Validation of the Cohen-Mansfield Agitation Inventory Observational (CMAI-O) tool

Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy

OBJECTIVE

40-60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD.

METHODS

Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools.

RESULTS

6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI).

CONCLUSIONS

The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.

Pain in Dementia: An Empirical Test of a Common Assumption

Numerous, and often largely overlapping, observational pain assessment tools have been developed specifically to assess pain in older adults with dementia under the assumption that a specialized approach is necessary to evaluate pain in this population. However, this assumption has never been tested empirically. As an empirical test of this implicit assumption, our goal was to compare existing tools for people living with dementia (with respect to psychometric properties), not only against each other, but also against a tool developed for a different population with cognitive impairments. Videos of older adults with severe dementia recorded in long-term care settings were coded for pain behaviors in the laboratory. Trained coders coded pain behaviors in video segments of older adults with dementia during a quiet baseline condition as well as during a physical examination (designed to identify painful areas), using various observational pain assessment tools. An observational measure of agitation was employed to facilitate the assessment of discriminant validity. Consistent with our expectations, all pain tools (including the tool developed for younger people with cognitive impairments) successfully differentiated between painful and nonpainful states, with large effect sizes. This was the first study to compare tools specifically developed to assess pain in people living with dementia to a tool developed for a different population. Given that all tools under study showed satisfactory psychometric properties when tested on persons with dementia, this study suggests that the assumption that different tools are necessary for different populations with cognitive impairments cannot be taken for granted. PERSPECTIVE: This article challenges an implicitly held assumption that specialized tools are needed to assess pain in different populations with cognitive impairments. Given commonalities in pain expression across populations, further research is needed to determine whether population-specific tools are needed.

Effects of simulated presence therapy on agitated behavior, cognition, and use of protective constraint among patients with senile dementia

The research was conducted to investigate the improvement of agitated behaviors, cognitive functions, and negative emotions among patients with senile dementia and the burden of caregivers after simulated presence therapy (SPT) intervention. 85 Patients with senile dementia were included as the research subjects and divided into control group (40 cases performed with routine nursing) and observation group (45 cases undergoing routine nursing combined with SPT) via a random number table method. Cohen-Mansfield agitation inventory (CAMI) and protective constraint were used to assess the improvement of agitated behaviors among patients. Besides, apathy evaluation scale-informant (AES-I), functional independence measure (FIM), self-rating depression scale (SDS), self-rating anxiety scale (SAS), clock drawing test, and caregiver burden inventory (CBI) were adopted to evaluate the differences in apathy, daily living and sociability, depression, anxiety, cognitive functions, and caregiver burden between the two groups. It was demonstrated that CAMI score, the duration of protective constraint use, AES-I score, SDS score, SAS score, and CBI score among patients in observation group all apparently decreased compared with those in control group after the intervention. In contrast, FIM and clock drawing test scores both notably increased (p < 0.05). The above findings suggested that SPT could obviously reduce the incidence of agitated behaviors, improve the level of apathy, daily living and sociability, depression, anxiety, and cognitive functions, and relieve caregiver burden among patients with senile dementia during SPT intervention for patients with senile dementia.

Assisted bathing of older adults with dementia: a mixed methods systematic review update

OBJECTIVE

This review update aimed to determine the best strategies for assisted bathing or showering for older adults with dementia.

INTRODUCTION

Assisted bathing is a high-risk activity, as it can trigger agitated behaviors. Assisted bathing of older adults with dementia can create caregiver challenges and stress.

INCLUSION CRITERIA

This review update considered quantitative, qualitative, and mixed methods studies that investigated, firstly, older adults with dementia who required assistance with bathing and, secondly, their caregivers and family members who provided this assistance. The quantitative component considered randomized controlled trials and quasi-experimental studies testing interventions for reducing agitated behaviors in older adults with dementia during bathing, as well as perceived confidence or satisfaction in caregivers. The qualitative component considered studies that reported on experiences of clients or caregivers during the bathing process.

METHODS

A JBI mixed methods review was conducted following the convergent segregated approach. The review considered studies published between 1990 and March 11, 2022. The databases searched were PubMed, CINAHL, and Embase. Gray literature was also searched. Two independent reviewers screened titles and abstracts. Full texts were retrieved for studies that met the inclusion criteria and were assessed further for eligibility. Two reviewers independently assessed the quality of included studies and extracted data using the standardized JBI tools. Due to methodological and clinical heterogeneity, the results were presented narratively in the quantitative section. For the qualitative component, meta-synthesis was conducted following the JBI approach of meta-aggregation. Finally, evidence from the 2 components was integrated following the convergent segregated approach.

RESULTS

Ten quantitative and 4 qualitative studies were included. The methodological quality was poor to moderate in the quantitative studies and moderate to high in the qualitative studies. Results from 3 quantitative studies suggested that providing training to caregivers on person-centered bathing reduced agitated behaviors in older adults with dementia. Other interventions did not show conclusive evidence of their effectiveness in any outcomes of interest. Two synthesized findings highlighted i) the importance of working within each person's reality by having the skills and knowledge required to deliver person-centered assistance and ii) the challenges experienced by caregivers, such as lack of support, time pressure, and safety-related fears. The integrated evidence showed that the quantitative and qualitative components complemented each other to promote the training of caregivers to deliver person-centered bathing.

DISCUSSION

Integrated findings can help inform an evidence-based strategy utilizing a person-centered bathing approach to reduce agitated behaviors in older adults with dementia. Due to the limited number of eligible studies, and the clinical and methodological heterogeneity of included quantitative studies, no statistical pooling was possible. More studies are needed, particularly intervention studies with high methodological quality.

CONCLUSIONS

This review update suggests that providing caregivers with person-centered bathing training should be encouraged prior to bathing older adults with dementia. Caregivers should have the knowledge and skills, such as relevant assessment and communication skills, enabling them to provide effective bathing experiences to older adults living with dementia. Organizations should provide caregivers with appropriate resources and training for bathing older adults with dementia.

REVIEW REGISTRATION

PROSPERO CRD42020208048.

SUPPLEMENTAL DIGITAL CONTENT

A Japanese-language version of the abstract of this review is available as supplemental digital content 1: http://links.lww.com/SRX/A37 .

Agitation in cognitive disorders: Progress in the International Psychogeriatric Association consensus clinical and research definition

BACKGROUND

The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original work group, we summarize the use and validation of criteria in order to remove "provisional" from the definition.

METHODS

This report summarizes information from the academic literature, research resources, clinical guidelines, expert surveys, and patient and family advocates on the experience of use of the IPA definition. The information was reviewed by a working group of topic experts to create a finalized definition.

RESULTS

We present a final definition which closely resembles the provisional definition with modifications to address special circumstances. We also summarize the development of tools for diagnosis and assessment of agitation and propose strategies for dissemination and integration into precision diagnosis and agitation interventions.

CONCLUSION

The IPA definition of agitation captures a common and important entity that is recognized by many stakeholders. Dissemination of the definition will permit broader detection and can advance research and best practices for care of patients with agitation.

A Visual Analog Scale for Self-Reported Quality of Life: A Comparison of VAS and QoL-AD in Older Adults

PURPOSE

People with dementia (PWD) are one of the fastest-growing clinical populations for speech-language pathologists. Self-reported quality of life (QoL) assessments are critical patient-reported outcome measures that align with person-centered care principles. However, proxy-reporting is most often used due to assumptions that PWD cannot provide reliable self-report. Visual analog scales (VASs) have been successfully used with people with expressive and cognitive deficits to measure subjective constructs such as QoL, mood, and pain. The purpose of this project is to evaluate the feasibility and reliability of a VAS QoL assessment tool.

METHODS

Twenty older adults free of cognitive impairment were assessed using the quality of life in Alzheimer's disease (QoL-AD) and the QoL-AD in combination with a VAS (VAS QoL-AD). The construct validity, internal consistency, and test-retest reliability of the VAS QoL-AD were assessed by performing both assessments twice, 4 weeks apart.

RESULTS

Significant correlations between the overall VAS QoL-AD and the QoL-AD scale ratings, between most of the QoL-AD and VAS QoL-AD subtests, and between the first and second assessment scores were observed.

CONCLUSIONS

Results indicated strong construct validity, internal consistency, and test-retest reliability of the VAS QoL-AD in people without dementia. These results warrant further research into the development of a dementia-specific, self-reported VAS QoL scale for PWD.

A Confirmatory and an Exploratory Factor Analysis of the Cohen-Mansfield Agitation Inventory (CMAI) in a European Case Series of Patients with Dementia: Results from the RECage Study

BACKGROUND

One of the most widely used instruments for assessing agitation in dementia patients is the Cohen-Mansfield Agitation Inventory (CMAI), nevertheless no global score has been proposed. The aim of this study is: (a) to conduct a confirmatory (CFA) and exploratory factor analysis (EFA) of CMAI on people with dementia and Psychological and Behavioral Symptoms (BPSD), and (b) to propose an alternative structure, based on clinical criteria including all CMAI items.

METHODS

Confirmatory and exploratory factor analyses were carried out on the CMAI 29 items administered at baseline to 505 patients with dementia (PwD) and BPSD enrolled in the international observational RECage study.

RESULTS

The three-factor structure has not been confirmed by the CFA, whilst the EFA was carried out respectively on 25 items disregarding 4 items with a prevalence ≤5% and then on 20 items disregarding 9 items with a prevalence ≤10%. The four-factor structure explaining 56% of the variance comprised Physically Aggressive behavior, Verbally Aggressive behavior, Physically non-aggressive behavior, and Physically and verbally aggressive behavior.

CONCLUSIONS

A new grouping of all items according to a clinical criterion is proposed, allowing for a more sensible evaluation of the symptoms leading to better differentiation.

The Significance and Limitations of Sensor-based Agitation Detection in People Living with Dementia

Agitation, a commonly observed behaviour in people living with dementia (PLwD), is frequently interpreted as a response to physiological, environmental, or emotional stress. Agitation has the potential to pose health risks to both individuals and their caregivers, and can contribute to increased caregiver burden and stress. Early detection of agitation can facilitate with timely intervention, which has the potential to prevent escalation to other challenging behaviors. Wearable and ambient sensors are frequently used to monitor physiological and behavioral conditions and the collected signals can be engaged to detect the onset of an agitation episode. This paper delves into the current sensor-based methods for detecting agitation in PLwD, and reviews the strengths and limitations of existing works. Future directions to enable real-time agitation detection to empower caregivers are also deliberated, with a focus on their potential to reduce caregiver burden by facilitating early support, assistance and interventions to timely manage agitation episodes in PLwD.

Agitation and aggression in people living with dementia and mild cognitive impairment in shared-housing arrangements - validation of a German version of the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF)

BACKGROUND

The Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF) is a 14-item scale for assessing agitation and aggression, derived from the original 29-item CMAI, and completed by a proxy. Because the CMAI-SF has not yet been validated in German language, the aim of this study is to explore its construct validity.

METHODS

Baseline data from a cluster-randomized trial to evaluate a non-pharmacological complex intervention for people living with dementia (PlwD) and mild cognitive impairment (MCI) were analyzed. The study sample consisted of 97 shared-housing arrangements (SHAs) in Germany, comprising N = 341 residents with mild to severe dementia and MCI. Trained nursing staff collected data by proxy-rating the CMAI-SF, Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), and QUALIDEM. They also conducted the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA).

RESULTS

In an exploratory factor analysis, three factors emerged: "aggressive behavior", "verbally agitated behavior", and "physically non-aggressive behavior". The CMAI-SF total score showed good internal consistency (α = .85), and the factors themselves showed adequate internal consistency (α = .75/.76/.73). The CMAI-SF showed convergent validity with the NPI-NH agitation item (r = .66) and the NPI-NH "agitation & restless behavior" factor (r = .82). Discriminant validity was confirmed by a low (r = .28) correlation with the NPI-NH apathy item. Quality of life decreased significantly with agitation, as the CMAI-SF showed a moderate negative correlation with the QUALIDEM total score (r = -.35).

CONCLUSIONS

The 14-item CMAI-SF is a time-efficient, reliable, and valid assessment instrument. Three factors emerged that were similar to those already found in nursing home samples for the original CMAI and the CMAI-SF and in day care samples for the CMAI-SF. The findings provide preliminary evidence that the CMAI-SF can be used instead of the CMAI to reduce time, costs, and burden in future trials.

TRIAL REGISTRATION

The DemWG study from which data were used to draft this manuscript was prospectively registered on 16 July 2019 at ISRCTN registry (ISRCTN89825211).

Methodology and outcome of trials involving older adults in UK care homes: A rapid review

BACKGROUND

The United Kingdom (UK) has a well-developed health and social care system, and strong research governance. However, there is limited evidence to guide best research practice among vulnerable older people in care homes and there is no consensus on clinical trial methodology that is deliverable in this setting.

OBJECTIVES

To review the literature on trials conducted among older adults residing in care homes within the UK and collate evidence on their methodological characteristics and outcomes.

METHODS

A systematic rapid review methodology was employed. MEDLINE, EMBASE and CENTRAL were searched in two incremental stages: stage 1 searched for oral health-related trials conducted within the UK care homes up to July 2021, whereas stage 2 sought for general health-related trials in the same setting from 2011 to 2021. The quality of included studies was assessed using Cochrane's RoB 2 and ROBINS-I tools. Findings were summarised descriptively.

RESULTS

Five oral health and 33 general health-related trials involving care home residents were included for analysis. The most common trial design was parallel group with two arms (n = 25) involving individual randomisation (n = 21). Consent was mainly obtained from residents and/or their proxies (n = 24), followed by residents only (n = 13) and care homes only (n = 1). Based on available data, the number needed to screen to recruit one participant ranged from 2 to 40 (median: 3; Q1-Q3: 2-9). Attrition rates ranged from 0% to 73% (median: 21%; Q1-Q3: 13%-32%) for follow-up periods between 1 and 52 weeks. The studies were of mixed methodological quality.

CONCLUSION

This rapid review outlines the methodological characteristics and outcomes of trials conducted among older adults in UK care homes. The findings of this review provide valuable information to assist in navigating and designing future research in this complex setting.

An Explorative Investigation of the Effect of Naturalistic Light on Agitation-Associated Behavior in Nursing Home Residents With Dementia: A Pilot Study

Aim:

To study the effect of naturalistic light, programmed to replicate the spectrum distribution of natural light from dusk to dawn, on agitation measured with a Cohen-Mansfield Agitation Inventory–inspired score of nursing home residents with dementia.

Background:

Though the effects of different types of light on the sleep-wake patterns of senior adults and people with dementia have been examined in several studies, the effects of naturalistic light systems, as a possible nonpharmacological intervention to improve sleep and reduce agitation, have yet to be extensively evaluated due to the relative novelty of the technology.

Methods:

The study was designed as a 6-month pilot study of a prospective interventional longitudinal cohort study, with five participants recruited from a single department of a Danish nursing home. The effect of naturalistic lighting on agitation-associated behaviors was recorded over a 3-day period pre- and postintervention. Results: An overall 71.2% reduction in the frequency of agitation-associated behaviors was recorded, with the frequency of some behaviors even reduced by 100%.

Conclusions:

This pilot study estimates that naturalistic lighting may be a promising nonpharmacological intervention to improve the overall agitation of nursing home residents with dementia, with a possible added benefit of an improved work environment for the staff. This study, therefore, finds indication for the performance of a randomized controlled trial with the same intervention and a larger cohort.

Nurses' Experience of Nursing Workload-Related Issues during Caring Patients with Dementia: A Qualitative Meta-Synthesis

The behavioral and psychological symptoms of dementia (BPSD), which appear in all dementia patients, demand sizable commitments of time and effort from nurses. This study aims to identify issues related to the workloads of nurses who provide care for dementia patients via qualitative meta-synthesis. Eleven articles were selected using a systematic review flowchart, which were then evaluated for their quality using the Critical Appraisal Skills Program checklist. Collected data were analyzed using a line-of-argument method. Theme clusters were "increased workload due to characteristics of dementia", "increased mental stress", "difficulty associated with playing a mediator role in addition to nursing duties", and "lacking systematic support for dementia patient care". To reduce the workload and mental stress of nurses in dementia care, supportive measures appropriate for their occupational characteristics should be developed, based on workload estimates that account for the attributes of dementia patients.

Feasibility of Group-Based Multiple Virtual Reality Sessions to Reduce Behavioral and Psychological Symptoms in Persons Living in Residential Aged Care

OBJECTIVES

To assess the feasibility of using group-based fully immersive virtual reality (VR) across multiple sessions to reduce behavioral and psychological symptoms (BPSs), including depression, anxiety, and agitated behaviors, in cognitively diverse aged care residents.

DESIGN

A 6-session feasibility trial was conducted within a residential aged care facility using convenience sampling to recruit N = 25 residents of varying cognitive capacity. Groups of 5 residents viewed 360-degree videos on a wireless head-mounted display to provide fully immersive VR experiences.

SETTING AND PARTICIPANTS

Half of the participants recruited from the 160-bed facility had a diagnosis of dementia (48%), whereas assessment with the Psychogeriatric Assessment Scale for cognitive impairment revealed that 64% experienced cognitive impairment (mild 20%, moderate 16%, and severe 28%). Additionally, 32% of participants had an existing anxiety or depression diagnosis.

MEASURES

The Cornell Scale for Depression in Dementia, Generalized Anxiety Disorder 7-item, and Cohen Mansfield Agitation Inventory-Short were used to assess changes in persisting BPS pre- to postintervention period. The Person-Environment Apathy Rating apathy subscale, Observed Emotions Rating Scale, and a visual analog scale (Smileometer) were used to assess immediate mood responses from residents at every VR session. VR tolerability and resident feedback was also recorded.

RESULTS

Pleasure (z = -5.892, P < .001) and general alertness (z = -2.455, P = .014) of participants improved at VR sessions, whereas apathy diminished (z = -5.275, P < .001). Compared to baseline, post-intervention depression was significantly lowered (z = -2.60, P = .009), whereas agitation increased (z = -2.98, P = .003). No significant changes in anxiety were observed. The quality of 360-degree videos and the device used did not induce any major VR-related negative side effects.

CONCLUSIONS AND IMPLICATIONS

Overall group-based VR reduced depressive symptoms and apathy, and induced a positive emotional response in most residents, with few observed side effects. Results indicate feasibility of group-based VR technological innovation within RAC.

Effectiveness of Dementia Care Mapping™ to reduce agitation in care home residents with dementia: an open-cohort cluster randomised controlled trial

OBJECTIVES

Agitation is common and problematic in care home residents with dementia. This study investigated the (cost)effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation in this population.

METHOD

Pragmatic, cluster randomised controlled trial with cost-effectiveness analysis in 50 care homes, follow-up at 6 and 16 months and stratified randomisation to intervention (n = 31) and control (n = 19). Residents with dementia were recruited at baseline (n = 726) and 16 months (n = 261). Clusters were not blinded to allocation. Three DCM cycles were scheduled, delivered by two trained staff per home. Cycle one was supported by an external DCM expert. Agitation (Cohen-Mansfield Agitation Inventory (CMAI)) at 16 months was the primary outcome.

RESULTS

DCM was not superior to control on any outcomes (cross-sectional sample n = 675: 287 control, 388 intervention). The adjusted mean CMAI score difference was -2.11 points (95% CI -4.66 to 0.44, p = 0.104, adjusted ICC control = 0, intervention 0.001). Sensitivity analyses supported the primary analysis. Incremental cost per unit improvement in CMAI and QALYs (intervention vs control) on closed-cohort baseline recruited sample (n = 726, 418 intervention, 308 control) was £289 and £60,627 respectively. Loss to follow-up at 16 months in the original cohort was 312/726 (43·0%) mainly (87·2%) due to deaths. Intervention dose was low with only a quarter of homes completing more than one DCM cycle.

CONCLUSION

No benefits of DCM were evidenced. Low intervention dose indicates standard care homes may be insufficiently resourced to implement DCM. Alternative models of implementation, or other approaches to reducing agitation should be considered.

The outcomes of a person-centered, non-pharmacological intervention in reducing agitation in residents with dementia in Australian rural nursing homes

BACKGROUND

There is limited best- practice evidence to address behavioral and psychiatric symptoms for those with dementia in Australian rural nursing homes. This study aims to evaluate the outcomes of a person-centered, non-pharmacological dementia care model, 'Harmony in the Bush', based on the Progressively Lowered Stress Threshold principles and person-centered music in rural Australia.

METHODS

A quasi-experimental (nonrandomized, pre-post) intervention study was conducted in five rural nursing homes in Queensland and South Australia. Seventy-four residents with dementia participated in this intervention study, which yielded a sample power of 80%. Eighty-seven staff completed the Caregiver Stress Inventory at pre-post four-weeks of intervention. Staff training workshops focused on the theory of the Progressively Lowered Stress Threshold principles and delivery of person-centered care plan with integrated music intervention. We used reported changes in agitation of the residents, measured using Cohen- Mansfield Agitation Inventory, and staff's caregiving stress, using Caregivers Stress Inventory. This study adheres to the CONSORT guidelines.

RESULTS

Mean age of residents with dementia was 82.4 (7.7) years and 69% were females. The mean age of admission was 80.1(8.4) years. Baseline measures indicated that 32.7% had mild- severe pain and 30.5% reported mild-severe sadness. The results showed statistically significant decline in aggressive behaviors, physically non-aggressive behaviors, verbally agitated behavior and hiding and hoarding. There was similar reduction in staff stress in the domains of aggressive behaviors, inappropriate behaviors, resident safety, and resource deficiency.

CONCLUSIONS

The Harmony in the Bush model is effective in reducing agitation among dementia residents with significant reduction in staff stress levels in nursing homes in rural Australia.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR) on 20/2/2018 (Registration No: ACTRN12618000263291p). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374458.

The Effect of Eucalyptol on Nursing Home Residents

Eucalyptol is one of the most popular volatile components. It is used in many essential oils for relieving sinus and lung congestion caused by a variety of conditions. This pilot study sought to analyze clinical evidence for the effect of the scent of eucalyptol on the cognitive function of elderly people. Seventy nursing-home residents with cognitive impairment were recruited. Three one-week experiments were performed: eucalyptol scent was diffused in bedrooms with a diffuser only at wake-up time in the first experiment, and at wake-up time and bedtime in the second and third experiments. Results showed that although an improvement was not seen when using Mini Mental State Examination (MMSE) and Cohen-Mansfild Agitation Inventory (CMAI) measures, Dementia Behavior Disturbance Scale (DBD) scores improved significantly, even though no subject reported perceiving the scent. The significant improvements of the behaviour were found not only among the subjects whose room had a diffuser but also among the subjects who were exposed to an unperceivable level of eucalyptol drifted in the living room.

Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT

BACKGROUND

The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required.

OBJECTIVE

To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care.

DESIGN

A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors.

SETTING

Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub.

PARTICIPANTS

Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation.

INTERVENTION

Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert.

MAIN OUTCOME MEASURES

The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life.

RESULTS

There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified.

LIMITATIONS

The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important.

CONCLUSIONS

There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes.

FUTURE WORK

Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82288852.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.

Validation of the Cohen-Mansfield Agitation Inventory Observational (CMAI-O) tool - ERRATUM

The above article (Griffiths et al., 2019) published with an incorrect abstract.The correct abstract is as follows.

OBJECTIVES

Behaviours associated with agitation are common in people living with dementia. The Cohen-Mansfield Agitation Inventory (CMAI) is a 29-item scale widely used to assess agitation completed by a proxy (family carer or staff member). However, proxy informants introduce possible reporting bias when blinding to the treatment arm is not possible, and potential accuracy issues due to irregular contact between the proxy and the person with dementia over the reporting period. An observational measure completed by a blinded researcher may address these issues, but no agitation measures with comparable items exist.

DESIGN

Development and validation of an observational version of the CMAI (CMAI-O), to assess its validity as an alternative or complementary measure of agitation.

SETTING

Fifty care homes in England.

PARTICIPANTS

Residents (N = 726) with dementia.

MEASUREMENTS

Two observational measures (CMAI-O and PAS) were completed by an independent researcher. Measures of agitation, functional status, and neuropsychiatric symptoms were completed with staff proxies.

RESULTS

The CMAI-O showed adequate internal consistency (α = .61), criterion validity with the PAS (r = .79, p = < .001), incremental validity in predicting quality of life beyond the Functional Assessment Staging of Alzheimer's disease (β = 1.83, p < .001 at baseline) and discriminant validity from the Neuropsychiatric Inventory Apathy subscale (r = .004, p = .902).

CONCLUSIONS

The CMAI-O is a promising research tool for independently measuring agitation in people with dementia in care homes. Its use alongside the CMAI could provide a more robust understanding of agitation amongst residents with dementia.