Rejection of Care and Aggression among Older Veterans with Dementia: The Influence of Background Factors and Interpersonal Triggers

Abstract

Objectives: To test relationships among background factors, interpersonal triggers, rejection of care, and aggression among veterans living with dementia in residential long-term care settings, based on the need-driven dementia-compromised behavior model.

Design: A mixed methods secondary analysis of program evaluation data from the Staff Training in Assisted Living Residences-Veterans Health Administration intervention implemented by the US Department of Veterans Affairs healthcare system.

Setting and participants: In total, 315 older veterans who participated in the 2013‒2016 Staff Training in Assisted Living Residences-Veterans Health Administration program at 76 Community Living Centers (Veterans Affairs-operated nursing homes).

Methods: Text data that captured the interdisciplinary team observations of distressed behaviors of concern and their circumstances were coded into categorical variables and then combined with existing quantitative data to test hypothesized relationships using structural equation modeling.

Results: Rejection of care was directly affected by interpersonal triggers (β = 0.32, P < .005) and background factors such as depression (β = 0.29, P < .018), anxiety (β = -0.18, P < .023), and cognitive status (β = 0.10, P < .049). Depression also had an indirect effect on rejection of care through interpersonal triggers (α × β = 0.13 × 0.32 = 0.04, P < .012). Aggression was directly affected by both interpersonal triggers (β = 0.19, P < .009) and functional status (β = 0.17, P < .011). Both function (α × β = 0.12 × 0.19 = 0.02, P < .035) and depression (α × β = 0.13 × 0.19 = 0.03, P < .005) had indirect effects on aggression through interpersonal triggers.

Conclusions and implications: Interpersonal triggers influenced rejection of care and aggression in veterans with dementia. Background factors such as depression and severity of functional impairment increased the likelihood of these symptoms. Study findings emphasize the importance of developing and implementing interventions that improve interpersonal relationships and developing targeted interventions for those with depressive symptoms.