An MDS 3.0 Distressed Behavior in Dementia Indicator (DBDI): A Clinical Tool to Capture Change

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.

Increase in blood pressure precedes distress behavior in nursing home residents with dementia

BACKGROUND

Distress behaviors in dementia (DBD) likely increase sympathetic nervous system activity. The aim of this study was to examine the associations among DBD, blood pressure (BP), and intensity of antihypertensive treatment, in nursing home (NH) residents with dementia.

METHODS

We identified long-stay Veterans Affairs NH residents with dementia in 2019-20 electronic health data. Each individual with a BP reading and a DBD incident according to a structured behavior note on a calendar day (DBD group) was compared with an individual with a BP reading but without a DBD incident on that same day (comparison group). In each group we calculated daily mean BP from 14 days before to 7 days after the DBD incident day. We then calculated the change in BP between the DBD incident day and, as baseline, the 7-day average of BP 1 week prior, and tested for differences between DBD and comparison groups in a generalized estimating equations multivariate model.

RESULTS

The DBD and comparison groups consisted of 707 and 2328 individuals, respectively. The DBD group was older (74 vs. 72 y), was more likely to have severe cognitive impairment (13% vs. 8%), and had worse physical function scores (15 vs. 13 on 28-point scale). In the DBD group, mean systolic BP on the DBD incident day was 1.6 mmHg higher than baseline (p < .001), a change that was not observed in the comparison group. After adjusting for covariates, residents in the DBD group, but not the comparison group, had increased likelihood of having systolic BP > = 160 mmHg on DBD incident days (OR 1.02; 95%CI 1.00-1.03). Systolic BP in the DBD group began to rise 7 days before the DBD incident day and this rise persisted 1 week after. There were no significant changes in mean number of antihypertensive medications over this time period in either group.

CONCLUSIONS

NH residents with dementia have higher BP when they experience DBD, and BP rises 7 days before the DBD incident. Clinicians should be aware of these findings when deciding intensity of BP treatment.

Factors Related to Higher and Lower Performance and Adherence in STAR-VA Program Sustainment in Department of Veterans Affairs (VA) Community Living Centers (CLCs)

OBJECTIVES

We identify factors associated with sustainment of an intervention (STAR-VA) to address distress behaviors in dementia (DBD), guided by the Organizational Memory Knowledge Reservoir (KR) framework, compared across 2 types of outcomes: (1) site performance improvement on a clinical outcome, the magnitude of change in levels of DBD, and (2) self-rated adherence to STAR-VA core components, a process outcome.

DESIGN

We used a cross-sectional sequential explanatory mixed methods design guided by the Organizational Memory Framework.

SETTING AND PARTICIPANTS

We selected 20 of 79 sites that completed STAR-VA training and consultation based on rankings on 2 outcomes-change in an indicator of DBD and reported adherence to STAR-VA core components. We recruited key informants most knowledgeable about STAR-VA resulting in a sample of 43% behavioral coordinators, 36% nurse champions, and 21% nurse leaders.

METHODS

We collected data with key informants at each Community Living Center (CLC) from December 2018 to June 2019. We analyzed data using within-case and cross-case matrixes created from the coded transcripts for each a priori KR domain. We then assessed if there were any similarities or differences for CLCs in comparable DBD performance and STAR-VA adherence categories.

RESULTS

We found 4 KRs that differentiated sustainment factors based on CLC implementation process and clinical outcomes-3 KRs related to DBD performance (people, relationships, and routines) and 2 related to STAR-VA adherence (relationships and culture).

CONCLUSIONS AND IMPLICATIONS

This evaluation found several knowledge retention mechanisms that differ in high and low performance/adherence sites. Our findings highlight knowledge retention/sustainment strategies based on site functioning to support sustainment strategies in the CLC. Understanding sustainment factors as they relate to clinical and process outcomes is innovative and can be used to support CLCs struggling with sustainment. More research is needed to inform tailored sustainment efforts based on site functioning in the nursing home setting.

Implementation Lessons Learned: Distress Behaviors in Dementia Intervention in Veterans Health Administration

BACKGROUND AND OBJECTIVES

Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide.

RESEARCH DESIGN AND METHODS

STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges.

RESULTS

STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation.

DISCUSSION AND IMPLICATIONS

STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health-nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice.

Identifying Factors Affecting the Sustainability of the STAR-VA Program in the Veterans Health Administration

BACKGROUND AND OBJECTIVES

Sustained implementation of new programs in complex care systems like nursing homes is challenging. This prospective qualitative evaluation examined factors affecting the sustainability of the Staff Training in Assisted Living Residences in Veterans Health Administration (STAR-VA) program in Veterans Health Administration (VA) Community Living Centers (CLC, i.e., nursing homes). STAR-VA is an evidence-based interdisciplinary, resident-centered, behavioral approach for managing distress behaviors in dementia.

EVALUATION DESIGN AND METHODS

In 2019, we conducted 39 semistructured phone interviews with STAR-VA key informants across 20 CLCs. We identified a priori themes based on the Organizational Memory Framework, which includes 7 Knowledge Reservoirs (KRs): people, routines, artifacts, relationships, organizational information space, culture, and structure. We conducted content-directed analysis of transcripts to identify factors to program sustainment.

RESULTS

We identified 9 sustainment facilitators across KRs: engaged site leaders and champions, regular meetings and trainings, written documentation and resources, regular and open communication, available educational tools (e.g., handouts and posters), adequate spaces, leadership support on many levels, staff buy-in across disciplines, and staff competencies and recognition. Ten barriers across KRs included: staffing concerns, inconsistent/inefficient routines, inconsistent documentation, lack of written policies, communication gaps, nonstandardized use of tools, constraints with meeting spaces and regulations on posting information, limited leadership support, division among staff, and missing performance expectations.

DISCUSSION AND IMPLICATIONS

Findings inform tailored strategies for optimizing STAR-VA program sustainment in CLCs, including the development of a sustained implementation guide, implementation resources, regional communities of practice, and STAR-VA integration into national CLC quality improvement routines for team communication and problem-solving.

Nursing Home to Nursing Home Transfers during the Early COVID-19 Pandemic

OBJECTIVES

To examine the nursing home to nursing home transfer rates before and during the early COVID-19 pandemic and to identify risk factors associated with those transfers in a state with a policy to create COVID-19-care nursing homes.

DESIGN

Cross-sectional cohorts of nursing home residents in prepandemic (2019) and COVID-19 (2020) periods.

SETTING AND PARTICIPANTS

Michigan long-term nursing home residents were identified from the Minimum Data Set.

METHODS

Each year, we identified transfer events as a resident's first nursing home to nursing home transfer between March and December. We included residents' characteristics, health status, and nursing home characteristics to identify risk factors for transfer. Logistic regression models were conducted to determine risk factors for each period and changes in transfer rates between the 2 periods.

RESULTS

Compared to the prepandemic period, the COVID-19 period had a higher transfer rate per 100 (7.7 vs 5.3, P < .05). Age ≥80 years, female sex, and Medicaid enrollment were associated with a lower likelihood of transfer for both periods. During the COVID-19 period, residents who were Black, with severe cognitive impairment, or had COVID-19 infection were associated with a higher risk of transfer [adjusted odds ratio (AOR) (95% CI): 1.46 (1.01-2.11), 1.88 (1.11-3.16), and 4.70 (3.30-6.68), respectively]. After adjusting for resident characteristics, health status, and nursing home characteristics, residents had 46% higher odds [AOR (95% CI): 1.46 (1.14-1.88)] of being transferred to another nursing home during the COVID-19 period compared to the prepandemic period.

CONCLUSIONS AND IMPLICATIONS

In the early COVID-19 pandemic, Michigan designated 38 nursing homes to care for residents with COVID-19. We found a higher transfer rate during the pandemic than during the prepandemic period, especially among Black residents, residents with COVID-19 infection, or residents with severe cognitive impairment. Further investigation is warranted to understand the transfer practice better and if any policies would mitigate the transfer risk for these subgroups.

Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization

STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 "as-needed" doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.

Impact of STAR-VA on Staff Injury and Disruptive Behavior Reports in VA Nursing Homes

OBJECTIVES

Workplace disruptive behavior incidents can be costly for organizations, employees, and customers. Persons with dementia living in long-term care settings have a high risk of exhibiting distressed behaviors. We examined whether a resident-centered, behavioral intervention for residents with dementia led to a reduction in reported workplace disruptive behaviors and staff injury rate due to assault. Impactful interventions are important for quality of care.

DESIGN

We examined whether a team-based behavioral program in community living centers (CLCs), where a nurse champion and behavioral coordinator were trained to work with the clinical team to understand and manage distressed behaviors commonly associated with dementia, was associated with reductions in behavior incidents.

SETTING AND PARTICIPANTS

The setting was Veterans Health Administration CLCs. The sample consisted of 120 aggregated CLCs operating between 2012 and 2017 with 62 completing training. CLCs were distributed across the United States.

METHODS

Outcomes included CLC-level rates of staff injury and number of workplace disruptive behavior incidents. Outcomes were regressed on measures of intervention completion, time since intervention, and several CLC characteristics.

RESULTS

The intervention was significantly associated with lower incidence of assault with staff injury rates overall, particularly following the first year of training, but not with other reported workplace disruptive behavior incident rates.

CONCLUSIONS AND IMPLICATIONS

A team-based behavioral intervention was associated with reduction of employee assaults, a critical repercussion of distressed behavior in dementia. Given rapid growth in patients with dementia in nursing homes, effective treatment practices, such as interdisciplinary behavioral management approaches may be impactful and valuable to implement.