Jane Fossey

Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial

Abstract Objective To evaluate the effectiveness of a training and support intervention for nursing home staff in reducing the proportion of residents with dementia who are prescribed neuroleptics. Design Cluster randomised controlled trial with blinded assessment of outcome. Setting 12 specialist nursing homes for people with dementia in London, Newcastle, and Oxford. Participants Residents of the 12 nursing homes; numbers varied during the study period. Intervention Training and support intervention delivered to nursing home staff over 10 months, focusing on alternatives to drugs for the management of agitated behaviour in dementia. Main outcome measures Proportion of residents in each home who were prescribed neuroleptics and mean levels of agitated and disruptive behaviour (Cohen-Mansfield agitation inventory) in each home at 12 months. Results At 12 months the proportion of residents taking neuroleptics in the intervention homes (23.0%) was significantly lower than that in the control homes (42.1%): average reduction in neuroleptic use 19.1% (95% confidence interval 0.5% to 37.7%). No significant differences were found in the levels of agitated or disruptive behaviour between intervention and control homes. Conclusions Promotion of person centred care and good practice in the management of patients with dementia with behavioural symptoms provides an effective alternative to neuroleptics.

Quality of life for people with dementia living in residential and nursing home care: The impact of performance on activities of daily living, behavioral and psychological symptoms, language skills, and psychotropic drugs

Many people with dementia reside in care facilities. Little is known about how key parameters impact upon their quality of life (QOL). All 209 people with dementia in six facilities received a standardized assessment (Neuropsychiatric Inventory [NPI], Barthel Scale, psychotropic drugs). One hundred twelve residents were assessed using Dementia Care Mapping, an observational method for QOL indices. Lower performance on activities of daily living (reduced well-being [WB] r = +0.39, p < .0001; social withdrawal [SW] r = +0.42, p < .0001; engagement in activities [EA] r = +0.31, p = .001) and taking psychotropics (WB 2.5 vs. 3.2, t = 2.3, p = .02; SW 11.4% vs. 2.7%, t = 3.0, p = .004; EA 56.5% vs. 71.9%; t = 3.5, p = .001) were associated with reduced QOL, but symptoms from the NPI were not. More focused prescribing of psychotropics and better staff training are essential.

Quality of care in private sector and NHS facilities for people with dementia: cross sectional survey

Editorial by Marshall Residential and nursing homes provide an essential contribution towards the care of people with dementia. It is a challenge to provide good care within tight budgets and often with a workforce that has little formal training. Most people are cared for within the private sector, although a limited number of NHS beds provide continuing care for people with severe dementia and intractable behaviour problems. Dementia care mapping1 is a direct, standardised assessment with good interrater reliability.2 Activities are coded according to category of behaviour, and they are recorded every five minutes. Wellbeing is measured using the dementia care index, which indicates the overall quality of care within a particular environment extrapolated from dementia care mapping evaluations of half of the residents.1 We used dementia care mapping to evaluate the quality of care in 10 private sector and seven NHS …

Improving quality of life for people with dementia in care homes: making psychosocial interventions work.

BACKGROUND Psychosocial interventions can improve behaviour and mood in people with dementia, but it is unclear how to maximise their effectiveness or acceptability in residential settings. AIMS To understand what underlies the successful implementation of psychosocial interventions in care homes. METHOD Systematic review and meta-synthesis of qualitative research. RESULTS The synthesis of 39 qualitative papers revealed that beneficial psychosocial interventions met the needs of people with dementia to connect with others, make a meaningful contribution and reminisce. Successful implementation rested on the active engagement of staff and family and the continuing provision of tailored interventions and support. This necessitated staff time, and raised issues around priorities and risk, but ultimately helped redefine staff attitudes towards residents and the caregiving role. CONCLUSIONS The findings from the meta-synthesis can help to inform the development and evaluation of psychosocial interventions in care homes and support their widespread implementation in clinical settings.

The value of personalized psychosocial interventions to address behavioral and psychological symptoms in people with dementia living in care home settings: a systematic review

BACKGROUND Several important systematic reviews and meta-analyses focusing on psychosocial interventions have been undertaken in the last decade. However, they have not focused specifically on the treatment of individual behavioral and psychological symptoms of dementia (BPSD) with personalized interventions. This updated systematic review will focus on studies reporting the effect of personalized psychosocial interventions on key BPSD in care homes. METHODS Systematic review of the evidence for psychosocial interventions for BPSD, focusing on papers published between 2000 and 2012. All care home and nursing home studies including individual and cluster randomized controlled trials (RCTs) and pre-/post-test studies with control conditions were included. RESULTS 641 studies were identified, of which 40 fulfilled inclusion and exclusion criteria. There was good evidence to support the value of personalized pleasant activities with and without social interaction for the treatment of agitation, and reminiscence therapy to improve mood. The evidence for other therapies was more limited. CONCLUSIONS There is a growing body of evidence indicating specific effects of different personalized psychosocial interventions on individual BPSD and mood outcomes.

Brief Psychosocial Therapy for the Treatment of Agitation in Alzheimer Disease (The CALM-AD Trial)

BACKGROUND Good practice guidelines state that a psychological intervention should usually precede pharmacotherapy, but there are no data evaluating the feasibility of psychological interventions used in this way. METHODS At the first stage of a randomized blinded placebo-controlled trial, 318 patients with Alzheimer disease (AD) with clinically significant agitated behavior were treated in an open design with a psychological intervention (brief psychosocial therapy [BPST]) for 4 weeks, preceding randomization to pharmacotherapy. The therapy involved social interaction, personalized music, or removal of environmental triggers. RESULTS Overall, 318 patients with AD completed BPST with an improvement of 5.6 points on the total Cohen-Mansfield Agitation Inventory (CMAI; mean [SD], 63.3 [16.0] to 57.7 [18.4], t = 4.8, df = 317, p < 0.0001). Therapy worksheets were completed in six of the eight centers, with the key elements of the intervention delivered according to the manual for >95% of patients. More detailed evaluation of outcome was completed for the 198 patients with AD from these centers, who experienced a mean improvement of 6.6 points on the total CMAI (mean [SD], 62.2 [14.3] to 55.6 [15.8], t = 6.5, df = 197, p < 0.0001). Overall, 43% of participants achieved a 30% improvement in their level of agitation. CONCLUSION The specific attributable benefits of BPST cannot be determined from an open trial. However, the BPST therapy was feasible and was successfully delivered according to an operationalized manual. The encouraging outcome indicates the need for a randomized controlled trial of BPST.

The disconnect between evidence and practice: a systematic review of person-centred interventions and training manuals for care home staff working with people with dementia†

The overall objective is to determine the availability of person‐centred intervention and training manuals for dementia care staff with clinical trial evidence of efficacy.

‘Getting to Know Me’: the development and evaluation of a training programme for enhancing skills in the care of people with dementia in general hospital settings

Objective: The aims of the study were to report on the development and evaluation of a staff training intervention in dementia care designed for use in the general hospital setting: the ‘Getting to Know Me’ training programme. The study also aimed to undertake initial psychometric analysis on two new outcome scales designed to measure knowledge and confidence in dementia care.Methods: The study comprised two phases. The first phase comprised the design of two questionnaires which are shared within this paper: Confidence in Dementia (CODE) Scale and Knowledge in Dementia (KIDE) Scale. In phase two, staff undertook the ‘Getting to Know Me’ training programme (n = 71). The impact of the programme was evaluated using a pre–post design which explored: (1) changes in confidence in dementia; (2) changes in knowledge in dementia; and (3) changes in beliefs about challenging behaviour.Results: The psychometric properties of the CODE and KIDE scales are reported. Statistically significant change was identified pre–post training on all outcome measures. Clinically meaningful change was demonstrated on the CODE scale.Conclusions: The ‘Getting to Know Me’ programme was well received and had a significant impact on staff knowledge and confidence. Our findings add to a growing evidence base which will be strengthened by further robust studies, the exploration of the impact of staff training on direct patient outcomes, and further identification of ways in which to transfer principles of care from specialist dementia environments into general hospital settings.

Longitudinal comparison of depression, coping, and turnover among NHS and private sector staff caring for people with dementia

Relatives caring for people with dementia show high levels of psychological distress and depression.1 However, the psychological health of staff in private and NHS care facilities for people with dementia has not been evaluated. Staff turnover is often high in these facilities, and mental health could be a contributory factor. View this table: Prevalence of stress among staff in private and NHS residential homes and stress coping mechanisms Active coping strategies reduce depression and psychological distress in family caregivers,2 and the same could be true for professional carers. We compared the prevalence of psychological distress among professional staff in private sector and NHS facilities and assessed the relation with coping strategies and rates of staff turnover. We measured emotional wellbeing (28 item general health questionnaire) and the use of positive coping strategies (active coping, planning, seeking social support, positive reinterpretation, and acceptance-COPE3) in the care staff of private sector residential or nursing homes and …

FITS into practice: translating research into practice in reducing the use of anti-psychotic medication for people with dementia living in care homes

Objectives: This paper reports on the acceptability and effectiveness of the FITS (Focussed Intervention Training and Support) into Practice Programme. This intervention was scaled up from an earlier cluster randomised-controlled trial that had proven successful in significantly decreasing antipsychotic prescribing in care homes. Method: An in depth 10-day education course in person-centred care was delivered over a three-month period, followed by six supervision sessions. Participants were care-home staff designated as Dementia Care Coaches (DCCs) responsible for implementing interventions in 1 or 2 care homes. The course and supervision was provided by educators called Dementia Practice Development Coaches (DPDCs). Effectiveness data included monitoring antipsychotic prescriptions, goal attainment, knowledge, attitudes and implementation questionnaires. Qualitative data included case studies and reflective journals to elucidate issues of implementation. Results: Of the 100 DCCs recruited, 66 DCCs completed the programme. Pre-post questionnaires demonstrated increased knowledge and confidence and improved attitudes to dementia. Twenty per cent of residents were prescribed antipsychotics at baseline which reduced to 14% (31% reduction) with additional dose reductions being reported alongside improved personalised goal attainment. Crucial for FITS into Practice to succeed was the allocation and protection of time for the DCC to attend training and supervision and to carry out implementation tasks in addition to their existing job role. Evaluation data showed that this was a substantial barrier to implementation in a small number of homes. Discussion and conclusions: The FITS into practice programme was well evaluated and resulted in reduction in inappropriate anti-psychotic prescribing. Revisions to the intervention are suggested to maximise successful implementation.