Nursing intervention for grooming of elders with mild cognitive impairments in Korea

Sample 

The Clinical Dementia Rating (CDR)1 was completed on all residents in a special dementia care facility. Criteria for the staging of dementia with the use of the CDR range from 0 (normal) to 3 (severe dementia). Eight elders with mild dementia who had a rating of 1 were selected. Four subjects were women and 4 were men, and their ages ranged from 66 to 90 (average = 78.63).

Design 

The Performance of Grooming Tasks (PGT) Instrument, shown in Table 1, was designed by the investigator to determine residents' capacity to perform three grooming tasks.

Table 1. Performance of Grooming Tasks (PGT)

	Step No	Assistance 0	Verbal prompt 1	Demonstration 2	Physical guidance 3	Full assistance 4
	1.Brush teeth Given: brush, toothpaste, cup Initial prompt: “Brush your teeth. ”
	Pick up toothpaste tube
	Unscrew cap
	Pick up toothbrush
	Squeeze paste onto brush
	Put toothpaste down
	Place brush in mouth
	Brush upper and lower teeth
	Remove toothbrush from mouth
	Spit out paste
	Rinse mouth
	Spit out rinsewater
	Rinse toothbrush in water
	Put brush down
	Score (total/number of steps)
	2.Wash face Given: bar of soap, towel Initial prompt: “Wash your face. ”
	Turn on water
	Place both hands in water
	Get soap
	Rub soap on hands
	Put soap down
	Rub hands on face
	Rinse face
	Turn off water
	Grasp towel
	Wipe towel over face
	Put towel down
	Score (total/number of steps)
	3.Comb hair Given: comb Initial prompt: “Comb your hair. ”
	Pick up comb
	Bring comb to hair
	Comb left side
	Comb right side
	Comb top
	Comb back
	Check in mirror
	Put comb down
	Score (total/number of steps)

The PGT is composed of 3 subscales: toothbrushing is broken down into 13 discrete component steps, facewashing is composed of 11 discrete component behaviors, and hair-combing consists of 8 discrete component behaviors. Each scale itemizes the caregiving assistance.

These ratings indicate the caregiver assistance required for the resident to complete each step of the grooming activity:

Higher scores indicate greater dependence. For example, to brush their hair, residents first picked up the comb with the caregiver's verbal prompt (1 point); brought the comb to the hair with the caregiver's gesturing (2 points); combed the left, right, top, and back of the hair with the caregiver's manual guidance (3 points); checked in a mirror with no assistance (0 points); and put the comb down with the caregiver's verbal prompt (1 point). The sum of these scores is divided by the number of steps performed. In this case, the calculation yielded a performance score of 2.0 as the average level of assistance required to complete the steps of this grooming activity.

Intervention 

The behavioral nursing strategies were derived from preliminary studies on improving grooming behavior of elders with cognitive impairments in the special dementia unit of a long-term care facility.3, 4, 5, 6 The intervention consisted of systematic prompting and social reinforcement to give residents a series of 1-step commands to guide their face-washing, toothbrushing, and hair-combing.

At the beginning of each intervention session, the resident was given an orientation to grooming. Lewis' protocol7 for reality orientation was used as follows. “Good morning, Mrs Kim (a polite greeting giving time and person information). My name is Carol (caregiver's name). It's 8:30 Monday morning (time). Did you like your breakfast this morning (general conversation)? It's a good time to clean your hands and face after breakfast (behavioral expectation). I'm here to help you get ready for washing your hands and face (ongoing activity). Let's go to the bathroom (ongoing activity). Here is the bathroom (place). Here are your soap and towel to wash your face (behavioral expectation).”

Residents were asked to wash their face, brush their teeth, and comb their hair. Each resident was allowed to do as much of each task as he or she could. The intervener assisted the resident to perform correctly and independently the sequence of steps necessary to complete each task. Prompts were graduated in strength from verbal to manual guidance, depending on the resident's responses.

Social reinforcements included verbal praise and positive nonverbal behavior. At the end of each task, the resident was verbally praised, acknowledged, and encouraged to express feelings, such as, “Thank you,” “You did a very nice job,” “Do you feel good?” or “How do you feel now?” While giving verbal approval, the intervener made eye contact with the resident, smiled, or delivered physical approval in the form of a friendly touch on the shoulder. Another type of social reinforcement was given at the end of grooming task when lotion was provided for the hands and face.

The intervener used prompts as sparingly as possible because the goal of nursing intervention was to maintain or improve the resident's functional ability. For example, a resident combed the back of her hair when prompted with verbal instruction. After several sessions, it was not necessary to prompt her to initiate the combing behavior.

Procedure 

A nurse intervener was trained for 3 sessions before the study. The training included written guidelines and a videotaped demonstration based on previous research.3

A total of 21 sessions (baseline, interventions, and postinterventions) for each resident was collected in this study. Toothbrushing, face-washing, and hair-combing exercises were videotaped after breakfast in each resident's bathroom. Each resident's bathroom had bar soap, a toothbrush, toothpaste, a water cup, a hair comb, and a towel near the washstand. Three videotape recordings in the first week established the baseline level of grooming assistance that each resident needed. The nurse intervener implemented the behavioral strategies with the subjects 3 times weekly during a 5-week period. Three videotapes during a 1-week period after the intervention also were recorded.

For the baseline and postintervention phases, nurse assistants were assigned to all 8 residents to brush their teeth, wash their face, and comb their hair in the routine fashion as before the study. For the intervention phase, the grooming equipment was arranged on the washstand 1 item at a time.

Raters were trained to rate the videotape perform-ances according to the PGT. One rater evaluated each tape. The rater scored the level of assistance required to complete each grooming step, using scores ranging from 0 to 4. The sum of those scores, divided by the total number of steps performed by the subject, yielded the performance score.