Behavioral management in the person with dementia

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia

OBJECTIVE

The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level.

DESIGN

This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)].

SETTING AND PARTICIPANTS

Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment.

MEASURES

Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use.

RESULTS

The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites.

CONCLUSIONS AND IMPLICATIONS

This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Clinical update on nursing home medicine: 2013

This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.

Recommendations of the Sleep Study Group of the Italian Dementia Research Association (SINDem) on clinical assessment and management of sleep disorders in individuals with mild cognitive impairment and dementia: a clinical review

Clinical assessment and management of sleep disturbances in patients with mild cognitive impairment and dementia has important clinical and social implications. Poor sleep results in an increased risk of morbidities and mortality in demented patients and is a source of stress for caregivers. Sleep disturbances show high prevalence in mild cognitive impairment and dementia patients and they are often associated one to another in the same patient. A careful clinical evaluation of sleep disorders should be performed routinely in the clinical setting of individuals with cognitive decline. The Sleep Study Group of the Italian Dementia Research Association (SINDem) reviewed evidence from original research articles, meta-analyses and systematic reviews published up to December 2013. The evidence was classified in quality levels (I, II, III) and strength of recommendations (A, B, C, D, E). Where there was a lack of evidence, but clear consensus, good practice points were provided. These recommendations may not be appropriate for all circumstances and should therefore be adopted only after a patient's individual characteristics have been carefully evaluated.

Systematic review of appropriate cognitive assessment instruments used in clinical trials of schizophrenia, major depressive disorder and bipolar disorder

Cognitive dysfunction is increasingly recognized as a symptom in mental conditions including schizophrenia, major depressive disorder (MDD), and bipolar disorder (BPD). Despite the many available cognitive assessment instruments, consensus is lacking on their appropriate use in clinical trials. We conducted a systematic literature review in Embase, PubMed/Medline and PsychINFO to identify appropriate cognitive function instruments for use in clinical trials of schizophrenia, MDD, and BPD. Instruments were identified from the articles. Instruments and articles were excluded if they did not address schizophrenia, MDD, or BPD. Instrument appropriateness was further assessed by the criteria of the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative: test-retest reliability, utility, relationship to functional status, potential changeability to pharmacological agents, and tolerability and practicality for clinical trials. The database search yielded 173 articles describing 150 instruments used to assess cognitive function. Seventeen additional instruments were identified through Google and clinicaltrials.gov. Among all these, only 30 (18%) were deemed appropriate for use in the diseases of interest. Of these, 27 were studied in schizophrenia, one in MDD and two in BPD. These findings suggest the need for careful selection of appropriate cognitive assessment instruments, as not all may be valid in these disorders.

Relation between caffeine and behavioral symptoms in elderly patients with dementia: an observational study

OBJECTIVES

Caffeine is known to improve concentration and reduce fatigue in healthy adults, but high doses may induce anxiety and agitation. Because the effects of caffeine in elderly people with dementia are unknown, this study explores the relation between caffeine and behavioral symptoms in a group of elderly patients with dementia.

DESIGN

An observational pilot study.

SETTING

A dementia special care unit of a Dutch nursing home.

PARTICIPANTS

A total of 29 elderly patients with dementia.

MEASUREMENTS

Behavioral symptoms were measured with the NPI-NH, and sleep and caffeine consumption were measured using questionnaires.

RESULTS

A significant relation was found between the total amount of caffeine consumed during the day and apathy [Kendall's tau (KT) -0.287 p=0.03], and the number of times that participants got up at night (KT 0.462; p <0.01). The amount of caffeine consumed after 6 p.m. was also significantly related to the number of times participants got up at night (KT 0.436; p <0.01). Multilevel analysis showed caffeine to be negatively correlated with aberrant motor behavior [b = -0.47 (0.22), Wald (461) = -2.12, p=0.03] and apathy [b = -0.88 (0.45), Wald (461)= -1.96, p=0.05], and showed a significant relation between caffeine consumption after 6 p.m. and the number of times participants got up at night [b=0.48 (0.22), Wald (461)= 2.20, p=0.03].

CONCLUSION

This study established an association between caffeine consumption and behavioral symptoms in elderly patients with moderately severe dementia. Therefore, adjusting caffeine consumption could be part of an interdisciplinary approach to behavioral symptoms, particularly when aberrant motor behavior, apathy or sleeping difficulties are involved. These results indicate that further research on the effects of caffeine on behavioral symptoms in dementia is warranted.

Geriatric psychiatry review: differential diagnosis and treatment of the 3 D's - delirium, dementia, and depression

The three D's of Geriatric Psychiatry-delirium, dementia, and depression-represent some of the most common and challenging diagnoses for older adults. Delirium is often difficult to diagnose and treatment is sometimes controversial with the use of antipsychotic medications, but it is common in a variety of patient care settings and remains an independent risk factor for morbidity and mortality in older adults. Dementia may affect a significant number of older adults and is associated with delirium, depression, frailty, and failure to thrive. Treatment of dementia is challenging and while medication interventions are common, environmental and problem solving therapies may have some of the greatest benefits. Finally, depression increases with age and is more likely to present with somatic complaints or insomnia and is more likely to be reported to a primary care physician than any other healthcare provider by older adults. Depression carries an increased risk for suicide in older adults and proven therapies should be initiated immediately. These three syndromes have great overlap, can exist simultaneously in the same patient, and often confer increased risk for each other. The primary care provider will undoubtedly benefit from a solid foundation in the identification, classification, and treatment of these common problems of older adulthood.