Institutionalized elderly people with dementia: an integrative review on nursing care

Siewert, Josiane Steil; Alvarez, Angela Maria; Santos, Silvia Maria Azevedo dos; Brito, Fabiana Almeida; Hammerschmidt, Karina Silveira de Almeida

doi:10.1590/0034-7167-2018-0419

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Revista Brasileira de Enfermagem

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REVIEW • Rev. Bras. Enferm. 73 (suppl 3) • 2020 • https://doi.org/10.1590/0034-7167-2018-0419 copy

Institutionalized elderly people with dementia: an integrative review on nursing care

Ancianos con demencia institucionalizados: revisión integrativa sobre los cuidados de enfermería

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To ascertain the characteristics of the nursing care provided to institutionalized elderly people with dementia.

Methods:

Integrative review of studies published between 2013 and 2017, in English, Spanish, and Portuguese, from the databases BDENF, LILACS, CINAHL, PubMed, SciELO, TRIP, and National Guideline Clearing House. Thematic data analysis was used.

Results:

From the data collected in the 41 included studies, three themes emerged: Care with a focus on the needs of elderly people in LTCIEs; Care based on the work process of the nursing team; and Shared care.

Final considerations:

Elderly care can take place from different perspectives: that of the elderly; the nursing team; and it can be shared among the different parties involved. The importance of communication must be stressed, as do the development of skills and attitudes of the team, as well as proper training and support, good environment in the care process, and an approach centered on the institutionalized elderly.

Descriptors:
Nursing care; Dementia; Nursing; Elderly People; Long-Term Institutions for the Elderly

Step	Description
Research question	What is the scientific production on nursing care for elderly people with dementia living in long-term institutions in the last five years?
Identification of articles	PubMed 97	Scopus 52	SciELO 30	LILACS / BDEFN 210	CINAHL 44	National Guidelines 82	Trip 42
Identification of articles	557 articles retrieved using search strategy
1^st Selection step	493 articles were excluded for not meeting the inclusion criteria or for being duplicates. 60 articles were selected for full reading.
2^nd Selection step	19 articles were excluded for not meeting the inclusion criteria.
3^rd Selection step	41 articles were included and analyzed in the review.

Id article	Selection of units of analysis	Units of meaning	Themes
19	In the care model Goals of Care, explanatory videos were presented to family members, so they would know the goals of care and the treatments available for each goal to be achieved. They chose what goals they wanted for their relatives from the treatments available. Subsequently, the nursing team discussed the choices with family members, deciding together what would be best for the elderly.	Family involvement	Shared care

Authors and year	Nursing care	Outcome
Van Haitsma KS, Curyto K, Abbot KM, Towsley GL, Spector A, Kleban M. 2015⁽¹⁰10 Van Haitsma KS, Curyto K, Abbot KM, Towsley GL, Spector A, Kleban M. A randomized controlled trial for an individualized positive psychosocial intervention for the affective and behavioral symptoms of dementia in nursing home residents. J Gerontol B Psychol Sci Soc Sci[Internet]. 2015 [cited 2018 Jan 23];70(1):35-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24304555 https://www.ncbi.nlm.nih.gov/pubmed/2430... ⁾.	Carry out daily activities with the elderly, but always in their interest	Both the individualized positive psychosocial intervention groups and the individualized intervention group with the nurse experienced similar benefits - they were more alert, involved, had positive touches and a positive verbal behavior compared to the usual care group. The group with individual care showed more negative behaviors, anger, lack of cooperation, than the group of psychosocial intervention and the usual care group.
McCabe MP, Bird M, Davison TE, Mellor D, MacPherson S, Hallford D, et al. 2015⁽¹¹11 McCabe MP, Bird M, Davison TE, Mellor D, MacPherson S, Hallford D, et al. An RCT to evaluate the utility of a clinical protocol for staff in the management of behavioral and psychological symptoms of dementia in residential aged-care settings. Aging Ment Health [Internet]. 2015 [cited 2018 Jan 23];19(9):799-807. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25319535 https://www.ncbi.nlm.nih.gov/pubmed/2531... ⁾.	Identify the possible causes of behavioral problems associated with dementia	The results demonstrated the effectiveness of using the behavioral problems protocol for reducing the elderly's behavioral problems and the team's stress, improving self-efficacy.
Tjia J, Hunnicutt JN, Herndon L, Blanks CR, Lapane KL, Wehry S. 2017 ⁽¹²12 Tjia J, Hunnicutt JN, Herndon L, Blanks CR, Lapane KL, Wehry S. Association of a Communication Training Program With Use of Antipsychotics in Nursing Homes. JAMA Intern Med[Internet]. 2017 [cited 2018 Jan 23];177(6):846-53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28418449 https://www.ncbi.nlm.nih.gov/pubmed/2841... ⁾.	Meet the daily needs of the elderly through a care program	The program helped to reduce the use of antipsychotics during the intervention period, but this decrease did not continue during the conservation stage. However, there was no increase in the use of psychotropics or in the occurrence of behavioral problems. The evidence suggests the use of non-pharmacological interventions to treat the behavioral and psychological symptoms of dementia.
Hall GR, Gallagher M, Hoffmann-Snyder C. 2013⁽¹³13 Hall GR, Gallagher M, Hoffmann-Snyder C. Bathing persons with dementia. Iowa City (IA): University of Iowa College of Nursing, John A. Hartford Foundation Center of Geriatric Nursing Excellence[Internet]. 2013 [cited 2018 Jan 23]. Available from: https://www.guideline.gov/summaries/summary/44984?f=rss&osrc=12 https://www.guideline.gov/summaries/summ... ⁾.	Bathing techniques for patients with dementia	Decrease in the frequency and severity of negative episodes during the bath of patients with dementia.
Jutkowitz, E, Brasure M, Fuchs E, Shippee T, Kane RA, Fink HA, et al. 2016⁽¹⁴14 Jutkowitz E, Brasure M, Fuchs E, Shippee T, Kane RA, Fink HA, et al. Care-delivery interventions to manage agitation and aggression in dementia nursing home and assisted living residents: a systematic review and meta-analysis. J Am Geriatr Soc[Internet]. 2016 [cited 2018 Jan 23];64:477-88. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27000321 https://www.ncbi.nlm.nih.gov/pubmed/2700... ⁾.	Non-pharmacological interventions to control agitation and aggression in patients with dementia	There is insufficient evidence on the effectiveness of care provided through non-pharmacological interventions to reduce agitation or aggression in long-term care facilities.
Söderman M, Rosendahl SP. 2016⁽¹⁵15 Söderman M, Rosendahl SP. Caring for Ethnic Older People Living with Dementia - Experiences of Nursing Staff. J Cross Cult Gerontol[Internet]. 2016 [cited 2018 Jan 23];31:311-26. Available from: https://link.springer.com/article/10.1007%2Fs10823-016-9293-1 https://link.springer.com/article/10.100... ⁾.	Verbal and non-verbal communication and cultural activities for elderly from different cultures	Although the nursing team that did not speak the same language as the elderly could provide care with equal quality, it was more difficult for them than for the team whose members were able to communicate in the language of the elderly.
Roberts G, Morley C, Walters W, Malta S, Doyle C. 2015⁽¹⁶16 Roberts G, Morley C, Walters W, Malta S, Doyle C. Caring for people with dementia in residential aged care: Successes with a composite person-centered care model featuring Montessori-based activities. Geriatr Nurs [Internet]. 2015 [cited 2018 Jan 23];36:106-10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25499658 https://www.ncbi.nlm.nih.gov/pubmed/2549... ⁾.	Care model that promotes activities based on the preferences of the elderly, considering their life history	The team reported increased knowledge about meeting the needs of people with dementia and changing organizational culture, demonstrating the efficiency of the model. The families were very pleased with the changes.
Sprangers S, Dijkstra K, Romijn-Luijten A. 2015⁽¹⁷17 Sprangers S, Dijkstra K, Romijn-Luijten A. Communication skills training in a nursing home: effects of a brief intervention on residents and nursing aides. Clin Interv Aging [Internet]. 2015 [cited 2018 Jan 23];10:311-19. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4309793/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾.	Communication between nursing and the elderly	Lower stress rate for the team and increased use of short instructions and positive communication between the team and the elderly.
Rodriguez-Martín B, Martínez-Andres M, Notario-Pacheco B, Martínez-Vizcaíno V. 2016⁽¹⁸18 Rodriguez-Martín B, Martínez-Andres M, Notario-Pacheco B, Martínez-Vizcaíno V. Conceptualizaciones sobre la atención a personas con demencia en residencias de mayores. Cad Saúde Pública[Internet]. 2016 [cited 2018 Jan 23];32(3):1-12. Available from: http://www.scielo.br/pdf/csp/v32n3/1678-4464-csp-32-03-e00163914.pdf http://www.scielo.br/pdf/csp/v32n3/1678-... ⁾.	Communication and interaction skills with the elderly with dementia	Due to the tendency of technification of care, families demand personalized and small-scale attention, in which they themselves are an active part of the care process.
Soderlund M, Cronqvist A, Norberg A, Ternestedt B, Hansebo B. 2016 ⁽¹⁹19 Soderlund M, Cronqvist A, Norberg A, Ternestedt B, Hansebo B. Conversations between persons with dementia disease living in nursing homes and nurses - qualitative evaluation of an intervention with the validation method. Scand J Caring Sci [Internet]. 2016 [cited 2018 Jan 23];30:37-47. Available from: http://onlinelibrary.wiley.com/doi/10.1111/scs.12219/epdf http://onlinelibrary.wiley.com/doi/10.11... ⁾.	Communication skills with the elderly with dementia	Considering the positive results after the intervention, the training given to nurses on communication may have improved their communication skills with elderly people with dementia.
Registered Nurses Association of Ontario. 2016 ⁽²⁰20 Registered Nurses Association of Ontario (RNAO). Delirium, dementia, and depression in older adults: assessment and care. Toronto, ON: Registered Nurses' Association of Ontario [Internet]. 2016 [cited 2018 Jan 23]. Available from: http://rnao.ca/sites/rnaoca/files/DDD_BPG.pdf http://rnao.ca/sites/rnaoca/files/DDD_BP... ⁾.	Guideline care for patients with dementia	This document provides numerous evidence-based interventions (through systematic reviews) in various areas of nursing care for elderly people with dementia.
Palm R, Trutschel D, Simon M, Bartholomeyczik S, Holle B. 2016 ⁽²¹21 Palm R, Trutschel D, Simon M, Bartholomeyczik S, Holle B. Differences in Case Conferences in Dementia Specific vs Traditional Care Units in German Nursing Homes: results from a cross-sectional study. J Am Med Dir Assoc[Internet]. 2016 [cited 2018 Jan 23];17(1):91.e9e91.e13. Available from: http://www.jamda.com/article/S1525-8610(15)00557-5/pdf http://www.jamda.com/article/S1525-8610(... ⁾.	Case study	Case discussion is an intervention widely used in institutions for the elderly in Germany as a way to treat behavioral problems of dementia, with no distinction between traditional and specialized units.
Karel MJ, Teri L, McConnel E, Visnic S, Karlin BE. 2016 ⁽²²22 Karel MJ, Teri L, McConnel E, Visnic S, Karlin BE. Effectiveness of Expanded Implementation of STAR-VA for Managing Dementia-Related Behaviors Among Veterans. Gerontologist[Internet]. 2016 [cited 2018 Jan 23];56(1):126-34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26185155 https://www.ncbi.nlm.nih.gov/pubmed/2618... ⁾.	Program to address the behavioral effects of dementia	Frequency and severity of target behaviors and symptoms of depression, anxiety and restlessness decreased significantly. The team assessed the benefits for patients, considering the program feasible.
Van de Ven G, Draskovic I, Adang EMM, Donders R, Zuidema SU, Koopmans RTCM, et al. 2013 ⁽²³23 Van de Ven G, Draskovic I, Adang EMM, Donders R, Zuidema SU, Koopmans RTCM, et al. Effects of Dementia-Care Mapping on Residents and Staff of Care Homes: A Pragmatic Cluster-Randomised Controlled Trial. PloS ONE[Internet]. 2013 [cited 2018 Jan 23];8(7):e67325. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699562 https://www.ncbi.nlm.nih.gov/pmc/article... ⁾.	Nursing care model	Findings did not confirm the effect on the primary outcome of agitation. Perhaps the model's nature, with such a variable and extensive implementation, explains this lack of effect.
Moyle W, Venturato L, Cooke M, Murfield J, Griffiths S, Hughes J, et al. 2016 ⁽²⁴24 Moyle W, Venturato L, Cooke M, Murfield J, Griffiths S, Hughes J, et al. Evaluating the capabilities model of dementia care: A non-randomized controlled trial exploring resident quality of life and care staff attitudes and experiences. Int Psychogeriatr[Internet]. 2016 [cited 2018 Jan 23];28(7):1091-100. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26960255 https://www.ncbi.nlm.nih.gov/pubmed/2696... ⁾.	Nursing care model	Despite the several limitations that the study has, the model appears to be more effective for providing dementia care than usual practice. The model should be evaluated in greater depth with participants from a diverse range of institutions and different stages of cognitive impairment.
Cooke M, Moyle W, Venturato L, Walters C, Kinnane J. 2014 ⁽²⁵25 Cooke M, Moyle W, Venturato L, Walters C, Kinnane J. Evaluation of an education intervention to implement a capability model of dementia care. Dementia[Internet]. 2014 [cited 2018 Jan 23];13(5):613-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24339075 https://www.ncbi.nlm.nih.gov/pubmed/2433... ⁾.	Elderly care model	The results suggest that the education protocol had positive impacts on participants' knowledge, skills, and attitudes, providing quality dementia care to residents.
Park M, Lim S, Kim E, Lee S, Chang S. 2017⁽²⁶26 Park M, Lim S, Kim E, Lee S, Chang S. Examining practical nursing experiences to discover ways in which to retain and invigorate the remaining functions of the elderly with a demented and complex disability in nursing homes. Jpn J Nurs Sci[Internet]. 2017 [cited 2018 Jan 23];15(1):77-90. Available from: http://onlinelibrary.wiley.com/doi/10.1111/jjns.12174/epdf http://onlinelibrary.wiley.com/doi/10.11... ⁾.	Promote elderly's physical capacities	The evidence provided new ideas for developing specialized nursing interventions and practical nursing models for elderly care institutions.
Kovach CR, Hekel B, Rababa M. 2015⁽²⁷27 Kovach CR, Hekel B, Rababa M. Feasibility Testing of a Protocol to Stop Ineffective Drug and Nondrug Treatments. West J Nurs Res[Internet]. 2015 [cited 2018 Jan 23];37(11):1404-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26250849 https://www.ncbi.nlm.nih.gov/pubmed/2625... ⁾.	Protocol to track and suspend ineffective treatments	The protocol was evaluated as useful and easy, although the nurses showed some difficulty in keeping the information organized.
Hanson LC, Song MK, Zimmerman S, Gilliam R, Rosemond C, Chisholm L et al. 2016⁽²⁸28 Hanson LC, Song MK, Zimmerman S, Gilliam R, Rosemond C, Chisholm L et al. Fidelity to a behavioral intervention to improve goals of care decisions for nursing home residents with advanced dementia. Clin Trials[Internet]. 2016 [cited 2018 Jan 23];13(6):599-604. Available from: http://journals.sagepub.com/doi/pdf/10.1177/1740774516650863 http://journals.sagepub.com/doi/pdf/10.1... ⁾.	Elderly care model	The methods used to ensure fidelity to the intervention were effective and allowed the model to be adopted and implemented by the nursing team. In the end, 69% of the discussions between the family and the team were implemented.
Rosendahl SP, Söderman M, Mazaheri M. 2016 ⁽²⁹29 Rosendahl SP, Söderman M, Mazaheri M. Immigrants with dementia in Swedish residential care: an exploratory study of the experiences of their family members and Nursing staff. BMC Geriatr [Internet]. 2016[cited 2018 Jan 23];16(18):1-12. Available from: https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-016-0200-y https://bmcgeriatr.biomedcentral.com/art... ⁾.	Communication skills and cultural adaptation	The family member is essential in the life of immigrants with dementia residing in an institution. They make it easier for nursing staff to communicate with the person with dementia.
Allen VJ, Methven L, Gosney M. 2014⁽³⁰30 Allen VJ, Methven L, Gosney M. Impact of serving method on the consumption of nutritional supplement drinks: randomized trial in older adults with cognitive impairment. J Adv Nurs[Internet]. 2014 [cited 2018 Jan 23];70(6):1323-34. Available from: http://onlinelibrary.wiley.com/doi/10.1111/jan.12293/full http://onlinelibrary.wiley.com/doi/10.11... ⁾.	Means for serving water	A liquid nutritional supplement should be administered to people with dementia in a glass or a glass with a straw.
Krumm N, Larkin P, Connolly M, Rode P, Elsner F. 2014⁽³¹31 Krumm N, Larkin P, Connolly M, Rode P, Elsner F. Improving dementia care in nursing homes: experiences with a palliative care symptom-assessment tool (MIDOS). Int J Palliat Nurs [Internet]. 2014 [cited 2018 Jan 23];20(04);187-92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24763327 https://www.ncbi.nlm.nih.gov/pubmed/2476... ⁾.	Palliative care model	The tool presented has the potential to improve palliative care for people with dementia.
Finucane AM, Stevenson B, Moyes R, Oxenham D, Murray SA. 2013⁽³²32 Finucane AM, Stevenson B, Moyes R, Oxenham D, Murray SA. Improving end-of-life care in nursing homes: Implementation and evaluation of an intervention to sustain quality of care. Palliat Med[Internet]. 2013 [cited 2018 Jan 23];27(8):772-8. Available from: http://journals.sagepub.com/doi/pdf/10.1177/0269216313480549 http://journals.sagepub.com/doi/pdf/10.1... ⁾.	Palliative care model	Despite the increase in adopting essential palliative care tools, the number of hospital deaths increased during the project's development. In order to incorporate palliative care, the presence of specialists in the field and nurses is essential, in addition to project management and leadership.
Koskenniemi J, Leino-kilpi H, Suhonen R. 2015⁽³³33 Koskenniemi J, Leino-kilpi H, Suhonen R. Manifestation of respect in the care of older patients in longterm care settings. Scand J Caring Sci[Internet]. 2015 [cited 2018 Jan 23];29(2):288-96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25213177 https://www.ncbi.nlm.nih.gov/pubmed/2521... ⁾.	Human treatment for the elderly	Respect in long-term care settings is manifested in patient care, through the nurses' presence and actions.
Jordan S, Gabe M, Newson L, Snelgrove S, Panes G, Picek A, et al. 2014⁽³⁴34 Jordan S, Gabe M, Newson L, Snelgrove S, Panes G, Picek A, et al. Medication Monitoring for People with Dementia in Care Homes: The Feasibility and Clinical Impact of Nurse-Led Monitoring. Scient World J [Internet]. 2014 [cited 2018 Jan 23]:2014. Available from: https://www.hindawi.com/journals/tswj/2014/843621/ https://www.hindawi.com/journals/tswj/20... ⁾.	Drug monitoring program	Participants benefited from monitored medication systematized by nurses.
Jordan S, Gabe-Walter ME, Watkins A, Humphreys I, Newson L, Snelgrove S, et al. 2015⁽³⁵35 Jordan S, Gabe-Walter ME, Watkins A, Humphreys I, Newson L, Snelgrove S, et al. Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial. PloS One [Internet]. 2015 [cited 2018 Jan 23];10(10);1-27. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603896/pdf/pone.0140203.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾.	Drug monitoring program	The program can improve the quality and safety of care; it deserves further investigation as a strategy to mitigate the known adverse effects of prescription drugs.
Kim H, Woods DL, Phillips LR, Ruiz ME, Salem B, Jeffers-Skrine K, et al. 2015⁽³⁶36 Kim H, Woods DL, Phillips LR, Ruiz ME, Salem B, Jeffers-Skrine K, et al. Nursing assistants' communication styles in Korean American older adults with dementia: a review of the literature. J Transcult Nurs [Internet]. 2015 [cited 2018 Jan 23];26(2):185-92. Available from: http://journals.sagepub.com/doi/abs/10.1177/1043659614547200 http://journals.sagepub.com/doi/abs/10.1... ⁾.	Communication with elderly people of other ethnicities	The model provides guidance on how to improve care and quality of life for residents of different racial and cultural groups.
Murphy JL, Holmes J, Brooks C. 2017⁽³⁷37 Murphy JL, Holmes J, Brooks C. Nutrition and dementia care: developing an evidence-based model for nutritional care in nursing homes. BMC Geriatr [Internet]. 2017[cited 2018 Jan 23];17(55):1-14. Available from: https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-017-0443-2 https://bmcgeriatr.biomedcentral.com/art... ⁾.	Nutritional care model	This model can help formulating new training and education tools.
Lykkeslet E, Gjengedal E, Skrondal T, Storjord M. 2016 ⁽³⁸38 Lykkeslet E, Gjengedal E, Skrondal T, Storjord M. 'On one's ownstrength' Healthcare providers' experience with introducing Marte Meo Counselling in dementia care. Int J Older People Nurs [Internet]. 2016 [cited 2018 Jan 23];11:24-31. Available from: http://onlinelibrary.wiley.com/doi/10.1111/opn.12085/epdf http://onlinelibrary.wiley.com/doi/10.11... ⁾.	Communication model with the elderly	Through this model, professionals discovered the value of considering the context of patients.
Galik E, Resnik B, Hammersla M, Brightwater J. 2014⁽³⁹39 Galik E, Resnik B, Hammersla M, Brightwater J. Optimizing function and physical activity among nursing home residents with dementia: testing the impact of function-focused care. Gerontologist[Internet]. 2014 [cited 2018 Jan 23];54(6):930-43. Available from: https://academic.oup.com/gerontologist/article/54/6/930/564371 https://academic.oup.com/gerontologist/a... ⁾.	Care model with emphasis on mobility and physical activity	Elderly people with severely impaired cognition can be involved in physical and functional activities.
Boekhorst ST, Depla MFIA, Francke AL, Twisk JWR, Zwijsen SA, Hertogh CMPM. 2013⁽⁴⁰40 Boekhorst ST, Depla MFIA, Francke AL, Twisk JWR, Zwijsen SA, Hertogh CMPM. Quality of life of nursing-home residents with dementia subject to surveillance technology versus physical restraints: an explorative study. Int J Geriatr Psychiatry[Internet]. 2013[cited 2018 Jan 23];28:356-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22644773 https://www.ncbi.nlm.nih.gov/pubmed/2264... ⁾.	Electronic surveillance	The residents' quality of life is not related to the use of electronic security, but to the use of physical restrictions.
Fitzsimmons S, Barba B, Stump M. 2014 ⁽⁴¹41 Fitzsimmons S, Barba B, Stump M. Sensory and nurturing nonpharmacological interventions for behavioral and psychological symptoms of dementia. J Gerontol Nurs[Internet]. 2014 [cited 2018 Jan 23];40(11):9-15. Available from: https://libres.uncg.edu/ir/uncg/f/S_Fitzsimmons_Sensory_2014.pdf https://libres.uncg.edu/ir/uncg/f/S_Fitz... ⁾.	Non-pharmacological sensory interventions	In order to treat the behavioral and psychological symptoms of dementia, nursing must strive to identify non-pharmacological actions that are meaningful, easy to apply and easily accepted by the elderly.
Peisah C, Weaver J, Wong L, Strukovski J. 2014⁽⁴²42 Peisah C, Weaver J, Wong L, Strukovski J. Silent and suffering: a pilot study exploring gaps between theory and practice in pain management for people with severe dementia in residential aged care facilities. Clin Interv Aging[Internet]. 2014 [cited 2018 Jan 23];9:1767-74. Available from: https://www.dovepress.com/silent-and-suffering-a-pilot-study-exploring-gaps-betweentheory-and-p-peer-reviewed-article-CIA https://www.dovepress.com/silent-and-suf... ⁾.	Pain assessment and management	Early and proactive pain care is recommended to address behavioral and psychological symptoms in dementia.
Mansah M, Coulon L, Bronw P, Reynolds H, Kissiaw S. 2014 ⁽⁴³43 Mansah M, Coulon L, Bronw P, Reynolds H, Kissiaw S. Tailoring dementia care mapping and reflective practice to empower assistants in nursing to provide quality care for residents with dementia. Aust J Adv Nurs[Internet]. 2014 [cited 2018 Jan 23];31(4):34-44. Available from: http://www.ajan.com.au/Vol31/Issue4/4Mansah.pdf http://www.ajan.com.au/Vol31/Issue4/4Man... ⁾.	Elderly care model	The study highlighted the usefulness of offering training to professionals as a strategy to encourage the development of creative care for residents with dementia.
Rokstad AM, Rosvik J, Kirkevold O, Selbaek G, Saltyte Benth J Enfedal K, 2013⁽⁴⁴44 Rokstad AM, Rosvik J, Kirkevold O, Selbaek G, Saltyte Benth J, Engedal K. The effect of person-centred dementia care to prevent agitation and other neuropsychiatric symptoms and enhance quality of life in nursing home patients: a 10-month randomized controlled trial. Dement Geriatr Cogn Disord[Internet]. 2013 [cited 2018 Jan 23];36(5-6):340-53. Available from: https://www.alz.co.uk/sites/default/files/conf2014/OC003.pdf https://www.alz.co.uk/sites/default/file... ⁾.	Two elderly care models	Two models of care for the elderly were tested, though no significant results were found for the primary outcome (agitation). Secondary outcomes: neuropsychiatric symptoms, psychotic symptoms, depression (only one of the models) and quality of life (only one of the models), obtained positive results.
Lejman E, Westerbotn M, Poder U, Wadensten B. 2013⁽⁴⁵45 Lejman E, Westerbotn M, Poder U, Wadensten B. The ethics of coercive treatment of people with dementia. Nurs Ethics [Internet]. 2013 [cited 2018 Jan 23];20(3):248-62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23329782 https://www.ncbi.nlm.nih.gov/pubmed/2332... ⁾.	Physical restrictions	Despite legal restrictions, nurses still used restrictions as a way to ensure quality and safety in care.
Fetherstonhaugh D, Tarzi L, Bauer M, Nay R, Beattie E. 2016 ⁽⁴⁶46 Fetherstonhaugh D, Tarzi L, Bauer M, Nay R, Beattie E. The Red Dress or the Blue?: how do staff perceive that they support decision making for people with dementia living in residential aged care facilities? J Appl Gerontol [Internet]. 2016 [cited 2018 Jan 23];35(2):209-26. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24762711 https://www.ncbi.nlm.nih.gov/pubmed/2476... ⁾.	Aid to the elderly in the decision-making process	The knowledge of the workers about the elderly should be used to facilitate decision-making in the care of dementia. One must be careful so that this knowledge is not used to manipulate them.
Niemeijer AR, Depla M, Frederiks B, Francke AL, Hertogh C. 2014⁽⁴⁷47 Niemeijer AR, Depla M, Frederiks B, Francke AL, Hertogh C. The use of surveillance technology in residential facilities for people with dementia or intellectual disabilities: a study among nurses and support staff. Am J Nurs[Internet]. 2014 [cited 2018 Jan 23];114(12):28-37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25396755 https://www.ncbi.nlm.nih.gov/pubmed/2539... ⁾.	Electronic surveillance	Institutions wishing to implement surveillance technology should encourage the dialogue about how team members see and understand the concepts of autonomy and risk for the elderly.
Harris M, Grando V. 2014⁽⁴⁸48 Harris M, Grando V. When is nighttime? A description of bedtime in persons with dementia in the nursing home. Geriatr Nurs[Internet]. 2014 [cited 2018 Jan 23];35:474-8. Available from: http://www.gnjournal.com/article/S0197-4572(14)00221-3/fulltext http://www.gnjournal.com/article/S0197-4... ⁾.	Sleep patterns	The results suggest that bedtime can be influenced by night tasks. Meeting these unique sleep patterns can facilitate the development of non-pharmacological forms of interventions to build sleep cycles around individual preferences and institutional routines.
Lautenbacher S, Sampson EL, Pahl S, Kunz M. 2016⁽⁴⁹49 Lautenbacher S, Sampson EL, Pahl S, Kunz M. Which facial descriptors do care home nurses use to infer whether a person with dementia is in pain. Pain Med[Internet]. 2016 [cited 2018 Jan 23];18(11):1-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28034977 https://www.ncbi.nlm.nih.gov/pubmed/2803... ⁾.	Pain evaluation	Although nurses used all facial descriptors, some were used more frequently than others to infer whether a resident with dementia was in pain.
Kolanowski A, Van haitsma KS, Penrod J, Hill N, Yevchak A. 2015⁽⁵⁰50 Kolanowski A,Van Haitsma KS, Penrod J, Hill N, Yevchak A. Wish we would have known that! communication breakdown impedes person-centered care. Gerontologist [Internet]. 2015 [cited 2018 Jan 23];55(S1):50-60. Available from: https://academic.oup.com/gerontologist/article/55/Suppl_1/S50/560959 https://academic.oup.com/gerontologist/a... ⁾.	Elderly care model	To improve the use of the model, the flow of information exchange requires: inclusion of all professionals, communication systems that consider available resources, development of educational programs; investment in nursing leadership to effect these changes; and financial approaches to encourage cultural change.

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[1] Corresponding author: Josiane Steil Siewert. E-mail: josianes@ifsc.edu.br