors, n (%) | 56572 | |
None (MDS-ABS = 0) | | 42,764 (75.6) |
Moderate (MDS-ABS = 1 – 2) | | 9,667 (17.1) |
Severe (MDS-ABS = 3 – 5) | | 3,390 (6.0) |
Very severe (MDS-ABS = 6 – 12) | | 751 (1.3) |
Agitated behaviors, n (%) | 56571 | |
None (revised MDS-CBP agitation = 0) | | 42,941 (75.9) |
Mild (revised MDS-CBP agitation = 1) | | 6,916 (12.2) |
Moderate (revised MDS-CBP agitation = 2) | | 5,099 (9.0) |
Severe (revised MDS-CBP agitation = 3) | | 1,615 (2.9) |
Measurement
MDS subscales and items were used to indicate the main study concepts: pain, wandering, aggression, and agitation. These are described below.
Pain
The MDS-pain severity scale [
24], combining both pain frequency (0 = no pain, 1 = pain less than daily, and 2 = pain daily) and pain intensity (1 = mild pain, 2 = moderate pain, and 3 = horrible or excruciating pain), was used to assess pain severity in NH residents with dementia. This scale can range from 0 to 3, with higher scores indicating greater pain severity. NH residents’ self-report is reflected in the MDS pain items if residents can self-report and staff completing the MDS assessments have confidence in residents’ self-report. Otherwise, the staff who complete the MDS assessment document pain symptoms based on proxy reports from facility nursing staff that provides care to the residents. The MDS-pain severity scale has been reported to have an inter-rater reliability coefficient of 0.73, and kappa coefficient of 0.70 with a Visual Analogue Scale in a study involving 95 U.S. nursing home residents at 25 Medicare-certified skilled nursing facilities in Massachusetts [
24].
Disruptive behaviors
The MDS-wandering item was used to measure the frequency of wandering in the last 7 days. Wandering frequency is recorded by staff observation. It is recorded as no wandering, wandering occurred 1 to 3 days, wandering occurred 4 to 6 days, and daily wandering. The wandering item has been reported to have a reliability coefficient of 0.63, and an inter-rater reliability of 0.95 [
36,
37].
The MDS-Aggression Behavior Scale (MDS-ABS) was used to measure the frequency of aggressive behaviors. The MDS-ABS is a sum score of four MDS items: verbally abusive behavioral symptoms, physically abusive behavioral symptoms, socially inappropriate behavioral symptom, and resisting care. The MDS-ABS can range from 0 to 12, with higher scores indicating more frequent aggressive behaviors. The MDS-ABS has been reported to have an internal consistency reliability of 0.79 to 0.95, and a criterion validity coefficient of 0.72 with Cohen-Mansfield Agitation Inventory aggression subscale scores [
26].
The revised MDS-Challenging Behavior Profile (MDS-CBP) agitation subscale was used to assess the frequency of agitated behaviors. The revised agitation scores, calculated using two MDS items (e.g., periods of restlessness and repetitive physical movements), can range from 0 to 3, with higher scores indicating more frequent agitated behaviors. This revised agitation scale has Cronbach’s alpha coefficient of .68. The original MDS-CBP agitation subscale, computing from 4 MDS items (e.g., periods of restlessness, repetitive physical movements, wandering, and socially inappropriate behavioral symptom), has been reported to have Cronbach’s alpha coefficient of 0.70, inter-rater reliability of 0.61, and a Spearman’s rank correlation coefficient of 0.50 with Behavior Rating Scale for Psychogeriatric Inpatients [
27].
Background factors
The MDS-cognitive performance scale (MDS-CPS) [
38] was used to measure the level of cognitive impairment. The MDS-CPS score is calculated using five MDS items: comatose, short-term memory, cognitive skills or daily decision making, making oneself understood, and self-performance in eating. The MDS-CPS can range from 0 to 6, with higher scores indicating more cognitive impairment. The MDS-CPS has been reported to have a kappa coefficient of 0.45-0.75 with Mini-Mental State Examination, a kappa coefficient of 0.41-0.77 against Global Deterioration Scale, a kappa coefficient of 0.66 against Psychogeriatric Dependency Rating Scale, a kappa coefficient of 0.45 against Mattis Dementia Rating Scale [
29,
38‐
41].
The MDS-Activities of Daily Living-Long Form (MDS ADL-Long Form) [
42] was used to measure the level of ADL impairment. The MDS ADL-Long Form scores are calculated using 7 MDS items: self-performance of bed mobility, transfer, locomotion on unit, dressing, eating, toilet use, and personal hygiene. MDS ADL-Long Form can range from 0 to 28, with higher scores indicating more impairment of ADLs. The MDS ADL-Long Form has been reported to have a reliability coefficient of 0.92-0.97, an inter-rater reliability coefficient of 0.61-0.95, and a kappa coefficient of 0.58 – 0.79 against Physical Self-Maintenance Scale [
31,
43].
Demographics characteristics (e.g., age and gender) were collected from the MDS form. Age was a continuous variable and gender was dichotomous (0 = female; 1 = male). They were included as covariates in the analyses.
Statistical analysis
Analyses were performed using SPSS, version 20 (IBM Inc., Armonk, NY). Multivariate analyses were conducted to explore the relationship between pain and disruptive behaviors in this sample. Aggression was severely positively skewed, and none of the transformations (e.g., logarithmic transformation, square root transformation, inverse transformation, and square transformation) resolved the normal distribution issue. Therefore, aggression was collapsed into four groups (none, moderate, severe, and very severe), based on published algorithms in the literature [
26]. Aggression was transformed as none (MDS-ABS = 0), moderate (MDS-ABS = 1–2), severe (MDS-ABS = 3–5), and very severe (MDS-ABS = 6–12). Due to concerns that NH residents who take psychotropic medications (e.g., antipsychotics, antidepressants, etc.) may exhibit less frequent disruptive behaviors [
44], we re-ran the statistical analysis excluding these subjects.
Since the level of measurement of the dependent variables was ordinal, logistic regression for ordinal variables was used to evaluate the effect of pain severity on the three disruptive behaviors, after controlling for covariates. Using the same independent variables in analysis with different dependent variables carries the risk of inflating the Type I error. To keep the overall risk of a Type I error to the 5% level, p-value for the each regression analysis is set at .017.