Behavior and Evolution of Young ONset Dementia part 2 (BEYOND-II) study: an intervention study aimed at improvement in the management of neuropsychiatric symptoms in institutionalized people with young onset dementia

Health Care Team Interventions to Reduce Distress Behaviors in Older Adults: A Systematic Review

OBJECTIVES

This review examines health care team-focused interventions on managing persistent or recurrent distress behaviors among older adults in long-term residential or inpatient health care settings.

METHODS

We searched interventions addressing health care worker (HCW) knowledge and skills related to distress behavior management using Ovid MEDLINE, Elsevier Embase, and Ovid PsycINFO from December 2002 through December 2022.

RESULTS

We screened 6,582 articles; 29 randomized trials met inclusion criteria. Three studies on patient-facing HCW interactions (e.g. medication management, diagnosing distress) showed mixed results on agitation; one study found no effect on quality of life. Six HCW-focused studies suggested short-term reduction in distress behaviors. Quality-of-life improvement or decreased antipsychotic use was not evidenced. Among 17 interventions combining HCW-focused and patient-facing activities, 0 showed significant distress reduction, 8 showed significant antipsychotic reduction (OR = 0.79, 95%CI [0.69, 0.91]) and 9 showed quality of life improvements (SMD = 0.71, 95%CI [0.39, 1.04]). One study evaluating HCW, patient-, and environmental-focused intervention activities showed short-term improvement in agitation.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Novel health care models combining HCW training and patient management improve patient quality of life, reduce antipsychotic use, and may reduce distress behaviors. Evaluation of intervention's effects on staff burnout and utilization is needed.

Usability of an app-based clinical decision support system to monitor psychotropic drug prescribing appropriateness in dementia

BACKGROUND

Guidelines recommend reluctant psychotropic drug (PD) prescribing in nursing home residents with dementia and neuropsychiatric symptoms (NPS), as efficacy of PDs is limited, and side effects are common. Nevertheless, PDs are commonly prescribed to reduce NPS. A smartphone application that evaluates appropriateness of PD prescriptions and provides recommendations from the revised Dutch guideline on problem behaviour in dementia may promote guideline adherence and increase appropriate prescribing.

OBJECTIVE

This study aimed to assess user experiences, barriers and facilitators of the Dutch 'Psychotropic Drug Tool' smartphone application (PDT) in the context of appropriate prescribing of PDs to nursing home residents with dementia and NPS.

METHODS/DESIGN

The PDT was developed according to the recommendations of the Dutch guideline for treatment of NPS in people with dementia. Feedback provided during usability testing with two end-users was applied to improve the PDT before implementation in day-to-day practice. Sixty-three prescribers were asked to use the PDT at their own convenience for four months. User expectations and experiences were assessed at baseline and after four months with the System Usability Scale and the Assessment of Barriers and Facilitators for Implementation.

RESULTS

Expected usability (M = 72.59; SD = 11.84) was similar to experienced usability after four months (M = 69.13; SD = 16.48). Appreciation of the PDTs user-friendliness (on average 6.7 out of 10) and design (7.3) were moderately positive, in contrast to the global rating of the PDT (5.7). Perceived barriers for PDT use were time consumption and lack of integration with existing electronic systems. Perceived facilitators were ease of use and attractive lay out. For broader implementation, physicians suggested a change in direction of the PDT: start assessment of appropriateness based on the list of NPS instead of PD as primary input.

CONCLUSIONS

In this pragmatic prospective cohort study we found that the PDT was used by elderly care physicians, with mediocre user satisfaction. The PDT will be optimized based on user feedback regarding experienced usability, barriers and facilitators, after which broader implementation can be initialized. The Medical Ethics Review Board of the University Medical Center Groningen declared this is a non-WMO study (UMCG RR Number: 201800284).

Scoping Review on Educational Programs for Medical Professionals on the Management of Acute Agitation

BACKGROUND

Agitation is a common reason for psychiatric consultation in the general hospital. The consultation-liaison (CL) psychiatrist is often tasked with teaching the medical team how to manage agitation.

OBJECTIVE

The purpose of this scoping review is to explore what resources the CL psychiatrist has for educational tools on teaching about agitation management. Given the frequency with which CL psychiatrists help with on-the-ground management of agitation, we hypothesized that there would be a scarcity of educational resources to teach front-line providers how to manage agitation.

METHODS

Following current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a scoping review was conducted. The literature search focused on the electronic databases MEDLINE (PubMed), Embase (Embase.com), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), PsycInfo (EbscoHost), Cumulated Index to Nursing and Allied Health Literature (CINAHL) (EbscoHost), and Web of Science. Using Covidence software, after screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, we created a predefined set of criteria according to which each article was analyzed. We then grouped the articles in the full-text review according to which patient population a curriculum was designed for.

RESULTS

The search yielded a total of 3250 articles. After removing duplicates and reviewing procedures, we included 51 articles. Data extraction captured article type and details; educational program information (staff training, web modules, instructor led seminar); learner population; patient population; and setting. The curricula were further divided based on their target patient population, specifically the acute psychiatric patient (n = 10), the general medical patient (n = 9), and the patient with a major neurocognitive disorder such as dementia or traumatic brain injury (n = 32). Learner outcomes included staff comfort, confidence, skills, and knowledge. Patient outcomes included measurements of agitation or violence using validated scales, PRN medication use, and restraint use.

CONCLUSIONS

Despite there being numerous agitation curricula in existence, we found that a large majority of these educational programs were done for patients with major neurocognitive disorders in the long-term care setting. This review highlights the gap in education related to agitation management for both patients and providers in the general medical setting, as less than 20% of total studies are focused on this population. The CL psychiatrist plays a critical role in assisting in agitation management in this setting, which often requires collaboration between technicians, nurses, and nonpsychiatric providers. It calls into question whether the lack of educational programs makes the implementation of management interventions more difficult and less effective, even with the assistance of the CL psychiatrist.

Residential aged care staff perceptions and responses towards neuropsychiatric symptoms: a mixed methods analysis of electronic healthcare records

OBJECTIVES

To investigate electronic care notes to better understand reporting and management of neuropsychiatric symptoms (NPS) by residential aged care (RAC) staff.

METHODS

We examined semi-structured care notes from electronic healthcare notes of 77 residents (67% female; aged 67-101; 79% with formal dementia diagnosis) across three RAC facilities. As part of standard clinical practice, staff documented the NPS presentation and subsequent management amongst residents. Using a mixed-method approach, we analyzed the type of NPS reported and explored care staff responses to NPS using inductive thematic analysis.

RESULTS

465 electronic care notes were recorded during the 18-month period. Agitation-related behaviors were most frequently reported across residents (48.1%), while psychosis (15.6%), affective symptoms (14.3%), and apathy (1.3%) were less often reported. Only 27.5% of the notes contained information on potential causes underlying NPS. When faced with NPS, care staff responded by either providing emotional support, meeting resident's needs, removing identified triggers, or distracting.

CONCLUSION

Results suggest that RAC staff primarily detected and responded to those NPS they perceived as distressing. Findings highlight a potential under-recognition of specific NPS types, and lack of routine examination of NPS causes or systematic assessment and management of NPS. These observations are needed to inform the development and implementation of non-pharmacological interventions and care programs targeting NPS in RAC.

Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2032597 .

Regrets of family caregivers in Israel about the end of life of deceased relatives

Objective: We aimed to clarify the content of different types of regrets or lack of regret, and the frequency of feeling regret among family caregivers who assisted their relatives during their end of life stage.Method: Seventy primary informal caregivers in Israel were interviewed (17 spouses, 52 children, and 1 cousin) concerning their regret about the end of life of their deceased relative, including a general question about regret and questions about regret concerning life-sustaining treatments. After calculating the frequency of regrets and lack of regret, we conducted a qualitative analysis, using a thematic approach to identify themes and interpret data.Results: A majority of caregivers (63%) expressed regret and about 20% expressed ambivalence involving both regret and denial of regret. Regrets pertained to care given, suffering experienced, and the caregiver's behavior towards, and relationship with the deceased, including missing opportunities to express love and caring toward relatives. Caregivers viewed almost 30% of 75 administered life-sustaining procedures as misguided. Most regrets involved inaction, such as not communicating sufficiently, or not fighting for better care.Conclusion: This article provides a comprehensive description of EoL regrets, and helps clarify the complexity of regrets, lack of regrets, and ambivalence concerning regrets, though the study is limited to one country. Analysis suggests the need for public education concerning the EoL process, and for changes within the health care system to improve communication, to improve understanding of the needs of the terminally ill, and to provide more instruction to family caregivers to help them understand EoL.

The Course of Quality of Life and Its Predictors in Nursing Home Residents With Young-Onset Dementia

OBJECTIVE

To explore the course of quality of life (QoL) and possible resident-related predictors associated with this course in institutionalized people with young-onset dementia (YOD).

DESIGN

An observational longitudinal study.

SETTING AND PARTICIPANTS

A total of 278 residents with YOD were recruited from 13 YOD special care units in the Netherlands.

METHODS

Secondary analyses were conducted with longitudinal data from the Behavior and Evolution in Young-ONset Dementia (BEYOND)-II study. QoL was assessed with proxy ratings, using the Quality of Life in Dementia (QUALIDEM) questionnaire at 4 assessment points over 18 months. Predictors included age, gender, dementia subtype, length of stay, dementia severity, neuropsychiatric symptoms, and psychotropic drug use at baseline. Multilevel modeling was used to adjust for the correlation of measurements within residents and clustering of residents within nursing homes.

RESULTS

The total QUALIDEM score (range: 0-111) decreased over 18 months with a small change of 0.65 (95% confidence interval -1.27, -0.04) points per 6 months. An increase in several domains of QoL regarding care relationship, positive self-image, and feeling at home was seen over time, whereas a decline was observed in the subscales positive affect, social relations, and having something to do. Residents with higher levels of QoL and more advanced dementia at baseline showed a more progressive decline in QoL over time. Sensitivity analyses indicated a more progressive decline in QoL for residents who died during the follow-up.

CONCLUSION AND IMPLICATIONS

This study shows that although overall QoL in nursing home residents with YOD was relatively stable over 18 months, there were multidirectional changes in the QoL subscales that could be clinically relevant. Higher levels of QoL and more advanced stages of dementia at baseline predicted a more progressive decline in QoL over time. More longitudinal studies are needed to verify factors influencing QoL in YOD.

Cost-consequence analysis of an intervention for the management of neuropsychiatric symptoms in young-onset dementia: Results from the BEYOND-II study

OBJECTIVE

To evaluate the cost-consequences of an intervention for the management of neuropsychiatric symptoms in nursing home residents with young-onset dementia.

METHODS

A stepped wedge design was used. The intervention consisted of an educational program and a multidisciplinary care program and was implemented in 13 nursing homes from September 2015 to March 2017. Costs' outcomes included the time investment of the elderly care physician and health care psychologists regarding the management of neuropsychiatric symptoms, residents' psychotropic drug use, nursing staff absenteeism, and costs of the educational program. Composite cost measure contained the sum of costs of staff absenteeism, costs on psychotropic drugs, and costs of the educational program. Costs of time investment were investigated by comparing means. Costs of psychotropic drug use were analyzed with mixed models at resident level and as part of the composite cost measure on unit level. Staff absenteeism was also analyzed at unit level.

RESULTS

Compared with care as usual, the mean costs of time invested decreased with €36.79 for the elderly care physician but increased with €46.05 for the health care psychologist in the intervention condition. Mixed model analysis showed no effect of the intervention compared with care as usual on the costs of psychotropic drug use, staff absenteeism, and the composite cost measure. The costs of the educational program were on average €174.13 per resident.

CONCLUSION

The intervention did not result in increased costs compared with care as usual. Other aspects, such as the lack of a structured working method, should be taken into account when considering implementation of the intervention.

Effects of a Multidisciplinary Intervention on the Presence of Neuropsychiatric Symptoms and Psychotropic Drug Use in Nursing Home Residents WithYoung-Onset Dementia: Behavior and Evolution of Young-Onset Dementia Part 2 (BEYOND-II) Study

OBJECTIVE

The effect of an intervention on neuropsychiatric symptoms (NPS), particularly agitation and aggression, and psychotropic drug use (PDU) in institutionalized people with young-onset dementia (YOD) was evaluated.

METHODS

A randomized controlled trial was conducted using a stepped wedge design. Thirteen YOD special care units were randomly assigned to three groups, which received the intervention at different time points. Four assessments took place every 6 months during a period of 18 months. Two hundred seventy-four people with YOD who resided in YOD special care units participated, of whom 131 took part in all assessments. The intervention consisted of an educational program combined with a care program, which structured the multidisciplinary process of managing NPS. The care program included the following five steps: evaluation of psychotropic drug prescription, detection, analysis, treatment, and evaluation of treatment of NPS. The Cohen-Mansfield Agitation Inventory and the Neuropsychiatric Inventory-Nursing Home version were used to assess NPS. Data on PDU were retrieved from residents' medical files. Multilevel models were used to evaluate the effect of the intervention, which accounted for clustering of measurements in clients within units.

RESULTS

No significant differences were found in agitation, aggression, other NPS, or PDU after crossing over to the intervention condition.

CONCLUSION

We found no evidence that the intervention for management of NPS in nursing home residents with YOD was more effective in reducing agitation, aggression, other NPS, or PDU compared with care as usual.

Differences in neuropsychiatric symptoms between nursing home residents with young-onset dementia and late-onset dementia

OBJECTIVE

The aims of the current study are (1) to explore the differences in neuropsychiatric symptoms (NPS) between young-onset dementia (YOD) and late-onset dementia (LOD), and (2) to investigate whether the possible differences can be attributed to differences in dementia subtype, gender, psychotropic drug use (PDU), or dementia severity.

METHOD

Three hundred and eighty-six nursing home (NH) residents with YOD and 350 with LOD were included. Multilevel modeling was used to compare NPS between the groups . Furthermore, dementia subtype, gender, PDU, and dementia severity were added to the crude multilevel models to investigate whether the possible differences in NPS could be attributed to these characteristics.

RESULTS

Higher levels of apathy were found in NH residents with YOD. After the characteristics were added to the models, also lower levels of verbally agitated behaviors were found in YOD .

CONCLUSION

We recommend that special attention be paid to interventions targeting apathy in YOD. Although no differences in other NPS were found, the PDU rates were higher in YOD, suggesting that the threshold for the use of PDU in the management of NPS is lower. This underscores the need for appropriate attention to non-pharmacological interventions for the management of NPS in YOD.

Non-pharmacological interventions for persons with dementia: what are they and how should they be studied?

The publication of four papers concerning non-pharmacological interventions for persons with dementia heralds progress in the science of dementia care. The four papers are very diverse in focus and methodology, and include a study of the impact of a visual arts program on quality of life, communication, and well-being by Windle et al. (2017); an overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia by Dyer et al. (2017); a systematic review of the efficacy of intervention in people with Lewy body dementia by Morrin et al. (2017); and a protocol of the Behavior and Evolution of Young Onset Dementia part two (BEYOND-II) study, an intervention study aimed at improvement in the management of neuropsychiatric symptoms in institutionalized people with young onset dementia by van Duinen-van den IJssel et al. (2017).