All ETDs from UAB

Advisory Committee Chair

Rita A Jablonski

Advisory Committee Members

Cindy L Cain

Maria L Geisinger

Carolyn E Z Pickering

Frank Puga

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Nursing


Persons living with dementia who exhibit care-resistant behaviors (CRB) are likely to resist mouth care and have poor oral health. Knowing the “balance” between providing optimal mouth care while managing CRB is critical for developing tailored interventions. No evidence has demonstrated a balance between CRB level, mouth care completion, and oral health status. The overarching goal of this study was to identify a balance or “sweet spot” between enough mouth care to maintain oral health and a manageable level of CRB intensity. The purpose of this study was to examine and describe the characteristics of CRB trajectories as they relate to the distal outcome of oral health among PLWD residing in nursing homes (NH). A secondary analysis was performed on a sample of 75 persons living with dementia (PLWD) living in nursing homes. The theoretical framework was a combination of the Pattern Theory and the Dynamic Pattern Theory to frame the daily and long-term pattern of CRB intensity in the context of everyday mouth care. Groupbased trajectory modeling (GBTM) was used to analyze dynamic changes in CRB intensity over time. The intensity of CRB was analyzed at two time-points (morning and afternoon) across 21 days. Characteristics of each trajectory group were described from sub-group analysis results. Bivariate regression and chi-square tests were used to determine predictor candidates; multinomial logistic regression was applied to explore ii the most important predictors. Censored normal regression of two-step distal models was used to explore the association between oral health variation and mouth care completion to identify CRB trajectories. Paired t-test was used to compare oral health at baseline and day 21. Statistical software The three most influential predictors were CRB intensity at baseline, duration of mouth care, and the number of antipsychotics prescribed. There were three groups of PLWD with distinctive trajectories over 21 days for both morning and afternoon CRB intensity levels. The sample distribution of the three morning and three afternoon CRB intensity trajectories was similar with one exception; one of the afternoon groups showed a statistically significant increase in CRB intensity. This group had the worst oral health status and lowest mouth care completion. Oral health status differed by CRB trajectory groups, and worse oral health status was associated with higher CRB trajectories. The number of mouth care completions differed by CRB trajectory group, with fewer mouth care completion associated with a higher level of CRB trajectory. High-start CRB trajectories suggested a significant difference in trajectory estimated oral health and actual oral health status. Oral health showed improvement across all three trajectory groups. Based on the trajectory trends and CRB characteristics of trajectory group membership, a tailored individual-level strategy based on a daily pattern of CRB intensity may provide the key to developing interventions that find the “sweet spot” between providing optimal mouth care while minimizing CRB. The modifiable predictors imply a potentially positive change in the dynamic CRB pattern. The variance between CRB levels of intensity and the distal outcome of oral health and completion of mouth care iii was determined. The consistent oral health status and mouth care completion in morning and afternoon CRB trajectory groups indicates a rigorous association between CRB patterns and oral health. Results indicate three implications: 1) Scientific. Use mathematical approaches to harmonize data framing deep learning in CRB or dementia behavior analysis; 2) Clinical. Balance CRB and mouth care by providing morning-only mouth care to those with high CRBs may allocate resources to PLWD most in need of mouth care. Antipsychotics have not shown usefulness in managing CRB; 3) Political. Integrate dementia care in CNA curriculum. Include additional reimbursement for CRB care.

Available for download on Sunday, December 22, 2024

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