The Relationship between Rejection of Care Behaviors and Pain and Delirium Severity in Hospital Dementia Care

Abstract

Background and Objectives

Rejection of care is common in hospitalized persons living with dementia. However, distinguishing between rejection of care behaviors related to care practices or other causes such as pain or delirium is challenging. The purpose of this study is to further understand the relationship between rejection of care and pain and delirium in hospitalized patients with dementia by identifying which rejection of care behaviors are associated with pain and delirium.

Research Design and Methods

Care encounters between hospitalized patients with dementia (n=16) and nursing staff (n=53) were observed on 88 separate occasions across 35 days. Rejection of care was measured using the 13 behaviors from the Resistiveness to Care Scale. Pain and delirium severity were measured using a variety of scales including the Pain Assessment in Advanced Dementia Scale (PAINAD), Checklist of Nonverbal Pain Indicators (CNPI), and numeric rating scale for pain severity and the Confusion Assessment Method—Severity (CAM-S) short form and Delirium Observation Screening Scale (DOS) for delirium severity. Linear-mixed-modeling was used to determine the relationship between rejection of care behaviors and pain and delirium severity for each measure.

Results

48.9% of the observations included rejection of care, 49.9% included a patient in pain, and 12.5% included a patient with delirium. Cry, push away, scream/yell, and turn away indicated a higher pain severity across pain measures. No rejection of care behaviors were found to indicate delirium severity.

Discussion and Implications

Certain rejection of care behaviors may be helpful in identifying pain in hospitalized patients with dementia suggesting that caregivers should be cognizant of pain when these rejection of care behaviors are present. However, in this sample rejection of care behaviors were not found to be a useful for identifying delirium severity in hospital dementia care.