Using direct observation to record the behaviour of long‐stay patients with dementia

Abstract

SUMMARYThis article describes the development of a direct observation system for the assessment of the behaviour of elderly demented long-stay patients. The technique of recording behaviour in real time has high face validity, and in conjunction with portable computers was found to be very reliable. The technique was used to assess the behaviour of patients during their waking day on seven wards. The findings suggest that almost two-thirds of the day is spent doing nothing, with aimless or disruptive behaviours also accounting for a significant period of the day. Only a small proportion of the day was spent in self-care or social behaviours.KEY woms-Dementia, long-stay wards, observation, behaviour.As part of a larger project to investigate the effects of ward environment on the behaviour of long-stay elderly confused patients, a method of behavioural assessment, via observation, was developed. The first part of this article will describe the development of an instrument which accurately measures the behaviour of demented patients. The second part reports the results of its application and gives an insight into what actually happens during aday in the life of these patients. The findings are compared with those of Godlove et al. (1982), whose observations suggested that the recipients of long-term care spent two-thirds of their time doing nothing. Despite the reactions to this finding at the time, the relative lack of activity in institutional care still appears to be high, and the question of 'What happens during the average day in the life of a long-stay demented patient?' is examined and quantified. DEVELOPMENT OF THE OBSERVATION INSTRUMENT Review of methods of collecting behavioural dataOne method of obtaining data about patient behaviour is via the application of rating scales. BehavCorrespondence to first author.iour rating scales, such as the Behaviour Rating Scale of the Clifton Assessment Procedures for the Elderly (Pattie and Gilleard, 1975), produce data that reflect patient dependency rather than a quantification of behaviour. A number of rating scales to assess aggressive behaviour in psychiatric patients have been developed, and more recently one specifically designed to assess aggressive behaviour in the elderly (Pate1 and Hope, 1992). Aggressive behaviour rating scales are by definition focusing on one small aspect of behaviour; other scales have been developed to assess a broader range of disruptive behaviours occurring in demented patients (Greene et al., 1982;Swearer et al., 1988; Mungas et al., 1989). These scales, however, tend to lack a comprehensive range of items and do not allow for comparisons with other non-disruptive behaviours which are not assessed.An alternative method of recording behaviour is by direct observation. Advocates of this method of research (Sanson-Fisher et al., 1979;Whatmore et al., 1975) argue that it is a richer and more accurate method of collecting information.Observational methods have been used for recording patientklient behaviour in a variety of settings for m...

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“…DCM incorporates 24 behaviour categories (with 77 footnotes to aid categorisation); six WIB values; 17 personal detraction codes (all with five severity ratings); and the positive event recording coding frame. As Bowie and Mountain (1993) comment; 'The more complex the category system, the more likelihood there is of observer error occurring' (p. 858). As numerous categories were rarely used, simplifying the code categorisation may make for a more reliable tool.…”

“…Error may occur if the observer has to make complex decisions within an interval as to which behaviour dominated (Bowie and Mountain, 1993), a particular problem if the participant with dementia engages in a range of behaviours and states of well or ill-being within a single five-minute time frame.…”

“…Second, within DCM each five-minute interval is interpreted as representing one behavioural event and thus does not permit the frequency of discrete behaviours to be recorded accurately (Bowie and Mountain, 1993). The method could explore the option of allowing for the recording of multiple behaviours within the five-minute time frame, which could more accurately reflect how that five-minute period was spent.…”

“…CTS has been shown to be a reliable method of recording behaviour when used in environments supporting older people with dementia (Bowie and Mountain, 1993;Proctor et al, 1998).…”

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“…The positive side of this is that the method yields a far richer body of data than most observational methods in general use, for example studies of engagement (McFayden, 1984), or the sevencategory system used by Bowie and Mountain (1993). The raw data can be processed in a variety of ways to yield both quantitative and qualitative indicators.…”